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Objective To assess the effectiveness of lunchbox interventions aiming to improve the foods and beverages packed and consumed by children at centre-based care or school; and subsequent impact on children’s adiposity. Methods Systematic search of nine databases for controlled trials published in English between 1995-January 2017. Where appropriate, data were pooled in a random effects meta-analysis. Results Of the 1601 articles identified, ten studies (centre-based care n  = 4, school n  = 6) were included of which eight were RCTs. The impact of interventions on the packing of discretionary foods, sugar-sweetened drinks and other core foods was inconsistent. Meta-analysis of four RCTs trials found a moderate increase in provision of vegetables (SMD = 0.40 95% CI 0.16 to 0.64, p  = 0.001, I 2  = 82%; equivalent to a mean difference of 0.28 serves) but not fruit. Four studies reported impact on children’s dietary intake, one reported no significant effect on consumption of discretionary foods, one reported improvements in the consumption of sugar-sweetened drinks and water, and two reported improvements in consumption of vegetables and fruit. Two studies, that were broader obesity prevention interventions, reported no significant impact on adiposity. Conclusions There is some evidence that lunchbox interventions are effective in improving the packing of vegetables in children’s lunchboxes, however more robust research is required to determine the impact on children’s dietary intake and adiposity. Trial registration PROSPERO 2016: CRD42016035646 .

Background Repeated, data-driven optimisation processes have been applied in many fields to rapidly transform the performance of products, processes and interventions. While such processes may similarly be employed to enhance the impact of public health initiatives, optimisation has not been defined in the context of public health and there has been little exploration of its key concepts. Methods We used a modified, three-round Delphi study with an international group of researchers, public health policy-makers and practitioners to (1) generate a consensus-based definition of optimisation in the context of public health and (2i) describe key considerations for optimisation in that context. A pre-workshop literature review and elicitation of participant views regarding optimisation in public health (round 1) were followed by a daylong workshop and facilitated face-to-face group discussions to refine the definition and generate key considerations (round 2); finally, post-workshop discussions were undertaken to refine and finalise the findings (round 3). A thematic analysis was performed at each round. Study findings reflect an iterative consultation process with study participants. Results Thirty of 33 invited individuals (91%) participated in the study. Participants reached consensus on the following definition of optimisation in public health: “ A deliberate, iterative and data-driven process to improve a health intervention and/or its implementation to meet stakeholder-defined public health impacts within resource constraints ”. A range of optimisation considerations were explored. Optimisation was considered most suitable when existing public health initiatives are not sufficiently effective, meaningful improvements from an optimisation process are anticipated, quality data to assess impacts are routinely available, and there are stable and ongoing resources to support it. Participants believed optimisation could be applied to improve the impacts of an intervention, an implementation strategy or both, on outcomes valued by stakeholders or end users. While optimisation processes were thought to be facilitated by an understanding of the mechanisms of an intervention or implementation strategy, no agreement was reached regarding the best approach to inform decisions about modifications to improve impact. Conclusions The study findings provide a strong basis for future research to explore the potential impact of optimisation in the field of public health.

Individual and environmental resilience protective factors are suggested to be associated with adolescent condom use; however, previous studies have not comprehensively examined such associations. This study aimed to determine the associations between condom use, and numerous individual and environmental resilience protective factors in sexually active Australian adolescents. Participants were Grade 10 students attending 28 Australian government high schools (n=1,688). An online survey (2011) collected data regarding: sexual intercourse (past year), condom use and 14 individual and environmental resilience protective factors. Multivariable backward stepwise logistic regression models examined associations between student condom use and protective factors (total, subscale). Only total environmental protective factors remained in the final total score model; students with higher total environmental protective factors scores were 2.59 times more likely to always use a condom(95%CI:1.80–3.74). Only three of 14 protective factor subscales were associated with a higher likelihood of always using a condom in the final subscale model (individual: goals/aspirations; environmental: community participation, pro‐social peers). Total environmental and three protective factor subscales demonstrated prominent associations with consistent use of condoms in sexually active adolescents. Consideration of particular resilience protective factors in adolescent sexual risk behaviour prevention, such as condom use, is warranted.

