Programs for promoting a healthy lifestyle in the context of school health: a scoping review

Ana Nicole Duarte Pereira Amorim1, Irma da Silva Brito2, Alexandre de Assis Bueno3, Renata Alexandra Evangelista3, Maria do Rosário Costa Pinto Ferreira Mendes4, Corália Maria Fortuna de Brito Vicente1

1 University of Porto

2 Coimbra Nursing School

3 Federal University of Catalão

4 Aveiro University

ABSTRACT

Introduction: The adoption of healthy lifestyles (HLs) in children is encouraged at school, but health education is mainly oriented towards children, neglecting the family. Objective: To map and examine school programs to promote HLs in children (3-10 years old) that address 3 or more topics. Method: A Scoping Review from 1992-2020 with the Joanna Briggs Institute methodology and using the Rayyan QCRI platform. Results: Out of 4,952 articles, 19 HL promotion programs from 13 countries were selected, with the following themes: healthy eating, physical activity and parental education, but also interventions on screen dependence, sleep and hygiene.Discussion: Although most of the programs found are efficient, there is no consensus on techniques for monitoring the dimensions of HLs, nor holistic interventions to promote Hls. Conclusion: Programs that involve parents become more efficient. The scientific evidence found can improve health interventions.

Descriptors: Life Style; Child; School; Health Education.

INTRODUCTION

Healthy lifestyle is a concept that the World Health Organization(1) has defined as a way of life aimed at reducing illness and early death, covering physical, mental and social well-being. The adoption of a healthy lifestyle influences not only the subject who adopts it, but also the way of life of the family members, especially children. From an early age, children's lifestyle is influenced by their family and community, with a direct impact on their health and well-being. In order to promote a healthy lifestyle for children and their families, several international guidelines were defined on which the National School Health Program (Programa Nacional de Saúde Escolar, PNSE)(2) was based. This advocates holistic intervention in 11 lifestyle dimensions: mental health and socio-emotional skills, education for affections and sexuality, healthy eating and physical activity, body hygiene and oral health, health sleep and rest habits, postural education and prevention of the consumption of tobacco, alcoholic beverages and other psychoactive substances, as well as non-chemical addictive behaviors. However, most school health education programs focus on one or two dimensions. The most effective healthy lifestyle promotion interventions are holistic projects to promote global well-being, based on the development of individual, social and emotional skills that facilitate interpersonal relationships and empower the educational community for health management(3).

In Portugal, as part of the reorganization of the health services, Community Care Units (CCUs) were created, whose mission includes the implementation of the PNSE. The clinical practice in this area highlights gaps in the projects: in general, they do not reflect scientific reasoning, advocate a multiplicity of interventions without result indicators, and focus almost exclusively on the training of children(3). The mapping of scientific evidence on interventions in the school context to promote healthy lifestyles in children will make it possible to establish recommendations for school health teams, in order to improve the projects. It is verified that most of the programs/projects implemented in schools are not holistic, as they operate in only one or two dimensions of lifestyles. In the formulation of the PCC (Population, Concept and Context), children from 3 to 10 years of age were defined as the study population, the concept refers to a healthy lifestyle, and the context corresponds to school health. In this sense, the following research question was elaborated: “What school health programs have been implemented to promote healthy lifestyles in the children?”, which guided this scoping review. Its objective is to map in the scientific literature and examine programs to promote healthy lifestyles in children (3 to 10 years old) in the context of school health that address 3 or more dimensions (PNSE). For the target population, the age group from 3 to 10 years old was chosen, which covers preschool and 1st cycle, levels of schooling in which children have little autonomy and their parents are the main responsible for their lifestyle.

