education and health journal 32:1, 2014

Published by SHEU since 1983 Volume 32 Number 1, 2014

ISSN 2049-3665

Education and Health

Health-E-PALS: promoting Healthy Eating and Physical Activity inLebanese school children - Intervention developmentCarla Habib-Mourad, Helen Moore, Maya Nabhani Zeidan, NahlaHwalla and Carolyn Summerbell

What’s the skinny? Evaluating the effects of instituting a ‘fat tax’in AmericaKristin Cook

Food and Healthy Eating in the Curriculum – a case of too manycooks spoiling the brothFrances Ryland

Child and adolescent social gaming: What are the issues ofconcern?Mark D. Griffiths

Finding Space to Mental Health - Promoting mental health inadolescents: Pilot studyLuísa Campos, Pedro Dias and Filipa Palha

Resilience and Results: How Promoting Children’s Emotional andMental Wellbeing Helps Improve AttainmentPaula Lavis

“Drink doesn’t mess with your head … you only get a hangover”:Adolescents’ views on alcohol and drugs, and implications forEducation, Prevention and InterventionMichael McKay and Séamus Harvey

2 Education and Health Vol.32 No.1, 2014

Education and Education and Education and Education and HealthHealthHealthHealthEditorDavid McGeorge(e-mail: [email protected])Welcome to the first issue for 2014. Thecombination of issue and volume numbers enableus to proclaim 321! – a rare event that lastoccurred in 1994 with vol.12 issue 3.We continue with the proud tradition ofindependent publishing and offer an eclectic mixof articles. Contributions come from thoseworking with young people and we welcome theinterest from around the world. Developments inopen access publications mean that our articlesare available where there is Internet access.The journal, published since 1983, is aimed atthose involved with education and health whoare concerned with the health and wellbeing ofyoung people. Readers, in the UK, come from abroad range of backgrounds and include:primary, secondary and further educationteachers, university staff, and health-careprofessionals working in education and healthsettings. Readers outside of the UK share similarroles. The journal is also read by those whocommission and carry out health educationprogrammes in schools and colleges.Articles focus on recent health educationinitiatives, relevant research findings, materialsand strategies for education and health-relatedbehaviour data.

Contributors (see a recent list)Do you have up to 3000 words about a relevantissue that you would like to see published?

ArchiveThe archive is also online. Please visit thisweblink: http://sheu.org.uk/content/page/ehI look forward to your company in the next issue.

SHEU publications

‘Education and Health’ is published by SHEU, anindependent organisation, providing research,survey and publishing services to thoseconcerned with the health and socialdevelopment of young people. SHEUincorporates the Schools Health Education Unit,founded in 1977 by John Balding.The address for all correspondence is:SHEU, 3 Manaton Court, Manaton Close,Matford Park, Exeter EX2 8PFMany publications can be viewed onlinehttp://sheu.org.uk or purchased from SHEUe-mail: [email protected]

Trends from 1983A series of reports showing trends from 1983.Recent reports are ‘Young People’s FoodChoices’, ‘Young People and Smoking’ and‘Young People and Illegal Drugs’. Latest datacome from a sample of over 629,000 youngpeople mostly between the ages of 10-15 fromacross the UK. Reports are priced from £10-£15including post and packaging (comb-bound orsaddle-stitched stapled).

The Young People serieshttp://sheu.org.uk/content/page/publicationsLarge numbers of young people, between theages of 10 and 15 years, respond to over 100questions about their health-related behaviour.

Free resourcesTopics include:- Planning PSHE in your school;Research news about young people’s health andwellbeing; Literature search resource; YoungPeople Reports into health and wellbeing; andmore.http://sheu.org.uk/content/page/res

SHEUSchools and Students Health Education Unit

The specialist provider of reliable local survey data for schools and collegesand recognised nationally since 1977.

"The survey reports have been used to inform commissioning at specific commissioning groups. They are also being used within ourExtended Schools Clusters and to inform The Annual Public Health and the Joint Strategic Needs Assessment."

Programme Manager - Young People

For more details please visit http://sheu.org.uk

TO SUPPORT YOUR WORK WITH YOUNG PEOPLE TRY SHEU’S FREE RESOURCES


Lebanon is a small middle-income country in theMiddle-East situated on the Mediterranean

coast. Over the last three decades, Lebanon hasexperienced a nutrition transition resulting in ashift towards a diet high in energy-dense foodand sedentary lifestyle. The results from anational population based study in Lebanonshowed high prevalence rates of overweightand obesity similar with those observed indeveloped countries, both in adults andchildren (Sibai et al., 2003). Recently, a study onthe secular trends in the prevalence ofoverweight and obesity in Lebanon over a 12year period found an alarming increase inobesity prevalence in the Lebanese population,especially in children (Nasreddine et al., 2012a).Multicomponent interventions, policies andnutritional strategies to promote weight controland physical activity nation-wide wererecommended to curb the childhood obesitycrisis in Lebanon (Sibai et al., 2003; Hwalla et al.,2005; Nasreddine et al., 2012b).

School-based interventions to promotehealthy eating and encourage physical activityare lacking in Lebanon. A reassessment of theLebanese Integrated Health Curriculum iswarranted, as well as the need to adopt acomprehensive school health programme(WHO, 2005). In an attempt to address this gap,a theory and evidence-based multi-componentschool intervention was developed that focusedon promoting healthy eating and physicalactivity to prevent weight gain in school-agedchildren. The intervention was pilot tested

using a mixed method study design involvingboth quantitative and qualitative researchmethodologies (Habib-Mourad, 2013). Eightschools were purposively selected from twodifferent communities in Beirut (capital ofLebanon) and were randomly assigned to eitherthe intervention or control group.Anthropometric measurements were taken, andquestionnaires on determinants of behaviouralchange, eating and physical activity habits werecompleted by the students in both groups (N=374) at baseline and post intervention. Focusgroup interviews were conducted inintervention schools at the end of the study.

The study was granted ethical approval bythe Institutional Review Board of the AmericanUniversity of Beirut. The present paperdescribes the development of the interventionand its components.

Intervention developmentThe school-based multicomponent

intervention was named in Arabic ‘Kanz alSoha’; which translates to health treasure.‘Health-E-PALS’ was deduced as the acronymfor: Intervention to promote Healthy Eating andPhysical Activity in Lebanese School children.

The intervention focused on the promotion ofhealthy food choices and active living ratherthan the achievement of an ideal body weight.By selecting this focus the intervention aimed tolessen the chance of stigmatization ofoverweight children and of contributing toeating disorders (Swinburn & Egger, 2002).

Dr Carla Habib-Mourad is a lecturer and project coordinator of the Healthy Kids School programme at the Department of Nutrition andFood Sciences, American University of Beirut, Lebanon. Dr Helen Moore is a Post-Doctoral Research Associate in the Obesity RelatedBehaviours (ORB) Research Group at Durham University, UK. Dr Maya Nabhani Zeidan is Accreditation and Program Review Officer atthe Faculty of Agriculture and Food Sciences, American University of Beirut, Lebanon. Professor Nahla Hwalla is a professor of HumanNutrition at Department of Nutrition and Food Sciences, American University of Beirut, Lebanon. Professor Carolyn Summerbell isProfessor of Human Nutrition in the Obesity Related Behaviours (ORB) Research Group School of Medicine, Pharmacy and Health,Durham University, UKFor communication, please email: [email protected]

Carla Habib-Mourad, Helen Moore, Maya NabhaniZeidan, Nahla Hwalla and Carolyn SummerbellHealth-E-PALS: promoting Healthy Eating and PhysicalActivity in Lebanese school children - Interventiondevelopment


Target behavioursWhen aiming at preventing unnecessary

weight gain studies showed that strategiesfocusing on: changes in dietary behaviours;leading to decrease in energy intake; changes inphysical activity and sedentary behaviours thatwould increase energy expenditure; were keyfactors in the onset of obesity (WHO, 2003).

The specific behaviours that make up theenergy balance equation have been referred toas the energy balance-related behaviours(Kremers et al., 2006). Diet and physical activitypatterns that can be a factor in weight gain maydiffer among groups depending on age, culture,gender and socioeconomic status. The energybalance behaviours mostly related to excessweight gain in schoolchildren were: breakfastskipping; sweetened drinks consumption;energy dense snacks intake; sedentary andphysical activities (Affenito et al., 2005;Bachman et al., 2006; Malik et al., 2006; Sallis etal., 2000). Based on the above evidence-basedliterature, the ‘Health-E-PALS’ interventiontargeted the following obesity related behavioursin 9-11 year old children:1. Increase consumption of fruits and

vegetables2. Favour healthy snacks over high energy

dense snacks and drinks3. Importance of having daily healthy

breakfast4. Increasing moderate physical activity5. Decreasing sedentary behaviour

Theoretical underpinningThe theoretical underpinning of this

programme is instruction with a behaviouralfocus; and goes beyond the acquisition ofknowledge. The ‘Health-E-PALS’ interventionwas based on the constructs of the SocialCognitive Theory (Bandura, 1986) which uses amulti-level approach involving individualbehaviour change and environmentmodifications to support individual changes.Personal factors influencing individualbehaviour include knowledge, skills and self-efficacy; environmental factors includereinforcement, modelling and availability.

‘Health-E-PALS’ had three coordinatedintervention components that addressed specificbehaviour determinants: nutrition knowledge;awareness; skills and self-efficacy; personalfactors. Modelling and availability covered the

environmental factors. The components weredevised to work together to addressbehavioural and environmental factors relatedto students dietary and physical activitybehaviours.

Consistent with the Social Cognitive Theory,the components were based on the expectationthat children will make healthier choices whenintroduced in a social setting that includesfamily and peers and uses active learningstrategies. According to Bandura (Bandura,1986, 2004), in order for an individual toperform a specific behaviour, he should knowwhat to do and how it should be done; this isreferred to as behavioural capability orknowledge; skills training helps in increasingmastery learning. Strategies that increase self-efficacy include self-monitoring andreinforcement, such as rewards and praise.

Role modelling refers to observationallearning, where one learns by observing othersactions, especially credible others, in this casethe parents and teachers. Availability andaccessibility of healthy food choices were alsoconsidered. Consequently, the intervention hadthree components:1 Culturally appropriate classroom sessions

designed to promote healthy eating and physical activity. This component was designed to cover the personal and psychosocial determinants as outlined by the Social Cognitive Theory.

2 A family programme which introduces theintervention to families and assists them increating a supportive environment at homefor healthy lifestyle behaviours. Thiscomponent covered the environmental factorsat home: modelling and availability.

3 A food service intervention targeting the school shop and the lunch boxes sent by the family. This component covered availability of food in the students’ school environment.Through these three components, ‘Health-E-

PALS’ attempted to increase students’knowledge and efficacy about food choices andphysical activity, and modify the school andfamily environment in order to provide moreopportunities for exercise and healthy eating.

Figure 1 (see page 5) outlines the interventioncomponents based on the Social Cognitive Theoryconstructs or determinants.


Intervention componentsThe following section provides further details

on the intervention components.Component 1: Classroom sessionsEducational material

Sessions’ topics and activities were developedbased on the five energy related behaviourstargeted in the intervention.

The goal of the ‘Health-E-PALS’ interventionsessions was to provide appropriate nutritioneducation in a simple and fun layout. Deliverystrategies reported to be effective in nutritioneducation include hands-on activities, andinteractive learning that gives opportunities toparticipate in discussions and food activities(Birkett et al., 2004; Holston et al., 2004; Edwardand Evers, 2001). Consequently, activities suchas games, hands on activities and foodpreparation were used to make the learning funand interactive and the themes easy toremember and relate to. The 45 minute sessionswere delivered each week for 12 weeks.

All materials were developed to suit Lebanesetraditions and cultures, and featured traditional

foods in most games, visual aids and recipes.Languages used on educational items wereArabic and English. However, only Arabicmaterials were used with students, except forsome posters and food cards that werebilingual.

The educational component was designed tobe integrative and interdisciplinary to facilitateimplementation and minimize excess burden onexisting school curriculum. Nutrition sessionswere integrated into various classroom subjectsduring the regular school day. For example,students used the measuring centres session topractice fractions in Maths, and breakfastplanning in writing topics in English or Arabicsubjects. Table 1 (page 6) summarizes the topics,objectives, activities of the classroom sessionswith the determinants targeted and the class inwhich they were integrated.

Each session consisted of two sections; 10 to15 minutes of discussion, information andinteraction about the topic of the week followedby 30 minutes of activity: game and/or foodpreparation. In order to make the sessions

Figure 1: Intervention components, behavioural, personal and environmental constructs


interesting and attractive to students, a set ofvisual aids have been developed. The teachingaids consisted of posters, pamphlets, activitybooklets, card and board games (Table 2 above).One of the researchers (C.H.M) implementedthe sessions with the help of a researchassistant. Teachers were participating in allphases of the sessions each during his class

hour. At the end of the intervention, theteachers received extensive two days trainingwith the complete educational kit and teachers’manual, to be able to implement the sessionslater on.Material testing

Educational material were pilot-tested on agroup of seven to ten children aged 9-11 yearswho were related to the researcher and hercolleagues. The children gathered few timesduring the summer vacation, prior to thebeginning of the academic year. They wereexposed to the educational material and tried allthe activities included in the educationalsessions.

Following the piloting several foodillustrations were changed as well as somenutrition terms that were modified to wordings

Table 1: Educational sessions’ topics, objectives and tools with the matching theory determinant and class integration

Title of the lesson Objectives of the lessons Activity / Tool Determinant Classsession

1Introduction to Foodgroups

Classify one day food intake into food groups.

Classify foods according to different food groups.Game : Food cards Knowledge Science

2Food Groups andNutrients

Know the nutritional characteristics of each foodgroup.

Food counter:

Visual tool that helpsstudents see what theyate

Knowledge Science

3 What is a portion Know the serving size of foods in different foodgroups.

Measuring centres: Realexperience with food

Food diary bookletKnowledge Math

4Fruits andvegetables: therainbow colours

Eat more fruits and vegetables

Try new types of fruits and vegetables

Build a character withfruits and vegetables,tasting is a must

Self-efficacy and skills Arts

5&6

Physical activity

Identify sedentary activities and try to minimizethem.

Increase regular Physical activities especiallywalking.

Pedometer workshop

Activity bookletSelf-efficacy and skills Sports

7Importance ofbreakfast

The role and importance of breakfast

Find ways to facilitate breakfast intake

Plan and prepare ahealthy breakfast(breakfast is yummy)

Self-efficacy and skills Language

8 Healthy snacksDifferentiate between healthy snacks and non-stop-nibbling.

Prepare healthy snacks at home

Plan and prepare ahealthy snack Skills / Role modelling Language

9Where do fats andsugars hide Identify high fat, high sugar containing foods Game board: Treasure

game Knowledge Math

10Clean teeth, goodteeth

Identify caries causing foods

Brush teeth the correct wayTooth brushing workshop Self-efficacy and skills Science

11 Water is the bestTo explain why water is the best fluid.

Encourage water intake instead of other sweetdrinks

Water tasting workshopKnowledge and skills

Social

Studies

12 Value of food Compare foods according to their nutrients andenergy content.

Game:

The traffic lightsKnowledge and skills

Civic

Education

Table 2: ‘Health-E-PALS’ educational Kit

• Classroom posters (10)• Take Home pamphlets (12 for each student)• Food diary booklet (one for each student)• Physical activity booklet (one for each student)• Set of 60 food cards• Board game: Treasure game• Traffic lights signs• Food counter box (one for each student)• Pedometers (one for each student)


more accessible to children. The board and cardgames were re-adjusted to fit within a 30minutes time frame. Snacks and recipesingredients were altered to suit children’s tastepreferences.

