Intervention Activities Associated with the Implementation of a Comprehensive School Tobacco Policy at Danish Vocational Schools: A Repeated Cross-Sectional Study
Abstract
:1. Introduction
Aim
2. Materials and Methods
2.1. Setting
2.2. The Smoke-Free Vocational Schools Intervention
2.3. Study Design
2.4. Data Collection
2.5. Study Population
2.6. Measures
2.6.1. Implementation Fidelity Measures—Dependent Variables
2.6.2. Intervention Activities—Independent Variables
2.6.3. Context—Confounding Variables
2.7. Statistical Analysis
3. Results
4. Discussion
4.1. Key Findings
4.2. Interpretation of Results
4.3. Operationalization of Policy Implementation Outcomes
4.4. Strengths and Limitations
4.5. Implications for Research and Practice
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Intervention Activity | Description | Purpose | Target Population |
---|---|---|---|
New school-break facilities | During a participatory workshop, students co-created ideas on how to improve the social environment, and the school received funding to implement ideas (€15,000 per school). | To replace social smoking with locally acceptable activities. | Students |
Smoke-free signage | Smoke-free signage (e.g., posters, go-cards) was provided for the schools, and the schools had the option to create their own smoke-free signage (e.g., a smoke-free logo). | To make the policy visible to students (and others). | Students |
Help for students to cope with not smoking during school hours | Selected staff and managers participated in a two-day motivational interviewing course, which was tailored to target students enrolled in upper-secondary education. During the course, the participants learned about the social, psychological, and physical aspects of nicotine dependence and how to address the students who were struggling with not smoking during school hours in a positive, communicative way. (Average of n = 10 educated staff at each intervention school.) | To provide support to students who find it difficult not to smoke during school hours | Students |
Smoking cessation assistance | Smoking cessation courses were offered in collaboration with the local municipality. The courses were offered to both students and staff/managers (separate courses). | To facilitate smoking cessation for students who were motivated to quit smoking. | Students |
A joint workshop before policy implementation | A joint workshop for all staff and managers was held to discuss the purpose and legitimacy of the smoke-free school hours policy. At the workshop, the principal presented the school’s motives for adopting the policy as well as the rules for sanctioning and enforcement. Knowledge about organizational change processes and the complexity of nicotine dependence was also presented by a psychologist from a public health NGO. In addition, facilitated group discussions and exercises took place. (n = 1 joint workshop at each school.) | To stimulate a shared understanding of why the school is implementing the policy. Additional goals were to develop a shared language and tools that can be used in the implementation process. | Staff/managers |
Internalization of fixed enforcement procedures | The schools were obliged to develop school-specific rules for sanctioning and enforcement. The schools were advised to establish rules with a progressive application of disciplinary measures. The rules were then integrated into the schools’ rules of conduct and communicated to all staff and students. | To clearly communicate the rules, so staff and managers know what to do if students violate the policy. | Staff/managers |
Support from public health NGOs and local municipality | Throughout the intervention, the schools were supported by both the local municipality and two Danish public health NGOs (the Danish Heart Foundation and the Danish Cancer Society). The NGOs delivered the intervention activities at the schools. Approximately n = 5–6 encounters per school in addition to the intervention activities. | To provide support for the schools in the implementation process, when needed. | Staff/managers |
