Abstract
Unhealthy behaviors contribute to the development of diseases such as diabetes, cardiovascular disease and psychiatric disorders. Most often these behaviors develop in the teenage years. This thesis addresses the following topics: (1) How do health-related behaviors cluster and affect health in adolescents, (2) how do they affect their school performances
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and (3) are they improved by a Health Promoting School intervention that applies a Whole School Approach? Firstly, it was studied how health-related behaviors cluster, or co-occur, within adolescents. In this thesis several overarching behavioral patterns/clusters were deduced from a range of health-related behaviors. It was demonstrated for example that smokers are more likely to drink alcohol and use cannabis than non-smokers and that spending more time watching TV, playing video games or using the internet would often go hand in hand with less physical exercise and poor nutrition habits. Such behavioral clustering has important implications for designing interventions, because when behaviors cluster, it might indicate that they share underlying causal factors. Therefore, targeting behaviors simultaneously, or ‘in clusters’, is likely to result in more effective and feasible interventions. In addition, we demonstrated that a broader perspective is needed in health promotion. Thus far, the focus has mainly been on improving conventional health behaviors such as smoking and healthy nutrition. In this thesis it was shown that non-conventional health topics such as bullying or screen time use also significantly affect adolescents’ psychosocial and physical well-being and should be included structurally in health promotion interventions. Health Promoting School interventions are becoming increasingly comprehensive and organizationally demanding. Therefore, in order for such interventions to be feasible, mutual benefits to health and school outcomes are needed to give schools an incentive to invest. Therefore, we studied the effects of health-related behaviors on adolescents’ school performance. Generally, students’ performances declined when involved in drinking alcohol, peer bullying, and excessive and/or compulsive screen time use (TV, computer use, gaming). Their performances improved when partaking in team sports. Most of these effects were dependent on contextual factors and often mediated by students’ psychosocial problems, social situations and demographics. Overall, it was shown that health-related behaviors affected students’ school performances. Therefore, more collaboration between schools and the health sector concerning Health Promoting Schools would be mutually beneficial. Thirdly, the effects and feasibility of Health Promoting School interventions that apply a Whole School Approach were evaluated. This approach combines evidence-based health education methods with a healthy school policy, healthy school environment and partnerships with students’ social environment. Promising results were shown via a systematic literature review and via a pilot and experiment study of a Dutch Health Promoting School example that used the Whole School Approach (Utrecht Healthy School). Alcohol use, smoking, excessive TV and internet use, and bullying were reduced in the pilot, while students’ psychosocial health improved. In the experiment study results were modest, but still students’ BMI and excessive internet use were reduced. Furthermore, lessons learned were identified to guide implementation of comparable interventions. Lastly, a complementary evaluation of implementation processes is needed in order to properly interpret the quantitative findings when evaluating Health Promoting School interventions.
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