Table 9. Body of Evidence according to GRADE assessment.
| Author | Design RCT/Obs | Indirectiveness of Evidence | Publication bias | RoB [Scale] Category |
Imprecision | Impact | |||
|---|---|---|---|---|---|---|---|---|---|
| Population | Intervention | Measures | N | CI* | |||||
| School Attendance | |||||||||
| Allen [13] | Obs | Children in elementary schools | Full-time school nurse | All day attendance, check out for medical reasons, health care insurance | No indication | High [8] E, F |
10,000 | / | The percentage of student checkouts for medical reasons in schools with a full-time nurse (M = 11.1%) was statistically significantly lower, t(20) = 2.27, a< .05, d = 2.77 than schools without a fulltime nurse (M = 15.7%). |
| Long et al. [61] | RCT | Children with more than 14 days absence in one year | Activity of the school nurse and record of her activity | Mean days of absence | No indication | Low [2] E |
302 | / | The control group’s mean decline was 5.10, resulting in a statistically significant mean difference of 1.98 between the intervention and control groups. In other words, pupils in the intervention group showed a decline in absences which averaged 2 days more than the reduction experienced by those in the control group, and this difference can be viewed as a non-chance occurrence. |
| Foster & Keele [87] | Obs | Children in kindergarten up to grade 5 | School nurses administer Over-the-Counter medications | Sent home rates | No indication | High [8] E, D |
Approx. 10,000 | / | There were no statistically significant differences found among sent home rates for the 2 school years after the policy change. The mean number of students sent home before the policy was implemented was 353, or 3.6%, whereas the mean number of students sent home in the first year after the policy was implemented was 342 students, or 3.4%, 2(23) = -.37, P = .72. The second year of implementation found 329 students, or 3.1%, were sent home. |
| Rodriguez, Rivera [88] | Obs | Children in pre-kindergarten to grade 8 | Trained full-time school nurse and part-time school nurses | Average Daily Attendance was measured through parent report + verification of school clerk, health measures | Unlikely, funded by Lucile Packard Foundation for Children’s Health and the Lucile Packard Children’s Hospital | High [8] H, F |
6,664 | √ | Decrease in the mean number of absences due to illness among students in demonstration schools, whereas the mean number of absences among students in control schools increased. This reduction in mean absences due to illness was statistically significant between demonstration and comparison groups (p < .05). students in demonstration schools were less likely than students in control schools to miss 1 or more days of school due to illness (OR = 0.876, 95% CI: 0.767–1.001, p < .05). |
| Telljohann, Dake [89] | Obs | Children with asthma in kindergarten to grade 6 | Full-time school nurse (5 days) vs. part-time school nurse (2 days) | Grade, race, sex, school lunch status, and number of days missed | No indication | High [9] D, I |
569 | / | Students with full-time school nurses missed significantly fewer school days (M = 510.6, SD = 59.2) than students with part-time school nurses (M = 513.0, SD = 511.6) (t = 522.68, DF = 5566, p < .05). |
| Van Cura [90] | Obs | Students with lower socioeconomic status | School-based health centers | Academic outcomes and loss of seat time (data on early dismissal) | No indication | Unclear [7] G, F |
764 | / | SBHCs significantly reduced the number of early dismissals from school (p = .013) in a comparison with students who received school nursing services alone. Students not enrolled in an SBHC lost 3 times as much seat time as students enrolled in an SBHC. |
| Weismuller, Grasska [116] | Obs | Children in kindergarten to grade 5 | Retrospective review of health records | Referrals to school nurse, interventions, outcome of school nurse intervention; Schools Administrative Student Information system (SASIS) to document reason for absence | No indication | High [10] G, J(1), I |
240 | / | The most common reason (65.8%) for referral was screening. After that, physical illness. No referrals to the school nurse for absenteeism and school nurse interventions were not targeted to attendance, despite 17% of students missing 11 or more school days. Documentation was sparse (primarily task related). Information about the outcome was insufficient to determine the effectiveness of nursing interventions. |
| Wiggs-Stayner, Purdy [91] | Obs | School-aged children and staff | Free Flu-Mist immunizations | Attendance rates | Unlikely, funded by the Parkview Hospital Community Health Improvement Program |
Unclear [7] H(2) |
277 + unknown control | / | The 2 schools receiving FluMist increased their attendance rates from 95.3% and 93.9% to 96.1% and 95.8%. Previously, the comparison schools each had a 94.6% attendance rate; one fell to 94.4% and the other rose very slightly to 94.7%. The differences in self- or parent reported influenza absences were not significant. However, the difference in days absent between individual vaccinated and nonvaccinated schools was statistically significant. |
| Overweight and Obesity Prevention | |||||||||
| Bonsergent, Agrinier [17,62] | 2x RCT | Children in high schools | Education, environment and screening by school nurse | Weight and height (waist circumference later excluded) | No indication | Low [2] D(3), F |
3,538 | √ | The 2-year change of outcomes was more favorable in the 12 month screening compared to the no-screening ones: a 0.11 lower increase in BMI (p<0.0303); a 0.04 greater decrease in BMI z-score (p<0.0173); and a 1.71% greater decrease in overweight/obesity prevalence (p_0.0386). Education and environment strategies were not more effective than no strategy intervention. |
| Hawthorne et al. [92] | Obs | Children in schools | Walking program 3 days a week/ 16 weeks | Body Mass Index (BMI), waist circumference, and cardio-respiratory (by using the Progressive Aerobic Cardiovascular Endurance Run test (PACER test) | Unlikely, funded by Kids Sports Stars for data analysis funding |
High [8] F, G |
1,074 | / | Cardio-respiratory fitness increased by 37.1% over baseline in the entire sample (p < .01). The increase in fitness was observed in both genders and across all grade levels. Furthermore, significant improvements in fitness were observed among healthy weight, overweight, and obese youth. However, obese youth had a smaller overall change in fitness compared to overweight or healthy weight participants. No significance changes in BMI or waist circumference (p > .05); |
| Johnston et al. [38,63] | RCT | Children aged 7–9 years | Curriculum with health information + health professional | Weight and height to measure Body Mass Index (BMI); Grades in math, science and reading to measure academic outcome |
No indication | Unclear [5] B, D, F |
835 | √ | After 2 years, children who were overweight/obese in the professional-facilitated intervention (PFI) condition significantly reduced their standardized BMI (zBMI) compared to children in the Self-help (SH) condition (Wald χ2 = 28.7, p < .001). End-of-year grades decreased for overweight/obese students in both conditions; however, students in the PFI exhibited a smaller decrease in grades compared to the SH condition (Wald χ2 = 80.3, p < .001). |