For more details on material content refer tohttp://etheses.dur.ac.uk/7322/Component 2: Family programme

The goal of the family involvementcomponent was to introduce the programme tofamilies and to assist them in creating asupportive environment at home for healthylifestyle behaviours. The family interventioncomponent consisted of the following activities:• Parents meetings: Parents were asked to

attend meetings where the differentcomponents of the project where providedalong with information and guidance onthe importance of healthy diet and physicalactivity. A healthy breakfast followed themeeting

• School events: These consisted of health fairsinvolving interactive forums using theeducational sessions’ themes covered inclass. The health fairs took place at schoolsat the end of the programme; parents wereinvited to participate in games preparedand presented by their children

• Take home pamphlets: The interventionincluded sending a summary of the majorpoints covered during the educationalsession home with the students as takehome action packs after each session.Samples of food prepared in class were alsosent home with the students. The goal ofthe take home pamphlets was to try toaddress non-compliance/ poor attendanceof parents’ school meetings.

Component 3: Food serviceFoods and drinks offered to students in the

sampled Lebanese school shops includeconvenience foods such as chips, candy bars,sweetened drinks as well as ready preparedsandwiches, traditional Lebanese pastries,croissants and donuts. Fresh juices, fruits andvegetables are not available. Recommendationsconcerning the healthy list of snacks and drinksthat should be available to children in the shopwere provided to shop administrators. Postersencouraging healthy food choices were postedat the points of sales whenever possible.

Lebanese children in primary schools alsobring with them food from home to school,which consists of sandwiches and conveniencefoods. Students were encouraged to enhance thequality of their lunch box so as to include atleast one fruit or vegetable portion and notmore than one high energy dense snack.

Results and ConclusionThis paper has concisely described the

effective development of the ‘Health-E-PALS’intervention and its components. Results fromthe cluster randomised controlled trial showedthat knowledge and self-efficacy scores doubledfor the intervention group but not for thecontrol. Students in the intervention group alsoreported purchasing and consuming less chipsand sweetened drinks compared with controls(86% & 88% less respectively p<0.001). Resultsfrom the focus group discussions conducted atthe end of the intervention, showed that theprogramme was generally well accepted bystudents, teachers and their parents. It wasviewed as novel due to its culturally sensitiveand innovative components. The studentslearned to change their eating habits in apleasurable way, and were successful in tryingnew healthy foods and preparing recipes. Theprogramme was well integrated within theschool curriculum and was well accepted byteachers and school principals. Finally, parentsacknowledged the fact that the programmepositively affected the family food environment.All agreed that longer duration interventionsand sustainability of the programme will berequired. More details about the pilot testing ofthe intervention, its research methodologies aswell as results of its efficacy can be foundelsewhere (Habib-Mourad, 2013).

The ‘Health-E-PALS’ intervention is currentlyrolled out in Lebanon and other countries in theregion as “Nestlé Healthy Kids –Ajyal Salima”programme in collaboration with health andeducation authorities in order to prevent theramping childhood obesity epidemic in the area.AcknowledgmentWe thank the Ministry of Higher Education in Lebanon; theschool children and their parents, and teachers, whoparticipated in the study; Hiba Houri for data entry; NancyAwada and Carla Maliha for referencing and proof reading.This research was funded by an Eastern MediterraneanRegional Office Special Grant for Research in Priority Areas ofPublic Health (EMRO/WHO).


References

Affenito, S. G., Thompson, D. R., Barton,B. A., Franko, D.L.,Daniels, S. R., Obarzanek, E. Schreiber, G. B., & Striegel-Moore, R. H. (2005). Breakfast consumption by African-American and white adolescent girls correlates positively withcalcium and fibre intake and negatively with body mass index,Journal of the American Dietetic Association, 105,(6), pp. 938-945.

Bachman, C.M., Baranowski, T. & Nicklas, T.A. (2006). Is therean association between sweetened beverages and adiposity?Nutrition Reviews, 64, (4) , pp. 153-174.

Bandura, A. (1986). Social Foundations of Thought and Action:A Social Cognitive Theory. Englewood Cliffs, NJ, Prentice-Hall.

Bandura, A. (2004). Health promotion by social cognitive means,Health Education and Behaviour, 31, (2), pp.143-164.

Birkett, D., Johnson, D., Thompson, J. & Oberg, D. (2004).Reaching Low-Income Families: Focus Group Results ProvideDirection for a Behavioural Approach to WIC Services. Journalof the American Dietetic Association, 104, (8), pp.1277-1280.

Edward, H.G. & Evers, S.(2001). Benefits and barriersassociated with participation in Food programs, CanadianJournal of Dietetic Practice and Research, 62, (2), pp.76-81.

Holston, D., O'Neil, C., Guarino, A. & Keenan, M. (2004).Assessing perception of family nutrition program characteristicsand nutrition education needs of low income families. Journal ofthe American Dietetic Association, 104, (8), pp.1-98. See alsohttp://etd.lsu.edu/docs/available/etd-03302004-105649/unrestricted/Holston_thesis.pdf Accessed January 2014

Hwalla, N., Sibai, A.M. & Adra, N.(2005). Adolescent Obesityand Physical Activity, World Review of Nutrition and Dietetics,94, pp. 42-50.

Kremers, S.P.J., De Bruijn., G.J., Visscher, T.L., van Mechelen,W., de Vries, N.K. & Brug, J. (2006). Environmental influenceson energy balance-related behaviors: A dual-process view,International Journal of Behavioral Nutrition and PhysicalActivity, 3, (9), pp. 1-10.

Malik, V.S., Schulze., M.B. & Hu., F.B. (2006). Intake of sugar-sweetened beverages and weight gain: a systematic review.The American Journal of Clinical Nutrition, 84, (2), pp. 274-288.

Mourad, C.H. (2013). An intervention to promote Healthy Eatingand Physical Activity in Lebanese School children: Health-E-PALS a pilot cluster randomised controlled trial, Doctoral thesis,Durham University. http://etheses.dur.ac.uk/7322/Accessed 27 January 2014Nasreddine L., Naja, F., Chamieh, M.C., Adra, N., Sibai, A.M. &Hwalla, N. (2012a). Trends in overweight and obesity inLebanon: evidence from two national cross-sectional surveys(1997 and 2009). BMC Public Health, 12, pp. 798-817.

Nasreddine, L., Naja, F., Akl, C., Adra, N., Sibai, A. &Hwalla, N.(2012b).Prevalence and Determinants of Overweight andobesity in a National Sample of 5-12 Years Old LebaneseChildren. The FASEB Journal, 26, 811.3.

Sallis, J.F., Prochaska, J.J. & Taylor, W.C. (2000). A review ofcorrelates of physical activity of children and adolescents.Medicine and Science in Sports and Exercise, 32,(5), pp.963-975.

Sibai, A., Hwalla, N. & Adra, N. (2003). Prevalence andcovariates of obesity in Lebanon: findings from the firstepidemiological study. Obesity Research, 11, (11), pp.1353-1361.

Swinburn, B.& Egger, G. (2002). Preventive strategies againstweight gain and obesity. Obesity and Reviews, 34, pp. 289-301.

World Health Organization. (2003). Diet, nutrition, and theprevention of chronic diseases (Report No. 797). Available fromhttp://whqlibdoc.who.int/trs/who_trs_916.pdfAccessed 27 January 2014.

World Health Organization. (2005). Lebanon, 2005, GlobalSchool-based Student Health Survey (GSHS). Available from:http://www.who.int/chp/gshs/lebanon/en/Accessed 27 January 2014.

Education and HealthThe journal, published by SHEU since 1983, is aimed at those involved with education and healthwho are concerned with the health and wellbeing of young people. Readership is worldwide andin the UK include: primary; secondary and further education teachers; university staff and health-care professionals working in education and health settings. The journal is online and open access,continues the proud tradition of independent publishing and offers an eclectic mix of articles.

Contributors (see a recent list) - Do you have up to 3000 words about a relevantissue that you would like to see published? Please contact the Editor





Parents, media, and peers inundate highschool students with concerns about health

and weight. Schools also make considerableefforts to offer healthier alternatives for lunchand advocate prevention methods, and parentsenrol their kids in after school activities for thepurpose of physical exercise; yet, despite theseattempts, obesity rates among adolescents inAmerica have more than tripled since the 1980sand 32% of children and teens are consideredoverweight or obese (Ogden et al., 2012).Countries around the world face similardilemmas and have approached the growingproblem in a variety of ways. In 2011, Denmarkintroduced the first ‘fat tax,’ a levy imposed onexcessively fattening foods. The country’s fattax added $2.70 per kilogram of saturated fats ina product and was levied on everythingcontaining saturated fats (ie. butter, milk, andprepared foods like pizza). However, only ayear later, Denmark pulled the plug on the fattax, claiming that the administrative costs andloss of jobs were not worth the effort (Khazan,2011). Despite the failed attempt of the fat tax inDenmark, other countries such as France andHungary are considering similar approaches tocombating obesity. In New York City, the trans-fat ban implemented in 2006, though recentlyruled unconstitutional, did reduce trans-fatconsumption significantly, according to a 2009study that found that the percentage ofrestaurants using trans-fats had decreased from50 percent to less than 2 percent (Angell et al.,2009).

Do high school students, enrolled in a healthcourse, think a fat tax would help US citizens

fight the battle of the bulge?Student debate

In this argumentation-based inquiry, studentsdebate the effects of instituting a nationwide fattax in America and collectively explore andarticulate varying viewpoints based on evidencewhile honing important 21st-century skills suchas gathering and assessing information, thinkingcritically, and communicating among multipleperspectives. The following four-day project forhigh school students culminates in a classroomdebate whereby students are assigned and mustdefend their position with regard to theeffectiveness of a proposed fat tax using evidence-based argumentation. I have used this projectmany times at the end of the units on food energy,so students enter into the project with anunderstanding that caloric needs differ amongindividuals, that foods contain varying amountsof saturated and unsaturated fats which arestored and utilized differently by our bodies, andthat metabolic rate can be affected by exercise andproper nutrition. Students can then apply theirunderstanding of food for balanced health andnutrition to considering societal values and thegovernments’ role regarding consumption of fattyfoods. As with other socio-scientific issues,allowing students to evaluate programmestargeting health through dialogue, discussion,and debate within a social and ethical contextencourages both motivation and ownership oflearning to the students. The intent is that suchissues are personally meaningful and engaging tostudents, require the use of evidence-basedreasoning, and provide a context forunderstanding and applying scientific

Dr Kristin Cook is an Assistant Professor at Bellarmine University, Louisville, KY.For communication, please email: [email protected]

Kristin CookWhat’s the skinny? Evaluating the effects of instituting a ‘fattax’ in America

Table 1. Curricular Connections

National Health Education Standards

Health Education Standard 1 – Students will comprehend concepts related to health promotion and disease prevention to enhance health. 1.12.7. compare and contrast the benefits of and barriers to practicing a variety of healthy behaviors.Health Education Standard 2 – Students will analyze the influence of family, peers, culture, media, technology and other factors on health behaviors. 2.12.10. analyze how public health policies and government regulations can influence health promotion and disease prevention.Health Education Standard 5 – Students will demonstrate the ability to use decision-making skills to enhance health.

5.12.7. evaluate the effectiveness of health- related decisions.


information (see Table 1 below for curricularconnections).

Activities and StrategiesTo begin the classroom investigation on the

feasibility of a fat tax in the United States,students are first introduced to the history ofthe fat tax in Denmark. While watching a shortYouTube video “Denmark’s failed fat taxexperiment” (Canadian Taxpayers Federation,2013) about the failure of the fat tax, studentsshould make a T-chart* that lists pros and consof the fat tax. This beginning activity will helpframe the sociopolitical and socioeconomiccomplexities of instituting such a tax. Informalclass discussion about the points listed on theirT-charts will help students summarize the issueand begin to pose questions and/or articulateviewpoints on the issue. Next, students read thearticle, ‘Denmark’s Failed Fat Tax,’ (Khazan,2011) to help them consider what othercountries, such as the United States, areproposing to help combat the increasinglyalarming obesity rates. Teachers should promptstudents to reflect by writing on the back oftheir T-charts their perspectives on whether afat tax would be feasible in the United States. Atthe end of Day 1, this formative assessmentprompt should be collected and reviewed by theteacher in an effort to begin a dialogue betweenthe teacher and each student that probes theirthinking (i.e. Have you considered…? Whatmight be an alternative perception to this view?Who might hold an alternative perception andwhy?). Formative feedback should be returnedto students at the start of Day 2. Note: Asweight can be an extremely sensitive topic,teachers should pay close attention to verbiageused and claims made by students in formativeassessment prompts and class discussions toaddress any concerns regarding lack of

sensitivity. Teachers should also be explicit withstudents that the ‘fat tax’ is a tax on foods, noton people.

On Day 2, teachers should assign eachstudent a role ‘for’ or ‘against’ the resolution #1or #2 (see Figure 1 at end). Students are alsoassigned a role to assume within theirargumentation (see Table 2 below). Homeworkfor students is to read Would a Fat Tax SaveLives? (Silverman, 2013) so that prior toembarking on the debate students will havereceived the same background information onthe fat tax. The article also contains several linksto research the science of fat cells andmetabolism should students should beencouraged to draw upon this information intheir research. An additional resource thatstudents should read to ensure theirconsideration of the differential economicimpact on people is Big Brother declares war onconsumption: How the move to mandatehealthier foods inadvertently hurts the poor(Hoffer et al., 2013). This editorial will probestudents’ thinking about the equity of such a taxon food, which should also be addressed intheir debates.

Preparation for the debate begins withbackground research, for which all studentsshould have access to the Internet. Dependingon their assigned role within the debate, theywill be exploring different types of websites. Forexample, if they are assigned a citizenperspective within the debate, they couldresearch recent student protests overexclusively healthier food options in theirschool cafeteria. Teachers should guide theirstudents to a variety of resources and probethem to consider the agenda and credibility ofthe site. Some students may need additionaltime preparing arguments based on their

* A T-chart is used mostly to compare things like pros and cons. It is called a T-chart because to make it, a line is drawn across the page andanother down the middle and looks like the letter T. Pros and cons are then listed in each column either side of the line.

Table 2. The four debate roles

Scientist Citizen Business Person Government Official

“Scientist” is a broad term and mayinclude a basic scientist (e.g.,dietician), applied scientist (e.g.,doctor or health consultant), orexpert science teacher

Any person who is not formallytrained in the natural sciences;Note: do not assume that justbecause this person is not ascientist that they are uneducated

A person from any sector ofbusiness who may have a vestedinterest in the outcome of thedebate—what types of businessesmight be affected by a fat tax?

Think more broadly than justmayor, state representative, orgovernor. A government officialcould also include a city/countyofficer, or someone who works forthe Department of Health


individual research, so teachers should allowtime enough time for formative feedback afterresearch is conducted in the classroom. To dothis, teachers can request students submit abrief outline of their resources and conclusionsprior to the debate.

Day 3 and 4 are classroom debate days. Witha group of 30 students, 15 will debate the firstresolution and 15 will debate the secondresolution. Those not debating will beconducting peer reviews and ultimatelydetermining which of the opposing sides wonthe debate. The student instructions (see Figure1 at end) outline helpful tips for preparing thedebate that will yield maximum points on theteacher and peer rubrics (see Figure 2 at end).Teachers should review specific instructionsand rubric with students prior to the debatedays to resolve any questions.

Assessment Technique: Students will beassessed in teams by both their instructor andpeers. The instructor assessment will gauge allthree performance indicators of NHES as wellas assess the use of evidence in andorganization of their argument. The peerassessment will gauge argumentationeffectiveness.

