Background: The prevalence of low well-being, perceived stress and unhealthy behaviours is high among high school students, but few interventions have addressed these problems. The aim of this paper is to present a study protocol of a cluster randomised controlled trial evaluating the Healthy High School (HHS) intervention programme. The intervention programme is designed to improve well-being (primary outcome) by preventing 1) stress and promoting 2) sleep, 3) sense of community, 4) physical activity (PA) and 5) regular and healthy meals among high school students in Denmark. Methods: The development of the HHS study was guided by the Intervention Mapping protocol. The intervention comprises four components: 1) a teaching material, 2) a smartphone app, 3) a catalogue focusing on environmental changes, and 4) a peer-led innovation workshop aiming at inspiring students to initiate and participate in various movement activities. The HHS study employs a cluster-randomised controlled trial design. Thirty-one high schools across Denmark were randomly allocated to intervention (16 schools) or control (15 schools) groups. The study included all first-year students (~16 years of age) (n = 5976 students). Timeline: Intervention: August 2016-June 2017. Collection of questionnaire data: Baseline (August 2016), 1st follow-up (May 2017) and 2nd follow-up (April 2018). All students were invited to participate in a monthly sub-study about perceived stress using text messages for data collection (September 2016-June 2017). PA was objectively assessed among a sub-sample of students using accelerometers (Axivity, AX3) in August 2016 and May 2017. Primary outcome measures: Student well-being measured by the Cantril Ladder and the five item World Health Organisation Well-being Index (individual level outcomes). Secondary outcome measures: Stress (10-item Perceived Stress Scale), sleep (quantity and quality), PA (hours of moderate-to-vigorous PA per week, hours of daily sedentary time and average daily PA), meal habits (daily intake of breakfast, lunch, snacks and water), and strong sense of community in class and at school, respectively (individual level outcomes). The study encompasses process and effect evaluation as well as health economic analyses.

Youth smoking remains a major challenge for public health. Socioeconomic position influences the initiation and maintenance of smoking, and alternative high school students are at particularly high risk. The school environment is an important setting to promote health, however there is a lack of evidence-based school intervention programs. This article presents the Focus study, which aims to test the implementation and effectiveness of a school-based intervention integrating 1 a comprehensive school smoking policy [i.e. smoke-free school hours (SFSH)] 2 , a course for school staff in short motivational conversations 3 , school class-based teaching material 4 , an edutainment session5, a class-based competition, and6 access to smoking cessation support. Together these intervention components address students’ acceptability of smoking, social influences, attitudes, motivation, and opportunities for smoking. The setting is alternative high schools across Denmark, and the evaluation design is based on a stratified cluster randomized controlled trial comparing the intervention group to a control group. Outcome data is collected at baseline, midway, and at the end of the intervention period. Moreover, a detailed process evaluation, using qualitative and quantitative methods, is conducted among students, teachers, and school principals. The results from this trial will provide important knowledge on the effectiveness of a smoke-free school environment. The findings will lead to a better understanding of which policies, environments, and cognitions, contribute to preventing and reducing cigarette use among young people in a diverse and high-risk school setting, and illuminate which complementary factors are significant to achieve success when implementing SFSH.

Process evaluation of public health interventions is important for understanding intervention results and can help explain why interventions succeed or fail. This study evaluated implementation of a school-based intervention combining educational and environmental strategies to prevent stress among Danish high school students. We investigated dose delivered, dose received, fidelity, appreciation, barriers and facilitators at the 15 intervention schools using mixed methods and multiple data sources: questionnaires among students, teachers and school coordinators; semi-structured interviews with school coordinators; telephone interviews with student counsellors; and focus group interviews with students and teachers. Implementation varied by schools and classes. Half of the intervention schools delivered the environmental strategies. For the educational strategies, dose delivered differed according to intervention provider. Students reported a lower dose received compared with dose delivered reported by school staff. Overall, student counsellors, school coordinators and students—especially those with low perceived stress—were satisfied with the stress preventive initiatives while teacher satisfaction varied. Five main barriers and three facilitators for implementation were identified. The use of multiple data sources and data methods created new knowledge of the implementation process which is important for the interpretation of effect evaluation and development of future interventions.