| Melin and Lenner [93] | Obs | Overweight children 7 years of age | Dietary advice | Weight, BMI, Changes in well-being and lifestyle were measured with the help of a structured interview | No indication | High [10] G, J(4), I |
20 | / | A good (91%) or fair (54%) adherence to dietary advice was found in children who decreased or maintained their z-score respectively. Mean BMI z-score reduced [)0.16 (p = 0.03)] during the intervention period. Generally, parents and school nurses were satisfied with the program, helping them to set limits and be more self-confident in their role as ‘health adviser’ respectively. |
| Note. Detailed risk of bias assessment (1) Use of existing health records; documentation varied widely among school sites and study information was limited to existing record contents; (2) No information on control group (size, population, etc.); (3) Lack of an “ideal” anthropometric outcome to evaluate the effectiveness of prevention strategies. BMI might be considered an inappropriate way to evaluate weight status in children and adolescents, as it naturally increases with age; (4) Fear for stigmatization, considering the intervention design with visits to the nurse during school hours | |||||||||
| Pbert, Druker [65] | RCT | Overweight or obese adolescents in grades 9 to 12 | School nurse-delivered cognitive behavioral counseling and an afterschool exercise program | BMI, 24-hour dietary recall interview, Physical activity (PA) with accelerometer, Survey to measure sedentary behaviour, TV, computer games, questionnaires to measure self-efficacy (11-item questionnaire) and perceived barriers |
Unlikely, funded by National Institutes of Health, National Heart, Lung and Blood Institute | Low [2] G |
126 | √ | Students in the intervention compared with control schools showed no significant differences in anthropometric variables including BMI, percent body fat, and waist circumference at follow-up. Students in intervention compared with control schools reported eating breakfast on significantly more days/weeks at follow-up, adjusted mean 4.65 vs. 3.84 days, respectively (adjusted mean difference 0.81 days; 95% CI 0.11–1.52). The mean number of days students reported being physically active in the past 7 days was similarly high in the intervention compared with control schools at follow-up, adjusted mean 4.54 days vs. 3.64 days, respectively (adjusted mean difference 0.89 days; 95% CI 0.25–1.53). |
| Pbert, Druker [64] | RCT | Overweight or obese adolescents in grades 9 to 12 | School nurse-delivered counseling intervention “Lookin’ Good Feelin’ Good”, utilizing cognitive-behavioral techniques |
BMI, 24-hour dietary recall interview, PA with accelerometer, Survey to measure sedentary behaviour, TV, computer games, questionnaires to measure self-efficacy and perceived barriers |
Unlikely, funded by National Institutes of Health, National Heart, Lung and Blood Institute | Unclear [4] E, G |
84 | √ | At 2 months, intervention participants ate breakfast on more days/week (difference = 1.01 days; 95% CI 0.11, 1.92), and had a lower intake of total sugar (difference = −45.79g; 95% CI −88.34, −3.24) and added sugar (difference = −51.35g; 95% CI −92.45, −10.26) compared to control participants. At 6 months, they were more likely to drink soda ≤ one time/day (OR 4.10: 95% CI 1.19, 16.93) and eat at fast food restaurants ≤ one time/week (OR 4.62: 95% CI 1.10, 23.76) compared to control participants. There were no significant differences in BMI, activity or caloric intake. |
| Sherman, Alexander [94] | Obs | Obese children in grades 4–6 | 9 lessons of a 9-week period which addressed self-esteem, food choices and nutrition, and PA and fitness | Weight skinfold measurements (desired outcome: amount of lean and fat tissue in the body), questionnaires to measure self-esteem and nutritional knowledge | No indication | High [10] G, I, F |
26 | / | Self-esteem increased significantly (p< .001) between the pre-test and post-test interval. Weight status and nutritional knowledge showed no improvement. |
| Speroni, Earley [95] | Obs | Children grade 2–5 | Kids Living Fit-Intervention ($100 fee to Participate) PA activity, dietary education | BMI, waist circumference, questionnaires to measure food, activity, and satisfaction | No indication | Unclear [7] H |
185 | / | All KLF intervention groups in the four schools experienced a decrease in BMI percentile from the baseline measure to remeasure recorded at Weeks 12 and 24. The two single largest decreases in BMI percentile occurred in the contrast groups in Schools 1 and 4, with an 8.5 and 7.9 (p< .1) percentile point decrease, respectively. By comparison, participants in the KLF group in School 1 had a 4.0 (p< .1) percentile point decrease in BMI. |
| Tucker and Lanningham-Foster [96] | Obs | Children in grade 4 and 5 | Refined health messaging (Let’s Go 5-2-1-0) program | BMI percentile, Healthy Habits Survey to measure nutrition, screen time, PA, and family eating patterns, a StepWatch Activity Monitor to measure PA levels |
No indication | High [10] G, D, I |
72 | / | School A: BMI percentile did not change significantly over time. The mean/median number of servings of fruits and vegetables per day significantly increased from baseline to end of year (p = .001), while the number of servings of 100% fruit juice per day significantly decreased (p = .003). There was also a trend in minutes of self-reported active play, which increased from baseline to end of year (p = .057). Objectively measured participant PA levels increased significantly (p < .005) from baseline (M = 12,139, SD = 401 steps) to end of year (M = 15,120, SD = 680). |
| Wong and Cheng [97] | Obs | Obese children in primary schools | Motivational interviewing (MI) counselling; + telephone consultation for parents (MI+) | Change in weight for- height percentage with reference to a territory-wide growth survey, changes in weight-related behaviours and anthropometric measures |
Unlikely, funded by the Hong Kong Institute of Education | Unclear [6] I |
185 | / | There was a significant decrease in the average calorie intake from food in the past seven days in the MI group (mean difference: 389 57; p < 0 01) and in the MI+ group (mean difference: 376 65; p < 0 01). It also showed a significant increase in the average calories consumed due to an increase in physical exercise in the past seven days in the MI group (mean difference: 2052 10; p < 0 01) and in the MI+ group (mean difference: 2590 64; p < 0 01). Control group had significant deterioration in their anthropometric measures. |
| Physical activity | |||||||||
| Robbins, Pfeiffer [98] | Obs | Middle school girls | Girls on the Move (3 motivational, individually tailored counseling sessions + after-school physical activity | Questionnaires on benefits/barriers of PA, self-efficacy, etc. to measure cognitive and affective variables related to PA, PA, cardiovascular, and body composition (BMI, waist circumference) | Unlikely, funded by National Heart, Lung, and Blood Institute and the National Institutes of Health |
High [8] J(5), G |
69 | / | Linear regressions controlling for baseline measures showed no statistically significant group differences, but directionality of differences was consistent with greater intervention group improvement for minutes of moderate to vigorous physical activity/ hour (t = 0.95, p = .35), cardiovascular fitness (t = 1.26, p = .22), body mass index (BMI; t = −1.47, p = .15), BMI z-score (t = −1.19, p = .24), BMI percentile (t = −0.59, p = .56), percent body fat (t = −0.86, p = .39), and waist circumference (t = −0.19, p = .85). |
