Caring Climate and Support, Mental Health, and Academic Adjustment: Effects from a Cluster Randomized Controlled Trial in Upper Secondary Schools in Norway.

This cluster randomized controlled trial (RCT) examined the effect of a three year follow up of a multi-tier intervention aiming at improving the psychosocial environment in upper secondary schools in Norway. Two intervention conditions were tested: a universal single-tier intervention focused on improving the psychosocial school climate, the dream school program (DSP), and a multi-tier intervention combining the DSP with a targeted measure, the mental health support team (MHST). A total of 2203 students responded to the baseline survey. Of the 2203 pupils, 1884 responded to the first follow-up survey (year 1), 1287 pupils to the second (year 2), and 756 pupils to the third (year 3). The direct and indirect effects on school completion were analyzed using a multi-level linear mixed model. The results showed no significant effects of either the DSP or the DSP and MHST in combination on support, the school climate, mental health, or academic adjustment. We found no significant effect of the interventions on the proportion who had completed school or were in training (the three groups varied between 76.6% and 77.8%). Future similar studies should be attentive to the potential challenges of implementing RCTs in the school setting. Furthermore, the long-term effects of school interventions on the constructs included in this study could be difficult to capture due to the complexity of the phenomena. The implications of these findings are discussed.

Civic engagement and mental health trajectories in Norwegian youth.

Introduction: Applying variable-centered analytical approaches, several studies have found an association between civic engagement and youth mental health. In the present study, we used a person-centered approach to explore whether civic engagement was related to optimal trajectories of mental health compared to other trajectories. We also examined how sociodemographic factors, such as socioeconomic status (SES), gender and age were related to youth mental health trajectories. Methods: Our sample comprised 675 students (aged 16-22) who had participated in three waves of data collection (Mage = 18.85, SD = 0.55; 43% males) in the COMPLETE project, a cluster-randomized controlled trial that involved Norwegian upper secondary schools. Results: The results revealed three trajectories of mental health (reflecting a combination of mental distress and mental well-being): optimal, intermediate, and sub-optimal. Contrary to our expectations, higher levels of civic engagement were not related to the optimal trajectory of mental health vs. other trajectories. However, we found that students who reported higher levels of SES and males were more likely to follow the optimal trajectory compared to other trajectories. Discussion: While the findings on civic engagement could be due to our measurement's inability to capture the concept of "dugnad," a well-established civic activity in the Norwegian society, the findings regarding the influence of SES and gender suggest that there is still more work to be done concerning the assessment and advancement of factors that can address mental health inequalities across SES and gender.

Preventing Loneliness and Reducing Dropout: Results from the COMPLETE Intervention Study in Upper Secondary Schools in Norway.

This study examines the impact of interventions aimed at improving psychosocial health on students' perception of a caring school climate, their feelings of loneliness, and school completion in Norwegian upper secondary education. Two intervention conditions were tested: a universal single-tier intervention focused on improving the psychosocial school climate: the Dream School Program, and a multi-tier intervention combining the Dream School Program with a targeted measure, the Mental Health Support Team. The direct and indirect effects of these interventions on school completion were analyzed using structural equation models (SEM), with data from 1508 students (mean age at Time 1: 17.02 (SD = 0.92); 60.7% girls; 72.1% Norwegian-born). The results indicated that loneliness levels did not differ significantly between the intervention conditions. However, students in the multi-tier intervention group reported a significantly higher perception of a caring school climate compared to those in the single-tier intervention group. The multi-tier intervention group had a lower rate of school completion compared to the control group and the single-tier intervention group. The SEM analysis revealed that the multi-tier intervention reduced loneliness in the second year of upper secondary school by promoting a caring school climate in the first school year. In contrast, the single-tier intervention was associated with increased loneliness due to a decrease in the perception of a caring school climate. The implications of these findings are discussed.

Academic Stress, Academic Self-efficacy, and Psychological Distress: A Moderated Mediation of Within-person Effects.