ConclusionIn this inquiry, students are challenged to

explore the controversy of a fat tax, which isinformed by the science of food energy andintegrates social aspects (moral, ethical,economic, etc…) to develop a position basedupon their research (Klosterman et al., 2010;Tanner, 2009). I am always struck by theengagement with which students prepare theirdebates and excitedly work with their peers toformulate strong arguments. The challenge towin the debate brings forth (often from studentsfrom whom I would least expect) dynamicdebate styles, with students assuming the rolesof a variety of actors and creating backgroundstories for their chosen personas. With this,however, some students get so excited about thepreparation of their debate and developing theircharacter that they neglect to connect thecontent and evidence they have researched intheir arguments. We have seen in research ondebates surrounding socio-scientific issues thatstudents’ privilege faulty reasoning, hastygeneralizations, and extreme examples to evoke

affective responses (Walker & Zeidler, 2007).For this reason, teachers should thoughtfullyutilize the formative assessment opportunitiesas mentioned above to prompt students toensure they are referencing appropriate data-based evidence on which to base theirarguments. At the end of the debate, a classdiscussion about which team won the debatescan lead to a focus on what constitutespersuasive argumentation. Students can reflecton what aspects of the debate persuaded themmost.

Through this lesson, students must play closeattention to the intersection of science andcomplex societal concerns, and teachers willfind that this activity engages students inlearning to make and articulate to others well-informed decisions about socio-scientific issues.References

Angell, S., Silver, L., Goldstein, G., Johnson, C., Deitcher, D.,Frieden, T., & Bassett, M. (2009). Cholesterol control beyondthe clinic: New York City's trans fat restriction. Annals of InternalMedicine, 151(2), 129-134.Canadian Taxpayers Federation. (2013). “Denmark’s failed fattax experiment” [Video File].Accessed 02/01/2014.http://www.youtube.com/watch?v=ZQm7owMs_IgHoffer, A., Shughart, W., & Thomas, M. “Big Brother declareswar on consumption: How the move to mandate healthierfoods inadvertently hurts the poor.” USA Today, 4 Aug. 2013.Web. 8 Sept. 2013. Accessed 02/01/2014.http://www.usatoday.com/story/opinion/2013/08/03/bloomberg-soda-taxes-column/2613613/Khazan, O. (2102, November 2011). What the world can learnfrom Denmark’s failed fat tax. The Washington Post.Accessed 02/01/2014.http://www.washingtonpost.com/blogs/worldviews/wp/2012/11/11/what-the-world-can-learn-from-denmarks-failed-fat-tax/Klosterman, M. & Sadler, T. (2010). Multi-level assessment ofscientific content knowledge gains associated withsocioscientific issues-based instruction. International Journal ofScience Education, 32, 1017-1043.Ogden, C., Carroll, M., Kit, B., & Flegal, K. (2012). Prevalence ofobesity and trends in body mass index among US children andadolescents, 1999-2010. JAMA, 307(5), 483-490.Silverman, J. (2013, June 3). “Would a fat tax save lives?”HowStuffWorks.com. Accessed 02/01/2014.http://money.howstuffworks.com/fat-tax.htmTanner, K. (2009). Talking to learn: Why biology students shouldbe talking in classrooms and how to make it happen. LifeSciences Education, 8, 89 –94.Walker, K. & Zeidler, D. (2007). Promoting discourse aboutsocioscientific issues through scaffolded inquiry. InternationalJournal of Science Education, 29, 1387-1410.


Figure 1.Class Debate Instructions

Goals of the activity:• Conduct research to gain understanding about the impacts of obesity for those affected and in our society• Communicate, persuasively, the impacts of obesity both for individual and society• Evaluate the quality of evidence articulated in arguments

What is a resolution?A resolution, when in context of law, is a written motion to be presented, debated, and adopted by a deliberative body.Half of the class will debate one resolution; while the other half will debate the other:

1. Be it resolved that the community will instigate extra fees for what is deemed to be excessively fatty foods.2. Be it resolved that the community will offer tax incentives for consumers choosing what is deemed to be healthy

food.

Presenting the debate:Students should determine the order with which they wish to present in the debate, with the ‘for group presenting beforethe ‘against’ group. Each person will have 2 minutes to present an argument and 1 Minute to present their rebuttal. Besure to practice speech/argument before presenting it to the class. This cannot be emphasized enough. Even the mostcompelling information may not come across effectively if pacing and tone are unpolished. Students may choose to bringa notecard of bulleted points to the podium, but should avoid reading from the card.

Preparing for the debate:Rather than attempting to rattle of facts about the fat tax, select a specific thread to make an argument. For example, ifthe debate were about global warming and a student is in the role of scientist, that student may choose to focus on therelated human health aspects rather than trying to cover everything about global warming.

Visuals can be very helpful in persuasive arguments, but only if they are related to and enhance the argument. However,the most important aspect of the prepared argument is that it is grounded in scientific evidence. Utilize original researcharticles from peer-reviewed journals and information from government websites. Students may use other sources forbackground information or as springboards to identifying specific sub-topics, but using original scientific research isrequired.

Students should be sure to listen to the opposing side and make notes of points that they could use in their rebuttals.Students will have 1 minute each for a rebuttal, and their teams will have 10 minutes to prepare rebuttals. Students shouldremember they are presenting as a “for” group and an “against” group. While it is not necessary to work together inpreparing arguments, it does make sense to coordinate sub-topics and ensure no overlap of points.

Students should submit:• A reference list of the sources used to prepare arguments• Notes, note cards, etc. used during your presentation• A peer-evaluation of other group’s presentation


Figure 2.Debate Rubric & Peer Evaluation

Team RubricCriteria 5 3 1

Content1.12.7. compare and contrastthe benefits of and barriers topracticing a variety of healthybehaviors.

All information presented wasclear, accurate, & thorough

Most information presentedwas clear and accurate, but notalways thorough

Information had some majorinaccuracies or was not clear

Content2.12.10. analyze how publichealth policies and governmentregulations can influencehealth promotion and diseaseprevention.




Content5.12.7. evaluate theeffectiveness of health- relateddecisions.




Rebuttal All counter-arguments wereaccurate, relevant, andeffective

Most counter-arguments wereaccurate and relevant, butseveral were weak

Counter-arguments were notaccurate and/or relevant

Use of Data Every major point was wellsupported with relevant dataand examples

Every major point wassupported by data, but therelevance or accuracy of somewas questionable

Every major point was notsupported by data

Organization Team’s arguments were clearlyorganized to connect to centralpremise

All arguments were tied to acentral premise, but theorganization was sometimesunclear

Arguments were not tied to acentral premise

Understanding of Issue Team clearly understood thetopic in-depth and informationwas conveyed persuasively

Team seemed to understandthe main points of the topic, butwere not thorough

Team did not show anadequate understanding of theissue

Presentation Style Team consistently usedgestures, eye contact, tone ofvoice, and a level ofenthusiasm that kept theattention of the audience

Team sometimes usedgestures, eye contact, tone ofvoice, and a level ofenthusiasm that kept theattention of the audience

Team’s presentation style didnot keep the attention of theaudience

TOTAL:

Peer EvaluationCriteria Rating (1-10) Comments

Opening Statement: Clear, factual, relevant, & well organized

1st Debater (Name: ):Argument was stated clearly, relevant, & well informed

1st Debater’s Rebuttal: Rebuttal was informed & effective

2nd Debater (Name: ):Argument was stated clearly, relevant, & well informed

2nd Debater’s Rebuttal: Rebuttal was informed & effective

3rd Debater (Name: ):Argument was stated clearly, relevant, & well informed

3rd Debater’s Rebuttal: Rebuttal was informed & effective

4th Debater (Name: ):Argument was stated clearly, relevant, & well informed

4th Debater’s Rebuttal: Rebuttal was informed & effective

Overall preparedness, effectiveness, & professionalism in the debate

Which team won the debate and why?


K nowledge about food and healthy eating isso important that it has found its way into

many areas of the National Curriculum in use inEngland today. Despite this, we are in the midstof an obesity crisis with The World HealthOrganisation (WHO, 2014) stating that ‘obesityis one of the greatest public health challenges ofthe 21st Century’. Paradoxically, anorexia casesrequiring hospital treatment in England havealso risen by 10% in the last 10 years (TheTelegraph, 2009). Food and healthy eating formspart of the Science, Design and Technology (DT)and Personal, Social and Health Education(PSHE) remits so one might assume that pupilsobtain a good understanding of the subjectthrough their schooling. However, the figuresappear to contradict this.

I approached this area as part of a doctoralresearch project looking at progression in theScience curriculum (Ryland, 2009a). There hadbeen reporting of pupils’ discontent due to poorprogression and repetition (Lord and Jones,2006). However, research was yet to confirmwhether these claims were justified. TheNational Curriculum is based on the spiralcurriculum proposed by Jerome Bruner (1960).Bruner (Ibid.) surmised:

A curriculum as it develops should revisit thebasic ideas repeatedly, building upon them untilthe student has grasped the full formalapparatus that goes with them. (p.13)This means that fundamental concepts are

introduced in a basic form in key stage 1 (KS1)and are then revisited and developed in laterkey stages. Progression is paramount in thesuccessful implementation of a spiralcurriculum.

The StudyMy study centred on concepts connected to

food and healthy eating for pupils in KS1 to

KS3. One primary and one secondary schoollocated in Birmingham were involved in thestudy. The research was designed to assessprogression through documentary analysis ofthe National Curriculum Science programme ofstudy (PoS) (DfEE and QCA, 1999; QCA, 2007);the Qualifications and Curriculum Authority’sschemes of work (QCA, 1998); the schools’schemes of work; and pupils’ exercise books.The views of pupils and teachers at the twoschools were also sought.

Documentary analysisThe National Curriculum Programme of Study(1999)

Food and healthy eating was found to betaught at each KS of the National Curriculum.When the statutory content was analysed, it wasfound to show clear progression. The statutorycontent developed progression in both the useof language and the depth of knowledge. In KS1the language focused on ‘types of food’. Iinterpreted this as meaning foodstuffs such asbread, meat, potatoes, fruit and etc. In KS2 thefocus was on what food is used for, thus makingthe link between food and activity, growth andhealth, for example, meat/beans help us grow.Some more technical terms such as ‘adequate’and ‘a varied diet’ were also introduced. In KS3the key term ‘a balanced diet’ and the scientificterms for the main nutrients such ascarbohydrates, proteins etc. were detailed. Thesources of these nutrients were also covered.Digestion was not covered at all in KS1; in KS2the very beginning of the digestive process wasintroduced by covering the function of teeth; inKS3 the digestive system was explored inaddition to the function of enzymes. At eachkey stage there were aspects that were revisitedand developed and further new aspects werealso introduced.

This article is based on a doctoral research project “Food and healthy eating: progression in the curriculum”.For communication, please email: [email protected]

Frances RylandFood and Healthy Eating in the Curriculum – a case of toomany cooks spoiling the broth


A new PoS for KS3 (QCA, 2007) wasintroduced in schools in 2008. The statutorycontent it proscribed was difficult to analyse forprogression in relation to the previous two keystages as it was particularly vague whencompared to the 1999 version. It seems relevantto note at this stage that despite the introductionof a new PoS in 2008 (during the field workstage of the research), both the school and QCAstated at the time that they had no plans tochange their existing schemes of work based onthe 1999 publication. Put simply, the new PoSwas introduced to little effect. The reasonsbehind this will be discussed later, along withteachers’ views of the curriculum.The Schemes of Work

The PoS is translated by schools into schemesof work. The QCA published schemes of work(QCA, 1998) as part of their non-statutoryguidance and these could be adopted byschools. The primary school in the study usedthese schemes whereas the secondary schooldeveloped their own.

The QCA schemes of work revisited the foodand healthy eating twice per KS from KS1 toKS3; this was in years 1, 2, 3, 5, 6, 8, and 9. Thesecondary school’s schemes of work alsorevisited the topic twice in KS3 in years 8 and 9.When the content of the schemes of work wereanalysed for progression, there seemed to belittle between the first and second revisit withinKS1 and KS2 and some between the revisits inKS3 (Ryland, 2009b). For example, in thelearning objectives, scheme 3A for year 3 states‘an adequate and varied diet is needed to keephealthy’ (p.2) and in the year 5 scheme 5A ‘tostay healthy we need an adequate and varieddiet’ (p.2). These objectives appear to beidentical and it is difficult therefore to identifypossible progression in their outcomes.Progression was much easier to observe in KS3,as the content covered was significantlydifferent in theme, with year 8 concentrating onnutrients included in a balanced diet, digestionand enzymes and year 9 getting to grips withthe intricacies of a balanced diet and focussingon deficiencies, disease, malnourishment andthe adverse health effects of an excess of someminerals such as salt.

The QCA schemes of work were also found tobe confusing as to when certain concepts shouldbe introduced. This was mainly because they

contained terms within their guidance toteachers which were unsuitable for use with thepupils. For example, Unit 5A for year 5 states:

‘…children do not need to be able to classifyfoods formally into groups such as protein orcarbohydrate’ and later ‘most children should beable to understand that energy foods are of twotypes - carbohydrates (starches and sugars) andfats.’ (p.2)To the casual reader it may appear that the

term carbohydrate was to be covered with year5 pupils. However this is not included in theNational Curriculum until KS3.

Another confusing example appears in thescheme 2A for year 2 (KS1), which outlines howsome pupils will be able to ‘describe how theirdiet is balanced’ (p.1). So the words ‘diet’ and‘balanced’ are being used in close connection,yet the National Curriculum does not introducethe term ‘diet’ until KS2 and ‘balanced’ untilKS3. This suggests that some pupils maydevelop some understanding of the concept of‘balance(d)’ two key stages earlier than planned.This may be an attempt to show potential fordifferentiation. However the mere mention inthe scheme could indicate to teachers that theyshould be teaching the term to all pupils. Iexpect that some pupils could adopt and use thephrase relatively easily, but without graspingthe true scientific interpretation as covered inKS3.Pupil exercise books

The analysis of pupils’ exercise books waspossibly the most informative aspect of thestudy. This revealed what had actually beenincluded in classwork and homework. Theanalysis included books from each of years 2, 3,5, 8 and 9. It showed that certain aspects wereintroduced much earlier than stated in theNational Curriculum and then repeated at eachrevisit throughout the pupils’ education. Forexample key nutrient types, such ascarbohydrates and proteins, were covered inyear 2 (KS1) and then repeated at each revisit inyears 3, 5, 8 and 9 although these concepts werenot included in the National Curriculum untilKS3. So pupils were being exposed to repetitivecontent throughout their education. Suchscientific terms were observed in the exercisebooks in pupils’ own notes and also inexternally produced worksheets for KS1 andphotocopies of KS2 revision guides (Parsons,


1999 reprinted 2005). Despite this repetition,some aspects did show progression. However,this was achieved by ‘borrowing’ content fromthe next key stage. For example, pupils in year 5(KS2) gained progression by learning about thefunction of the digestive system which was onlydescribed in the PoS for KS3. As a result of thisearly introduction pupils were exposed torepetitive content in KS3.Comparative analysis of documentary sources

When the documentary sources werecompared, it was found that 42% of theconcepts identified in the National CurriculumPoS were introduced early in the exercise books.It was also noted that more concepts and keywords were observed in the exercise books thanwere observed in the corresponding schemes ofwork in KS1 and KS2. For example, in the QCAscheme of work for year 2 fifteen concepts andkey words were included yet twenty-nine wereobserved in the books. Thus, more content wascovered with the pupils than was required bythe statutory content of the NationalCurriculum or the non-statutory guidance givenin the QCA schemes of work and this was thecase for all years in KS1 and KS2 in the study.Pupils’ voice

Pupils in years 5, 8 and 9 participated in thepupils’ voice phase of the study, completingquestionnaires on the food and healthy eatingtopic. A sub-set of pupils also took part in focusgroups.