| Williams and Warrington [99] | Obs | Children in grade 3–5 (8–10 years of age) in elementary school | Pedometer-based walking program, Get Fit Kids | Change in step counts from the children’s pedometers, participant satisfaction, and program costs | No indication | Unclear [7] D, J(6) |
231 | √ | There was a statistically significant difference in the step counts from Time 1 (M = 6,567.73, SD = 5,189.51) to Time 2 (M = 10,804.60, SD = 11,664.81), t = 3.374, p = 0.001 (two-tailed). The mean difference in the step counts was 4,236.87, with confidence levels ranging between 1,715.633 and 6,758.098. |
| Wright, Giger [66] | RCT | Children aged 8–12 years | Kids N Fitness (45 min PA), nutrition education, school-wide wellness activities | Child and Adolescent Trial for Cardiovascular Health School Physical Activity and Nutrition Student Questionnaire, anthropometric measures (Height, weight, body mass index, resting blood pressure, and waist circumference) | Unlikely, funded by the NIH/ NCMHD Loan Repayment Program and Robert Wood Johnson Foundation | Low [2] G |
251 | √ | Significant results for students in the intervention, included for boys decreases in TV viewing; and girls increases in daily physical activity, physical education class attendance, and decreases in body mass index z-scores from baseline to the 12-month follow-up. |
| Note. Detailed risk of bias assessment: (5) non-compliance with accelerometer wear; (6) Not a validated questionnaire; | |||||||||
| Emotional Health | |||||||||
| Attwood et al. [14] | 1 x RCT 1 x Obs |
Children with mean age of 10.6 years | Computerized cognitive therapy | Spence Children’s Anxiety Scale (SCAS), Strengths and Difficulties Questionnaire (SDQ) to measure desired outcome of anxiety and parental perception of child behavior | No indication | Unclear [7] B, J(7),F, G |
12 | / | A statistically significant post-intervention reduction in total child anxiety ratings on the SCAS-C for the cCBT (Z =) 1.79, p < .05), but not for the gaming condition (Z =) 1.59, p > .05). Analysis of subscale scores revealed a statistically significant post-intervention reduction on the social anxiety (Z =) 1.80, p < .05) and generalized anxiety (Z =) 1.73, p < .05) sub-scale scores for the cCBT group only. |
| Clausson and Berg [23] | Obs | Children aged 11–17 and their families | Calgary Family Assessment Model (CFAM), Calgary Family Intervention Model (CFIM), Illness Beliefs Model (IBM) | SDQ to measure desired outcome of emotional symptoms, conduct, hyperactivity, peer problems, and prosocial behavior | No indication | High [10] G(8), F, C, E |
4 | / | The families reported feeling relief and described positive affective, behavioral, and cognitive changes as a consequence of the interventions. The school nurses experienced the family sessions as time-saving and easy-to-use tools in their work. |
| DeSocio et al. [100] | Obs | Children aged 10–12 | Education program (brain, managing stress, resources, help) | 16-item pre-and posttest covering content delivered in the modules to measure the desired outcome of knowledge gain | Unlikely, funded by Northwest Health Foundation | High [8] H, F |
370 | / | Overall, student scores improved significantly from pre- to posttest (mean score increased by 1.5, P = .000). Greatest improvements in: (a) knowledge that mental illness is not the same as mental retardation; (b) knowledge that genetic factors, internal thoughts, and environmental events contribute to mental health; (c) recognition that when someone talks about suicide, it is a message to be taken seriously-the person is not just trying to get attention; (d) awareness that relationships, as well as events, can generate stress; I knowledge of chemical changes that occur in the body during stress; and (f) awareness that it is not possible to tell if someone has a mental illness just by looking at them. |
| Houck, Darnell [101] | Obs | Adolescents with depressive symptoms and related problems | 1: cognitive–behavioral intervention„ 2: A Peer Group Approach to Building Life Skills | Questionnaires to measure desired outcome of emotional distress, resources and coping skills and survey of risk to measure suicide risk factors | No indication | High [10] E, G, I |
12 | / | Assessment revealed that the students were at suicide risk. At the conclusion of the group intervention, there was a 55% decrease in suicidal ideation, a 27% decrease in perceived stress, and a 26% decrease in family distress. In addition, most of the students became engaged in formal treatment for the first time. |
| Lamb et al. [67] | RCT | Children 14–18 years in rural area | Screening of depressive symptoms, suicidal ideation, nurse-led coping skills group | The Jalowiec Coping Scale (JCS) to measure desired outcome of coping skills, The Reynolds Adolescent Depression Scale (RADS) to measure depressive symptoms | No indication | Unclear [3] G, J(9) |
40 | / | Intervention subjects showed marginally significant greater decrease than control subjects (p < .001), intervention subjects showed a marginally significant greater decrease than control subjects (p = .074). Analysis of the depression screening tool (RADS) score demonstrated that 86.9% of the intervention group showed decreased depressive symptomatology with mean improvement of 15 points, whereas 61.1% of controls showed mean improvement of 13.8 points on RADS. |
| Note. Detailed risk of bias assessment: (7) Absence of an appropriate comparison group limits the strength of any conclusions as it is unclear whether the reported improvements were due to cCBT or the passage of time; differences in both child-rated total anxiety and parent-rated SDQ scores between the cCBT and gaming groups at baseline; (8) Insufficient reporting of results, descriptive; (9) Unclear if control group didn’t realize they weren’t in the intervention group, as they didn’t receive any treatment, not even a placebo. It seems as if there was a lack of allocation concealment | |||||||||
| Muggeo, Stewart [102] | Obs | Children with anxiety symptoms aged 5–11 years | Child Anxiety Learning Modules (CALM), (cognitive behavioral strategy) | Screen for Child Anxiety-Related Emotional Disorders, Child and Parent Versions (SCARED) to measure desired outcome of anxiety; Woodcock–Johnson Tests—Achievement and Cognitive Batteries (WJ-III) to measure academic achievement and cognitive abilities | Possibly, funded by the Dep. Of Education’s Institute of Education Sciences | High [10] I, G, J(10) |
11 | √ | Results indicated significant reductions in anxiety based on child self-reported SCARED-C; t(9) = 3.36, p = .004, 95% CI [3.24, 16.56], Cohen’s d = 0.81. Significant reductions in somatic symptoms were reported at post-intervention by parents CSI-24; t(10) = 2.49, p = .016, 95% CI [41, 7.58], Cohen’s d = .78 9 and children CSI-24; t(9) = 2.21, p = .027, 95% CI [-.18, 15.98], Cohen’s d = .85. Global functioning scores, as measured by the CGAS, were significantly higher at post-intervention, with a small effect size, t(10) = -3.45, p = .003, 95% CI [-12.11, -2.61], Cohen’s d = .35 |
| Ramirez, Harland [103] | Obs | Trauma-exposed children | Listen, Protect, Connect (LPC) | Modified Child PTSD Symptom Scale, Center for Epidemiologic Studies Depression Scale (CES-D) to measure depression, Multidimensional Scale of Perceived Support (MSPSS) to measure perceived social support and Healthy Kids Resilience Measure of School Connectedness | Unlikely, funded by the University of Iowa Injury Prevention Research Center | High [10] G, E, I |