Background Depressive and anxiety disorders share major risk factors and can often be effectively prevented or treated with similar interventions. However, less than half of young people with mental health problems seek professional help and hence innovative approaches to support this group are needed. To this end Coping with Anxiety and Depression shows promise. The aim of this paper was to evaluate the implementation of Coping with Anxiety and Depression for young people aged 15–25 years showing symptoms of anxiety and/or depression in a Danish community setting. Methods The programme was implemented in 39 Danish municipalities. To evaluate the implementation of the programme, we collected quantitative and qualitative data simultaneously and subsequently we triangulated it in the data analysis. The qualitative data collection comprised semi-structured interviews in seven case municipalities. In each municipality we conducted interviews with a local municipality coordinator of the program, a group interview with two voluntary instructors facilitating the program and a group interview with two to seven participants in the programme. In total, seven local coordinators, 14 voluntary instructors and 23 participants (8 men and 15 women) were interviewed. We also carried out a baseline and post-intervention survey. Interview data was coded via an inductive and deductive analysis approach. Survey data was analysed via descriptive statistics in the statistical software programme STATA 16. Results The evaluation showed that the implementation of the programme is feasible, and that most participants (83%) were satisfied with the programme to a high/very high extent. In total, 84% of the participants strongly agreed/agreed that it was advantageous that instructors themselves had experience with anxiety and depression. Qualitative data showed that the participants were very positive about the group format. It also showed that recruitment and retention of participants and especially young instructors were challenging but doable. Thus our findings suggest that the programme can be implemented in a way that is perceived as useful and satisfying to young people. Conclusions Coping with Anxiety and Depression constitutes a feasible peer-to-peer, group-based community programme that is well-received by its target group. Recruitment and retention of participants and instructors is challenging but doable.

Background Social inequality in smoking remains an important public health issue. Upper secondary schools offering vocational education and training (VET) comprise more students from lower socioeconomic backgrounds and have higher smoking prevalence than general high schools. This study examined the effects of a school-based multi-component intervention on students’ smoking. Methods A cluster randomized controlled trial. Eligible participants were schools offering VET basic courses or preparatory basic education in Denmark, and their students. Schools were stratified by subject area and eight schools were randomly allocated to intervention (1,160 invited students; 844 analyzed) and six schools to control (1,093 invited students; 815 analyzed). The intervention program comprised smoke-free school hours, class-based activities, and access to smoking cessation support. The control group was encouraged to continue with normal practice. Primary outcomes were daily cigarette consumption and daily smoking status at student level. Secondary outcomes were determinants expected to impact smoking behavior. Outcomes were assessed in students at five-month follow-up. Analyses were by intention-to-treat and per protocol (i.e., whether the intervention was delivered as intended), adjusted for covariates measured at baseline. Moreover, subgroup analyses defined by school type, gender, age, and smoking status at baseline were performed. Multilevel regression models were used to account for the cluster design. Missing data were imputed using multiple imputations. Participants and the research team were not blinded to allocation. Results Intention-to-treat analyses showed no intervention effect on daily cigarette consumption and daily smoking. Pre-planned subgroup analyses showed statistically significant reduction in daily smoking among girls compared with their counterparts in the control group (OR = 0.39, 95% CI: 0.16, 0.98). Per-protocol analysis suggested that schools with full intervention had higher benefits compared with the control group (daily smoking: OR = 0.44, 95% CI: 0.19, 1.02), while no marked differences were seen among schools with partial intervention. Conclusion This study was among the first to test whether a complex, multicomponent intervention could reduce smoking in schools with high smoking risk. Results showed no overall effects. There is a great need to develop programs for this target group and it is important that they are fully implemented if an effect is to be achieved. Trial registration https://www.isrctn.com/ISRCTN16455577, date of registration 14/06/2018.