SYSTEMATIC REVIEW METHOD

This scoping review followed the Institute Joanna Briggs (JBI) methodology(4) with the following structure: identification of the research question, search for relevant studies, selection of studies, data mapping, compilation, summary and reporting of the results. A preliminary survey conducted in MEDLINE, CINAHL, LILACS, SCOPUS, WEB OF SCIENCE revealed that there is no scoping review (published or to be carried out) on projects to promote healthy lifestyles in the school context in children from 3 to 10 years old. In the database search in COCHRANE and PROSPERO no other reviews were identified with proposals similar to the themes of this review. This study focuses on the characterization of school health programs that have been implemented to promote healthy lifestyles in children, on the analysis of the dimensions of the lifestyles (focus of intervention), as well as on the effects of the interventions.

INCLUSION CRITERIA

The study population included all those that describe programs or strategies to promote healthy lifestyles for children aged 3 to 10 years old and the studies excluded were those aimed at children aged 0 to 2 years old, adolescents and adults. Community-based studies that covered the entire school were included. In reference to the concept, healthy lifestyles, all programs, strategies and interventions to promote healthy lifestyles in children were considered, excluding all that addressed only one or two dimensions. Regarding the context, studies carried out in schools were included, excluding those that, even when recruiting children from school, took place in other spaces. Regarding the type of study, all those that showed some intervention were included, that is, experimental studies: randomized controlled clinical trials, non-randomized controlled clinical trials or other quasi-experimental studies, such as before/after studies or studies related to the reliability, validity and accuracy of available instruments or tools, cohort studies, case studies, and experience reports. Studies published after 1992 were selected, the year in which the European Network of Health Promoting Schools was created to improve the school environment and facilitate healthy practices in the general community(5). Those that did not offer free access were excluded.

The following descriptors were used: "Life Style” [Mesh]; "Child” [Mesh]; "Health Education” [Mesh], adding the Boolean operator “AND”. The initial search was limited to the MEDLINE (via Pubmed) and CINAHL (via EBSCO, SCOPUS, WEBSCIENCE and LILACS) databases, followed by an analysis of text words in the titles and abstracts and the index terms used to describe the article. Data was extracted using a “Data extraction instrument” table (Appendix I) as recommended by the JBI for scoping reviews(4). Data extraction was conducted by ten independent reviewers by using the Rayyan QCRI platform(6). PRISMA was applied(7) (Figure I) in the selection of the articles. In a first phase, the 4,952 articles resulting from the research were analyzed and 529 were removed due to duplication. After reading and analyzing the title and/or abstract by two to two reviewers, 4,267 articles that did not meet the inclusion criteria were removed. Disagreements between the reviewers were solved through discussion with the first and second authors. Of the remaining 156 articles, 20 were not available. Of the remaining 136, for the full text analysis, 116 articles were removed for the following reasons: Age (n=45); not having interventions (n=16); without evidence of results (n=19) and programs that address only 2 lifestyle dimensions (n=35). A total of 19 articles constituted the documentary corpus of the present scoping review.

Figure I. Strategy for the selection of articles according to PRISMA. Coimbra, 2020.

Source:  the authors.

The synthesis of the 19 articles is shown in Table I, which gathers the following data: authors; year of publication; origin/country of origin (where the study was conducted); objectives; methodology (design, sample, type and duration of the intervention, results, limitations). Subsequently, we proceed to the evaluation of the methodological quality and analysis of meta-aggregation for synthesis, looking for similarities and divergences.

Source: the authors.

RESULTS

The studies included were carried out between 2013 and 2020, 8 were implemented on the American continent: 1 in Argentina(8), 1 in Colombia(9), 1 in Brazil(10), 1 in Mexico(11) and 4 in the United States of America(12)(13)(14)(15). 7 programs were found in Europe: 2 in Spain(16)(17), 2 in Italy(18)(19), 1 in the United Kingdom(20), 1 in Sweden(21), 1 in the Netherlands(22). A study was found that was applied in 6 European countries(23) (Belgium, Bulgaria, Germany, Greece, Poland and Spain). 3 articles were included from Asia: 1 from Israel(24), 1 from China(25) and 1 from South Korea(26). We did not obtain any publication from Portugal. Each study was coded with the initials of its country to ease its analysis.