20 | √ | A significant decline in depressive symptoms was seen from baseline to each follow-up period, all levels below the clinical cut point for depression. PTSD symptoms decreased 3.7 points from baseline to the 8-week follow-up, although this change was not statistically significant (range 15.5–11.8; p = 0.09). Total social support increased from baseline to the 2-week follow-up (p = 0.08) and increased significantly from baseline to the 8-week follow-up (p < 0.01). Students felt more connected to their school at 2- (mean = 63.8, p = 0.06) and 4-weeks (mean = 68.9, p < 0.01) than at baseline (mean = 58.6), but this relationship diminished by 8-weeks. |
| Stallard et al. [104,105] | Obs | Children aged 9 and 10 | Evidence-based emotional health cognitive behaviour therapy programme, (FRIENDS) |
Spence Children’s Anxiety Scale and Culture-Free Self-Esteem Questionnaire Form B to measure desired outcome of levels of anxiety and self-esteem | No indication | High [10] G, I, E |
106 | / | Initial ANOVAs revealed a significant change for total anxiety (F = 5.84, df = 2,315, p = 0.003) and self-esteem (F = 2.98, df = 2,315, p = 0.052) across time. Post-hoc comparisons using Tukey’s test revealed no significant change in anxiety or self-esteem over the two pre-intervention assessments (T1—T2) but a significant change from T1 to post intervention (T3) for both anxiety (p = 0.002) and self-esteem (p = 0.040). There were no significant differences between the three and 12-month follow- up (T3–T4) suggesting that post FRIENDS gains were maintained. |
| Note. Detailed risk of bias assessment: (10) Participation in study was on voluntary bases for students who were motivated. This could have an impact on the results when only motivated students are considered in study | |||||||||
| Asthma care | |||||||||
| Bruzzese et al. [106] | Obs | Children in Kindergarten up to grade 5 | School nurses coordinating between families, primary care providers (PCPs), and school personnel | Paediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ) to measure desired outcome of impact on children’s quality of life; school absence | No indication | Unclear [7] H |
591 | / | Relative to controls, 12-months post-test intervention students had a reduction in activity limitations due to asthma (35% vs _9%, p, .05) and days with symptoms (26% vs 39%, p. .06). The intervention had no impact on the use of urgent health care services, school attendance, or caregiver’s quality of life. There were also no improvements at 24-months postintervention. |
| Christian-sen et al. [21] | Obs | Children in grade 4 (age 9–12 years) | Asthma education by school nurses | Asthma knowledge test and symptoms questionnaire to measure desired outcome of severity of asthma symptoms | No indication | Unclear [7] G |
42 | / | Mean scores for the asthma quiz improved from 9.9 (SEM = 0.44) to 13.7 (SEM = 0.30). Peak flowmeter scores improved from 3.9 (SEM = 0.33) to 6.4 (SEM = 0.29), and inhaler technique scores improved from 2.3 (SEM = 0.26) to 4.3 (SEM = 0.26). All changes in this group were highly significant (p -< 0.00001). After 180 days, the symptom scores validated for functional asthma severity were significantly lower in the educated group (2.87 + 0.447) compared with the control group (4.36 + 0.573, p = 0.0188). Asthma-related school absences, emergency department visits, and hospitalizations showed no differences between the education and control groups |
| Engelke et al. [25] | Obs | Children in grade 1–12 | Case management | PedsQL 3.0 SF22 to measure desired outcome of quality of life, grades to measure academic achievements, individualized goals evaluated by school nurses | Unlikely, funded by a grant from the Kate B. Reynolds Charitable Trust. |
High [8] E, D(11) |
143 | / | The proportion of children reporting symptom and treatment problems was significantly lower at the end of the program compared to baseline (p < .01). The largest improvement in asthma symptom and treatment problems was among students who met the goal of reducing emergency department (ED) visits/hospitalizations, symptom gain: n = 42, M = 16.0, SD = 17.0; treatment problem gain: M = 13.3, SD = 15.3) compared to those who did not met the goal [symptom gain: n = 19, M = 6.2, SD = 10.2, t(54). 2.20, p = .03, η2 = 08; treatment problem gain: M = 1.7, SD = 9.6, t(54). 2.86, p = .01, η2 = .13]. |
| Fransisco et al. [107] | Obs | Children with asthma aged 5–14 years | School nurse training, 4 key messages from EPR-3, nurses supplied with assessment tools | self-reported Inhaled corticosteroid (ICS) use and adherence, CHSA-C to measure desired outcome of impairments and inspiratory flow rate, Forced expiratory volume (FEV) and EPR-3 to assess asthma control | No indication | High [9] E, J(12), D |
178 | √ | At enrolment, 69.7% of students had “not well-controlled” or “Very poorly controlled” asthma. Postintervention, FEV significantly improved (82.9% to 92.1% predicted), and self-reported impairment and tobacco smoke exposure significantly declined (P < .001). For Teaming Up for Asthma Control (TUAC) students enrolled in Medicaid, there was an average 12-month health care cost difference (−$1,431) compared with controls. |
| Note. Detailed risk of bias assessment: (11) Not all students received grades and could be compared on academic outcome; (12) Control group was not described appropriately | |||||||||
| Halterman et al. [68] | RCT | Children with asthma aged 3–10 years | Preventive asthma medications by school nurses | Symptom-free days | No indication | Unclear [5] B, G |
530 | √ | Children receiving preventive medications through school had significantly more symptom-free days compared to children in the control group (adjusted difference = 0.92 days per 2 weeks) and also had fewer night-time symptoms, less rescue medication use, and fewer days with limited activity (all P < .01). |
| Harrington et al. [69] | RCT | Children with asthma in kindergarten up until grade 8 | Nurse-administered inhaled corticosteroids (ICS) | Morning doses of ICS, Questionnaires to measure desired outcome of asthma-related morbidity, quality of life, and health-care utilization | Unlikely, funded by EJF Philanthropies | Unclear [4] G, D, F |
46 | √ | Intervention patients reported significantly less functional limitation (42.9% vs. 73.9%, p = 0.04), adjustment to family life (23.8% vs. 56.5%, p = 0.03), and sleep loss (1.7 vs. 4.1 nights in last 2weeks, p = 0.035) than control patients at the end of the 60-days study period. There were no differences in unscheduled health-care utilization by group. |
| Janevic et al. [108] | Obs | Children with asthma mean age 7 in underserved communities | Medical–social care coordination program | Childhood Asthma Control Test to measure daytime and night-time symptoms | Possibly, Funded by Merck Childhood Asthma Network, Inc. (MCAN) | High [8] C, F |
805 | √ | At follow-up, intervention participants had 2.2 fewer symptom days per month (SD = 0.3; P < .01) and 1.9 fewer symptom nights per month (SD = 0.35; P < .01) than did the comparison group. The relative risk in the past year associated with the intervention was 0.63 (95% confidence interval [CI] = 0.45, 0.89) for an emergency department visit and 0.69 (95% CI = 0.47, 1.01) for hospitalization. |