Previous research has largely failed to separate the between- and within-person effects in the longitudinal associations between academic stress, academic self-efficacy, and psychological distress (symptoms of anxiety and depression). Filling this research gap, this study investigated if academic self-efficacy mediated the relationship between academic stress and psychological distress at the intraindividual level during 3 years of upper secondary school. Gender moderation was also examined in the hypothesised model. The present sample consisted of 1508 Norwegian adolescents (baseline M age = 16.42; 52.9% high perceived family wealth; 70.6% Norwegian-born). The random intercept cross-lagged panel model results indicated (1) positive and time-invariant direct effects from academic stress to psychological distress, (2) academic self-efficacy partially mediated these effects, and (3) psychological distress impacted later academic stress. Academic stress was more strongly related to academic self-efficacy and psychological distress at the interpersonal level for boys, while the intraindividual impact of academic stress on psychological distress was stronger for girls. The study findings might have implications for school-based implementation strategies and theoretical development.

Hello Darkness, My Old Friend: Moderating a Random Intercept Cross-lagged Panel Model of Loneliness and Symptoms of Anxiety and Depression.

The present study investigated the trait- and state-like associations between loneliness and symptoms of anxiety and depression during three years in middle to late adolescence. The moderating effect of gender and social self-efficacy was examined on the hypothesised model. The sample consisted of 1508 Norwegian upper secondary school students (61% female; mean age at T1 = 16.33; 52.9% high socioeconomic position; 70.6% Norwegian-born). We found 1) strong and positive trait- and state-like associations between loneliness and symptoms of anxiety and depression, 2) that anxiety and depressive symptoms consistently predicted later loneliness but not the other way around, 3) that gender moderated parts of the state-like associations between loneliness and symptoms of anxiety and depression, and 4) that social self-efficacy had no moderating effect on the longitudinal relationship between loneliness and anxiety and depressive symptoms. The present study might inform future research, theory development, and intervention strategies in middle to late adolescent samples.

The Within-Person Effect of Psychological Distress on Social Self-Efficacy: A Random Intercept Cross-Lagged Panel Model.

This study investigated the temporal relationship between social self-efficacy and psychological distress during 3 years in middle to late adolescence. The sample comprised 1508 participants (60.7% female; baseline mean age = 16.33, SD = .62; 52.9% high perceived family wealth; 70.6% born in Norway). We used a random intercept cross-lagged panel model to investigate the concurrent and subsequent associations between the two constructs. The results indicated (1) small to moderate and negative associations between the trait-like components and within-person fluctuations of social self-efficacy and psychological distress, (2) positive and significant carry-over stability effects on both constructs across time, and (3) that psychological distress predicted subsequent social self-efficacy more consistently across four time points, than social self-efficacy predicted later psychological distress.

Positive Youth Development and Mental Well-Being in Late Adolescence: The Role of Body Appreciation. Findings From a Prospective Study in Norway.

Although a vulnerable period, adolescence is a time of great potential for healthy development. Understanding factors that contribute to mental well-being in this period is of great importance to facilitate for healthy development. During the adolescence period the body goes through rapid and considerable changes, and the focus on body appearance and perfection is substantial at societal, media, and peer level. In this study, we investigated the association between dimensions characterizing positive youth development, and mental well-being among Norwegian adolescents 16-17 years 1 year later, and whether this association was mediated by degree of body appreciation. We further tested whether the indirect and direct paths between positive youth development dimensions and mental well-being were moderated by gender. We used data from the first and second follow-up of the control arm of the COMPLETE study, a cluster randomized controlled trial in upper secondary schools in Norway. Findings showed that positive youth development in grade 1, as measured by both a combined global PYD and the dimensions competence, and connection were significantly associated with mental well-being in grade 2 in models adjusted for mental well-being in grade 1, gender and perceived family affluence. Also, body appreciation in grade 1 significantly predicted mental well-being in grade 2 in models including each of global PYD, competence, connection, character, and caring dimensions. Contrary to our hypothesis, no mediating effects of body appreciation were observed, and no moderation of indirect effects by gender were observed.

Indicators of positive youth development can be maladaptive: The example case of caring.