Of the 19 studies, 11 (57.9%) were found with randomization and control group (RCT), 5 (26.3%) without randomization and with before-and-after measurements, and 3 (15.8%) quasi-experimental, without a control group and with repeated and paired measurements. Only 14 (73.7%) studies had 2 measurements, but 6 (31.6%) evaluated the effect within 3 to 6 months, 9 (47.4%) within 9 to 12 months, and 21.1% within 2 to 4 years. As for the target population of the selected articles, 1 (5.3%) was not a community-based program (US3), that is, directed and implemented in all the children in a class or in all the classes of a school.

The 19 programs found included the following lifestyle dimensions: healthy eating, physical exercise, parental education, sleep/rest, body hygiene, and non-chemical dependences. It was verified that 16 (84.2%) of the interventions focused on healthy eating, physical exercise and parental education and 11 (57.9%) exclusively on these (AR1, CO1, CN1, ES1, IT2, US1 , KR1, US2, IL1, UK 1, MX1). The IT1 and EU1 studies, in addition to the dimensions described above, also addressed screen dependences. The SW1 program also addresses the area of sleep and rest. As for the NL1 and US4 programs, they include healthy eating, physical exercise and non-chemical dependences. The ES2 study presents the following areas of intervention: healthy eating, physical exercise, parental education, sleep/rest, and body hygiene. The BR1 and US3 programs focused on screen dependences, the first also included exercise and parental education while US3, food and sleep/rest. As for the context, it is noteworthy that, of the 19 programs, 7 (36.8%) were implemented in preschool classes, in children aged 3 to 5 years old, and that the remaining 12 were applied in other schools, in children aged 6 or more. The SW1, NL1 and AR1 studies were implemented in schools located in disadvantaged areas, with evidence of low socioeconomic status. The CN1 study was carried out in urban schools. Among these 19 studies, no holistic programs were found, that is, that encompass all dimensions to promote healthy lifestyles.

DISCUSSION

This scoping review has as its main objective to map and examine programs to promote healthy lifestyles in children (3 to 10 years old) in the context of school health addressing more than 2 dimensions. In the database search, we found 4,952 articles but, of the 136 included for full-text analysis, only 19 programs met the criteria. Both in the excluded and included studies, a great focus on the energy balance dimension (food and physical exercise) was verified. The principles of health promoting schools advocate holistic interventions in at least 11 lifestyle dimensions. The studies analyzed made little reference to mental health and socio-emotional skills, education for affections and sexuality, and prevention of non-chemical addictive behaviors. Now, even energy balance is very much related to psychological well-being and self-control. In 2018, the mindfulness program for parents with stress (USA)(27) proposes a new approach to preventing obesity in young children, which has proven to be beneficial for the parents' behavior and for the child's BMI. In the Home Styles program (USA)(28) of lifestyle changes (aimed at parents), important effects were observed in the participants of the experimental group, at the intra-personal, inter-personal and environmental levels. The parents of the experimental group improved their own level of physical activity. In addition, children from families in the experimental group increased their level of physical activity and reduced their screen time(28). The parents' behavior influenced the children's behavior. The families are seen as influencing entities in people's well-being and health processes and these are governed by the relationships they establish with each other and the contexts in which they live(3).