| Levy et al. [70] | RCT | Medically underserved inner-city children aged 6–10 years | School-based asthma case management (open airways curriculum) | Student records to measure absences, hospital utilization; knowledge tests to measure student’s knowledge and skills | No indication | Unclear [3] E, F |
243 | / | Case management (CM) students had fewer school absences than their counterparts in Usual care (UC) schools (mean 4.38 vs 8.18 days, respectively) and experienced significantly fewer emergency department visits (p < .0001) and fewer hospital days (p < .05) than UC students. No such differences existed before program initiation. Replication and follow-up in year 2 showed continued significant improvements. |
| Liptzin et al. [109] | Obs | School aged children in inner-city schools | School centered asthma program “Step-Up Asthma Program” | Inhaler technique, Open Airways for School (OAS) scare and Kickin`Asthma (KA) score to measure desired outcome of asthma knowledge, Asthma control was measured with a questionnaire. | Possibly, authors received support by different organizations | High [9] I, D |
252 | / | Inhaler technique, OAS scores, and modified KA scores improved significantly from baseline to the 1-year follow-up. Students who participated in the Step-Up Asthma Program experienced decreased asthma exacerbations. Emergency department and urgent care visits, use of systemic corticosteroids, and missed school days all decreased significantly from baseline. Hospital admissions decreased significantly from baseline to the 1-year follow-up (P = .002), but baseline to 2-year follow-up was not significant (P = .2). |
| Mickel, Shanovich [110] | Obs | Children with asthma; 7–11 years of age in a Midwest metropolitan school district | Iggy and the Inhalers—an asthma education program | Children’s knowledge and family awareness of asthma management was measured with the help of test questions | Unlikely, funded by a Wisconsin State Asthma Coalition | High [10] F, I, D, G |
147 | √ | Asthma knowledge increased significantly (p < .001) between pre-test and post-test, and this increase was retained at 1-month follow-up. This program evaluation suggests that our program had a significant, sustained impact on students’ asthma knowledge |
| Moricca, Grasska [111] | Obs | Children with asthma aged 7–12 years | Screening for asthma risk status, case management | CST-ELA and CST-Math scores to measure desired outcome of academic achievements, postintervention absenteeism | No indication | Unclear [7] G |
142 | √ | Grade did emerge as a statistically significant predictor of students’ CST-Math scores with fifth to sixth grade students outperforming second to fourth grade students (p < .001). While year, gender, and the interaction of group and year failed to serve as statistically significant predictors of postintervention absenteeism (p > .05 for each), younger children (grades 2–4) missed approximately 2 more days per year than older children (Grades 5–6) 7.1 days (SE = 0.85). versus 5.1 days (SE. 0.42), p. .019. |
| Noyes, Bajorska [71] | RCT | Children with asthma aged 3–10 year | 1 dose of preventive asthma medication | Mean number of symptom free days and parent questionnaire to measure desired outcome of health serves utilization | No indication | Low [1] F |
525 | √ | The health benefit of the intervention was equal to ∼158 SFD gained per each 30-day period (P, .05) per 100 children. The programmatic expenses summed to an extra $4822 per 100 children per month. The net saving due to the intervention (reduction in medical costs and parental productivity, and improvement in school attendance) was $3240, resulting in the incremental cost-savings difference of $1583 and CE of $10 per 1 extra SFD gained. |
| Persaud, Barnett [72] | RCT | Children with asthma aged 8–12 years (mean 10,2) | School nurse-delivered asthma self-management and skills, personal peak flow meter | Devilbiss surveyor 1 Spirometer to measure Pulmonary function, 5 questionnaires (parent’s and child’s asthma knowledge, control, feeling, attitude) | Unlikely, funded in part by Health Services and Resources Administration, U.S. Public Health Service. | Unclear [3] G, F |
36 | / | Both treatment and control subjects demonstrated improvement in asthma knowledge and child health locus of control: 2.2 +/- 2.3 for the intervention and .8 +/-3.5 for the control group. The groups did not differ significantly in the magnitude of this effect. The intervention group experienced a small positive change in asthma attitude (1.4 +/- 8.7), while the control group showed a small negative change of -1.4 +/-8.1. The functional impact score was unchanged for both groups. |
| Splett, Erickson [73] | RCT | School-aged children with asthma | Enhanced asthma management, as defined in The Healthy Learners Asthma Initiative (HLAI) procedures | Daily visit log, student medication, and health records, clinic process improvements, attendance data, | Unlikely, funded by Member Organizations of the Healthy Learners Board, Controlling Asthma in American Cities | Unclear [5] H, E(13), D(14) |
1,561 | / | Control schools had significantly more total visits (p = .02) and episodic visits (p = .003) than intervention schools. No significant differences were found in attendance between control and intervention schools overall or for students with or without asthma for each of the 2 study years. From 1999–2000 to 2000–2001, attendance for students without asthma increased by 0.6% or nearly half of a day. This reached statistical significance for control (p = .04) and intervention schools (p = .02). There was no significant change for students with asthma, and a significant interaction was found between asthma status and time (p = .01). |
| Taras, Wright [112] | Obs | Children with asthma | Case management protocol | Asthma severity, medication, peak flow, case management provided, days absent | No indication | High [10] D, G, I |
1,094 | / | Students with moderate/severe asthma were more likely to receive a larger number of school nurse case management activities than students with mild asthma for all three years. Students with mild and moderate/ severe asthma who received at least one nurse case management activity in Year 1 were more likely to have an asthma medication available at school and to use a peak flow meter in Year 2. Change in absentee rate from Year 1 to Year 2, and Year 2 to Year 3, showed no significant association with nurse case management the previous year. |
| Note. Detailed risk of bias assessment: (13) Practice changes in the intervention group could not be controlled, risk of confounding factors; (14) Attendance rate might not be an appropriate tool to measure the effectiveness of an asthma initiative | |||||||||
| Trivedi, Patel [113] | Obs | Children with asthma (mean age 10,5) | Daily inhaled corticosteroid at school, supervised by their school nurse | Number of emergency department visits, hospital admissions, school absences, rescue medication use | No indication | High [10] G, I |
84 | / | Asthma-related ED visits over a 1-year period decreased 37.5%, from a pre-intervention mean of 0.8 visits to a post-intervention mean of 0.3 visits (p < 0.001). Asthma-related hospital admissions decreased from a pre-intervention mean of 0.3 admissions to post-intervention mean of 0 admissions (p < 0.001). Asthma rescue medication refills decreased by 46.3% from the pre- to post-intervention period (p = < .001). There were also non-significant declines in school absences and oral steroid use for children enrolled. |