The majority of pupils felt learning aboutfood and healthy eating was important andshould be taught in school because theyrecognised the health benefits arising from suchknowledge. However, pupils also felt that it wascovered too frequently and this lead torepetition and boredom. The pupils alsoreported learning about food and healthy eatingfrom many sources both inside and outside ofschool and this compounded their negativefeelings. They identified how the same content,such as food groups (fats, carbohydrates andproteins etc.) and a balanced diet was coveredin Science, DT and PSHE lessons. Pupils wereleft feeling that they learnt about food ‘everyyear’ and this was too much.Teacher Voice

Four teachers were interviewed as part of thestudy. These included a class teacher and a head

of department from each school who wereinvolved in teaching the pupils in the study.

The teachers were largely unaware of whatthe pupils had learnt about food and healthyeating in the previous KS. For example, a KS2teacher stated that he had ‘no idea’ what wastaught about food and healthy eating in KS1and a KS3 teacher stated ‘I think they vaguelycover healthy eating’ at KS2. As they wereunaware of the detailed knowledge that thepupils had, they unwittingly included conceptsin their lessons that were repetitive for thepupils.

However they were much clearer about whathad been taught earlier in the KS they wereteaching as all the teachers in the study taughtboth years within a KS. This in-depthknowledge of the schemes of work and ofpupils’ experiences led the KS2 teachers tointroduce KS3 concepts early because they feltthe QCA scheme did not offer enoughprogression for their pupils. The primary headof department, when speaking generally aboutthe entire curriculum, stated:

We are aware that we cover some material fromsecondary school…we like to extend thechildren…[I am aware] they then get bored inyear 7 and 8.The KS3 teachers were aware that some KS3

content was covered in KS2. The head ofdepartment stated:

In my view for primary schools to make theirexperience more pleasant they are nicking all theKS3 practicals [experiments]. So when the kidsget here they find it dead boring… You see thisis where prescription would be (pause) ISessential.He also outlined concerns that the 2008 PoS

was too vague and described the content asappearing to be ‘top secret’ and felt that‘absolutely anything’ could be included inexams. It was this feeling of vagueness that ledthe schools not to alter their schemes of workwhen the new PoS was introduced in 2008.

Discussion of the studyThe three phases of the study highlighted

some key areas of concern regarding therepetition of concepts in Science lessons andidentified some areas where future researchcould identify the extent of the overlap with DT


and PSHE. Since the completion of the study,the new Coalition Government instigated aconsultation on the National Curriculum. Isubmitted detailed data to that consultation,outlining my concerns regarding the teaching offood and healthy eating. This consultationculminated in the publishing of a newcurriculum (Department for Eduation (2013b)for Science and DT (Department for Eduation(2013a) and I will now reflect on thesedocuments.Curriculum 2013

My first observation is that the new PoS forScience details content on a yearly basis in KS1& KS2 as opposed to the KS basis detailed inearlier documents. Looking at KS1 and KS2,food and healthy eating first appears in year 2.The 2013 statutory content is very similar to thatincluded in the 1999 PoS, including types offood in the right amounts and the importance ofexercise. Similar concepts are covered in year 3,including food types and amounts of ‘nutrition’.The non-statutory guidance for this year alsomentions ‘food groups’, but does not specifyterms such as carbohydrates etc. In year 4pupils look at teeth. This again mirrors thecontent of the 1999 PoS, but differs in that thebasic function of the digestive system is alsoincluded. This was previously KS3 content,although this study observed it beingintroduced in year 5. The topic is also revisitedin year 6, when pupils consider the ways inwhich nutrients are transported within animals.This was previously included in KS3 in the 1999PoS. So, in summary, the food topic is revisitedin years 2, 3, 4 and 6 in the new 2013curriculum, whereas those following the non-statutory guidance of the QCA schemes basedon the 1999 version revisited it in years 1, 2, 3and 5.

In KS3 the content is not described on a yearlybasis and includes the key scientific termscarbohydrates, proteins etc., the consequencesof imbalances, deficiency disease and thedigestive system and enzymes. This reflectsclosely the 1999 PoS for KS3.

The overall feel of the 2013 PoS is that is verysimilar to the 1999 version, all bar a smallamount of tweaking to reflect what was beingtaught in schools anyway. My overriding

concern however is that I do not believe it willsolve the problem of repetition as it is notprescriptive enough. This is highlighted by thefact that the terms for the nutrient types onlyappear in the statutory content for KS3, yetevidence suggest their use in school from KS1.Indeed they were included in publishedrevision guides for KS2 (Parsons, 1999 reprinted2005).

I shall now turn to the new DT PoS andidentify a potential overlap with the Sciencecurriculum. In the ‘cooking and nutrition’section, content is detailed for each from KS1 toKS3. Content which has a clear identifiableoverlap with Science includes the principles of ahealthy and varied diet in KS1 and KS2 whichwould almost undoubtedly lead to the inclusionof food types. These concepts are revisited inKS3 when pupils should be taught tounderstand and apply the principles ofnutrition and health. As an example of howsuch overlap or repetition is likely to occur, theScience PoS for year 3 ‘notes and guidance’suggests that pupils (Department for Education,2013b):

Might research different food groups and howthey keep us healthy and design meals based onwhat they find out (p.17)This also seems to be an entirely appropriate

activity for the KS2 DT statutory content(Department for Education, 2013a):

Understand and apply the principles of ahealthy diet (p.5)In Science, pupils research how certain foods

keep us healthy this is directly comparable tothe pupils in DT understanding the principles ofa healthy diet. Further, when the guidance inthe Science PoS suggests pupils design meals,this could also be thought of as applying theprinciples of a healthy diet as outlined in the DTPoS.

In summary, the 2013 National Curriculumcontinues to be vague, thus allowing a varietyof different interpretations for a wide age groupof pupils. Although this might appear to makeit flexible, it is easy to see how repetition couldcontinue to occur.ReferencesBruner, J. (1960). The process of education. Cambridge,Massachusetts: Harvard University Press.


Department for Education (2013a). National curriculum inEngland: design and technology programmes of study [online].Available from:https://www.gov.uk/government/publications/national-curriculum-in-england-design-and-technology-programmes-of-study/national-curriculum-in-england-design-and-technology-programmes-of-study Accessed 13 January 2014Department for Education (2013b). National curriculum inEngland: science programmes of study [online]. Available from:https://www.gov.uk/government/publications/national-curriculum-in-england-science-programmes-of-study/national-curriculum-in-england-science-programmes-of-studyAccessed 13 January 2014Department for Education and Employment (DfEE) andQualifications and Curriculum Authority (QCA) (1999). Science:The National Curriculum for England. London, DfEE and QCA.Lord, P. and Jones, M. (2006). Pupils' experiences andperspectives of the National Curriculum and Assessment: Finalreport for the research review. Slough, NFER.Parsons, R. (1999; reprinted 2005 3rd ed.). Key stage twoScience: the important bits. Coordination Group Publications Ltd.QCA (1998). Schemes of Work [online]. Available from:http://webarchive.nationalarchives.gov.uk/20090608182316/standards.dfes.gov.uk/schemes3/ Accessed 13 January 2014QCA (2007). Science Programme of Study for Key Stage 3.London, QCA.

Ryland. F. (2009a). “Food and healthy eating: documentanalysis to explore progression in the curriculum, Years 5-9.”Ph.D. thesis. School of Education, University of Birmingham.Available from: http://etheses.bham.ac.uk/4342/ Accessed 13January 2014Ryland. F. (2009b). “Food and healthy eating: documentanalysis to explore progression in the curriculum, Years 5-9.” InCorcoran C. and Cooke S. (eds.) Papers from studentconference. Education research, education researchers: diverseexperiences and perspectives. Birmingham: University ofBirmingham School of Education. pp135-144The Telegraph (2009). Anorexic girls admitted to hospital rise by80% in a decade [online]. Available from:http://www.telegraph.co.uk/health/women_shealth/4682209/Anorexic-girls-admitted-to-hospital-rise-by-80-per-cent-in-a-decade.html Accessed 13 January 2014WHO (2014). Obesity [online]. Available from:http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/obesity Accessed 13 January 2014





"The (named) Children and Young People's Partnership has benefitted from the results of the SHEU survey locally for many yearsnow, and we should like to continue to do so in future."

Consultant in Public Health Medicine



Over the last year, there have been anincreasing number of media reports about

the potentially exploitative and/or addictivenature of various types of social game that caneither be played via social networking sites orbe played after downloading apps from onlinecommercial enterprises such as iTunes (Griffiths,2013a). Most social games are easy to learn andcommunication between other players is often(but not always) a feature of the game, and theytypically have highly accessible user interfacesthat can be played on a wide variety of differentdevices (e.g., smartphones, tablets, PCs, laptops,etc.). According to Church-Sanders, (2011) thereare eight different types of social gaming (seeTable 1), most of which can (and are) played bychildren and adolescents.

In my own household, the two most populargames played by my family at the moment arethe competitive casual games Candy Crush Sagaand 4 Pics, 1 Word (both highly popular gamesacross the UK more generally). In fact, at thetime of writing this article, the most populargame being played worldwide on Facebook wasCandy Crush Saga (CSS) with over 133 millionpeople playing monthly. Most players of CSSappear to be adult but around 10% of playersare thought to be adolescents. Clearly, mostpeople that play social games find them fun andenjoyable to play with little or no problem.However, I have been receiving an increasingnumber of emails from parents, teachers, andthe press about some of the more negativeaspects of social gaming.

Table 1: Social networking games by genre (from Parke et al., 2013, adapted from Church-Sanders, 2011)

Genre Features Examples

Role playing gamesUse the social graph (a player’ssocial connections) as part of thegame

Parking Wars, PackRat, Mobsters,Fashion Wars, Mafia Wars,Vampire Wars, Spymaster

Management/nurturing gamesMain gameplay involves socializingor social activities like trading orgrowing

YoVille, Pet Society, FarmVille,Cupcake Corner, CityVille

Turn-based card, board and parlourgames

Played within a social context orwith friends

Farkel Pro, Monopoly

Virtual currency gamblingGames which would otherwise beplayed in a gambling context

Texas Hold’Em Poker, Bingo, Slots

Competitive casual gamesOften word-based with friends onlyleaderboards

Words with Friends, Scramble,Scrabble

Dating and Flirting Aim to meet (or dump) peopleFriends for Sale, Human Pets,Chump Dump

Sports games Based on real-life sporting activitiesPremier Football, Tennis Mafia,FIFA Superstars

Virtual jokesGimmicky games that tend to bepopular when initially launchedthen fade in popularity

Pillow Fight, Kickmania, WaterGun Fight

Dr Mark D. Griffiths is Professor of Gambling Studies and Director of the International Gaming Research Unit, Psychology Division,Nottingham Trent University.For communication, please email: [email protected]

Mark D. GriffithsChild and adolescent social gaming: What are the issues ofconcern?


There are arguably three main concernsrelating to adolescent social gaming that havebeen aired in the national media. Firstly, thereare concerns about the way games companiesare making money from players by makingthem pay for in-game assets, in-game currency,and/or access to other levels within the game.Secondly, there are concerns about howengrossing the games can be that have led tovarious news reports claiming that a smallminority of people appear to be “addicted” tothem. Thirdly, there have been concerns thatsome types of social games are a gateway toother potentially problematic leisure activities –most notably gambling. This latter issue wascovered in a previous issue of Education andHealth (see Griffiths, 2013b). Therefore the restof this article looks at these two remainingissues.

Exploitative practices in social gamingAlmost anyone that has engaged in social

gaming will have played 'freemium' products.Freemium social games give free access to thegame being played, but players must pay for so-called 'premium' services. A recent review onsocial gaming and gambling by Parke, Rigbye,Parke and Wardle (2013) defined ‘freemium’games as:

“A business model in which users of the service(in this context, game) usually play for free butare encouraged to pay: for extended game play;to compete with others/status; to expressthemselves; to give virtual gifts; and to obtainvirtual goods which are valuable due to theirscarcity” (p.16).In games like CCS, players are not charged to

advance through the first 35 levels but afterthat, it costs 69p for another 20 levels. Playerscan avoid paying money by asking their friendson Facebook friends to send them extra lives.Players on CCS are encouraged to buy 'boosters'such as virtual 'candy hammers' for around £1.Although this does not appear to be muchmoney, the buying of in-game assets and itemscan soon mount up.

In 2013, many news outlets covered the storyof how two boys (aged just six and eight yearsof age) spent £3200 on their father’s iPhonebuying virtual farm animals and virtual farmfood with real money at £70 a time (Talbot,2013). Another case involved a ten-year-old boy

who ran up a £3,000 bill on the game ArcaneEmpire on iTunes (Gradwell, 2013). As aconsequence of these and other high profilecases, the UK Office of Fair Trading is nowinvestigating whether children and adolescentsare being unduly pressured and/or encouragedto pay for in-game content (including theupgrading of their game membership and thebuying of virtual currency) when they play freegames.

I have noted in a number of my more generalwritings about games played via socialnetworking sites that ‘freemium’ games arepsychological ‘foot-in-the-door’ techniques (seeGriffiths, 2010a) that lead a small minority ofpeople to pay for games and/or gameaccessories that they may never have originallyplanned to buy before playing the game (akin to‘impulse buying’ in other commercialenvironments). I’ve also argued in a number ofarticles that many of the games played on socialnetwork sites share similarities with gamblingespecially as they both involve in-gamespending of money (e.g., Griffiths, 2010b;2013b).

Although social gaming operators need to bemore socially responsible in how they markettheir games and how they stimulate in-gamepurchasing, parents themselves also need totake responsibility when letting their childrenplay social games or allowing them todownload gaming apps. Simple measures thatcan help stopping children unwittingly buy in-game items for real money include:(i) not giving children access to online store

passwords(ii) personally overseeing any app that they

download(iii) using parental controls on phones and

tablets(iv) unlinking debit/credit card cards from

online store accounts (i.e., do not storepayment details with online stores)

(v) actually talking with children themselvesabout the buying of in-game extras

‘Addiction’ to social gamingIn my interviews to the national press and

online media (e.g., Foster, 2013; Hall, 2013;Pressmen, 2013; Rose, 2013) about what makesgames like CCS attractive and potentiallyaddictive, I have noted a number of different


aspects. Games like CCS are gender-neutralgames that have a ‘moreish’ quality (a bit likeeating chocolate), and as such may appeal moreto girls than boys (although I know boys amongmy own children’s peer group that play CCS).Social games like CCS and Farmville take up allthe player’s cognitive ability because anyoneplaying on it has to totally concentrate on it. Bybeing totally absorbed, players can forget abouteverything else while engaging in the activity.These are some of the psychologicalconsequences of other more mainstreamchemical addictions (e.g., alcoholism) andbehavioural addictions (e.g., gamblingaddiction).

At their heart, social games are deceptivelysimple and fun but can be highly rewarding onmany different levels (e.g., psychological, social,physiological, and financial). As I argued in aprevious article (Griffiths, 2013), social gameslike CCS and Farmville may not seem to havemuch connection to gambling, but thepsychology used by the games developers isvery similar. People cannot become addicted tosomething unless they are being constantlyrewarded for engaging in the activity. Likegambling and video game playing moregenerally, the playing of social games providesconstant rewards (i.e., behavioural andpsychological reinforcement) that in a smallnumber of instances could result in a personbecoming ‘addicted’ to the game they areplaying.