On the other hand, the results obtained in the selected studies reveal that the majority apply health education programs that focus on knowledge acquisition. The 11 articles focused exclusively on the 3 dimensions obtained little consistent and similar results. The AR1 program has managed to increase the intake of healthy foods, but was able to significantly reduce the intake of less healthy foods. In the CO1 study, the children in the intervention group had a 10.9% increase in the weighted score, compared to the control group (5.3%), maintaining after 1 year of the intervention. In the CN1 program, the students in the experimental group consumed less fried snacks, soft drinks, but more meat, and reported having spent less time in front of the screens. However, there was no difference in the time of physical activity between the two groups. Regarding the ES1 program, it was verified that, after an academic year, the program proved to be an effective and viable strategy to increase knowledge and improve children's lifestyle habits, reported by the parents. In the IT2 program, the results point to an increase in children's adherence to the Mediterranean Diet, changes in healthy habits and greater awareness of the parents about their educational responsibilities in relation to food and physical activity. As for the SW1 study, it was verified that it is possible to exert an influence on the intake of unhealthy food and drinks and on the weight of obese children, providing individual parental support (motivational interview) in a school context. However, there were significant effects in relation to the consumption of unhealthy food and drinks; and there was no effect of the intervention on sedentary lifestyle or BMI. In the US1 study, the parents' eating and physical activity patterns significantly influenced the consumption of fruits and vegetables, processed food and the sedentary lifestyle of their preschoolers; while the children in the control group showed a significant increase in the consumption of junk food and sedentary behavior from T1 to T2. The teachers did not significantly influence preschool children in terms of food or physical activity. In the KR1 program, the intervention group showed significant improvements in healthy lifestyle behaviors, but not in childhood obesity status; and significant improvements in parental behaviors. The US2 study, the Sustainability via Active Garden Education (SAGE) program, presents the first results of the pilot test(29): children significantly increased physical activity during SAGE classes compared to normal classes, but they consumed more calories in the absence of hunger after the intervention. The parents' reports did not show changes in the consumption of fruits and vegetables or in the physical activity of the parents, possibly due to the low involvement of the families.

In the IL1 program, it was verified that excess weight decreased significantly within the intervention group, with no significant change in the control group. Religious children presented a two-fold risk of excess weight or obesity. Knowledge was improved in both study groups, with no effect on health behaviors. As for UK1, there was a significant reduction between the pre- and post-intervention. There were no changes in the Body Mass Index (BMI) from the post-intervention to the 6-month follow-up. The psychosocial variables did not change significantly. The MX1 program showed improvements in the BMI of overweight or obese children and in triglycerides in the three ethnic groups. The mestizo ethnic group showed more significant improvements in BMI in the second intervention; while the Seris ethnic group showed improvements only in cardiovascular risk factors, and the Yaquis showed improvements in the diabetes risk factors.

The IT1 and EU1 studies, in addition to including the intervention areas of the studies described above, also addressed non-chemical dependences (screen time). In the IT1 study, the program demonstrated that 48.4% of the children in the intervention group had a low risk Combined Health Behaviour Score (CHBS) compared to 28.0% of the children in the control group and with no influence on the BMI results. In the EU1 European study, half of the sample (50.4%) did not meet the recommendations for physical exercise or screen time in any of the periods. Of those who adhered, only 0.6% met the recommendations for physical exercise or screen time at T0 and T1. The children who met the recommendations at T0 and T1 consumed significantly less milk-based desserts and snacks compared to those who did not meet any of the recommendations. Those who met both recommendations at T0 and only one at T1 had a significantly lower consumption of soft drinks and savory snacks and higher consumption of fruits and vegetables compared to the control group. In addition, those children who met one of the recommendations at T0 and T1 had a significantly lower consumption of soft drinks, sweets, desserts and snacks, and a higher consumption of fruits and vegetables. Those children who did not adhere to the recommendations at T0 and performed one of them at T1 had a lower consumption of soft drinks, juices, sweets, desserts and savory snacks compared to the reference group.

The SW1 program, which also addresses the area of sleep and rest, shows that it is possible to influence the intake of unhealthy food and drinks by obese children, providing individual parental support in a school context. There was no effect of the intervention on sedentary lifestyle. In addition, the intervention had no apparent effect on the BMI for the entire sample.

The ES2 study focused on the following intervention areas: healthy eating, physical exercise, parental education, sleep/rest, and body hygiene. Positive effects were observed on emotional perception and resilience in the intervention group. Children and families showed high acceptability of the program and, due to their participation in it, important barriers and facilitators for the implementation process were identified.

The BR1 and US3 programs focused on screen dependences: The first also included physical exercise and parental education and US3, food and sleep/rest. In the BR1 community-based program, it was verified that physical activity did not change although the physically inactive subgroup had increased its levels of physical activity. Television and video game time during the week decreased, while computer time increased. Overweight and obese participants reduced their BMI z score but were unable to change the proportion of physical inactivity and sedentary behavior in young individuals. In the US3 study, there was an increase in agricultural knowledge, about sugar in drinks, and about bedtime routines. The only significant change was observed for knowledge about the bedtime routine, which was 15% higher in the intervention school.