Implementation Fidelity Concepts | Definition | Items | Response Categories. Satisfactory Levels of Implementation for the Binary Transformation in Bold |
---|---|---|---|
Student level | |||
Adherence | Familiarity with policy entailments | What are the school’s rules on smoking? | We are allowed to smoke everywhere on school property/We are allowed to smoke in designated smoking areas/We are only allowed to smoke outside school premises/We are not allowed to smoke during the entire school day-neither on school grounds nor outside school grounds/I don’t know the school’s rules on smoking/The school doesn’t have rules on smoking |
Dose | Exposure to smoking during school hours | How often do you see school students smoking during school hours? | Every day or several times a day/Almost daily or a couple of times per week/Circa once a week/Less than once a week/A few times per month/Rarer/Never |
Quality of delivery | Enforcement of policy | What normally happens when students break the school’s rules on smoking? | Reprimand or negative sanctioning/Help to cope with not smoking during school hours (e.g., referral to school or municipal smoking cessation counselors)/Other/Nothing happens/I don’t know |
Participant responsiveness | Sense of policy implementation | At your school, do you sense that students smoke during school hours? | Yes, on the school premises/Yes, outside the school premises/No/I don’t know |
Staff/manager level | |||
Adherence | Familiarity with policy entailments | Is it currently permitted for school students to smoke cigarettes during the school day? | Yes/Yes, outside school premises/No/I don’t know |
Dose | Exposure to smoking during school hours | How often do you see school students smoking during school hours? | Every day or several times a day/Almost daily or a couple of times per week/Circa once a week/Less than once a week/A few times per month/Rarer/Never |
Quality of delivery | Enforcement of policy | New variable constructed by a crosstab of: How often do you articulate/enforce the smoke-free school hours policy? AND ‘Exposure to smoking during school hours’ construct (Dose) | Policy is enforced every day/Almost daily/Circa once a week/Less than once a week/A few times per month AND Students are seen smoking every day/Almost daily/Circa once a week Policy is enforced every day/Almost daily/Circa once a week/Less than once a week/A few times per month AND Students are seen smoking less than once a week/A few times per month/Rarer/NeverPolicy is never/rarely enforced AND Students are seen smoking less than once a week/A few times per month/Rarer/Never Policy is never/rarely enforced AND Students are seen smoking every day/Almost daily/Circa once a week |
Participant responsiveness | Sense of policy implementation | To what extent do you feel that smoke-free school hours are currently a normal part of everyday life at school? | 1 = Very little extent, 2 = Little extent, 3 = Neutral, 4 = Large extent, 5 = Very large extent |
Intervention Activity | Definition | Items | Responses Categories | Timing |
---|---|---|---|---|
Student level | ||||
New school-break facilities | Appraisal | Do you agree or disagree with the following statement: After the school established smoke-free school hours, there are a lot of things to do during school breaks | 1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly agree | At T1 and T2 |
Smoke-free signage | Prominence of smoke-free signage | To what extent do you think the smoke-free school hours signage is visible at your school? | 1 = Very little extent, 2 = Little extent, 3 = Neutral, 4 = Large extent, 5 = Very large extent | At T1 and T2 |