Even when games do not involve money,most social games introduce players to theprinciples and excitement of gambling. Smallunpredictable rewards lead to highly engaged,repetitive behaviour. In a minority, this maylead to addiction (Griffiths, 2013b). Basically,people keep responding in the absence ofreinforcement hoping that another reward isjust around the corner – a psychologicalprinciple rooted in operant conditioning andcalled the partial reinforcement extinction effect– something that is used to great effect in bothslot machines and most video games (Griffiths,2010b). At present there is little empiricalevidence that social gaming is causingaddiction-like problems on the scale of moretraditional online games (e.g., World of Warcraft,League of Legends, etc.), although researchers are

only just beginning to research into the socialgaming area.

Looking aheadIn a previous article on social gaming I

argued that the introduction of in-game virtualgoods and accessories (that people pay realmoney for) was a psychological masterstroke(Griffiths, 2012). It becomes more akin togambling, as social gamers know that they arespending money as they play with little or nofinancial return. The real difference betweenpure gambling games and some free-to-playgames is the fact that gambling games allowyou to win your money back, adding an extradimension that can potentially drive revenueseven further.

The psychosocial impact of social gaming onadolescents is only just beginning to beinvestigated by people in the field of gamingstudies. Empirically, we know almost nothingabout the psychosocial impact of these games,although as I noted in my previous Educationand Health article (Griffiths, 2013b), researchsuggests the playing of free games amongchildren and adolescents is one of the riskfactors for both the uptake of real gambling andproblem gambling.

Parke et al. (2013) recommended that stricterage verification measures should be adopted forsocial games particularly where children andadolescents are permitted to engage ingambling-related content, even where realmoney is not involved. I would add that ageverification should be carried out in any gamethat requires the spending of money (even if iton virtual assets and items). Social media hasenabled (and arguably encouraged) childrenand adolescents to spend money in-game andthere is certainly some evidence that thetechniques used to monetize social games haveresulted in a minority of children andadolescents spending large amounts of money.

To date, there is less evidence that youth aredeveloping addictions to social games althoughthis is more due to the fact that scientificresearch has yet to study such activity. Giventhe growing evidence on adolescent onlinevideo game addiction and adolescent socialnetworking addiction more generally (e.g., Kuss& Griffiths, 2011; 2012; Griffiths, Kuss &


Demetrovics, 2014), there is no reason tosuppose that a small minority of children andadolescents would not develop an addiction tosome types of social gaming.

References

Foster, J. (2013). How women blow £400,000 a day playingCandy Crush, the most addictive online game ever. Daily Mail,October 17. Located at: http://www.dailymail.co.uk/femail/article-2463636/How-women-blow-400-000-day-playing-Candy-Crush-addictive-online-game-ever.html Accessed 27 January 2014.Church-Sanders, R. (2011). Social Gaming: Opportunities forGaming Operators. iGaming Business: London.Gradwell, H. (2013). How to stop your kids accidentallyspending your money on apps and games. Think Money, April12. Located at: http://www.thinkmoney.co.uk/news-advice/stop-kids-accidentally-spending-your-money-on-apps-and-games-0-4111-0.htm Accessed 27 January 2014.Griffiths, M.D. (2010a). Online gambling, social responsibilityand ‘foot-in-the-door techniques’. i-Gaming Business, 62, 100-101.Griffiths, M.D. (2010b). Gaming in social networking sites: Agrowing concern? World Online Gambling Law Report, 9(5), 12-13.Griffiths, M.D. (2012). The psychology of social gaming.i-Gaming Business Affiliate, August/September, 26-27.Griffiths, M.D. (2013a). The psychosocial impact of gamblingapps. Youth Gambling International, 13(1), 6-7.Griffiths, M.D. (2013b). Adolescent gambling via socialnetworking sites: A brief overview. Education and Health, 31,84-87. http://sheu.org.uk/sites/sheu.org.uk/files/imagepicker/1/eh314mg.pdf Accessed 27 January 2014.

Griffiths, M.D., Kuss, D.J. & Demetrovics, Z. (2014). Socialnetworking addiction: An overview of preliminary findings. In K.Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria,Evidence and Treatment (pp.119-141). New York: Elsevier.Hall, C. (2013). Just how addictive are mobile games? Yahoo!News, October 18. Located at: http://uk.news.yahoo.com/how-addictive-are-mobile-games--143654713.html#P1M3U7aAccessed 27 January 2014.Kuss, D.J. & Griffiths, M.D. (2011). Online social networking andaddiction: A literature review of empirical research. InternationalJournal of Environmental and Public Health, 8, 3528-3552.Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction inadolescence: A literature review of empirical research. Journalof Behavioral Addictions, 1, 3-22.Parke, J., Wardle, H., Rigbye. J., & Parke, A. (2013). Exploringsocial gambling: Scoping, classification and evidence review.Report Commissioned by the UK Gambling Commission. TheGambling Lab: London.Pressman, A. (2013). Candy Crush: Insanely addictive today,but likely on borrowed time. The Exchange, July 11. Located at:http://finance.yahoo.com/blogs/the-exchange/candy-crush-insanely-addictive-today-likely-borrowed-time-171103788.htmlAccessed 27 January 2014.Rose, M. (2013). Chasing the Whales: Examining the ethics offree-to-play games. Gamasutra, July 9. Located at:http://www.gamasutra.com/view/feature/195806/chasing_the_whale_examining_the_.php?page=7 Accessed 27 January 2014.Talbot, B. (2013). My 6yr-old spent £3,200 playing iPhone game– How to stop it. Money Saving Expert. February 19. Located at:http://www.moneysavingexpert.com/news/phones/2013/02/kids-spent-3200-iphone-avoid-app-charge-hell Accessed 27 January2014.





"The survey reports have been used to inform commissioning at specific commissioning groups. They are also being used withinour Extended Schools Clusters and to inform The Annual Public Health and the Joint Strategic Needs Assessment."




M ental health is an essential component ofsocial cohesion, productivity, peace and

stability in the living environment, contributingto social capital and economic development insocieties (World Health Organization, 2008). In2005, the World Health Organizationestablished the promotion of mental health as apublic health priority, and recognized theimportance of intervening primarily in youngpeople (World Health Organization, 2005).

Different reasons support the need to focus onthis target group including: youngsters’ naturalrisk of developing a mental disorder (Patel etal., 2007); early stage of life is a period whenattitudes are developing and can still bechanged (Corrigan and Watson, 2002;Livingstone et al., 2013).

Considering the current scenario of economicand social crisis in Europe, promotion of mentalhealth has become even more urgent, sincevulnerabilities associated with earlydevelopment are being even more threatenedby external factors, such as financial difficultiesor unemployment of parents, which may leadadolescents to develop mental health problems[e.g., depression (European Parliament, 2012)].

Improving mental health literacy in youngpeople, in order to increase their capacity todeal with expected and unexpected challenges,is an unquestionable priority. The concept ofmental health literacy refers to the “knowledgeand beliefs about mental disorders which aidtheir recognition, management or prevention”(Jorm et al., 1997, p. 182). Mental health literacyis not limited to having knowledge, since

knowledge is linked to beliefs that togetherdetermine attitudes (e.g. resistance to seekprofessional help). Early recognition of mentalhealth problems and the appropriate help-seeking behaviours will only occur if youngpeople are appropriately “literate” in this field(Jorm et al., 1997).

The last decades have witnessed thedevelopment of effective programmes topromote mental health (WHO, 2005, 2010);school setting is considered the privilegedcontext to develop such initiatives (Kelly et al.,2007).

Based on the lack of systematic healtheducation initiatives concerned with mentalhealth in Portugal, the "Finding Space to MentalHealth” project was carried out, in order todevelop a school-based intervention to promotemental health literacy in young people (12-14year olds). It comprises three major phases: pilotstudy, intervention and follow-up.The pilot study included two major steps:1. A qualitative study, using focus groups,

aimed at developing the “Mental HealthLiteracy questionnaire” and

2. The “mental health promotion intervention”2

The implementation of a pilot intervention inorder to study its appropriateness and to studythe psychometric properties of the questionnaire.This allowed to guarantee the adequacy of theintervention’s message to the specific target group(methodological accuracy - contents, format, and“wording”); to conduct a preliminary evaluationof the intervention; and to improve theprogramme’s contents and methods.

Luísa Campos, Pedro Dias and Filipa Palha are researchers at the Centre for Studies in Human Development, and Professors at theFaculty of Education and Psychology, Catholic University of Portugal.For communication, please email: [email protected]

Luísa Campos, Pedro Dias and Filipa PalhaFinding Space to Mental Health1 - Promoting mental healthin adolescents: Pilot study

1"Finding Space to Mental Health - Promoting mental health in adolescents (12 – 14 years old): development and evaluation of an intervention”(PTDC/PSI-PCL/112526/2009) - is developed by the Faculty of Education and Psychology of the Catholic University of Portugal (Oporto RegionalCenter), and funded by Science and Technology Foundation, in partnership with ENCONTRAR+SE – Association for the promotion of mental health.2 For more detailed information regarding the methodology developed in the pilot study see: project website(www.porto.ucp.pt/fep/abrirespacosaudemental/); Campos, et al (in press)


Considering the challenge of engaging youngpeople in a subject not “appealing” and usuallyassociated with stigmatised beliefs, the need toconsider age-related issues (e.g., language,group dynamics, and age-related life events),and the importance to use attractive materials(e.g., music, videos) were considered whendeveloping the intervention.

This article presents the results concerning theimpact of the mental health promotionintervention, developed and tested during thepilot study.

MethodParticipants

Seventy students from three classes attendinga private secondary school (38.6% in 7th grade,41.8% in 8th grade and 20% in 9th grade) wereincluded in this study. Students were agedbetween 12 to 14 year-olds (M=13.11; SD=0.81),and 41.8% were female. Concerning caregivers’professional status, 91.4% were employed.MeasureMental Health Literacy questionnaire

The version3 of the Mental Health Literacyquestionnaire that was used in this studycomprised 4 sections: 1) social-demographicinformation. 2) knowledge about mental healthproblems. 3) First Aid skills & help seeking. 4)self-help strategies. Sections 2 to 4 include 48items organized in a 5-point Likert scale(1=strongly disagree; 5=strongly agree) and amultiple-choice item.

The social-demographic form includesstudents’ age, gender, school year, andcaregivers’ professional status.

A preliminary analysis of the psychometricproperties of the questionnaire – constructvalidity and internal consistency – wasconducted with a sample of 239 students agedbetween 12 to 14 years old (M=12.95; SD=0.88),46.4% female. An exploratory factor analysis(EFA) suggested a 3-factor structure: 1)knowledge, 2) First Aid skills & help seeking,and 3) self-help strategies. Internal consistency,assessed with Cronbach’s alpha, revealed goodreliability scores for the three dimensions:knowledge = 0.76; First Aid skills & helpseeking = 0.78; self-help strategies = 0.73(Campos et al., 2012).

The Knowledge section comprised 32 itemsregarding prevalence and general characteristicsof mental health problems, risk factors,symptoms of five mental disorders (Depression,Generalized anxiety disorder, Anorexia,Schizophrenia and Substance-related disorder),impact and stereotypes related to mental healthproblems. This section also includes onemultiple-choice item, asking students to identifymental health problems from a list of elevenhealth problems.

The First Aid skills & help seeking sectioncomprised 10 items, including issues regardinginformal help seeking, formal help seeking, andFirst Aid skills.

The self-help strategies section included 6 itemsrelated to behaviours that can promote mentalhealth.

Based on the psychometric analysis of thequestionnaire (EFA and Cronbach’s alpha), 11items were removed from the followinganalyses.Mental health promotion intervention

The intervention was developed based on aliterature review on mental health literacy andpromotion, school based interventions andstigma towards mental health problems; adiscourse content from four focus groupsessions held with 34 students; the materialproduced during an anti-stigma campaign(www.encontrarse.pt/upa08); and the UPAMakes the Difference (Campos et al., 2012)project’s material.

The mental health promotion intervention isorganized in two sessions (90 minutes each),implemented with one-week interval. Theintervention was conducted by a graduatepsychologist and one master’s level psychologystudent. The first session includes:• the presentation of the project and

establishment of group rules• the exploration of students’ knowledge and

beliefs about physical and mental health andillness

• the exploration of mental health problems’signs, their impact and risk factors

• the identification of symptoms and signs offive mental disorders – Depression,Generalized anxiety disorder, Anorexia,Schizophrenia and Substance-related disorder

3Further study of the questionnaire, based on the results of the pilot study, allowed the development of the final version of the MHLq (Campos andDias, in prep).


• the promotion of non-stigmatized behaviourstowards mental disorders.

The second session aims:• to explore beliefs related to mental disorders• to raise students’ awareness of mental health

problems and their impact• to identify formal and informal help-seeking

options• to promote First Aid skills towards people

with mental health problems, and addressself-help strategies (mental health promotingbehaviours).Both sessions follow an interactive

methodology (e.g. group dynamics, videos, andmusic), using materials, language, andstrategies specifically developed taking intoaccount this target-group.Procedures

The Portuguese Ministry of Education and thePortuguese Data Protection Authorityauthorized data collection. Informed consentwas given by students’ caregivers and bystudents prior to their inclusion in the project.

Pre-intervention assessment was conductedone week prior to the implementation of thefirst session, and post-intervention assessmentoccurred one week after the second one. Schoolteachers collaborated in this task.

The sessions were scheduled to fit students’timetable, and delivered in their classrooms.Data analysis

Data was analyzed with IBM SPSS 21.0.Descriptive statistics were used for socio-demographic characterization, knowledge, FirstAid skills and help seeking, and self-helpstrategies; Paired Samples t Tests and WilcoxonSigned Rank Tests were performed in order toassess pre-post intervention differences.

A mean score was obtained for each section ofthe questionnaire (total scores persection/number of items). The values obtainedrange from 1-5, and higher scores refer to highermental health literacy. Seven knowledge itemsand one First Aid skills & help-seeking itemwere reverse-coded for calculating factor scores,since they are negatively phrased items.

A McNemar test was used to test pre-postdifferences in mental health problems identifiedon the multiple-choice item.

An alpha of 0.05 was used for statisticalsignificance.

ResultsKnowledge

There were significant differences betweenthe mean value before (M=3.92; SD=0.30) andafter (M=4.29; SD=0.23) the mental healthpromotion intervention (t(45)=-8.67; p<0.001). A detailed analysis shows significant differencesin 12 items of the knowledge section (see Table 1).

Concerning stereotypes, on post-intervention,significant differences were associated to thoseitems with higher levels on pre-intervention,namely item 8 (M=2.17; SD=0.99 – pre-test;M=1.48; SD=0.80 – post-test; Z=-4.52; p<0.001),item 9 (M=2.23; SD=0.90 – pre-test; M=1.61;SD=0.95; Z=-3.89; p<0.001), and item 38(M=2.67; SD=1.15 – pre-test; M=1.70; SD=1.03 –post-test; Z=-4.65; p<0.001).

Table 2 presents the percentage of studentsthat, from a list of 11 health conditions,considered them mental health problems. Therewas a significant decrease of physical problemsand disabilities identified by participants, frompre to post-intervention, as mental healthproblems (Down’s syndrome, Parkinson’sdisease and Cerebral palsy). On the other hand,there was a significant increase in mentaldisorders adequately recognized (Depressivedisorder and Generalized anxiety).First Aid skills and help seeking

There was a significant increase from pre(M=4.19; SD=0.58) to post-intervention (M=4.44;SD=0.49) students’ scores on First Aid skills &help seeking [t(61)=-3.26; p<0.001]. A detailedanalysis shows significant differences in fiveitems of the First Aid skills and help-seekingsection, two of which were the lowest in thepretest [items 17 and 43 (see Table 3)].Self-help strategies

Results showed a significant increase of self-help strategies (M=4.19; SD=0.48 – pre-test;M=4.65; SD=0.41 – post-test; t(62)=-5.79;p<0.001).

