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Public Health (2008) 122, 25–33

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0033-3506/$ - sdoi:10.1016/j.p

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Original Research

Evaluation of a school-based health promotionprogramme for adolescents aged 12–15 years withfocus on well-being related to stress

Katarina S. Haraldssona,b,�, Eva-Carin M. Lindgrena,b,Bengt G.A. Fridlundb,c, Amir M.A.E. Baigia,b,Marie C. Lydella,b, Bertil R.G. Marklunda,b

aGeneral Practice and Public Health, Halland County Council, Falkenberg, SwedenbDepartment of Public Health and Community Medicine, Goteborg University, Goteborg, SwedencSchool of Health Sciences and Social Work, Vaxjo University, Vaxjo, Sweden

Received 18 October 2006; received in revised form 12 March 2007; accepted 6 April 2007Available online 24 August 2007

KEYWORDSAdolescence;Health promotion;Intervention;Stress;Sweden Well-being

ee front matter & 2007uhe.2007.04.016

ng author. Research an966.ess: katarina.haraldsso

Summary Objective: The aim of this study was to evaluate a school-basedadolescent health promotion programme with focus on well-being related to stress.Study design: Interventional and evaluative with tests before and after theintervention. The study was performed in two secondary schools in a town on thewest coast of Sweden.Methods: A health promotion programme comprising massage and mental trainingwas implemented for a single academic year in one school (intervention school, 153participants) in order to strengthen and maintain well-being. No intervention wasimplemented in the other school (non-intervention school, 287 participants). Aquestionnaire was developed and tested, resulting in 23 items distributed across thefollowing six areas: self-reliance; leisure time; being an outsider; general and homesatisfaction; school satisfaction; and school environment.Results: A pre- and postintervention comparison of the six areas was made withineach school. In the intervention school, the boys maintained a very good or goodsense of well-being related to stress in all six areas, while the girls’ sense of well-being was maintained in five areas and deteriorated in one area. In the non-intervention school, the boys maintained a very good or good sense of well-beingrelated to stress in four areas and deteriorated in two areas, while the girls’ sense ofwell-being was maintained in two areas and deteriorated in four areas.

The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.

d Development Unit, Box 113, SE-311 22 Falkenberg, Sweden. Tel.: +46 346 56292;

n@lthalland.se (K.S. Haraldsson).

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K.S. Haraldsson et al.26

Conclusion: Massage and mental training helped to maintain adolescents’ very goodor good sense of well-being related to stress. A questionnaire with acceptablevalidity and reliability was developed and tested in order to evaluate the healthpromotional approach. However, there is a need for further study to develop boththe intervention and the questionnaire for young people.& 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rightsreserved.

Background

In many countries, adolescents experience a senseof well-being.1 However, at this sensitive age,future health behaviour and lifestyle are beingshaped.2,3 Recent surveys of health behaviour inyoung people in Europe, Canada and the USA havereported worrying data in terms of health riskbehaviour.2 More girls than boys report illhealth.1,4,5 Stress poses a risk to health in societytoday, due to an imbalance between the demandsplaced on a person, and the inner and outerresources available to meet these demands.6 Theproblem is widespread and becoming increasinglycommon in younger age groups.1,7 Stress increasesin line with growing up.1,3 Among other things, theexperience of stress and lack of well-being inadolescents are linked to school,8 bullying,9,10

family structure, social support and self-reli-ance.11–13 It has also been shown that sense ofcoherence (SOC)14 is of importance for the experi-ence of stress in both adults15 and adolescents, andfor the latter, a relationship exists between SOCand school-related stress.16