Motivational interviewing | Support to cope with not smoking during school hours and smoking cessation assistance | To what extent do you experience that there are staff at this school who can… (1) help you deal with smoking urges during school hours, (2) help you with smoking cessation | 1 = Very little extent, 2 = Little extent, 3 = Neutral, 4 = Large extent, 5 = Very large extent | At T1 and T2 |
Smoking cessation assistance | ||||
Staff/manager level | ||||
Joint workshop for all organizational members | A shared understanding, new competences and ideas, and a shared language (mutual engagement, joint enterprise, and shared repertoire) | Do you agree or disagree with the following statements: The joint meeting contributed to… (1) give us a shared understanding of why we have/are going to have smoke-free school hours, (2) give us concrete ideas about how to support students to cope with smoke-free school hours, (3) give me new knowledge about the complexity of nicotine dependence, (4) set in motion a dialogue about smoke-free school hours at the school, (5) give us a shared language, which we use when we talk about smoke-free school hours among employees | 1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly agree | Before policy |
Internalization of fixed enforcement procedures | Internalization of fixed enforcement procedures | To what extent do you feel equipped to enforce smoke-free school hours? (i.e., know what to do or who to refer to do) | 1 = Very little extent, 2 = Little extent, 3 = Neutral, 4 = Large extent, 5 = Very large extent | At T1 and T2 |
Experienced support from NGOs and local municipality | Appraisal | Do you agree or disagree with the following statement: External help from the municipality or The Danish Cancer Society or The Danish Heart Foundation is supportive in relation to our work with smoke-free school hours | 1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly agree | At T1 and T2 |
Students T1 | Students T2 | Staff/Managers T1 | Staff/Managers T2 | |
---|---|---|---|---|
Individuals, N (%) | 1222 (100) | 1452 (100) | 419 (100) | 452 (100) |
Age, range | 15–63 | 15–66 | 20–67 | 17–76 |
Age, mean (SD) | 23.5 (9.3) | 22.5 (8.5) | 48.6 (9.8) | 46.9 (10.2) |
Male gender, % | 59.0 | 58.5 | 42.7 | 42.7 |
Smoking prevalence *, % | 30.5 | 27.3 | 12.9 | 12.4 |
Educational track, % | ||||
Care, health, and pedagogy | 29.2 | 28.2 | NA | NA |
Administration, commerce, and business service | 17.9 | 27.7 | NA | NA |
Food, agriculture, and hospitality | 5.8 | 7.0 | NA | NA |
Technology, construction, and transportation | 47.1 | 37.0 | NA | NA |
Educational level, % | ||||
Vocational school-normal | 74.0 | 66.0 | NA | NA |
Vocational school-higher | 26.0 | 34.0 | NA | NA |
School position, % | ||||
Manager | NA | NA | 11.0 | 5.7 |
Teacher | NA | NA | 62.8 | 65.9 |
Counsellor | NA | NA | 6.7 | 6.9 |
Administrative | NA | NA | 11.7 | 11.0 |
Other positions | NA | NA | 7.9 | 10.6 |
Special function in relation to health promotion **, % | NA | NA | 47.5 | 47.0 |
Intervention Activities * | Students T1 Mean (SD) | Students T2 Mean (SD) | Staff/Managers T1 Mean (SD) | Staff/Managers T2 Mean (SD) |
---|---|---|---|---|
New school-break facilities | 2.82 (±1.1) | 2.91 (±1.2) | NA | NA |
Smoke-free signage | 2.58 (±1.3) | 2.52 (±1.3) | NA | NA |
Help to deal with not smoking during school hours and smoking cessation assistance | 2.01 (±1.2) | 1.73 (±1.0) | NA | NA |
Joint workshop before policy implementation | NA | NA | 3.35 (±0.9) | 3.35 (±0.9) |
Internalization of fixed enforcement procedures | NA | NA | 3.07 (±1.1) | 2.98 (±1.0) |
Experienced support from NGOs and local municipality | NA | NA | 3.46 (±0.9) | 3.36 (±0.8) |
Students T1 % | Students T2 % | Staff/Managers T1 % | Staff/Managers T2 % | |
---|---|---|---|---|
Adherence | 87.3 | 86.8 | 93.6 | 93.8 |
Dose | 28.2 | 32.7 | 65.4 | 68.6 |
Quality of delivery | 91.1 | 92.6 | 70.6 | 62.8 |
Participant responsiveness | 25.3 | 28.4 | 51.1 | 67.7 |
Total implementation fidelity, mean (SD) * | 2.24 (0.8) | 2.36 (0.8) | 2.80 (0.8) | 2.92 (0.7) |