A detailed analysis shows significantdifferences in almost all items of the self-helpstrategies section except on item 25 (see Table 4).

DiscussionThis article presented results from the pilot

study of a larger project aimed to promotemental health in adolescents. At pre-test,participants showed high-level scores in the


three sections of the Mental Health Literacyquestionnaire. Participants of this studyattended a private school and 91.4% of theircaregivers were employed. School setting,combined with a very high rate of employmentof caregivers, are indicative of a higher socio-economic background. Both of these featuresmay partially explain the results in the pre-test.Literature suggests a significant impact of socioeconomic background in knowledge related tomental health (von dem Knesebeck et al., 2012;Campos et al., 2013).

Results from the pre-intervention assessmentare also in line with international datasuggesting that higher levels of knowledgerelated to mental disorders are associated withreduced stereotypes (Addington et al., 2012;Jorm, 2012). These levels of knowledge andstereotypes are related to:

a) an increased capacity of young people toseek help and to know where to get thissupport (Jorm, 2012; WHO, 2010)

b) the development of more appropriatemental health promoting behaviours

c) an increased capacity to seek informationabout mental health (Jorm; 2012; BourgetManagement Consulting, 2007)

d) a greater motivation to help (Pinfold et al.,2005; Jorm, 2012; Loureiro et al., 2013;WHO, 2010).

Furthermore, these results confirm thatstereotypes in young people are still notcompletely consolidated and seem to be lessnegative when compared to adults (Corriganand Watson, 2002; Farrer et al., 2008).

Despite the fact that these students showedhigh overall scores in the mental health literacyquestionnaire, the item analysis highlightsrelevant information gaps on the items relatedto the prevalence of mental health problems andthe identification of Down’s Syndrome,Cerebral Palsy and Parkinson’s Disease asmental health problems. This difficulty indifferentiating mental disorders from physicaldisabilities has also been referred in otherstudies (Jorm et al, 1997).

Focusing on the impact of the intervention,results from the post-intervention assessmentshowed a significant increase on knowledge,First Aid skills and help seeking, and self-helpstrategies.

A detailed analysis of the knowledge section

showed increased results in items presentinglower levels at the pre-intervention assessment (inparticular item 1 in 5 people will develop a mentaldisorder at some point in their lives – in whichparticipants scored the lowest in the pre-test andthe highest in the post-test assessment).Regarding the stereotypes, there was a significantdecrease on items presenting the highest values inthe pre-test.

Concerning the multiple-choice items, therewas a significant increase in the percentage ofparticipants who identified depression andanxiety as mental disorders, and a significantdecrease in the identification of Down’ssyndrome, Cerebral Palsy and Parkinson’sdisease as mental disorders. An unexpectedresult relates to the significant decrease in theidentification of mental retardation as a mentaldisorder. This result shows the complexityrelated to this issue and highlights the need fora different approach when discussing thisdisorder during the intervention.

Regarding First Aid skills and help-seeking,results showed a significant increase, from pre-to post- intervention, particularly in itemspresenting lower levels at pre-intervention.

Finally, regarding self-help strategies, eventhough results at pre-intervention were alreadyhigh, participants showed a significant increasein this dimension.

Although the intervention showed itself to beadequate to reach the purposed goals,improvements will be made and contextualspecificities will be taken into account, such asthe socio-economic background of students.

In conclusion, the present study showed thekey importance of conducting a pilot study withthe target groups when developing anintervention tailored to increase mental healthliteracy in young people (Campos, 2013).AcknowledgmentThe authors would like to thank the support from Ana Duarte (researchassistant), Elisa Veiga (research team member) and the school wheredata collection took place – its board, teachers, and students.

ReferencesAddington, D., Berzins, S. and Yeo, M. (2012). Psychosisliteracy in a Canadian health region: results from a generalpopulation sample. Canadian Journal of Psychiatry, 57(6),pp.381-388.Bourget Management Consulting for the Canadian Alliance onMental Illness and Mental Health (2007). Mental Health Literacy:A Review of the Literature. [Online] Available from:http://www.camimh.ca [Accessed 14 January 2014]


Campos, L. (2013). Commentary on the paper, ‘Evaluation of acampaign to improve awareness and attitudes of young peopletowards mental health issues’ (Livingston et al., 2013).Education and Health, 31(1), pp.45-50. Available from:http://sheu.org.uk/x/eh311lc.pdf [Accessed 14 January 2014]Campos, L., Losada, A., Pinho, S., Duarte, A., Palha, F., Dias,P. and Veiga. (2013). Mental Health Literacy in students frompublic & private schools: Preliminary results from Finding Spaceto Mental Health. Atención Primaria, 45, p.164.Campos, L. and Dias, P. Development and psychometricproperties of a new questionnaire for assessing Mental HealthLiteracy in adolescents (in prep).Campos, L., Palha, F., Dias, P., Lima, V. S., Veiga, E., Costa. N.and Duarte, A (2012). Mental health awareness intervention inschools. Journal of Human Growth and Development, 22(2),pp.259-266.Campos, L., Palha, F., Sousa Lima, V., Dias, P., Duarte, A. andVeiga, E. School-based interventions to promote mental healthliteracy in Portugal. In Innovative practices and interventions forchildren and adolescents with various disorders/disabilities (inpress).Corrigan, P. and Watson, A. (2002). Understanding the impactof stigma on people with mental illness. World Psychiatry, 1(1),pp.16-20.European Parliament (2012). Mental health in times of economiccrisis. Workshop conducted on European Parliament, Brussels,Belgium. [Online] Available from: http://www.europarl.europa.eu/[Accessed 14 January 2014]Farrer, L., Leach, L., Griffiths, K., Christensen, H. and Jorm, A.(2008). Age differences in Mental Health Literacy. BioMedCentral Public Health, 8(125), pp.1-8. DOI: 10.1186/1471-2458-8-125Jorm, A. (2012). Mental Health Literacy: empowering thecommunity to take action for action for better mental health.American Psychologist, 67(3), pp.231-243.DOI:10.1037/a0025957Jorm, A., Korten, A., Jacomb, P., Christensen, H., Rodgers, B.and Pollit, P. (1997). Mental health literacy": a survey of thepublic's ability to recognise mental disorders and their beliefsabout the effectiveness of treatment. Medical Journal ofAustralia, 166(4), pp.182-186.Kelly, C., Jorm, A. and Wright, A. (2007). Improving mentalhealth literacy as a strategy to facilitate early intervention formental disorders. Medical Journal of Australia, 187(7), pp.S26-S30.Livingstone, J., Tugwell, A., Kork-Uzan, K., Cianfrone, M. andConiglo, C. (2013). Evaluation of a campaign to improveawareness and attitudes of young people towards mental healthissues. Social Psychiatry and Psychiatric Epidemiology, 48(6),pp.965-973. DOI: 10.1007/s00127-012-0617-3Loureiro, L, Jorm, A., Mendes, A., Santos, J., Ferreira, R. andPedreiro, A. (2013). Mental health literacy about depression: asurvey of Portuguese youth. BioMed Central Psychiatry, 13(129), pp. 1-8. DOI: 10.1186/1471-244X-13-129Patel, V., Flisher, A., Hetrick, S. and McGorry, P. (2007). Mentalhealth of young people: a global public-health challenge. Lancet,369, pp. 1302-1313. DOI:10.1016/S0140- 6736(07)60368-7Pinfold, V., Stuart, H., Thornicroft, G. and Arboleda-Florez, J.(2005). Working with young people: the impact of mental healthawareness programmes in schools in the UK and Canada.World Psychiatry, 4(1), pp. 48-52.von dem Knesebeck, O., Mnich, E., Daubmann, A.,Wegscheider, K., Angermeyer, M., Lambert, M., Karow, A. andKofahl, C. (2012). Socioeconomic status and beliefs aboutdepression, schizophrenia and eating disorders. SocialPsychiatry and Psychiatric Epidemiology, 48(5), pp. 775-782.DOI: 10.1007/s00127-012-0599-1World Health Organization (2005). Mental health: facing thechallenges, building solutions: report from the WHO EuropeanMinisterial Conference. [Online] Available from:

http://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdf [Accessed 14 January 2014]World Health Organization (2008). Social cohesion for mentalwell-being among adolescents. Copenhagen, WHO RegionalOffice for Europe, 2008. [Online] Available from:http://www.euro.who.int/__data/assets/pdf_file/0005/84623/E91921.pdf [Accessed 14 January 2014]World Health Organization (2010). Mental Health Promotion inYoung People – an investment for the future. [Online] Availablefrom:http://www.euro.who.int/__data/assets/pdf_file/0013/121135/E94270.pdf [Accessed 14 January 2014]

Tables 1-4 are on pages 28-29


Table 1. Significant differences between pre-test and post-test on Knowledge’s items.

Pre-test Post-testN Mean (SD) N Mean (SD) Z

1. 1 in 5 people will develop a mental disorder at some point in their lives 69 3.13 (0.68) 64 4.78 (0.72) -6.45**6. A person with depression feels very sad 70 3.90(1.28) 64 4.17(1.03) -1.547. A person dependent on alcohol feels bad when not using 70 3.95 (1.03) 64 4.34 (0.78) -2.27*10. People with schizophrenia usually have delusions (i.e., may believe they are being

persecuted and observed)70 3.63 (0.78) 64 4.47 (0.78) -4.88**

15. Mental disorders don’t affect people’s behaviours a 70 4.16(0.81) 64 4.23(0.89) -0.2720. A person with anxiety disorder may panic in situations that she/he fears 70 4.26(0.70) 64 4.38(0.75) -0.8823. Alcohol use may cause mental disorders 70 4.06 (0.83) 64 4.53 (0.62) -3.54**24. Mental disorders don’t affect people’s feelings a 70 4.03(1.05) 64 4.09(1.04) -0.7833. One of the symptoms of depression is the loss of interest or pleasure in normally

enjoyable activities70 3.73 (0.99) 64 4.30 (0.99) -3.45**

34. A person with anxiety disorder avoids situations that may cause her/him distress 70 3.72 (0.83) 64 4.16 (0.74) -3.49**35. People dependent on drugs feel bad when they don´t use it 70 4.29(0.76) 64 4.48(0.67) -1.5739. Drugs use may cause mental disorders 70 4.22 (0.75) 64 4.45 (0.73) -2.21*40. Mental disorders affect people’s thoughts 70 4.03(0.83) 64 4.08(0.97) -0.1241. Anorexia involves great weight loss 70 4.61(0.73) 64 4.73(0.48) 0.8745. A person with schizophrenia may see and/or hear things that nobody else sees/hears 70 3.73 (1.16) 64 4.45 (0.78) -3.90**48. Highly stressful situations may cause mental disorders 70 4.17 (0.68) 64 4.42 (0.79) -2.40*Stereotypes1

8. People with mental disorders are less intelligentb 70 2.17(0.99) 64 1.48(0.80) -4.52**9. Only some people may be affected by mental disordersb 70 2.23(0.90) 64 1.61(0.95) -3.89**21. People with mental disorders come from families with little money b 70 1.37(0.78) 64 1.33(0.59) -0.2126. Only adults have mental disorders b 70 1.47(0.61) 64 1.31(0.69) -1.4838. Depression is not a true mental disorder b 70 2.67(1.15) 64 1.70(1.03) -4.65**

* p<.05**p<.001a reverse-coded itemb item coded on its original form1 Taking into account stereotypes as a result of misconceptions regarding to mental health issues, this analysis consider items on their original form (not recoded), whereupon higher

mean values correspond to higher level of stereotypes.

Table 2. Differences between pre-test and post-test related to health problems considered, by participants, as mental health problems.

Pre Post P*N % N %

Depressive disorder 55 78.6 61 87.1 <0.05Schizophrenia 60 85.7 55 78.6 1.000Anorexia 54 77.1 55 78.6 0.332Generalized anxiety 37 52.9 53 75.7 <0.001Substance-related disorder 46 65.7 44 62.9 0.839Trauma 46 65.7 35 50.0 0.286Trisomy 21 (Down’s Syndrome) 42 60.0 24 34.3 <0.05Mental retardation 51 72.9 21 30.0 <0.001Parkinson’s disease 29 41.4 13 18.6 <0.05Cerebrovascular accident 14 20.0 10 14.4 0.581Cerebral palsy 31 44.3 9 12.9 <0.001

*McNemar Testp≤.05


Table 3. Significant differences between pre-test and post-test on First Aid skills and help seeking section items.


4. If a friend of mine developed a mental disorder, I would offer her/him support 63 4.52(0.69) 63 4.78(0.66) -2.81*12. If I had a mental disorder I would seek for help from my family 68 4.46(0.87) 64 4.44(0.94) -0.5614. If a friend of mine developed a mental disorder, I would encourage her/him to look for a psychologist 70 4.29(0.85) 64 4.48(0.69) -1.4717. If a friend of mine developed a mental disorder, I would talk to her/his parents 64 3.78(1.08) 64 4.17(1.08) -2.45*19. If I had a mental disorder I would seek for professional help (psychologist and/or psychiatrist) 70 4.30(0.81) 64 4.28(0.86) -0.1722. If a friend of mine developed a mental disorder, I would listen to her/him without judging or criticizing 63 4.16(0.99) 63 4.56(0.67) -3.03*29. If a friend of mine developed a mental disorder, I would encourage her/him to get medical support 70 4.24(0.77) 64 4.38(0.79) -1.3831. If I had a mental disorder I would seek for help from my friends 70 4.13(0.96) 64 4.30(0.85) -1.5436. If a friend of mine developed a mental disorder, I wouldn’t be able to help her/him a 64 4.08(1.10) 64 4.39(1.03) -2.10*43. If a friend of mine developed a mental disorder, I would talk to the form teacher or other teacher 64 3.75(1.07) 64 4.33(0.86) -4.20**

* p<.05**p<.001a reverse-coded item

Table 4. Significant differences between pre-test and post-test on Self-help strategies’ items.


5. Physical exercise helps to improve mental health. 70 4.20 (0.94) 64 4.83 (0.52) -4.07**18. Good sleep helps to improve mental health. 70 4.39 (0.64) 64 4.70 (0.53) -3.47**25. The sooner mental disorders are identified and treated, the better. 70 4.43 (0.79) 64 4.63(0.58) -1.3532. Having a balanced diet helps to improve mental health. 70 3.91 (1.00) 64 4.61 (0.70) -4.69**44. Doing something one enjoys helps to improve mental health. 70 4.24 (0.73) 64 4.66 (0.67) -3.34**46. Talking over problems with someone helps to improve mental health. 69 4.17 (0.77) 64 4.52 (0.69) -2.84*

* p<.05**p<.001




This article looks at why children and youngpeople’s1 mental health and emotional well-

being is such an issue and why it is essentialthat they receive appropriate support whenproblems first emerge. In particular it will focuson the Children & Young People’s MentalHealth Coalition’s work connected to schools.

The Children & Young People’s MentalHealth Coalition (Coalition2) brings together 14leading children’s and mental health charities tocampaign with and on behalf of young peoplein relation to their mental health and wellbeing.We have a shared vision of a nation wheremental health is prioritised, positive mentalhealth is promoted and early interventionpractices are in place to secure mentallyhealthier futures for children and young people.