While there is some guidance to support the adaptation of evidence-based public health interventions, little is known about adaptation in practice and how to best support public health practitioners in its operationalization. This qualitative study was undertaken with researchers, methodologists, policy makers and practitioners representing public health expert organizations and universities internationally to explore their views on available adaptation frameworks, elicit potential improvements to such guidance, and identify opportunities to improve implementation of public health initiatives. Participants attended a face to face workshop in Newcastle, Australia in October 2018 where World Café and focus group discussions using Appreciative Inquiry were undertaken. A number of limitations with current guidance were reported, including a lack of detail on ‘how’ to adapt, limited information on adaptation of implementation strategies and a number of structural issues related to the wording and ordering of elements within frameworks. A number of opportunities to advance the field was identified. Finally, a list of overarching principles that could be applied together with existing frameworks was generated and suggested to provide a practical way of supporting adaptation decisions in practice.

ObjectivesResearch suggests that individual and environmental resilience protective factors may be associated with adolescent substance use; however, the associations between a broad range of such factors and use of various types of substances have not been examined. The study aimed to determine the association between a comprehensive range of adolescent individual and environmental resilience protective factors and measures of tobacco, alcohol and illicit substance use.DesignCross-sectional study.Setting32 Australian secondary schools.ParticipantsGrade 7–10 students (aged 11–17 years).MeasuresData regarding 14 student individual and environmental resilience protective factors and seven substance use measures (tobacco, alcohol, marijuana, other illicit drug use) were obtained via an online self-report survey. Adjusted multivariate logistic regression analyses examined the association between all student resilience protective factors and seven substance use measures.ResultsInverse univariate associations were found for 94 of 98 relationships examined (n=10 092). Multivariate analyses found: consistent inverse associations between 2 of 14 protective factors and all substance use measures (‘goals and aspirations’, ‘prosocial peers’); inverse associations between 4 protective factors with multiple substance use measures (‘home support’ (5 of 7), ‘school support’ (3 of 7), ‘self-awareness’ (2 of 7), ‘community meaningful participation’ (2 of 7)); positive associations between 2 resilience protective factors with multiple measures of substance use (‘community support’ (3 of 7), ‘peer caring relationships’ (5 of 7)) and 6 protective factors not to be associated with any substance use measure.ConclusionsDespite individual relationships between the majority of resilience protective factors and substance use types, the protective benefit of such factors for adolescent substance use was limited to only a small number of such factors when considered collectively. Such results suggest that interventions seeking to reduce adolescent substance use may need to target specific protective factors to address specific types of substance use.Trial registration numberACTRN12611000606987, Results.

