The "Fortaleça Sua Saúde" Program for Active and Healthy Lifestyle Among Brazilian Students
Condition: Adolescent Behavior
Study type: Interventional

Summary: 
      Background:

      Interventions on lifestyle among adolescents are important, but the main mechanisms that
      explain the changes (mediating variables) on lifestyle have been little explored.
      Investigators present the rationale and methods of a cluster-randomized controlled trial
      aimed to promote promotion active and healthy lifestyle (especially physical activity [PA]
      practice and reducing screen time use) among Brazilian students - the "Fortaleça sua Saúde"
      ("Strengthen Your Health" in Portuguese) program.

      Methods/Design:

      This is a school-based cluster-randomized controlled trial that included students from six
      elementary full-time public schools (7-9 grades) in Fortaleza, northeastern Brazil. The
      intervention duration was one academic semester (approximately four months) in 2014. The
      intervention strategies focused on teachers' training and activities on health in curriculum
      (including a specific training to Physical Education teachers), active opportunities in the
      school environment (availability of spaces and materials for PA) and health education
      (production and exhibition of health material at school, and distributing pamphlets to
      patients). Data collection will be performed before and immediately after 4 months of
      intervention. The primary variables include the practice of PA (weekly PA volume) and the
      screen time use (TV/computer/video games). Intrapersonal, interpersonal and environmental
      variables associated to PA and screen time use will be evaluated by standardized
      questionnaire. Other components of the lifestyle (e.g., eating habits), psychological (e.g.,
      self-rated health, body satisfaction), biological (general and abdominal obesity) and
      academic performance will be also evaluated in the patients. Depressive symptoms, eating
      disorders, sleep quality, objectively-measured physical activity will be evaluated in obese
      patients.

      Discussion:

      Is effective, this program will contribute to the development of public policies for active
      and health lifestyle promotion among young population, especially from low- and middle-income
      countries. The main variables (intrapersonal, interpersonal and/or environmental stimulus)
      that help the young people to adopt an active lifestyle also may be indicated. Finally,
      investigators expect that the proposed strategies may be adaptable to the public school
      reality and they may be extended to the entire school system.
    

Detailed description: 
      Setting and Population:

      Fortaleza is the capital of Ceara state, northeastern Brazil, and has a population of
      2,452,185 inhabitants (the fifth largest city in Brazil considering the population). This
      municipality has an area of 314 km² and a Human Development Index (HDI) of 0.754. The city of
      Fortaleza is geographically divided into six administrative regions.

      According to the Municipal Education Department, forty schools attended 6-9 grades and
      included the Programa Saúde na Escola, and six out of these schools had a full-time education
      model. These six schools attended approximately 2,500 students, of which 1,272 were enrolled
      in classes from 7th to 9th grades.

      These six schools had similar characteristics (e.g., size, target audience, curriculum, etc.)
      and were located in different administrative regions (geographically disperses). Therefore,
      there was no need to conduct peer schools during random selection to prevent study
      contamination. Three schools were randomly selected to intervention group and other schools
      were control group. The neighborhood-HDI from where the six schools were located was similar
      between groups (neighborhood-HDI of 0.215, 0.341 and 0.443 for intervention schools, and
      0.170, 0.377 and 0.491 for control schools).

      Theoretical basis of the "Fortaleça sua Saúde" program:

      The "Fortaleça sua Saúde" program was structured considering different theoretical aspects.
      The Socioecological Theory emphasizes that intrapersonal (e.g., knowledge, self-efficacy),
      interpersonal (social support, peer and family model) and environmental (perception and
      environmental characteristics) aspects interfere independently and interactively in the
      individual's behavior. The actions of the program "Fortaleça sua Saúde" program were directed
      to achieve these different levels. The concepts of the Health Promoting in Schools was also
      used. Three characteristics were used in order to choice the program components: Health
      education topics in the formal school curriculum, health values, attitudes and opportunities
      promoted within the school, and schools seek to engage with families, outside agencies and
      the wider community.

      Description of the Intervention:

      The "Fortaleça sua Saúde" intervention during the second scholar semester (approximately four
      months).

      Training and activities in general curriculum:

      All teachers from three intervention schools were invited to participate of training and to
      execute class activities focused on the discussion of active and healthy lifestyle. Full
      training was structured in three stages (two face-stages and one distance-stage) with
      certification recognized by the University.

      A four-hour training were performed at the beginning of school semester. Discussions on
      primary health concepts and the importance of these issues were made, including the
      relationship between health, school and academic performance. Proposals for cross-cutting
      issues including the National Curriculum Standards were also discussed. Finally, strategies
      directed to combine teaching tools (e.g., homework, tests presentations) and health issues
      (e.g., physical activity [PA], quality of life, health eating) were discussed.