Our priority areas include promoting earlyintervention and ensuring that support is easilyaccessible for young people when mental healthproblems first emerge; and ensuring thateveryone working with young people receivesappropriate training about mental health andchild development. With this in mind, theCoalition has been working to help schoolsunderstand the importance of mental healthand how to support their students.

What is Mental Health?People often confuse the term ‘mental’ with

mental health problems. The World HealthOrganisation (WHO) defines mental health asbeing ‘a state of wellbeing in which theindividual realises his or her own abilities, cancope with the normal stresses of life, can workproductively and fruitfully, and is able to makea contribution to his or her community’ (WHO.

2011). This definition illustrates that mentalhealth is a positive term and a key componentof health and is similar to other terms, such as,emotional wellbeing and psychologicalwellbeing.

Mental health problems refer to a wide rangeof difficulties, which vary in their persistenceand severity. Mild problems are at one end ofthe spectrum and severe mental illness at theother.

Risk and Protective Factorsfor Mental Health

It is well-established that children and youngpeople who experience certain risk factors are ata greater risk of developing mental healthproblems. These risk factors can be within thechild, within the family and within theirenvironment (Department of Health, 2008). Themore risk factors experienced, the greater thechance they will develop mental healthproblems. Research has found that 28% ofyoung children are growing up in householdswith more than one risk factor, and with someexperiencing five or more risk factors (Sabatesand Dex, 2013). Outcomes for cognitive,emotional and conduct development andhyperactivity were all worse for childrenexposed to multiple risks by age five (Sabatesand Dex, 2013).

Conversely, there are well known protectivefactors, which help build resilience in the childand reduce the risk of mental health problemsdeveloping. These factors include: havinghigher levels of self-esteem, being securelyattached to a main carer, having a good supportnetwork, having a good relationship with your

Paula Lavis is the Coalition Co-ordinator Policy and Campaigns, Children and Young People’s Mental Health Coalition.For communication, please email: [email protected]

Paula LavisResilience and Results: How Promoting Children’sEmotional and Mental Wellbeing Helps Improve Attainment

1 The term young people will be used throughout this article to refer to both children and young people.2 Coalition is used throughout this article to refer to the Children and Young People’s Mental Health Coalition, and doesn’t refer to the CoalitionGovernment.


parents, good housing and having access toschools with strong academic and non-academicopportunities (Department of Health, 2008).

This is why early intervention is so crucial,both in terms of working to reduce the impactof risk factors and helping the child be moreresilient and able to cope with the difficultiesthey may face.

Why Young People’s Mental Healthis an Issue

One in 10 young people are known to have amental disorder (Green et al., 2004). Mentalhealth problems often have their roots inchildhood, so tackling problems when they firstemerge is both morally right and cost effective(Department of Health, 2011). Mental healthproblems in childhood are associated with pooroutcomes in adulthood. For instance, peoplewho had severe conduct problems in childhoodwere more likely to: have no educationalqualifications, be economically inactive andhave been arrested (Richards et al., 2009).

How Mental Health ProblemsImpact on Educational Attainment

Mental health problems have a profoundeffect on the educational attainment of someyoung people.● Young people with persistent conduct or

emotional disorders are:o more likely to be excluded from schoolo more likely to be assessed as having

special educational needs, ando more likely to leave school without

educational qualifications (Parry-Langdon,2008)

● Young People with emotional problems are:o much more likely to do poorly at schoolo they are twice as likely as other children to

have marked difficulties in reading, spelling and mathematics (Green et al., 2005)

● Young people with conduct disorders and hyperkinetic disorder may be four to five times more likely to struggle to attain literacyand numeracy skills (Green et al., 2005)

● Young people with higher levels of emotionalwellbeing have higher levels of academic attainment and are more engaged in school (Morrison & Vorhaus, 2012).

Training in Mental Health andEmotional Wellbeing

The Coalition is concerned that most teachershave no or little training in mental health andemotional wellbeing, and child development.This is a big issue given the prevalence ofmental health problems and the impact mentalhealth difficulties have on the child and the restof the school, including the teachers. While weknow that many schools really do understandthe importance of promoting children andyoung people’s mental health and emotionalwellbeing, and see it as their business, others donot.

Anecdotally, we have heard that schools arenot always good at engaging with their pupils’mental health. To support this finding, a recentstudy found that a problematic pupil-teacherrelationship significantly increased the odds ofa child having a psychiatric disorder or conductdisorder (Lang et al., 2013). While not causal,there is a clear association between developinga psychiatric condition and a poor pupil-teacherrelationship. In another study concerning eatingdisorders, 16% of young people said that staffhad little or no knowledge about eatingdisorders (Knightsmith et al., 2013). Worryinglyonly 1 in 10 young people thought that theirschool would provide a supportiveenvironment for someone recovering from aneating disorder (Knightsmith et al., 2013).

This lack of training is not just theresponsibility of schools. It is something that theGovernment needs to address through teachertraining. Hopefully the MindEd e-portal (2013),which the Government are funding, will helpprovide school staff with some knowledgeabout mental health. This portal will providefree online education to help adults to identifyand understand children and young peoplewith mental health issues. The NationalAssociation of Independent Schools and Non-Maintained Special Schools (NASS) (2012) havealso produced an eLearning training resource,which is called Making Sense of Mental Health.This training pack is aimed at staff working inschools with children and young people whohave complex Special Educational Needs (SEN).Schools can help by encouraging their staff tocomplete this on-line training or to ensure that


they develop their knowledge of mental healthin other ways.

Ensuring that school staff have training inmental health and emotional wellbeing isimportant in light of the SEN reforms.Government have proposed in the SEN Code ofPractice that the Behaviour, Emotional andSocial Difficulties (BESD) category be revisedand renamed as Social, Mental and EmotionalHealth (Department for Education, 2013).Schools will need to be able to identifyemerging mental health problems. So additionaltraining in mental health will be essential ifschool staff are to be able to do this.

Helping Schools promote their Pupil’sMental Health and Emotional WellbeingSchools have a responsibility to look after and

nurture their pupils. There is some research thatshows that young people would rather speak totheir teacher about their problems, than go totheir GP or a mental health professional (RightHere Brighton and Hove, 2012; Green, et al.,2004). School staff are in a good position to helpreduce the stigma around mental health,identify emerging mental health difficulties andwork with local statutory and voluntary sectorproviders to help ensure that young peopleaccess specialist support when they need it.

There are lots of things that schools can do tohelp support young people’s mental health, andfor that reason the Coalition (2012) haveproduced a guidance document for schoolscalled Resilience and Results. This documentaims to encourage schools to think about howthey can promote mental health within theirschool and provide additional support for thosewith mental health problems. It includes casestudies, which illustrate what support isavailable, and quotes from young people,parents, and teachers.

A whole school approach to promotingmental health within schools is a way ofputting in place the right systems anddeveloping the right culture for this to beimplemented. It has been shown that to achievethis head teachers and senior staff need to beeffective leaders and champion mental health(Durlak and DuPre, 2008). Research has foundthat a lack of leadership around emotional andmental wellbeing has a detrimental impact onthe implementation of this vital work (Kendall,

et al., 2013). The study by Kendall et al. (2013)found that staff often didn’t feel they weresupported by managers to participate in themental health promotion project beingimplemented within their school. A schoolculture that doesn’t support help-seeking maydiscourage pupils accessing emotional support.

There are opportunities to use existing lessonsand other systems that already exist within theschool. A good pastoral system and staff suchas learning mentors, teaching assistants, higherlevel teaching assistants and school nurses areall important resources to draw on to helpchildren and young people who areexperiencing difficulties.

PSHE lessons could potentially be used toincrease young people’s knowledge of mentalhealth and wellbeing, increase their emotionalliteracy and reduce stigma. The young peoplethat Coalition members work with have allexperienced mental health problems; and theytold us that they didn’t learn about mentalhealth within their PSHE lessons. Most of theseyoung people were very frightened anddistressed when they started to experiencemental health difficulties, and if they had learntabout this subject at school, they said theywould have felt less frightened and moreempowered to help themselves.

OFSTED (2013) has reported that 40% ofschools’ PSHE provision required improvementor was inadequate. OFSTED (2013) also asked apanel of young people what they would like tolearn about in school, but currently didn’t.Young people told them that mental healthissues were at the top of their list, with:• 38% wanting to learn how to deal with

bereavement• 33% wanted to know how to cope with

stress• nearly a third wanted to know more about

eating disorders such as anorexiaEmbedding mental health and emotional

wellbeing education within other subjects is oneadditional method of ensuring young peoplelearn about this important topic. For example,English lessons could cover literature andpoetry that deals with distress; students couldlearn about the mind, brain, emotions andmedication through science lessons; theimportance of exercise and nutrition in thecontext of mental health could be covered in


physical education and food technology; andpupils could be encouraged to identify andexpress emotions through their music, art anddrama classes.

Commissioning External SupportThese days head teachers have more control

over their own budgets, so are in a position todevelop or commission services that are tailoredto the needs of their school. There are a numberof different types of support that the school cancommission. This might be commissioning anexternal organisation to provide mentors, or amindfulness course. Some schools alreadyemploy their own counsellor, or commission anagency to provide counselling. The Coalitionwould advocate the latter, as there are a numberof safeguarding issues that need to beaddressed, such as whether they are suitablyqualified, how their practice is supervised andso on.

While this work isn’t free, there is goodevidence to show that you get a good return onyour money. A cost-effectiveness analysisconducted on behalf of the Department ofHeath found that every £1 spent on theprevention of conduct disorders through socialand emotional based interventions in schoolgave a total return of nearly £84 (Knapp, et al.,2011). So in the current economic climate,investing in school based services to supportchildren and young people’s mental healthmakes both financial and clinical sense.

Resilience and Results from the Coalition (2012)gives schools some guidance aboutcommissioning external services and provideslinks to other resources which have more of afocus on commissioning, such as the BONDConsortium (2013). The focus in Resilience andResults is on how the voluntary sector can helpand, with that in mind, it includes examples ofhow these organisations are working to supportschools. However, there will also be statutoryservices such as educational psychologyservices and possibly private sector services thatwill also be able to help schools support themental health of their pupils.

How Schools are PromotingMental Health

The Coalition held a competition in 2013 tofind out how their guidance, Resilience and

Results, was being implemented in schools andto identify good practice in supporting pupil’semotional and social development. A panel ofeducational and health professionals, with inputfrom young people, picked the winners. Thecompetition was generously funded by theZurich Community Trust

The competition winner was the KingsHedges Educational Federation, which is aCambridgeshire primary school and nursery for357 pupils aged 3-11. This school impressed thejudges by really putting wellbeing at the centreof their work. They have used their PupilPremium money and other funds to help allpupils by providing universal support, and theyhave commissioned targeted services aimed atthose who are more vulnerable. For instance,they provide lessons to help all early years’pupils to relax; they have commissioned acounseling service called Blue Smile; and theyalso have the Red Hen project, which works withparents.

The runner ups were the Newall Green HighSchool, which is a mixed sex secondary schooland sixth form centre in Greater Manchester;and the Epsom Downs Primary School &Children’s Centre, which is based in Surrey.

A highly commended award was given toThe Harbour School, a special school inPortsmouth, which adopted a collaborativeapproach across the school to facilitate inter-agency working.

Further information about the winners can befound on our website - http://www.cypmhc.org.uk/schools_competition_2013/

References

BOND Consortium (2013). http://www.youngminds.org.uk/training_services/bond_voluntary_sectorAccessed 27 January 2014.Children and Young People’s Mental Health Coalition (2012).Resilience and results: how to improve the emotional andmental wellbeing of children and young people in your school,London: Children and Young People’s Mental Health Coalition.http://www.cypmhc.org.uk/resources/resilience_results/Accessed 27 January 2014.Department for Education (2013). Draft Special EducationalNeeds (SEN) Code of Practice: for 0 to 25 years, London:Department for Education. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/251839/Draft_SEN_Code_of_Practice_-_statutory_guidance.pdfAccessed 27 January 2014.Department of Health (2008). Children and young people inmind: the final report of the National CAMHS Review, London:Department of Health. http://tinyurl.com/ozdltt6 Accessed 27January 2014.


Department of Health (2011). No health without mental health,London: Department of Health. https://www.gov.uk/government/publications/the-mental-health-strategy-for-englandAccessed 27 January 2014.Durlak, J. A. and DuPre, E.P. (2008). ‘Implementation matters: areview of research on the influence of implementation onprogram outcomes and the factors affecting implementation’,American Journal of Community Psychology, 41, pp. 327-350.Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mentalhealth of children and young people in Great Britain 2004,London: Palgrave. See http://www.statistics.gov.uk/downloads/theme_health/GB2004.pdfAccessed 27 January 2014.Kendal, S. et al. (2013). ‘Students help seeking from pastoralcare in UK high schools: a qualitative study’, Child andAdolescent Mental Health, online early.Knapp, M. et al. (2011). Mental health promotion and mentalillness prevention: the economic case, London: Department ofHealth. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdfAccessed 27 January 2014.Knightsmith, P. et al. (2013). ‘My teacher saved my life’ versus‘Teachers don’t have a clue: an online survey of pupils’experiences of eating disorders’, Child and Adolescent MentalHealth, online early.Lang, I.A. et al. (2013). ‘Influence of problematic child-teacherrelationships on future psychiatric disorder: population surveywith 3-year follow-up’, British Journal of Psychiatry, 202, pp.336-341.Royal College of Paediatrics and Child Health (2013). MindEd e-portal, http://www.rcpch.ac.uk/mindedAccessed 27 January 2014.Morrison, L.M. & Vorhaus, J. (2012). The impact of pupilbehaviour and wellbeing on educational outcomes, London:Department for Education. http://dera.ioe.ac.uk/16093/1/DFE-

RR253.pdf Accessed 27 January 2014.The National Association of Independent Schools and Non-Maintained Special Schools (NASS) (2012). Making sense ofmental health, http://www.nasschools.org.uk/making_sense_of_mental_health.aspxAccessed 27 January 2014.OFSTED (2013). Not yet good enough: personal, social, healthand economic education in schools, London: OFSTED.http://www.ofsted.gov.uk/resources/not-yet-good-enough-personal-social-health-and-economic-education-schoolsAccessed 27 January 2014.Parry-Langdon, N. (eds) (2008). Three years on: survey of thedevelopment and emotional well-being of children and youngpeople, London: Office for National Statistics.http://tinyurl.com/qzlwlxm Accessed 27 January 2014.Richards, M. et al. (2009). Childhood mental health and lifechances in post-war Britain, London: Sainsbury Centre forMental Health. http://www.centreformentalhealth.org.uk/publications/life_chances.aspx?ID=596Accessed 27 January 2014.Right Here Brighton and Hove (2012). Young people’s viewsand experiences of GP services in relation to emotional andmental health, London: Right Here.http://www.righthere.org.uk/home/assets/pdf/young-people-views-experiences-gp-services-report.pdfAccessed 27 January 2014.Sabates, R. & Dex, S. (2013). 'The impact of multiple risk factorson young children’s cognitive and behavioural development',Children and Society, Online Early.World Health Organisation (2011). Mental health: a state ofwellbeing, http://www.who.int/features/factfiles/mental_health/en/Accessed 27 January 2014.



"The survey reports have been used to inform commissioning at specific commissioning groups. They are also being used withinour Extended Schools Clusters and to inform The Annual Public Health and the Joint Strategic Needs Assessment."






Within each of the four countries of the UnitedKingdom (UK) there exist different strategic

approaches to the issue of alcohol and drugs.England (DH, 2007; H.M. Government, 2010)and Scotland (The Scottish Government, 2009)operate discrete alcohol and drug strategies,while Wales (The Welsh AssemblyGovernment, 2008) and Northern Ireland (NI)(DHSSPSNI, 2006) strategically address“substances” collectively. Historically, NIoperated discrete alcohol and drug strategiesbut, in May 2001, a Model for the JointImplementation of the existing Drug andAlcohol Strategies (or Joint ImplementationModel (JIM)), was adopted.