ObjectivesInitiation of tobacco, alcohol and illicit substance use typically occurs during adolescence, with the school setting recommended to reduce adolescent substance use. Strengthening individual (eg, problem solving) and environmental (eg, caring relationships at school) resilience protective factors of adolescents has been suggested as a strategy for reducing substance use by adolescents; however, few studies have examined this potential. A study was conducted to investigate the effectiveness of a pragmatic school-based universal ‘resilience’ intervention in reducing the prevalence of tobacco, alcohol and illicit substance use, and increasing the individual and environmental protective factors of students.DesignA cluster-randomised controlled trial.SettingThirty-two Australian secondary schools (20 intervention; 12 control).ParticipantsCohort of grade 7 students followed-up in grade 10 (2014; aged 15–16 years).InterventionA pragmatic intervention involving school staff selection and implementation of available programmes and resources targeting individual and environmental ‘resilience’ protective factors for all grade 7–10 students was implemented in schools (2012–2014). School staff were provided implementation support.MeasurementsAn online survey collected baseline and follow-up data for primary outcomes: tobacco (ever, recent) and alcohol (ever, recent, ‘risk’) use, and secondary outcomes: marijuana and other illicit substance use, and individual (six-factor subscales, aggregate) and environmental (three-factor subscales, aggregate) protective factor scores. Generalised and linear mixed models examined follow-up differences between groups.ResultsFollow-up data from 2105 students (intervention=1261; control=844; 69% of baseline cohort) were analysed. No significant differences were found between intervention and control students for any primary (ever tobacco: OR 1.25, 95% CI 0.92 to 1.68, p=0.14; recent tobacco: OR 1.39, 95% CI 0.84 to 2.31, p=0.19; recent ever alcohol: OR 1.11, 95% CI 0.83 to 1.48, p=0.46; alcohol: OR 1.13, 95% CI 0.78 to 1.62, p=0.51; ‘risk’ alcohol: OR 0.98, 95% CI 0.70 to 1.36, p=0.89) or secondary outcomes (marijuana: OR 1.12, 95% CI 0.74 to 1.68, p=0.57; other illicit substance: OR 1.19, 95% CI 0.67 to 2.10, p=0.54; individual protective factors: MD=0, 95% CI −0.07 to 0.06, p=0.89; environmental protective factors: MD: −0.02, 95% CI −0.09 to 0.06, p=0.65).ConclusionsThe universally implemented pragmatic school-based intervention was not effective in reducing the prevalence of tobacco, alcohol or illicit substance use, or in increasing the protective factors of students.Trial registrationAustralia and New Zealand Clinical Trials Register reference: ACTRN12611000606987

ObjectivesInterventions addressing the individual and environmental protective factors of adolescents are suggested to have potential for reducing adolescent substance use. While universally delivered school-based substance use prevention interventions are common, previous studies have suggested variable effectiveness by subgroups of students. An exploratory study was undertaken to examine the differential effectiveness of a universal school-based resilience intervention on adolescent substance use and protective factors according to their sociodemographic and previous substance use.DesignSecondary analysis of data from a cluster-randomised controlled trial.Setting32 Australian secondary schools.ParticipantsCohort of grade 7 students (n=3155) followed up in grade 10 (aged 15–16 years; 2014; n=2105).InterventionThree-year universal school-based intervention implemented by school staff that targeted a range of student resilience protective factors (2012–2014).MeasurementsPrimary outcomes included: tobacco (recent, number of cigarettes) and alcohol (recent, ‘risk’ and number of drinks) use, and secondary outcomes included: marijuana (recent) and other illicit substance (recent) use, and aggregate individual and environmental protective factor scores. Generalised and linear mixed models examined interactions between treatment and student subgroups (gender; socioeconomic disadvantage (low/high); geographic location (major city/inner regional/outer regional-remote); and previous substance use (non-user/user)) at follow-up (36 models).ResultsAnalysis of student follow-up data showed no differential intervention effect for any substance use or protective factor outcome for any subgroup, with the exception of one differential effect found by socioeconomic status for the outcome of mean number of cigarettes smoked by recent smokers (p=0.003). There was no evidence of an intervention effect within the low (mean difference (MD) −12.89, 95% CI −26.00 to 0.23) or high (MD 16.36, 95% CI −1.03 to 33.76) socioeconomic subgroups.ConclusionsNo evidence of an intervention effect on substance use and protective factors was found according to student subgroups defined by sociodemographic characteristics or previous substance use.Trial registration numberACTRN12611000606987.