INTRODUCTION: Research on positive youth development typically takes a more-is-better approach in which higher scores on measures of positive youth development indicate better outcomes. We question the validity of this assumption and describe how an imbalance among the Five Cs of Positive Youth Development can lead to a situation where "more" is actually "less." We then provide an empirical illustration using cross-sectional data. METHODS: We examined conditional associations between indicators of thriving and the C of caring using survey data obtained from a sample of 2,386 students in Norway (mean age 16.60 years [SD = 1.98]; 44.8% girls). Multilevel models assessed whether associations between caring and the thriving indicators (here defined as greater mental well-being and lower anxiety and depressive symptoms) differed when versus when not controlling for overall positive youth development. RESULTS: When positive youth development was not included as a covariate, caring was positively associated with mental well being and anxiety but not significantly associated with depressive symptoms. After adding positive youth development to the model, caring became less strongly associated with mental well-being, more strongly associated with anxiety, and significantly (positively) associated with depressive symptoms. CONCLUSIONS: Our results indicate that, after controlling for a set level of positive youth development, caring does not predict adaptive outcomes in a monotonic more-is-better way. These findings illustrate an instance where developmental regulations benefit the context at the cost of the individual and therefore speak to a growing acknowledgement in the literature-young people may suffer if they "care too much."

The Influence of Maternal and Household Resources, and Parental Psychosocial Child Stimulation on Early Childhood Development: A Cross-Sectional Study of Children 36⁻59 Months in Honduras.

Optimal early childhood development (ECD) is currently jeopardized for more than 250 million children under five in low- and middle-income countries. The Sustainable Development Goals has called for a renewed emphasis on children’s wellbeing, encompassing a holistic approach that ensures nurturing care to facilitate optimal child development. In vulnerable contexts, the extent of a family’s available resources can influence a child’s potential of reaching its optimal development. Few studies have examined these relationships in low- and middle-income countries using nationally representative samples. The present paper explored the relationships between maternal and paternal psychosocial stimulation of the child as well as maternal and household resources and ECD among 2729 children 36⁻59 months old in Honduras. Data from the Demographic and Health Surveys conducted in 2011⁻2012 was used. Adjusted logistic regression analyses showed that maternal psychosocial stimulation was positively and significantly associated with ECD in the full, rural, and lowest wealth quintile samples. These findings underscore the importance of maternal engagement in facilitating ECD but also highlight the role of context when designing tailored interventions to improve ECD.

Household food security and adequacy of child diet in the food insecure region north in Ghana.

BACKGROUND AND OBJECTIVES: Adequate diet is of crucial importance for healthy child development. In food insecure areas of the world, the provision of adequate child diet is threatened in the many households that sometimes experience having no food at all to eat (household food insecurity). In the context of food insecure northern Ghana, this study investigated the relationship between level of household food security and achievement of recommended child diet as measured by WHO Infant and Young Child Feeding Indicators. METHODS: Using data from households and 6-23 month old children in the 2012 Feed the Future baseline survey (n = 871), descriptive analyses assessed the prevalence of minimum meal frequency; minimum dietary diversity, and minimum acceptable diet. Logistic regression analysis was used to examine the association of minimum acceptable diet with household food security, while accounting for the effects of child sex and age, maternal -age, -dietary diversity, -literacy and -education, household size, region, and urban-rural setting. Household food security was assessed with the Household Hunger Scale developed by USAID's Food and Nutrition Technical Assistance Project. RESULTS: Forty-nine percent of children received minimum recommended meal frequency, 31% received minimum dietary diversity, and 17% of the children received minimum acceptable diet. Sixty-four percent of the children lived in food secure households, and they were significantly more likely than children in food insecure households to receive recommended minimum acceptable diet [O.R = 0.53; 95% CI: 0.35, 0.82]. However, in 80% of food secure households, children did not receive a minimal acceptable diet by WHO standards. CONCLUSIONS: Children living in food secure households were more likely than others to receive a minimum acceptable diet. Yet living in a food secure household was no guarantee of child dietary adequacy, since eight of 10 children in food secure households received less than a minimum acceptable diet. The results call for research into factors besides household food security in the search for determinants of child diet adequacy. In this study at least, household food security was a very weak marker of child diet adequacy. This finding is of significance to public health practice, since it calls into question any assumption that having enough food in a household necessarily results in adequately fed children.

Changes in Optimal Childcare Practices in Kenya: Insights from the 2003, 2008-9 and 2014 Demographic and Health Surveys.