| Smoking cessation | |||||||||
| Cameron et al. [19] | RCT | Children in grade 6 to 8 | Teacher workshop, School nurse (SN) workshop, teacher self-preparation, sn-self-preparation | Breath sample and self-reports to measure desired outcome of smoking habits | Unlikely, funded by the National Heart, Lung, and Blood Institute (NHLBI) | Low [114] |
3,972 | / | The overall smoking rate was 18.6% (95% confidence interval [CI] = 16.8%, 20.4%). Fewer than half (46.3%; 95% CI = 44.1%, 48.5%) of the students had never smoked by the end of grade 8. All 4 treatment conditions produced smoking rates that were less than the control group rate but were not significant. After adjustment for extrabinomial variation with the Pearson goodness-of-fit statistic, this model showed a significant interaction between condition and senior smoking rate (F4,84 = 3.88, P = .006). |
| Lamb et al. [67] | Obs | Pregnant African American teens aged 15–20 years | Eight group sessions “Teen fresh start” | Questionnaire and self-report to measure desired outcome of smoking behavior | Unlikely, funded by the American Nurse Foundation | High [10] G, F, D, I |
9 | / | While the number of subjects was too small to demonstrate significance, the team was encouraged to learn that five girls quit smoking and two cut down on their smoking. Descriptive analysis of results. |
| Thomson [115] | Obs | School-aged children | School-based smoking cessation programme | Questionnaire to measure | No indication | High [9] H, E |
4,505–4,999 | / | The target schools showed a reduction in smoking prevalence of 8% compared to a reduction of only 5.7% in the comparison schools. School E showed the highest percentage with a reduction of 14.1%. In this school smoking prevalence was 25.3 in 2006–2007 and only 11.2 in 2008–2009.The Department of Health (DoH) requires that stop smoking services collect and submit information on the number of smokers who remain abstinent for 4 weeks following their quit date. Although much good work in terms of health promotion was reported during the 2005–2006 pilot project, there were no 4-week quitters. During the Local Area Agreement (LAA), the quit rate rose from 0 to 24%. |
| Immunization | |||||||||
| Ferson et al. [35] | RCT | Children in Kindergarten and primary schools | Letters and leaflets + telephone calls | Immunization rate | Unlikely, funded by the Prince Henry Hospital Centenary Research Fund | Low [1] J(15) |
239 | / | Excluding children lost to follow up and those fully immunized at the start of the study, 20 (37%) of 54 were immunized following the passive intervention, and 35 (71%) out of 49 following the active intervention (P = 0.001). Receipt of the letter and leaflet was associated with an increased uptake of booster vaccination (P = 0.036). These proportions are significantly different (Yates corrected) χ2 = 10.9, P = 0.001). |
| Note. Detailed risk of bias assessment: (15) Excluding children lost to follow up | |||||||||
| Luthy et al. [116] | Obs | Children in grade 6 and 7 | Educational and incentive program | Tetanus, diphtheria, and acellular pertussis (Tdap) booster compliance rates | Unlikely, funded by Association of Pediatric nurse Practitioners and Wyeth Pharmaceutical Company | High [10] G, I |
958 | / | The compliance rate expanded from 4% to 57% during a 4-week intervention program. Notably, the Tetanus, diphtheria, and acellular pertussis (Tdap) immunization compliance rate in the previous year (2008) was 54%. Researchers concluded that the intervention did not improve compliance rates significantly. |
| Toole and Perry [117] | Obs | High risk-students in inner-city schools | Immunization audits + immunization at school at no cost | Immunization rate | No indication | High [8] I |
2,222 | / | Immunization compliance rates have gone from an average of 64% to an average of 97%. An audit of 2,222 kindergarten records performed 5 years after the intervention indicated that less than 1% had no immunization records on file, only 2% needed immunizations, and less than 3% were out of compliance. |
| Vernon, Conner [118] | Obs | School-aged children | A: inviting immunization-deficient children; B: permission slips; C: health education program | Immunization rate | No indication | Unclear [7] E |
5,636 | / | Using an average of 38 hours of school nurse time, Method A succeeded significantly better than Method B in immunizing more immunization-deficient children and raising immunization levels, while giving fewer unnecessary immunizations. Method C did not produce significant improvement of immunization levels. |
| Sexually transmitted Virus Prevention | |||||||||
| Borawski et al. [74] | RCT | Children in 9th and 10th grade high schools | Be Proud! Be Responsible (BPBR) curriculum taught by school nurses and teachers | Questionnaires to measure desired outcomes of knowledge, efficacy, participants’ beliefs, perceived peer beliefs, and behavioral intentions | No indication | Unclear [5] E, J(16), G |
1,357 | / | Both groups reported significant improvements in Human immunodeficiency virus (HIV)/ Sexually transmitted infections (STI)/condom knowledge immediately following the intervention, compared to controls. Yet, those taught by school nurses reported significant and sustained changes (up to 12months after intervention) in attitudes, beliefs, and efficacy, whereas those taught by health education teachers reported far fewer changes, with sustained improvement in condom knowledge only. |
| Grandahl et al. [75] | RCT | Teenagers 16 years of age | Specific Human papillomavirus (HPV) education guided by Health belief Model (HBM) | Questionnaire based on HBM to measure desired outcome of health behavior, beliefs, knowledge awareness | No indication | Low [1] D(17) |
741 | √ | The intervention had a significant effect on HBM total score (p = 0.003), (i.e., the students perceived more benefits of vaccination, perceived themselves to be at increased risk for an HPV infection or HPV-related disease, considered HPV-related disease a severe threat and perceived fewer barriers against HPV vaccination), with a 2.559 points higher score for the intervention compared to the control group. |
| Note. Detailed risk of bias assessment: (16) Only 25% of the classes could be randomly assigned to school nurses, reducing the sample size and power to detect smaller intervention effects; sample size of teacher-led classrooms was not large enough; (17) It is questionable if questionnaires on beliefs and intentions are the method of choice to measure health behavior | |||||||||
| Teenage pregnancy | |||||||||
| Chen et al. [76] | Obs | Pregnant students | Monthly visits to the school nurse (nutrition, infant care, father of baby, finance, family support, future plans, education… | Birth weight and parental care was measured by conducting month prenatal care began and frequency of visits | No indication | High [8] D, E |
578 | / | The program effects on birth weight have two pathways. To test the direct effect, a two-tailed, paired t test was applied to compare the difference of birth weight between cases and controls (M = 27.6g, SD = 864.7g) and the result was not statistically significant (t (287) = 0.543; P>0.05). However, the finding showed a higher mean birth weight (27.8g) for cases than for controls. |
| Allergies | |||||||||