Introduction Tobacco, alcohol and illicit drug use contribute significantly to global rates of morbidity and mortality. Despite evidence suggesting interventions designed to increase adolescent resilience may represent a means of reducing adolescent substance use, and schools providing a key opportunity to implement such interventions, existing systematic reviews assessing the effectiveness of school-based interventions targeting adolescent substance use have not examined this potential. Methods and analysis The aim of the systematic review is to determine whether universal interventions focused on enhancing the resilience of adolescents are effective in reducing adolescent substance use. Eligible studies will: include participants 5–18 years of age; report tobacco use, alcohol consumption or illicit drug use as outcomes; and implement a school-based intervention designed to promote internal (eg, self-esteem) and external (eg, school connectedness) resilience factors. Eligible study designs include randomised controlled trials, cluster randomised controlled trials, staggered enrolment trials, stepped wedged trials, quasi-randomised trials, quasi-experimental trials, time series/interrupted time-series trials, preference trials, regression discontinuity trials and natural experiment studies with a parallel control group. A search strategy including criteria for participants, study design, outcome, setting and intervention will be implemented in various electronic databases and information sources. Two reviewers will independently screen studies to assess eligibility, as well as extract data from, and assess risk of bias of included studies. A third reviewer will resolve any discrepancies. Attempts will be made to quantify trial effects by meta-analysis. Binary outcomes will be pooled and effect size reported using ORs. For continuous data, effect size of trials will be reported using a mean difference where trial outcomes report the same outcome using a consistent measure, or standardised mean difference where trials report a comparable measure. Otherwise, trial outcomes will be described narratively. Dissemination Review findings will be disseminated via peer-reviewed journals and conferences.

Schools are identified as a key setting to influence children’s and adolescents’ healthy eating. This umbrella review synthesised evidence from systematic reviews of school-based nutrition interventions designed to improve dietary intake outcomes in children aged 6 to 18 years. We undertook a systematic search of six electronic databases and grey literature to identify relevant reviews of randomized controlled trials. The review findings were categorised for synthesis by intervention type according to the World Health Organisation Health Promoting Schools (HPS) framework domains: nutrition education; food environment; all three HPS framework domains; or other (not aligned to HPS framework domain). Thirteen systematic reviews were included. Overall, the findings suggest that school-based nutrition interventions, including nutrition education, food environment, those based on all three domains of the HPS framework, and eHealth interventions, can have a positive effect on some dietary outcomes, including fruit, fruit and vegetables combined, and fat intake. These results should be interpreted with caution, however, as the quality of the reviews was poor. Though these results support continued public health investment in school-based nutrition interventions to improve child dietary intake, the limitations of this umbrella review also highlight the need for a comprehensive and high quality systematic review of primary studies.

Background Childhood overweight and obesity is increasingly prevalent, can persist into adulthood, and lead to lifelong negative health trajectories. Schools are a recommended setting for childhood obesity prevention interventions; however, these interventions are often complex and multicomponent. While previous reviews have demonstrated their effectiveness, they have not identified which behaviour change techniques (BCTs – active ingredients of an intervention) are most effective. Objectives Describe BCTs used in healthy eating (HE) and physical activity (PA) intervention components of obesity prevention interventions supporting children aged 6–18 years; and explore which BCTs are associated with child weight. Methods A secondary analysis of school-based trials included in a 2022 update of a Cochrane systematic review was undertaken. The previous review included 195 randomised controlled trials of childhood obesity prevention interventions targeting HE and/or PA that assessed the body mass index of children aged 6–18 years. For this study, only trials delivered in schools that compared an intervention to a non-intervention control group and targeted HE, PA or both were eligible. Individual BCTs of each HE and PA intervention were coded according to the BCT taxonomy v1. Meta-regressions were conducted to determine the association between BCTs included in the trials and child weight. Results This secondary analysis included 124 eligible trials. Fifty-five of the 93 BCTs from 14 of the 16 BCT domains were identified across interventions. Interventions with a HE component that included BCTs from three domains ( Goals and planning; Social support; Comparison of behaviour ) were found to have a significant association with a positive effect on child weight, whereas there were no significant associations found for interventions with a PA component. Conclusion School-based obesity prevention interventions with HE components that included BCTs within the Goals and planning, Social support, and Comparison of behaviour domains, such as Goal setting (outcome) , Social support (unspecified) and Demonstration of the behaviour were associated with a positive effect on child weight and should be considered for prioritisation in future interventions. Further research is required to identify effective BCTs for PA intervention components, and for effective individual BCTs and combinations of BCTs for all obesity prevention interventions broadly. Trial registration CRD42022366743.