School-based preventive interventions targeting e-cigarette use among adolescents: a systematic review protocol.

INTRODUCTION: Electronic cigarette (e-cigarette) use has drastically increased in recent years, particularly among adolescents. This poses several acute and chronic harms to young people, including poisonings, burns, serious lung injury and-where nicotine e-liquid is used-the potential to impact healthy brain development and precipitate future nicotine addiction. School-based prevention programmes have the potential to address this growing public health concern by reaching large numbers of young people during a critical period for intervention; however, the efficacy of such interventions has not been systematically explored. This systematic review aims to determine the existence and efficacy of school-based preventive interventions targeting e-cigarette use. METHODS AND ANALYSIS: A systematic search of MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Database of Systematic Reviews and international clinical trials registries will be conducted from 2000 to April 2022 to identify eligible studies (randomised controlled trials, cluster randomised controlled trials and quasiexperimental studies) evaluating school-based interventions to prevent e-cigarette use among adolescents. Two reviewers will independently screen title, abstract and full text of all studies for eligibility. Both reviewers will independently extract the data and assess the risk of bias. Any discrepancies will be resolved by a third reviewer. Results will be summarised in a narrative synthesis and data will be meta-analysed if appropriate. Heterogeneity in findings will be assessed narratively, and using the I2 statistic (where meta-analysis is feasible), meta-regression will be used to explore potential factors associated with programme efficacy, where data permit. ETHICS AND DISSEMINATION: This research is conducted on published work and does not require ethics approval. The findings will be published in a peer-reviewed journal and used to guide the development of new school-based e-cigarette preventive interventions. TRIAL REGISTRATION NUMBER: CRD42022323352.

Lifestyle risk behaviours among adolescents: a two-year longitudinal study of the impact of the COVID-19 pandemic.

OBJECTIVE: To examine changes in the prevalence of six key chronic disease risk factors (the "Big 6"), from before (2019) to during (2021) the COVID-19 pandemic, among a large and geographically diverse sample of adolescents, and whether differences over time are associated with lockdown status and gender. DESIGN: Prospective cohort study. SETTING: Three Australian states (New South Wales, Queensland and Western Australia) spanning over 3000 km. PARTICIPANTS: 983 adolescents (baseline Mage=12.6, SD=0.5, 54.8% girl) drawn from the control group of the Health4Life Study. PRIMARY OUTCOMES: The prevalence of physical inactivity, poor diet (insufficient fruit and vegetable intake, high sugar-sweetened beverage intake, high discretionary food intake), poor sleep, excessive recreational screen time, alcohol use and tobacco use. RESULTS: The prevalence of excessive recreational screen time (prevalence ratios (PR)=1.06, 95% CI=1.03 to 1.11), insufficient fruit intake (PR=1.50, 95% CI=1.26 to 1.79), and alcohol (PR=4.34, 95% CI=2.82 to 6.67) and tobacco use (PR=4.05 95% CI=1.86 to 8.84) increased over the 2-year period, with alcohol use increasing more among girls (PR=2.34, 95% CI=1.19 to 4.62). The prevalence of insufficient sleep declined across the full sample (PR=0.74, 95% CI=0.68 to 0.81); however, increased among girls (PR=1.24, 95% CI=1.10 to 1.41). The prevalence of high sugar-sweetened beverage (PR=0.61, 95% CI=0.64 to 0.83) and discretionary food consumption (PR=0.73, 95% CI=0.64 to 0.83) reduced among those subjected to stay-at-home orders, compared with those not in lockdown. CONCLUSION: Lifestyle risk behaviours, particularly excessive recreational screen time, poor diet, physical inactivity and poor sleep, are prevalent among adolescents. Young people must be supported to find ways to improve or maintain their health, regardless of the course of the pandemic. Targeted approaches to support groups that may be disproportionately impacted, such as adolescent girls, are needed. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12619000431123).

eHealth Interventions Targeting Poor Diet, Alcohol Use, Tobacco Smoking, and Vaping Among Disadvantaged Youth: Protocol for a Systematic Review.

BACKGROUND: Chronic disease burden is higher among disadvantaged populations. Preventing lifestyle risk behaviors such as poor diet, alcohol use, tobacco smoking, and vaping in adolescence is critical for reducing the risk of chronic disease and related harms in adolescence and adulthood. Although eHealth interventions are a promising prevention approach among the general population, it is unclear whether they adequately serve adolescents from disadvantaged backgrounds such as those living in geographically remote or lower socioeconomic areas. OBJECTIVE: This is the first systematic review to identify, evaluate, and synthesize evidence for the effectiveness of eHealth interventions targeting adolescents living in geographically remote or lower socioeconomic areas in preventing poor diet, alcohol use, tobacco smoking, and vaping. METHODS: A systematic search will be conducted in 7 electronic databases: the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PROSPERO, MEDLINE (Ovid), Embase (Ovid), Scopus, and PsycInfo (Ovid). The search will be limited to eHealth-based experimental studies (ie, randomized controlled trials and quasi-experimental studies) targeting diet, alcohol use, tobacco smoking, and vaping among adolescents (aged 10-19 years). Eligible studies will be those reporting on at least one marker of socioeconomic status (eg, social class, household income, parental occupation status, parental education, and family affluence) or geographical remoteness (eg, living in rural, regional, and remote areas, or living outside major metropolitan centers). One reviewer will screen all studies for eligibility, of which 25% will be double-screened. Data will be extracted and summarized in a narrative synthesis. Risk of bias will be assessed using the Cochrane Revised Risk of Bias Tool. RESULTS: As of December 2021, the title and abstract screening of 3216 articles was completed, and the full-text review was underway. The systematic review is expected to be completed in 2022. CONCLUSIONS: This systematic review will provide an in-depth understanding of effective eHealth interventions targeting poor diet, alcohol use, tobacco smoking, and vaping among adolescents living in geographically remote or lower socioeconomic areas and the factors that contribute to their effectiveness. This in turn will provide critical knowledge to improve future interventions delivered to these populations. TRIAL REGISTRATION: PROSPERO CRD42021294119; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=294119. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/35408.