As for the NL1 and US4 programs, they include healthy eating, physical exercise, and screen dependences. The NL1 study demonstrated that the significant favorable effects for the Healthy Primary School of the Future (HPSF) in the full version versus control schools for school water consumption, vegetable and dairy food intake, sedentary time and light physical activity, among others. Almost no significant favorable effects were found for partial HPSF. Complete HPSF is effective in promoting children's health behaviors at T1 and T2 compared to control schools. The US4 program showed a statistically significant improvement in the consumption of fruits and vegetables among the children in the control group and the intervention group. The parents in the intervention group reported that their children were much less involved with post-intervention screens than reported by the parents in the control group.

In summary, we can assert that, as far as efficiency is concerned, the programs analyzed managed to partially achieve the objectives for which they were proposed. However, there is a clear lack of holistic programs to promote healthy lifestyles in the school context, aimed at children aged 3 to 10. In recent years, a number of strategies and programs have evolved, with names as diverse as Health Promoting Schools, Global School Health, Child Friendly Schools and the Focusing Resource on Effective School Health. All of these strategies have in common the school's global approach and the recognition that all aspects of the school community life are potentially important for health promotion(30), but there is no consensus on techniques and instruments for monitoring the several dimensions of lifestyles, let alone holistic interventions to promote healthy lifestyles.

SCOPING REVIEW LIMITATIONS

Only studies in Portuguese, Spanish and English were included, as well as studies that were available in full text; we run the risk of excluding other studies of great interest for this scoping review.

CONCLUSION

A healthy lifestyle in children includes behaviors and habits that encompass several dimensions that contribute to their well-being and health. Although childhood obesity is an important issue, programs that focus only on dimensions such as food, physical activity, screen dependences, and sleep and rest habits (even privileging playful educational activities and training for parents and teachers) do not reveal very significant effects. However, it was verified that interventions involving children up to 5 years of age, parents and teachers become more efficient, since they are the ones that most influence and shape the lifestyles of the children. It also reveals that the programs assume that, by promoting health literacy, they are influencing better lifestyles, which is not true. According to the National School Health Program, all dimensions of a child's life should be trained by parents and educators in order to increase health literacy and predispose them to adopt healthier lifestyles. Studies that mobilize the entire educational community tend to be more effective and have made it possible to identify barriers and facilitating factors.

It is suggested to carry out scientific studies that propose holistic interventions on lifestyles. Thê diverse scientific evidence found in the present study is important to guide the practice of community Nursing, since it can guide the design of interventions in ̧school health and their implementation with a view to promoting ̧healthy lifestyles in the childreņ. In this sense, the “Gostar de Mim” (“Like Me”) school health program was conceived and is being validated in Portugal, in the Center Region. This program reaches 28 schools (approximately 835 families) with a view to increasing health literacy for families and children in primary schools. “Gostar de Mim” recommends that, for this age group, the interventions focus on raising awareness among the families, the main caregivers of the childreņ and modulators of their health-related lifestyle.

ACKNOWLEDGMENTS

The authors would like to thank Nurses Andreia Vanessa Veiga de Almeida Cruz; Mariana Rodrigues de Matos; Ophélie Santos Môço; Beatriz Esgueira Lourenço; Raquel Santos Borges do Nascimento; Ricardo José dos Santos Ferreira; and Emanuele Pozzebon Caurio for their collaboration. The authors are grateful for the support of the Research Unit ̧in̂ Health Sciences: Nursing (Unidade de Investigação em Ciências da Saúde: Enfermagem, UICISA: E), from the Coimbra Nursing College (Escola Superior de Enfermagem de Coimbra, ESEnfC).

Appendix I - Data extraction instrument. (5)

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Received: 10/12/2020

Revised: 11/24/2020

Approved: 12/10/2020