Due to a failure to achieve core alcoholobjectives (Parker, 2005), the JIM was replacedby the New Strategic Direction for Alcohol andDrugs (NSD) (DHSSPSNI, 2006) in 2006, whichincluded among its long-term aims anaspiration to “increase awareness on all aspectsof alcohol and drug-related harm in all settingsand for all age groups” (p.17) and thepromotion of opportunities “for those under theage of 18 years to develop appropriate skills,attitudes and behaviours to enable them toresist societal pressures to drink alcohol and/oruse illicit drugs …” (p.17). A revised version ofthis strategy, the New Strategic Direction forAlcohol and Drugs Phase 2 (DHSSPSNI, 2011),retained these long-term aims.

Prevalence surveys have consistentlysuggested that alcohol consumption among 15-16 year olds in the UK is among the highest inthe European Union (EU) (Hibell et al., 2009).Furthermore, while alcohol consumption may

be decreasing in some EU countries, the UK isan exception (Eisenberg-Stangl & Thom, 2009);and compared with the UK as a whole, alcoholconsumption has increased since 1986 to agreater degree in NI (Smith & Foxcroft, 2009).This is largely due to an increase inconsumption by 15-16 year olds through topeople in their mid-20s.

On the other hand, frequent and problematicdrug consumption is less prevalent in the UKthan in other EU countries (Hibell et al., 2009).Compared to other countries, cannabis use hasfallen since 1995; with lifetime ecstasy use andthe simultaneous use of alcohol andtranquilisers or sedative drugs also decreased(Hibell et al., 2009).

Although the use of alcohol and controlleddrugs by young people may share commonantecedent risk factors (e.g. Donovan, 2004;Cleveland et al., 2008), findings suggest that useamong 15-16 year olds in the UK followsdifferent behavioural patterns. Whereas alcoholuse is widespread, the use of controlled drugsremains relatively low. Given the co-existingrealities of different prevalence rates and thejoint strategic approach in NI, a series of focusgroups were conducted in order to explorewhether 15- and 16-year olds viewed the use ofalcohol and drugs as similar or unrelatedphenomena or behaviours. The data collectedwould help to inform the content of future alcoholinterventions and education and facilitate anassessment of whether a joint strategy rather thana discrete strategy in terms of alcohol and drugsbest serves the health interests of adolescentdrinkers and/or drug users.

Dr Michael McKay is the STAMPP Co-ordinator and Séamus Harvey is a Research Assistant with the Centre for Public Health,Liverpool John Moores University.For communication, please email: [email protected]

Michael McKay and Séamus Harvey“Drink doesn’t mess with your head … you only get ahangover”: Adolescents’ views on alcohol and drugs, andimplications for Education, Prevention and Intervention


MethodParticipants

24 focus groups were held in May and June2008 in 24 post-primary schools in the greaterBelfast area. A total of 216 young people fromyear 11 (age 15/16) participated, with a mean of9 participants in each group (maximum 11,minimum 6).Procedure

All participants gave informed consent toparticipate. The focus groups lasted between 50and 75 minutes, depending on the length anddepth of participant responses. All groups wereasked the same set of prompt questions,although follow-up discussion was open ended.During the current set of focus groups, oneyoung person, often the most experienceddrinker, usually took the lead in responding.The facilitators were keen to avoid a situationwhere the most confident member woulddictate the view of the group, particularly giventhe range of experience with alcohol amongparticipants, so sought individual support for orchallenge of this lead position from othermembers.

The discussions were free-flowing, neededlittle facilitator intervention beyond the openingdiscussion or statement and involved a gooddegree of debate and at times differences ofopinion. Detailed notes were taken by tworesearchers present at all focus groups.

Data AnalysisThe responses to individual questions were

grouped and thematically analysed in order toidentify and code recurring themes. Thethematic approach to analysis advised by Braunand Clarke (2006) was used and the followingphases were applied to data analysis: (1)familiarization with the notes, (2) generatinginitial codes, (3) search for themes, (4) review ofthemes, (5) definition and naming of themesand (6) manuscript preparation. The groupingand coding was undertaken by one of theauthors and by two colleagues, one of whomwas present at the focus groups and one ofwhom acted as a third party at the coding andwhose role was to challenge any unwarrantedinterpretation of raw data. Within this part ofthe analysis, the facilitators who had beenpresent at the groups were able to describe the

group interactions and dynamics to the thirdparty so that while the coding identified thefrequency of response types, the weight orimportance of these response types werecoloured by the passion or enthusiasm withwhich they were given in the initial groupdiscussion.

ResultsAlcohol and Drugs… are they the same ordifferent?

Groups were asked to consider the differencesbetween alcohol and drugs in general termswith subsequent specific prompts on whether ornot both behaviours were “wrong” or involved“risk-taking”. The majority of groups rejectedthe idea that drugs and alcohol were the samefor three main reasons.

Firstly, discussion focussed on the “moredamaging and dangerous” pharmacologicaleffects of drugs compared to alcohol; forexample, “Alcohol makes people moreaggressive but drugs are more harmful” or“Drink doesn’t mess with your head … youonly get a hangover”. One aspect of this was theonset of action of drugs compared with alcohol,and also the fact that participants believed thatdrugs can kill first-time users while alcohol isunlikely to. However, the more powerful andimmediate effects of drugs were not alwaysconsidered negative. Some argued that the morerapid effects of drugs could be positive (forexample, with respect to anxiolysis) while theeffects of alcohol could often be more negative(i.e. aggressive behaviour).

The second issue centred on the cultural andsocial acceptability of alcohol compared todrugs. It was argued that because so manypeople drink alcohol and because it is so widelyavailable that it is not really seen as a seriousissue. On the other hand, fewer people in widersociety would consider drugs to be acceptableor safe:

“The effects are different … drugs are like taboo… alcohol is everywhere and is not as harmful… alcohol is more sociable, parents do it …people of all ages do it” (Boy).

The legal status of drugs and alcohol was thethird main issue. Participants believed that


“alcohol is legal and drugs are not” and citedthis as a reason for viewing and treating themdifferently.

Additionally respondents argued that “thereis a safe limit” for alcohol, you “get in moretrouble” if you get caught with drugs, alcohol is“easier to access”, and you can “control yourselfbetter” when consuming alcohol. In a smallnumber of cases, respondents argued thatalcohol may be as or more dangerous thandrugs from a health point of view:

“I don’t understand why drinking is legal anddrugs are not … people don’t know what theyare doing when they are drinking” (Boy).

Consuming Drugs and Alcohol “safely”The majority of young people believed that it

was acceptable for young people to drink aslong as they did it ‘safely’. However, drugswere viewed as unsafe because they candamage the body even when taken in smallquantities, first-time use can lead to death,different people react to the same drug indifferent ways, drugs are normally impure andcontain unknown additives, and drug use canquickly lead to addiction.

“There is no such thing as ‘safely’ when you aretalking about drugs” (Boy).

A small minority of participants argued that itwas okay to take drugs if they were taken‘safely’ and even among individuals who at firstclaimed that it could never be done safely, theysuggested techniques or methods which, intheir opinion, would serve to reduce harm.These included using drugs indoors, usingdrugs from a known dealer or supply route,using drugs supplied by a doctor, making surethat somebody knows what you are doing whenusing drugs, making sure that somebody else isnot using and can help if necessary, not usingdrugs at parties where you do not know thepeople very well, not using dangerous drugs,not using a mix of different types of drugs, notusing too much at any one time, and only usingenough to make you “happy”.Drug and Alcohol Education in School

Both drug and alcohol education in schoolsreceived negative appraisals. Drug education

was described as “boring”, “stuff that wealready know”, “not relevant to everyone” andit “makes some people feel uncomfortable”;while alcohol education was viewed as“repetitive” and “overly factual”.

The majority of young people reported thatthey would like to learn more about alcohol anddrugs in a “realistic” and non-patronising waywhich was “relevant to them”. They would liketo learn about the effects and consequences ofalcohol and drug use and the real-lifeexperiences of people. Furthermore, theyindicated a desire to learn how to recognise ifsomeone has been using drugs, and whatdifferent drugs look like and the differencesbetween them.Taught by teachers?

A small minority of participants said that theywould prefer to have drug education deliveredby teachers with whom there is an existing“good relationship” and because there “couldbe continuity [of message with on-goingcontact]” or because “some outsiders use videos[and resources] that are really cheesy [oldfashioned and simplistic]”.

However, the majority of participantsindicated that they would prefer to receivealcohol and drug education from externalfacilitators. It was believed that in comparisonto teachers who have “little knowledge aboutthe subject”, external facilitators would havegreater expertise and would relate to the pupilsin a more informed “on their level” way.Participants believed that some teachers wouldbe “boring” and for some, if certain teacherswere to teach alcohol and drug education, thatin itself would be an obstacle to learning. Issuessuch as “not liking a particular teacher” and“teachers having a biased opinion” were citedas particular obstacles.

Participants feared that teachers wouldbreach confidentiality and discuss or pass ondisclosed information to other teachers, yearheads or parents. They also feared that if theydisclosed the true extent of their alcohol use,they would be judged by their teachers.External facilitators were viewed with lessdistrust and as people with whom it would bepossible to have an open discussion; anonymitywould allow young people to be open andhonest; and they would be less likely to judge


students because of the short period of contact.

DiscussionThe focus group discussions demonstrated

that the majority of participants view alcoholand drug use as distinct behaviours, with druguse considered more pharmacologicallydangerous and less culturally and sociallyacceptable than alcohol use, with bothconsidered very differently from a legal point ofview. The majority of participants also believedthat it is acceptable for young people to drinkalcohol as long as they do it safely whereas anydrug use was not considered safe. Despitestating reasons as to why drug-taking couldnever be considered safe, many participantswere aware of harm reduction methods.

In this sample of 15- to 16- year olds, therewas informed discussion about the effects ofalcohol, cannabis and sedative hypnoticmedicines, but prejudiced speculation about theeffects of other illicit drugs. There was a lack ofconsistency in the views presented andprincipally this would appear to result from arelative lack of experience of the effects of thesedrugs compared with alcohol. Equally worryingfrom a public health perspective was thatparticipants’ discussion comparing drugs andalcohol was a simplistic one, generally lackingdiscrimination of types, quantities or drugpurity and strengths of alcoholic drinks. Theparticipants’ conversations suggested that itwould be important for them to understand thatall drugs have both acute and long-term effects,regardless of legal status or social and culturalacceptability. It is critical that those in healthpromotion try to engage young people honestlyand meaningfully so that when faced with thedecision about whether or not to use alcohol ordrugs, their decisions are based on accurateinformation rather than speculation.Furthermore, because inaccurate knowledgeand understanding of alcohol and drugs isapparent among students, educationalistsshould obtain an understanding of pupils’views and attitudes toward alcohol and drugseven before the educational phase commences;this would also correspond with good practicerecommendations that such education shouldbe developmentally appropriate (AGDAE,2008).

Participants articulated concerns with drug

education in school, labelling what theycurrently receive as boring, patronising andlacking in real-world credibility. Of particularconcern to educators might be the disparitybetween what young people are told byteachers and what they observe or hear fromtheir friends. Teachers might want to considerthe dangers inherent in risk amplification ofabstinence-focussed education particularly if, asdesired by the participants, alcohol and drugeducation is to be more credibly, maturely andhonestly delivered. Participants indicated adesire to learn about alcohol and drugs in a waythat was realistic, relevant and considered theconsequences and real-life experiences ofpeople. In relation to the participants wanting“real-life” educators (i.e. drug dependentindividuals); schools might consider thiscarefully as there is likely to be a lack ofconcordance with the typical ex-user story andyoung people’s own experiences.

The majority of students indicated apreference for alcohol and drug education to bedelivered by outside facilitators rather thanschool teachers. While this is most likelyunfeasible, school-based educators need to beaware of the need to present the issues in amature and transparent fashion; otherwiseyoung people cannot be expected to engageoptimally.

ConclusionYoung people in these groups did view

alcohol and drugs differently. However, in aneconomic climate where services will beincreasingly asked to do more for less money, abilateral approach to universal prevention foralcohol and drugs seems difficult to justify.

However, given the prevalence datasuggesting that many 15- to 16-year olds drinkto intoxication, yet fewer use drugs, and thedata herein which suggest that drug awarenessis often immature and illogical, public healthmight be better served by treating them asdiscrete issues. There are arguably two discretetarget groups depending on whether or not oneis discussing drugs or alcohol. For alcohol the‘potentially vulnerable’ group are the majorityof young people, who are exposed to harmresulting from their own or others’ drinking.Thus, specific harm reduction initiativesdelivered on a population level appear


warranted. For drugs, the vulnerablepopulation are smaller in number, but thediscussions in this paper suggest that a generalnaivety among the adolescent populationregarding drugs and drug use, calls for ageneral review of drug education content andspecific drug-harm education messages for thefewer who are at most risk.

Above all there would appear to be thedanger that strategically addressing alcohol anddrugs jointly in an environment where theirprevalence is so different, might lead the manydrinkers to view it naively and simplistically (asthey did generally with drugs) and/or tominimise the dangers of drugs as a result of therelative infrequency of adverse alcohol-relatedevents.

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Department for Health, Social Services and Public Safety(Northern Ireland), (2006). New Strategic Direction for Alcoholand Drugs 2006 – 2011, Belfast: DHSSPSNI.Department for Health, Social Services and Public Safety(Northern Ireland), (2011). New Strategic Direction for Alcoholand Drugs Phase 2 (2011-2016) – A Framework for ReducingAlcohol and Drug Related Harm in Northern Ireland, Belfast:DHSSPSNI.Donovan, J. (2004). Adolescent Alcohol Initiation: A Review ofPsychosocial Risk Factors. Journal of Adolescent Health, 35, 6,529 e7-18.Eisenberg-Stengl, I. & Thom, B. (2009). Intoxication andintoxicated behaviour in contemporary European cultures:myths, realities and the implications for policy, (prevention)practice and research, Vienna: European Centre for SocialWelfare Policy and Research.H.M. Government, (2010). Drug Strategy 2010, ReducingDemand, Restricting Supply, Building Recovery: SupportingPeople to Live a Drug Free Life, London: The Home Office.Hibell, B., Guttormsson, U., Ahlström, S., Balakireva, O.,Bjarnason, T., Kokkevi, A. & Kraus, L. (2009). The 2007 ESPADReport - Substance Use Among Students in 35 EuropeanCountries, Stockholm: The Swedish Council for Information onAlcohol and Other Drugs (CAN).Parker, H. (2005). Better Managing Northern Irelands’ Alcoholand Drug problems: A Review of the Northern Ireland Alcoholand Drug Strategies and the Efficiency and Effectiveness oftheir Implementation, [Online], Available:www.dhsspsni.gov.uk/drugs-alcohol-report-ni-review.pdfAccessed 12 February 2014.Smith, L., & Foxcroft, D. (2009). Drinking in the UK: Anexploration of trends, York: Joseph Rowntree Foundation.[Online] Available: http://www.jrf.org.uk/publications/drinking-in-the-uk Accessed 12 February 2014.The Scottish Government, (2009). Changing Scotland’sRelationship with Alcohol: A Framework for Action, Edinburgh:Scottish Government.The Welsh Assembly Government. (2008). Working Together toReduce Harm: The Substance Misuse Strategy for Wales 2008-2018. Cardiff: Welsh Assembly.






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