A Multiple Health Behavior Change, Self-Monitoring Mobile App for Adolescents: Development and Usability Study of the Health4Life App.

BACKGROUND: The link between chronic diseases and the Big 6 lifestyle risk behaviors (ie, poor diet, physical inactivity, smoking, alcohol use, sedentary recreational screen time, and poor sleep) is well established. It is critical to target these lifestyle risk behaviors, as they often co-occur and emerge in adolescence. Smartphones have become an integral part of everyday life, and many adolescents already use mobile apps to monitor their lifestyle behaviors and improve their health. Smartphones may be a valuable platform for engaging adolescents with interventions to prevent key chronic disease risk behaviors. OBJECTIVE: The aim of this paper is to describe the development, usability, and acceptability of the Health4Life app, a self-monitoring smartphone app for adolescents that concurrently targets the Big 6 lifestyle behaviors. METHODS: The development of the Health4Life app was an iterative process conducted in collaboration with adolescents and experts. The development process consisted of three stages: scoping the literature; end user consultations, which included a web-based survey (N=815; mean age 13.89, SD 0.89 years) and a focus group (N=12) among adolescents; and app development and beta testing. Following this development work, 232 adolescents were asked to rate the usability and acceptability of the app. RESULTS: The process resulted in a self-monitoring smartphone app that allows adolescent users to track and set goals for the Big 6 health behaviors, using in-app rewards and notifications to enhance engagement. The overall adolescent feedback was positive in terms of user-friendly design, content, relevance, and helpfulness. Commonly identified areas for improvement were to increase interactive features and display recorded health behaviors differently to improve interpretability. CONCLUSIONS: The Health4Life app is a co-designed, self-monitoring smartphone app for adolescents that concurrently targets the Big 6 lifestyle behaviors. Adolescents rated the app as highly acceptable and usable. The app has the potential to efficiently and effectively modify important risk factors for chronic disease among young people and is currently being evaluated in a world-first trial of 6640 secondary school students in 71 schools across Australia.

A Web-Based Intervention to Prevent Multiple Chronic Disease Risk Factors Among Adolescents: Co-Design and User Testing of the Health4Life School-Based Program.

BACKGROUND: Chronic diseases are the leading cause of death worldwide. Addressing key lifestyle risk factors during adolescence is critical for improving physical and mental health outcomes and reducing chronic disease risk. Schools are ideal intervention settings, and electronic health (eHealth) interventions afford several advantages, including increased student engagement, scalability, and sustainability. Although lifestyle risk behaviors tend to co-occur, few school-based eHealth interventions have targeted multiple behaviors concurrently. OBJECTIVE: This study aims to summarize the co-design and user testing of the Health4Life school-based program, a web-based cartoon intervention developed to concurrently prevent 6 key lifestyle risk factors for chronic disease among secondary school students: alcohol use, smoking, poor diet, physical inactivity, sedentary recreational screen time, and poor sleep (the Big 6). METHODS: The development of the Health4Life program was conducted over 18 months in collaboration with students, teachers, and researchers with expertise relevant to the Big 6. The iterative process involved (1) scoping of evidence and systematic literature review; (2) consultation with adolescents (N=815) via a cross-sectional web-based survey to identify knowledge gaps, attitudes, barriers, and facilitators in relation to the Big 6; (3) content and web development; and (4) user testing of the web-based program with students (n=41) and teachers (n=8) to evaluate its acceptability, relevance, and appeal to the target audience. RESULTS: The co-design process resulted in a six-module, evidence-informed program that uses interactive cartoon storylines and web-based delivery to engage students. Student and teacher feedback collected during user testing was positive in terms of acceptability and relevance. Commonly identified areas for improvement concerned the length of modules, age appropriateness of language and alcohol storyline, the need for character backstories and links to syllabus information, and feasibility of implementation. Modifications were made to address these issues. CONCLUSIONS: The Health4Life school-based program is the first universal, web-based program to concurrently address 6 important chronic disease risk factors among secondary school students. By adopting a multiple health behavior change approach, it has the potential to efficiently modify the Big 6 risk factors within one program and to equip young people with the skills and knowledge needed to achieve and maintain good physical and mental health throughout adolescence and into adulthood.