OBJECTIVE(S): Using nationally representative surveys conducted in Kenya, this study examined optimal health promoting childcare practices in 2003, 2008-9 and 2014. This was undertaken in the context of continuous child health promotion activities conducted by government and non-government organizations throughout Kenya. It was the aim of such activities to increase the prevalence of health promoting childcare practices; to what extent have there been changes in optimal childcare practices in Kenya during the 11-year period under study? METHODS: Cross-sectional data were obtained from the Kenya Demographic and Health Surveys conducted in 2003, 2008-9 and 2014. Women 15-49 years old with children 0-59 months were interviewed about a range of childcare practices. Logistic regression analysis was used to examine changes in, and correlates of, optimal childcare practices using the 2003, 2008-9 and 2014 data. Samples of 5949, 6079 and 20964 women interviewed in 2003, 2008-9 and 2014 respectively were used in the analysis. RESULTS: Between 2003 and 2014, there were increases in all health facility-based childcare practices with major increases observed in seeking medical treatment for diarrhoea and complete child vaccination. Mixed results were observed in home-based care where increases were noted in the use of insecticide treated bed nets, sanitary stool disposal and use of oral rehydration solutions, while decreases were observed in the prevalence of urging more fluid/food during diarrhoea and consumption of a minimum acceptable diet. Logit models showed that area of residence (region), household wealth, maternal education, parity, mother's age, child's age and pregnancy history were significant determinants of optimal childcare practices across the three surveys. CONCLUSIONS: The study observed variation in the uptake of the recommended optimal childcare practices in Kenya. National, regional and local child health promotion activities, coupled with changes in society and in living conditions between 2003 and 2014, could have influenced uptake of certain recommended childcare practices in Kenya. Decreases in the prevalence of children who were offered same/more fluid/food when they had diarrhea and children who consumed the minimum acceptable diet is alarming and perhaps a red flag to stakeholders who may have focused more on health facility-based care at the expense of home-based care. Concerted efforts are needed to address the consistent inequities in the uptake of the recommended childcare practices. Such efforts should be cognizant of the underlying factors that affect childcare in Kenya, herein defined as region, household wealth, maternal education, parity, mother's age, child's age and pregnancy history.

Associations between intimate partner violence, childcare practices and infant health: findings from Demographic and Health Surveys in Bolivia, Colombia and Peru.

BACKGROUND: Child health is significantly poorer in homes with intimate partner violence (IPV). However, a possible link to parental provision of childcare has been neglected. METHODS: Utilizing data from Demographic and Health Surveys, this study examined the association between IPV and illness signs in children 0-59 months in Bolivia (n = 3586), Colombia (n = 9955) and Peru (n = 6260), taking into account socio-demographic factors, childcare and severe child physical punishment. Data were collected in the years 2008, 2010 and 2012 for Bolivia, Colombia and Peru respectively. RESULTS: The study found weak but persistent effects of IPV on illness signs in Bolivia (OR 1.37, 95% CI 1.14-1.63) and Peru (OR 1.49, 95% CI 1.26-1.77), after adjusting for the effects of childcare. These effects were not observed in Colombia. CONCLUSIONS: The results call for a mix of qualitative and quantitative research that can map direct, mediating and moderating patterns of relationships between IPV, childcare practices and child health. Can good childcare mitigate the negative effects of IPV? Can poor childcare exacerbate the negative effects of IPV? Such interactions were not observed in the present study, but should be the focus of much more intensive investigation, to help inform child health promotion. Answers could lead to better interventions to improve child health, and perhaps to tackle IPV.

Influence of childcare practices on nutritional status of Ghanaian children: a regression analysis of the Ghana Demographic and Health Surveys.

