Sustainability of the Health Benefits of the APPLE Schools Comprehensive School Health Program

  • Author / Creator
    Ofosu, Nicole N
  • The global epidemic of chronic noncommunicable diseases has been largely associated with unhealthy environmental influences which impact on lifestyles. Whole school approaches to health promotion provide opportunity to build health promoting environments to support healthy lifestyles among young people. Whole school approaches such as the Comprehensive School Health (CSH) approach have demonstrated effectiveness in improving students’ health behaviors and promoting healthy body weights, the sustainability of these benefits is yet to be established. This thesis research aimed to: i) evaluate the sustainability of the health benefits of APPLE Schools, a CSH initiative, in graduates of APPLE elementary schools, who are now in junior high/high school, and ii) explore factors that influence the practice of healthy behaviors among adolescents. Quantitative and qualitative methods were used to address the objectives. Data were collected in a 2015/16 Youth Health Survey among junior high and high school students (grades 7-12) in Northern Alberta, Canada. Participants included graduates from APPLE elementary schools (APPLE School graduates; n = 202) and comparison elementary schools (comparison school graduates; n = 338). Health-related knowledge, attitudes, self-efficacy, diet (24-hour dietary recall), physical activity (pedometer step count) and weight status were assessed. Baseline data on APPLE Schools and comparison schools accessed from the APPLE Schools survey and the Raising healthy Eating and Active Living Kids in Alberta (REAL Kids Alberta) survey carried out in 2008/09 were also utilized. Three interconnected papers were produced. The first paper assessed the long-term effects of participation in the APPLE Schools project on health-related knowledge, attitudes, self-efficacy, diet, physical activity and body weights of APPLE School graduates. Using mixed effects regression, differences in these outcomes between APPLE School graduates and comparison school graduates were assessed. Comparisons between elementary school (2008/09) and junior high/high school (2015/16) on self-efficacy, physical activity and weight status were also determined. The results showed no significant differences between APPLE School graduates and comparison school graduates for the outcomes. However, APPLE School students in 2008 had started worse off with regards to healthy dietary habits in physical activity levels and obesity prevalence relative to other students but, within two years of the APPLE Schools program, were at par with students in comparison schools. Therefore, finding no significant differences between the two groups suggested one of two possibilities: 1) that the effects of APPLE Schools continued into junior high/high school, or 2) that the new school environment has an equalizing effect on students regardless of where they started. The second paper assessed whether there was a dose-response association between duration in APPLE elementary schools and the health outcomes (dietary intake, physical activity levels and body weight status) of APPLE School graduates. Mixed effects linear/logistic regression models were employed to examine this association. The results showed no dose-response association between duration in the APPLE Schools project and the outcomes. This finding further supported the possibility that the new school environment (junior high/high school) could have had an impact on behaviors of the students, and possibly masked the program effects. The third paper explored adolescents’ perspectives on factors influencing their practice of healthy behaviours within the junior high/high school environment. In-depth interviews were conducted in a qualitative descriptive study with 22 junior high and high school students who participated in the 2015/16 Youth Health Survey. The data were analyzed using content analysis. Findings revealed three themes: 1) knowledge, 2) contextual factors (home environment and school environment) and 3) individual factors (self-motivation and personal responsibility). Overall, the students were knowledgeable about what it takes to be healthy. The home environment and school environment were highlighted as contextual factors perceived to influence the practice of health behaviors in the junior high/high school environment by providing the right kind of knowledge, structure and opportunities to cultivate and maintain a healthy lifestyle. Students identified self-motivation and personal responsibility as individual factors influencing the practice of their health behaviors. This thesis supports the need for continuity in life-stage appropriate initiatives that promote and support healthy lifestyles among young people. Such programs can provide the needed consolidation and reinforcement of messages and learned behaviors to encourage sustainability into adulthood.

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  • Degree
    Doctor of Philosophy
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