| Spina, McIntyre [79] | RCT | Children (mean age 15 years) diagnosed with a life-threatening allergy + auto-injectable epinephrine | Education (for intervention and control), showing school nurse their epinephrine | Periodic checks and expiry checks | No indication | Unclear [4] G, E(18) |
77 | / | No significant differences were found between the intervention and control groups in the proportion of students who had epinephrine available during the initial check (x2 = 1.63, df = 1, p = .2) or the final check at the end of the study (x2 = 1.73, df = 1, p = .189). In the intervention group, all participants who had unexpired epinephrine during the first check continued to have current epinephrine, while one person with expired epinephrine on the first check had acquired current epinephrine during the final check (p < .01). For the control group, of the 21 participants who reported having unexpired epinephrine during the first check, 5 participants had expired epinephrine during the final check. |
| Nutrition | |||||||||
| O’Donnell et al. [77] | Obs | Children in Kindergarten to grade 6 | Educating teachers and offering mini grant materials | Knowledge test on nutrition for students to measure desired outcome of effectiveness of mini grant materials | No indication | High [10] D, E, F, I, G |
1,106 | / | In summary, most of the classroom teachers used the nutrition resource materials, and it would appear that the availability of these nutrition resource materials caused an increase in time spent on nutrition education. |
| Alcohol use prevention | |||||||||
| Werch, Carlson [80] | RCT | Children in grade 6–8 (mean age 12,2 years) in inner-city school | STARS program (Start Taking Alcohol Risks Seriously) | Alcohol use, Alcohol consumption patterns, negative consequences experienced during drinking | Unlikely, funded in part by National Institute on Alcohol Abuse and Alcoholism | Low [2] G |
138 | / | A significant difference was found on heavy alcohol use with intervention subjects showing a reduction and control subjects an increase in heavy drinking (t = -2.33, I20dJ; p = .02). No differences were found between groups on other alcohol use measures. |
| Note. Detailed risk of bias assessment: (18) The educational intervention available to both the control and the intervention group to ensure the safety of students. The education may have had an impact on increasing the likelihood that students would carry epinephrine. | |||||||||
| Hearing screening | |||||||||
| Sekhar et al. [119] | Obs | Children in Kindergarten, 1st-3rd grade; adolescents in grade 7 and 11 | High-frequency screen and PA-screen | PA-screen to measure low-frequency, conductive hearing losses; high-frequency screen for adolescent hearing loss | Unlikely, funded by Academic Pediatric Association and Child Health Bureau | High [10] G(19), D(20), F, J(21) |
282 | / | Five participants (2%) were referred on the Pennsylvania school screen, and 85 (30%) were referred on the high-frequency screen. Of the 48 who returned for gold standard testing with audiology, hearing loss was diagnosed in 9/48 (19%). Sensitivity of the Pennsylvania and high frequency screens were 13% (95% confidence interval [CI] 0–53%) and 100% (95% CI 66–100%) respectively. |
| Cardiovascular Health | |||||||||
| Harrell et al. [82] | RCT | Elementary school children aged 7–12 years | Classroom-based and risk-based interventions (nutrition, physical activity and smoking) | Questionnaires to measure desired outcome of knowledge, attitude and physical activity; Health outcome was measured with BMI, cholesterol level, blood pressure, aerobic power and skinfolds | Unlikely, funded by the National Institute for Nursing Research | Unclear [3] F, E |
2,109 | √ | Total knowledge in the classroom-based intervention schools was significantly greater than that in the control schools (7.86; 95% CI = 3.32, 12.40). The physical activity score improved significantly only in the risk-based schools (3.87; 95% CI = 1.35, 6.39). There were statistically significant differences among the 3 groups in regard to changes in cholesterol (P< .01), but only the classroom-based approach reduced mean cholesterol significantly more than in the control group. Adjusted differences among the groups were nonsignificant for systolic blood pressure but were significant for diastolic blood pressure (P = .03). Both the classroom-based and risk-based groups exhibited a significantly smaller increase in diastolic blood pressure than the control group. |
| Psychosomatic headaches | |||||||||
| Larsson and Carlsson [83] | RCT | Children aged 10–15 | Nurse-administered relaxation training | Headache diary to measure headache free days | No indication | Low [2] G |
26 | / | Nine pupils (69%) who were treated with relaxation training had achieved a clinical improvement level (of at least 50%), whereas only one subject (8%) in the no-treatment control condition had attained such an improvement level, a difference that was highly significant, x2(1) = 10.40, p < .001. Although a small improvement was noticed in the no-treatment control group at the 6-month follow-up, the difference between the two treatment conditions was still significant, x2 = 3.94, p < .05. Pearson product-moment correlation analysis revealed a nonsignificant association between children’s age and their headache (pre—post) improvement (r = .07). |
| Diabetes | |||||||||
| Izquierdo et al. [84] | RCT | Children with diabetes aged 5–14 years | Usual care + a videoconference between school nurse, child, and diabetes team every month. | Hemoglobin A1c to measure the long-term glycaemic control and Pediatric Quality of Life (PedsQL) to measure quality of life | No indication | Low [2] G |
41 | / | There was a significant difference in slopes between the telemedicine and usual care groups during the first 6 months (P < .02). A1c values increased from baseline to 6 months for students in the usual care group (not statistically significant) but decreased in the telemedicine cohort (P < .02), and the improvement was maintained over the next several months. No significant differences in slopes, or within-group slopes were observed after the 6-month point. |
| Note. Detailed risk of bias assessment: (19) Statistically, the small number of adolescents presenting for gold standard testing resulted in wider confidence intervals around the estimates of sensitivity and specificity; (20) Time lapse between two screenings too big; (21) Expectation bias | |||||||||
| Nguyen, Mason [85] | RCT | Children with high levels of HbA1c | Insulin glargine, insulin aspart, OneTouch Ultra glucometer, access to the GlucoMON system | Blood glucose records during school hours; Hemoglobin A1c (HbA1c) level and BMI (to measure weight gain) | Unlikely, funded by investigator-initiated grant Rubina Heptulla from Sanofi-Aventis | Unclear [4] G, F, J(22) |
36 | √ | The HbA1c level remained unchanged in the control group but was decreased significantly in the intervention group. For the intervention group, the rate of hypoglycemia (BG<59 mg/dL) was 0.86 +/-0.55 episode/patient-week. No data of hypoglycemia in control group. There was no difference in BMI between the 2 groups either before or after the 3-month study period. There was no correlation between the change in BMI and the change in HbA1c level in the intervention group (r = 0.24). |
| Teasing and Bullying | |||||||||