OBJECTIVES: Guided by the UNICEF framework for childcare, this study examined the association of childcare practices (CCP) with infant and young children's growth (height-for-age Z-scores, HAZ), and investigated whether care practices are more important to growth in some sociodemographic subgroups of children. DESIGN: Cross-sectional survey. SETTING: Urban and rural Ghana. PARTICIPANTS: The study sample comprised 1187 dyads of mothers aged 15-49 years and their youngest child (aged 6-36 months). RESULTS: The results showed that CCP was a significant predictor of HAZ, after controlling for covariates/confounders at child, maternal and household levels. Children with higher CCP scores had higher HAZ. A 1-unit increase in the CCP score was associated with a 0.17-unit increase in HAZ. Child's and mother's age, number of children under 5 years, place of residence, maternal weight and wealth index were also significantly associated with HAZ. Statistical interaction analyses revealed no subgroup differences in the CCP/HAZ relationship. CONCLUSIONS: This study found a significant, positive association between CCP and child growth, after accounting for other important determinants of child growth at maternal and household levels. This calls for research into the effects on growth of various CCP components, with longitudinal cohort study designs that can disentangle causal relationships.

Reliability of demographic and socioeconomic variables in predicting early initiation of breastfeeding: a replication analysis using the Kenya Demographic and Health Survey data.

OBJECTIVES: Examine the reliability of sociodemographic variables in predicting initiation of breastfeeding within an hour of birth (EarlyBF), using data from 1998, 2003 and 2008-2009. STUDY DESIGN: A replication analysis using the Kenya Demographic and Health Survey (KDHS) data collected in 1998, 2003 and 2008-2009. The candidate predictor variables were child's gender, home or health facility place of birth, vaginal or caesarean mode of birth, urban or rural setting, province of residence, Wealth Index and maternal education, occupation, literacy and media exposure. SETTING: Kenya. PARTICIPANTS: 6375 dyads of mothers aged 15-49 and their children aged 0-23 months (2125 dyads in each of the survey years). RESULTS: Mode of birth and province were statistically significant predictors of EarlyBF in 1998, 2003 and 2008-2009. Children delivered through caesarean section were non-EarlyBF in 1998 (OR 2.63, 95% CI 1.72 to 4.04), 2003 (OR 3.36, 95% CI 1.83 to 6.16) and 2008 (OR 3.51, 95% CI 2.17 to 5.69). The same was true of those living in the Western province in 1998 (OR 2.67, 95% CI 1.61 to 4.43), 2003 (OR 4.92, 95% CI 3.01 to 8.04) and 2008 (OR 6.07, 95% CI 3.54 to 10.39). CONCLUSIONS: The 1998 KDHS data do not provide the basis for reliable prediction of EarlyBF, with reliability conceptualised as replicability of findings using highly similar data sets from 2003 and 2008-2009. Most of the demographic and socioeconomic variables were unreliable predictors of EarlyBF. We speculate that activities in parts or all of Kenya changed the analysis context in the period between 1998 and 2008-2009, and these changes were of a sufficient magnitude to affect the relationships under investigation. The degree to which this is a general problem in child health research is not known, calling for further research to investigate this methodological issue with other health end points and other data.

Validity of a single item food security questionnaire in Arctic Canada.

OBJECTIVES: Assess sensitivity and specificity of each of the 18 US Department of Agriculture (USDA) Household Food Security Scale Module (HFSSM) questionnaire items to determine whether a rapid assessment of child and adult food insecurity is feasible in an Inuit population. METHODS: Food insecurity prevalence was assessed by the 18-item USDA HFSSM in a randomized sample of Inuit households participating in the Inuit Health Survey and the Nunavut Inuit Child Health Survey. Questions were evaluated for sensitivity, specificity, predictive value (+/2), and total percent accuracy for adult and child food insecurity (yes/no). Child food security items were evaluated for both surveys. RESULTS: For children, the question "In the last 12 months, were there times when it was not possible to feed the children a healthy meal because there was not enough money?" had the best performance in both samples with a sensitivity and specificity of 92.3% and 97.3%, respectively, for the Inuit Health Survey, and 88.5% and 95.4% for the Nunavut Inuit Child Health Survey. For adults, the question "In the last 12 months, were there times when the food for you and your family just did not last and there was no money to buy more?" demonstrated a sensitivity of 93.0% and a specificity of 93.4%. CONCLUSIONS: Rapid assessment of child and adult food insecurity is feasible and may be a useful tool for health care and social service providers. However, as prevalence and severity of food insecurity change over time, rapid assessment techniques should not replace periodic screening by using the full USDA HFSSM questionnaire.

Trends in stunting and overweight in Peruvian pre-schoolers from 1991 to 2011: findings from the Demographic and Health Surveys.

