Title: Engaging adolescents in changing behaviour (EACh-B): a programme of research to improve the diets and physical activity levels of teenagers
Funder: Department of Health and Social Care

Abstract: Aim: To develop and test a complex intervention designed to engage, motivate and support 13 to 14 year old students to improve their diets and physical activity levels. By the end of the programme we will have i) developed and evaluated a new three-component intervention and ii) determined the most efficient and cost-effective methods of integrating this intervention into school curricula. PPI: This proposal has been developed with input from three PPI groups, two of which solely comprise adolescents. We will work closely with our PPI representatives throughout this programme, involving them in our Steering Committee, intervention planning and the interpretation of our findings and the factors influencing the acceptability, feasibility and effectiveness of the intervention. Public health relevance: Poor diet costs the NHS &pound;6 billion annually; physical inactivity &pound;1 billion. Meeting current dietary recommendations would reduce years-of-life-lost to coronary heart disease by 2 million, stroke by 400,000, and type-2 diabetes by 19,000 over 20 years. Small increases in activity reduce non-communicable disease (NCD) risk. UK adolescents have poorer diets than other age groups, and fewer than 20% meet physical activity guidelines. Health behaviours track into adulthood; sub-optimal diet and activity in adolescence affects immediate health but also increases risks of obesity and NCDs later, and in the next generation. Adolescents have unique physiological and psychological characteristics, and unrecognised and unmet needs. Building a cheap, sustainable way of engaging them in making healthier choices will benefit their health and that of their future children. Motivated and engaged adolescents can improve their health behaviours. Unfortunately, little is known about how to motivate them to change or how to sustain changes long-term. Background: Evidence suggests school-based interventions may be effective, with those offering combinations of peer-modelling, social support and choice improving diet and increasing activity. More work is needed to understand how these influences can be harnessed to be optimally acceptable and persuasive to adolescents, who vary in their response to interventions. Digital platforms offer potential for engaging adolescents in health behaviour change but have suffered from low usage and high attrition. More focus is needed on incorporating effective behavioural techniques and better methods of engagement. Our PPI groups said social support and competition are important in helping them maintain healthy lifestyle behaviours. Adults engagement with digital interventions has benefitted from addition of face-to-face support. Incorporating game features is a strategy that holds promise for adolescents. We plan to develop a complex, three-component intervention, LifeLabPlus, involving: 1) motivating adolescents to improve their diets and increase physical activity through a school-based education programme (LifeLab); plus 2) face-to-face support from specially trained teachers, and 3) a personalised digital intervention with game and peer-support features. LifeLab is a three-week science module linked to the National Curriculum which helps 13-14 year old students think about the science underlying their health. Cost-effectiveness analysis, stakeholder engagement and PPI will maximise the likelihood of rapid/inexpensive roll-out into routine practice in schools. Research plan: We propose three closely-linked, parallel research streams. RS1 includes systematic review and evidence synthesis of the literature to identify key intervention features associated with effectiveness, cost-effectiveness, engagement, acceptability and feasibility to inform intervention development (WP1.1), economic modelling to estimate cost-effectiveness of the intervention tested in RS3 and the wider health benefits and costs of diet and physical activity interventions for adolescents (WP1.2), and understanding implementation issues through stakeholder consultations and involvement, and policy analysis (WP1.3). RS2 will plan, develop and usability-test an intervention that is feasible and acceptable to adolescents, parents and teachers. It includes qualitative studies to identify barriers to eating healthily and being active and techniques to support change (WP2.1), intervention planning using a person-based approach (WP2:2), development and usability-testing of digital intervention content, structure and delivery using an agile approach to design (WP2.3), and development of teacher training in skills to support behaviour change through a process of co-creation (WP2.4). RS3 comprises a pilot (WP3.1) and full cluster-randomised trial (WP3.2) of LifeLabPlus to assess its effectiveness/cost-effectiveness with students. Dissemination: Main output from this research will be a fully-developed, replicable intervention to improve adolescents diet quality and physical activity. We will determine the success of co-creation processes with adolescents, short, medium and long-term health benefits from intervening in adolescence, intervention cost-effectiveness, including reach/affordability and feasibility of rapid/inexpensive roll-out into routine practice in schools via the national curriculum. Dissemination pathways include: close collaboration with stakeholders, reporting findings to teachers and students, interactive workshops with stakeholders; conference presentations and a series of papers in open access peer-reviewed journals; links with professional societies and policy-makers; regular press releases. Relevant expertise Our stakeholder partnership shaped this intervention and is well-placed to deliver impact. Our team combines world-leading expertise in designing complex public health interventions, health psychology, digital intervention implementation, health economics and game design, nutrition, body composition and public health policy. Three team members are NIHR Senior Investigators.

Lay abstract: Background: Poor diet and lack of exercise cost the NHS &pound;7 billion a year and cause many to die early. We aim to build and test an intervention to help teenagers eat better and exercise more. Habits formed as teenagers tend to last, and physical and psychological changes during adolescence make it an important time to help them form healthier habits. Making small sustained changes, e.g. eating more fruit and vegetables and being more active, can reduce risks of heart disease or diabetes in later life. Existing interventions for helping teenagers eat better or exercise more, only work for those ready to change, or who see diet and exercise as important. We know: school-based interventions may be most effective; face-to-face support is helpful; role of friends/family is important; websites and smartphones are widely used; teenagers spend time playing games on phones and computers. Intervention: Using existing knowledge, we will develop an intervention that motivates and supports teenagers to eat better and exercise more, andl test this with teenagers from state secondary schools. There are three aspects: 1) participation in LifeLab: a three-week science module linked to the National Curriculum, which helps 13-14 year olds think about science and their health; 2) encouragement from teachers trained to support students to improve their diets and exercise, and 3) a specially-designed, interactive smartphone app that involves friends and has game features. Three research streams (RS) will: RS1: Find the best methods for helping teenagers make healthier choices by looking at previous research and talking to experts. Build a computer model to estimate the costs and benefits of existing interventions. RS2:Develop an intervention that teenagers, parents and teachers find helpful in improving diet and increasing exercise. RS3: Test the intervention to see how well it works, whether it offers good value for money and the best way of using it in schools. Our research team includes experts with experience in intervention development, psychology, behaviour change, education, game design, health economics, public health and trial design. Partnership: The research questions have been developed with teenagers and school students, with whom we will work closely when building the intervention and making sense of our findings. Our partnership between teenagers, education and healthcare providers, not-for-profit organisations and academics is key to ensuring our research benefits the community. Public health implications: Teenagers health needs are often ignored and they can be difficult to engage in behaviour change. Building a cheap, sustainable way of engaging them in making healthier choices will benefit their health and that of their future children. Dissemination: We will plan this with groups of teenagers and parents, will present at school assemblies and public meetings, NHS and university audiences, and engage with the media.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: STROKE;CARDIOVASCULAR;METABOLIC AND ENDOCRINE;CANCER AND NEOPLASMS;ORAL AND GASTROINTESTINAL