| Vessey and O’Neill [78] | Obs | Children with diabetes aged 5–14 years | Identification of at-risk students, web-based program to build resiliency, biweekly support/discussion group | Child-Adolescent Teasing Scale (CATS) measuring 4 components of teasing, Pediatric Symptom Checklist (PSC) measuring parent’s perception of psychological functioning, Piers-Harris Children’s Self-concept Scale (PHCSCS) measuring self-concept | Unlikely, funded by Deborah Munroe Noonan Memorial Research Fund | High [10] I, E |
65 | / | Statistically significant, positive differences were noted in students’ total scores on the CATS (t = 3.432, p = .001) and PHCSCS (t = 2.546, p = .007). These results imply that the participants, after completing the study intervention, perceived that they experienced fewer bothersome peer interactions and that they felt better about themselves, as reflected in their view of their self-concepts. Scores on the PSC, reflective of parental assessments of their children’s global psychosocial functioning, did not differ significantly following the intervention |
| Hygiene | |||||||||
| Kimel [120] | Obs | Children in Kindergarten and 1st grade | Handwashing program | Absentee rates | No indication | High [8] E, F |
199 | / | After the intervention, absenteeism was significantly higher among non-participants. Percentages of students absent because of flu-like illness in on-participating classes were approximately double those of participating classes. Chi-square values were significant at the p = 0.05 level: x2 (1, N = 199) = 22.225, p = .001 |
| Morton and Schultz [121] | RCT | Children in Kindergarten to 3rd grade | A 45-minute ‘‘Germ Unit” and use of alcohol gel | Communicable illnesses, vacations, respiratory-, gastrointestinal illnesses and days absent | Unlikely, funded by Maine Administrative School District | Low [1] D |
253 | / | Using McNemar’s test for dichotomous variables with paired subjects, significantly fewer children became ill while using the alcohol gel as an adjunct to regular handwashing than when using regular handwashing only (chi square 5 7.787; p 5 .0053). The odds of being absent due to infectious illness were reduced by 43% with the adjunct use of the alcohol gel. Fewer children were absent in total during phase two. |
| Note. Detailed risk of bias assessment: (22) No Blood glucose records were available for the control group, because these subjects did not bring their BG logbooks to their visits as required | |||||||||
| Studies with mixed outcomes | |||||||||
| A. Challenging behavior | |||||||||
| Buckland et al. [122] | Obs | Children aged 4–15 (mean 8) | School nurse-led interventions (group work, class work, partnership work) | SDQ (parent and teacher perspective) to measure desired outcome of hyperactivity, peer problems, conduct, emotional symptoms and prosocial behavior | No indication | High [10] G, F, E, C, I |
6 | √ | Changes in Total difficulty score (TDS) of 3 or more were assumed to be clinically meaningful. Based on this, all six children were reported to have improved (clinically meaningful) according to either their parents or their teacher. However, in three cases, the teacher believed that children had deteriorated marginally (by two points in each case). The mean improvement in parents TDS ratings was 5.6 and in teacher rating 1.3. |
| Krug et al. [86] | RCT | Children in areas with high rates of crime (Kindergarten to grade 5) | PeaceBuilders | Number of school nurse visits to measure desired outcome of level of violence | No indication | High [10] E, D, F, G, A, B |
3,899 | / | When the data were aggregated across the intervention schools, the weekly rate of visits for all reasons per 1,000 student days decreased by 12.6% (P < .001). The patterns for injury-related visits were the same as the patterns for visits for all reasons. Rates of confirmed fighting-related injuries did not change significantly in the intervention schools but increased 56.0% (P = .01) in the control schools. |
| B. Chronic Illnesses (asthma, diabetes, severe allergies, seizures, and sickle-cell anemia) | |||||||||
| Engelke et al. [123] | Obs | Children aged 5–19 | Care Coordination (teaching, direct care, school personnel, families, referrals) | PedsQL 3.0 SF22 (asthma treatment), PedsQL 3.0 (diabetes symptoms) and PedsQL 4.0 SF15 (physical health, emotional, social functioning) | Unlikely, funded by the Kate B. Reynolds Health Care Trust | High [9] J(23), C(24), F |
114 | / | For children with asthma, there was a significant improvement in total quality of life (p < .001, Eta squared = .47), treatment scale (p < .001, Eta squared = .49) and the symptom scale (p = .001, Eta squared = .18). For children with diabetes, there was a significant improvement in the treatment barrier subscale (p = .01, Eta squared = .19). |
| C. Physical activity and mental health | |||||||||
| Hoying and Melnyk [124] | Obs | Children aged 11–13 | Creating Opportunities for Personal Empowerment (COPE), Healthy Lifestyles Thinking, Emotion, Exercise, and Nutrition (TEEN), physical activity and mental health | Healthy lifestyle belief scale, OMRONTM pedometer to measure PA, The Beck Youth Inventory (BYI-II) to measure depressive symptoms, anxiety, anger, disruptive behavior and self-concept | Possibly, Bernadette Melnyk’s company, COPE2THRIVE, disseminating the COPE program; funded by Sigma Theta Tau | High [10] F, G, I, E |
31 | / | Preadolescents who received COPE reported significant decreases in anxiety. Although there was not a statistically significant improvement in healthy lifestyle beliefs, there was a small to medium positive effect. Students demonstrated significant increases in PA. The subgroup of anxious, depressed, or low self-concept preadolescents who received the COPE intervention demonstrated significant increases in self-concept and significant decreases in anxiety and depression scores. Four out of six students who scored positive for suicidal ideation at T0 no longer scored positively for suicidal ideation at T1. |
| Note. Detailed risk of bias assessment: (23) Difficulty retrieving data from the PDA, it was not possible to determine the number of times a nurse provided a specific intervention; (24) Grades were not available for all children, all goals were not appropriate for all children | |||||||||
| D. Resilience and mixed health outcomes | |||||||||
| Olowokere and Okanlawon [125] | Obs | Vulnerable children in secondary schools | Experimental group (E)1: resilience training, E2: peer support group (basic life skill support and sharing of feelings + coping techniques) E3: E1+E2 | Adapted anxiety, depression, and self-esteem questionnaires to measure psychosocial outcomes; knowledge scores | No indication | High [8] F, G(24) |
109 | / | No significant difference in the anxiety scores of the children in the intervention group compared with the control group (M = 5.37, t 0.870, p = .386). Significant reduction in the depression score in the intervention group compared with the control group postintervention (M = -4.94, t = -2.26, p = .03). For self-esteem, the independent t-test showed a significant increase in self-esteem scores in the intervention group (M = 3.27, t = -.2.26, p = .03). A significant increase in social connection was also observed in the intervention group compared with the control group (M = 2.86, t = 3.16, p = .002). |
| Note. Detailed risk of bias assessment: (24) Study with lager power >.80 needs to be conducted to be able to generalize effectiveness of the intervention | |||||||||
*CI (Confidence interval) was described “√” and can be looked at in detail in respective study; “/” is not available.