OBJECTIVE: To examine trends in stunting and overweight in Peruvian children, using 2006 WHO Multicentre Growth Reference Study criteria. DESIGN: Trend analyses using nationally representative cross-sectional surveys from Demographic and Health Surveys (1991-2011). We performed logistic regression analyses of stunting and overweight trends in sociodemographic groups (sex, age, urban-rural residence, region, maternal education and household wealth), adjusted for sampling design effects (strata, clusters and sampling weights). SETTING: Peru. SUBJECTS: Children aged 0-59 months surveyed in 1991-92 (n 7999), 1996 (n 14 877), 2000 (n 11 754), 2007-08 (n 8232) and 2011 (n 8186). RESULTS: Child stunting declined (F(1, 5149) = 174·8, P ≤ 0·00) and child overweight was stable in the period 1991-2011 (F(1, 5147) = 0·4, P ≤ 0·54). Over the study period, levels of stunting were highest in rural compared with urban areas, the Andean and Amazon regions compared with the Coast, among children of low-educated mothers and among children living in households in the poorest wealth quintile. The trend in overweight rose among males in coastal areas (F(1, 2250) = 4·779, P ≤ 0·029) and among males in the richest wealth quintile (F(1, 1730) = 5·458, P ≤ 0·020). CONCLUSIONS: The 2011 levels of stunting and overweight were eight times and three and a half times higher, respectively, than the expected levels from the 2006 WHO growth standards. The trend over the study period in stunting declined in most sociodemographic subgroups. The trend in overweight was stable in most sociodemographic subgroups.

Child diet and healthy growth in the context of rural poverty in the peruvian andes: what influences primary caregivers' opportunities and choices?

This study explored opportunities and choices related to child feeding among women living in a remote and low-income district in the Andean highlands. Data were collected through in-depth interviews with mothers (N = 7) with reputations for providing good child care, and who participated in an NGO-run social and health programme. The aim of this study was to learn about women's positive experience with child feeding, in the context of living in low-income communities. Such knowledge could be of substantial practical value to health promotion practitioners, in illuminating existing local circumstances and practices that produce good child nutrition. The women who were most knowledgeable about child health and diet were better educated and had relatively higher social positions in the community. Regarding contextual factors related to child feeding, numerous references were made to the extensive use of own crops and food stuffs, seen to provide a better diet than that available in cities where people buy their food. In discussing food and meal preparation habits, there were clear references to child welfare and health as motivating factors in the choices that were made. The NGO programme was not mentioned by the interviewer, to avoid prompting, yet the respondents referred to it explicitly, and attributed improved health-related knowledge and skills to the NGO education interventions (e.g. education about nutritious meal preparation, child care skills, and sanitation practices). It is concluded that the women were concerned about providing a good diet to their children, they were aware of the impact of feeding practices on child health, and that education about health and diet helped them to improved feeding practices.

Socioeconomic status and chronic child malnutrition: Wealth and maternal education matter more in the Peruvian Andes than nationally.

This study investigated the association of parents' socioeconomic status (SES) with child stunting in the Peruvian Andes and in Peru nationally. It was hypothesized that the relationship of SES to child stunting would be weaker in the Andean compared with the national sample. This is consistent with earlier research indicating that the relationship of SES to health may be weak in poor regions. The data were from the Demographic and Health Survey 2004 to 2006. Two samples of children 3 to 60 months old were compared: a national sample (n = 1426) and an Andean sample (n = 543). Malnutrition was measured using the indicator "stunting," which is small stature for age. Socioeconomic status was measured using parental education, occupation, and household wealth index (WI). In both samples, SES was significantly related to stunting. The odds of stunting in the poorest WI quintile were significantly higher than in the richest quintile. The same pattern was observed in children of mothers having incomplete primary education compared with children of mothers having complete secondary or higher education. The odds of stunting were significantly lower in children of mothers working at home compared with mothers in professional occupations. The associations of WI and maternal education with stunting were significantly stronger in the Andean compared with the national sample; the study did not find support for the hypothesis. Even in very poor regions such as the Andes, SES may be associated with child health, suggesting the importance of public health measures to overcome the health disadvantages experienced by children living in low SES households.