Odds Ratio (OR) with 95% Confidence Interval (95% CI) p-Value | Linear Effect with 95% CI and p-Value | ||||
---|---|---|---|---|---|
Intervention Activities | Adherence | Dose | Quality of Delivery | Participant Responsiveness | Total Implementation Fidelity |
Student level-time 1 (T1) | |||||
New school-break facilities | 1.24 [1.05–1.45] 0.008 | 1.16 [1.03–1.31] 0.009 | 1.26 [1.02–1.56] 0.002 | 1.06 [0.94–1.20] 0.290 | 0.08 [0.03–0.12] 0.000 |
Smoke-free signage | 1.43 [1.24–1.65] 0.000 | 0.94 [0.86–1.04] 0.291 | 1.15 [0.96–1.37] 0.119 | 0.93 [0.87–1.04] 0.223 | 0.02 [−0.008–0.06] 0.145 |
Help to cope with not smoking during school hours and smoking cessation assistance | 1.06 [0.77–1.46] 0.687 | 1.04 [0.86–1.26] 0.665 | 1.70 [1.02–2.83] 0.037 | 1.05 [0.84–1.30] 0.654 | 0.06 [−0.008–0.12] 0.082 |
Student level-time 2 (T2) | |||||
New school-break facilities | 0.89 [0.77–1.03] 0.139 | 1.18 [1.06–1.31] 0.001 | 1.25 [1.04–1.50] 0.017 | 1.27 [1.14–1.43] 0.000 | 0.07 [0.03–0.11] 0.000 |
Smoke-free signage | 1.39 [1.22–1.58] 0.000 | 0.92 [0.84–1.00] 0.06 | 1.14 [0.97–1.35] 0.103 | 0.94 [0.86–1.03] 0.175 | 0.01 [−0.01–0.05] 0.255 |
Help to cope with not smoking during school hours and smoking cessation assistance * | 1.02 [0.72–1.46] 0.881 | 0.89 [0.71–1.13] 0.364 | 0.99 [0.59–1.65] 0.978 | 1.05 [0.84–1.32] 0.631 | −0.003 [−0.08–0.07] 0.934 |
Odds Ratio (OR) with 95% Confidence Interval (95% CI) p-Value | Linear Effect with 95% CI and p-Value | ||||
---|---|---|---|---|---|
Intervention Activities | Adherence | Dose | Quality of Delivery | Participant Responsiveness | Total Implementation Fidelity |
Staff/manager level-Time 1 (T1) | |||||
Joint workshop before policy implementation | 1.45 [0.50–4.21] 0.489 | 0.95 [0.65–1.40] 0.821 | 1.17 [0.81–1.68] 0.394 | 1.66 [1.13–2.46] 0.010 | 0.13 [0.02–0.25] 0.022 |
Internalization of fixed enforcement procedures | 1.92 [1.28–2.88] 0.001 | 1.09 [0.89–1.33] 0.402 | 1.17 [0.95–1.44] 0.131 | 1.59 [1.29–1.97] 0.000 | 0.19 [0.13–0.26] 0.000 |
Experienced support from NGOs and local municipality | 1.08 [0.69–1.68] 0.702 | 1.09 [0.86–1.39] 0.442 | 1.19 [0.93–1.51] 0.150 | 1.51 [1.18–1.95] 0.001 | 0.14 [0.05–0.22] 0.001 |
Staff/manager level-Time 2 (T2) | |||||
Joint workshop before policy implementation | 1.46 [0.46–4.65] 0.514 | 1.03 [0.65–1.64] 0.869 | 1.10 [0.69–1.73] 0.679 | 1.73 [1.08–2.76] 0.021 | 0.13 [0.004–0.24] 0.05 |
Internalization of fixed enforcement procedures | 1.57 [1.05–2.34] 0.023 | 1.17 [0.94–1.45] 0.140 | 1.05 [0.86–1.28] 0.617 | 1.66 [1.33–2.06] 0.000 | 0.16 [0.10–0.23] 0.000 |
Experienced support from NGOs and local municipality | 0.80 [0.48–1.31] 0.383 | 1.01 [0.77–1.33] 0.926 | 1.12 [0.87–1.45] 0.352 | 1.09 [0.83–1.43] 0.504 | 0.04 [−0.05–0.12] 0.421 |
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Hjort, A.V.; Kuipers, M.A.G.; Stage, M.; Pisinger, C.; Klinker, C.D. Intervention Activities Associated with the Implementation of a Comprehensive School Tobacco Policy at Danish Vocational Schools: A Repeated Cross-Sectional Study. Int. J. Environ. Res. Public Health 2022, 19, 12489. https://doi.org/10.3390/ijerph191912489
Hjort AV, Kuipers MAG, Stage M, Pisinger C, Klinker CD. Intervention Activities Associated with the Implementation of a Comprehensive School Tobacco Policy at Danish Vocational Schools: A Repeated Cross-Sectional Study. International Journal of Environmental Research and Public Health. 2022; 19(19):12489. https://doi.org/10.3390/ijerph191912489
Chicago/Turabian StyleHjort, Anneke Vang, Mirte A. G. Kuipers, Maria Stage, Charlotta Pisinger, and Charlotte Demant Klinker. 2022. "Intervention Activities Associated with the Implementation of a Comprehensive School Tobacco Policy at Danish Vocational Schools: A Repeated Cross-Sectional Study" International Journal of Environmental Research and Public Health 19, no. 19: 12489. https://doi.org/10.3390/ijerph191912489