      Teachers received a supplemental manual in order to help the classroom activities. This
      manual was prepared by program staff based on other productions on health in school, but they
      were adapted to the reality of Fortaleza's schools and students. Brazilian documents on
      education were consulted including the Learning Expectations of the Municipal Education
      Department and the National Curriculum Standards on health topics. Ministerial reports on
      health and education were also consulted. The manual included proposals for activities
      according to knowledge areas (i.e., languages, social sciences, natural sciences and
      mathematics). For example, in mathematics, an included proposal was about teaching
      "quantities and measures" using body measures, PA energy expenditure energy consumption in
      meals. Each proposal included description, required material, alternative, observations and
      supporting texts. Teachers who could not attend the training also had access to the manual
      and could participate in other stages of formation.

      Teachers were encouraged to make the activities during the semester that were discussed
      during training, or create and implement similar strategies in the classroom. In general, the
      activities performed in the classroom included text production, videos/posters/booklets
      production and exposition with health issues content. The issues content in the manual could
      be suitable for the interests and expertise of teachers and patients (students) as well as
      the structural conditions of each school. A social page was created in order to monitor,
      assist and promote activities among teachers from the intervention schools. Finally, a
      meeting with the teachers of each school was made at the end of the semester to discuss the
      implementation of these activities.

      Training and activities in Physical Education classes:

      Investigators conducted a four-hour training specified to the Physical Education teachers at
      the beginning of school semester. Theachers were instructed to structure the predominantly
      active Physical Education classes, even in classes with theoretical content purposes. For
      example, a class focused on PA types and the relation between PA and healthy diet would be
      structured with a dynamic way. Investigators considered this because the active time in
      Physical Education classes can be a beneficial factor to total PA and adolescent health.

      A supplemental manual with lesson plans and handouts was also developed and distributed to
      teachers. This manual was built for the program staffs and was organized by grades (7-9
      grades). Materials from the Educação Física+ Project, Physical Education-specific National
      Curriculum Standards and health issues were used to create the manual. The manual included
      four units with different chapters: (i) PA and health (e.g., PA and leisure, cooperative
      games, PA with parents); (ii) health factors (e.g., excessive sedentary time, diabetes,
      hypertension, quality of life); (iii) sports (e.g., athletics, volleyball, functional
      training, fights); and (iv) popular games (e.g., games and dance, adventure sports). The
      production of posters and texts by the patient (students) with health issues content was
      performed as classwork or homework.

      All Physical Education classes (20 classrooms with two Physical Education classes per week)
      during the semester were supported by a undergraduate Physical Education student. This staff
      collaborated in the planning of activities, material procurement organization and
      implementation of lessons. Additionally, one Physical Education-related event (e.g., dance
      festival or games competitions) were organized in order to combine Physical Education classes
      and school cultural events (e.g., student's week) and to encourage the active participation
      during school events.

      Active opportunities in school environment:

      These intervention strategies aimed to promote PA opportunities within the school and
      stimulate it in out-school time, as well as disseminate information on the importance of an
      active and healthy lifestyle. Supervised and unsupervised activity were considered. Some of
      these strategies were focus on the engagement of girls - a high-risk subgroup for inactive
      lifestyle.

      All these strategies were implemented at the beginning of the program. Staffs, implemented
      these strategies in the first two weeks of semester in order to guide the execution, material
      access and understanding of the rules of the games. During the semester, some Physical
      Education classes and "Gym in School" sessions were performed using these games in order to
      stimulate its realization during free-time at school. Explanatory banners were exposed in
      schools with content on the games rules and material access. Motivational (e.g., "Let's play
      with the friends!") and health (e.g., "Practice PA with friends is very good for health!")
      messages were also included in the banners.

      Health education in school community:

      Some of the previous strategies had an additional focus on promoting awareness about the
      benefits of an active and healthy lifestyle. Principally, the materials produced in the
      classroom in general and Physical Education classes and the banners exposed in schools.

      Additionally, pamphlets with messages on active and healthy lifestyle were distributed at
      intervention schools. The program team made these pamphlets and they based on other materials
      programs. The content was adapted to the program objectives and local reality. Teachers and
      professionals specialized in health education to young people made the content selection.
      After this, marketing experts of the Municipal Education Department executed the graphical
      structure of the pamphlets.

      The pamphlets were delivered in the first month to a member of the school administration
      (coordinator or director). Guidelines were passed on the objectives of the pamphlets and as
      they could be distributed. In general, the pamphlets focused on the patients (students were
      delivered during the early times of the school day or during classes. The pamphlets focused
      on parents were delivered during parents/teachers meetings or in parent visits to school.
      Teachers were encouraged to use the pamphlets during lessons with health messages.
    

Intervention name(s): "Fortaleça sua Saúde" program
Intervention type(s): Behavioral
Intervention description(s): The program duration was of one academic semester (approximately four months) in 2014. The intervention strategies focus on teachers' training and activities on health in curriculum (including a specific training to Physical Education teachers), active opportunities in the school environment (availability of spaces and materials for PA) and health education (production and exhibition of health material at school, and distributing pamphlets to students and parents).
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Lifestyle; Intervention; Motor Activity; Mediating Variables; Mental Health; Obesity; Adolescent Health; School; Health Promotion; Brazil