Massage and mental training are beneficial toolsfor strengthening well-being, and have a preven-tive and therapeutic effect by reducing theexperience of stress. Massage increases the levelof oxytocin and reduces that of cortisone, makingthe individual feel calmer.17,18 A study of adultsfound that gentle touch improved both physical andmental functions, and, more importantly, led to amarked reduction in stress.19 In a study focusing onaggressive adolescents, a massage interventionreduced both worry and aggression and made themfeel less hostile.20 Giving and receiving massageincreases the opportunities to create positiverelationships, promoting health and preventingbullying.17,18,20 Mental training involves influencingone0s own feelings, thoughts and thereby actions bymeans of relaxation, easing of tension and imagetraining, thus promoting and strengthening well-being as well as facilitating achievement ofpersonal goals.21,22 Thus, in line with Lazarus,mental training can be a stress managementtechnique for dealing with and overcoming the

impact of stress,3,6,22 in which the inter-relation-ship between thoughts, feelings and actions isemphasized. The basic mental training techniquecommences with relaxation and training to easetension, and primarily consists of progressive andautogenic training followed by image training.21,22

Studies of adults confirm that mental trainingfunctions as a stress vaccine,23–25 while studies ofadolescents describe an improvement in theirpsycho-emotional condition26 as well as a reductionin anxiety and stress.27 Few, if any, studies havecombined massage and mental training in order tostrengthen well-being in schoolchildren, therebypreventing stress.

In 1986, the World Health Organization (WHO)approved the Ottawa Charter for health promo-tion,28 which highlights the school as an importantplatform for improvement of public health. Thebasis of health promotion is, amongst other things,participation, supportive environments andempowerment. Important areas are the physicaland social school environment, personal healthskills and relationships both within and outsideschool.29 This holistic view is essential as tradi-tional health education directed towards individualrisk areas has only resulted in minor changes inschoolchildren’s health behaviours and attitudes.30

A considerable gap exists between prevention,mental health promotion and early interventionprogrammes.31 As such, it is both a challenge and anecessity to design interventions aimed atstrengthening mental health in schools.32 Accord-ingly, the aim of this study was to evaluate aschool-based adolescent health promotion pro-gramme with focus on well-being related to stress.

Subjects and methods

Design and setting

This study, which had an interventional andevaluative pre- and post-test design, was under-taken in two secondary schools in a town on thewest coast of Sweden. These schools did not offer

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Health promotion programme for adolescents 27

any health promotion activities, and pupils ofsimilar socio-economic background were chosenfor both the intervention (IS) and non-interventionschool (NIS). The IS expressed an interest inintroducing a health promotion intervention, butthe NIS had no such plans.

InterventionA health promotion programme was introduced as aregular school subject with one lesson each weekfor one academic year (total 25–30 lessons). Thegoal was to strengthen the pupils’ well-being andthereby prevent stress using massage and mentaltraining. The classes were divided into groups of15–20 pupils. A physiotherapist with experience ofstress management was responsible for the inter-vention, which consisted predominantly of practi-cal exercises with theoretical components. One ofthe practical exercises was mate-to-mate massagecomprising hand, foot, face, back and neckmassage. The technique consisted of various typesof strokes following a specific pattern. Anotherexercise was basic mental training including pro-gressive muscular relaxation consisting of tensing–

relaxing steps for various muscle groups, andautogenic training comprising tensing–relaxing byfocusing on visualization of the body in a relaxedstate. The theoretical components in the lessonswere based on well-known stress theories as well asbasic information about massage and mental train-ing, including breathing techniques and bodyawareness.6,14,17,18,21

Participants and inclusion criteria

All pupils aged 12–15 years (Classes 6–8) from the twoschools were approached regarding this study [IS,n ¼ 170 (100 boys and 70 girls); NIS, n ¼ 346 (171 boysand 175 girls)]. A letter was sent to the pupils andtheir parents containing information about the study,its design and the voluntary nature of participation.Inclusion criteria were: written consent to participatefrom both pupils and their parents; and pupilparticipation on two measurement occasions. In total,440 pupils met the inclusion criteria [IS, n ¼ 153,response rate 90% (90 boys and 63 girls); NIS, n ¼ 287,response rate 83% (142 boys and 145 girls)].

InstrumentA questionnaire entitled ‘Adolescents’ sense ofwell-being related to stress’ (ADWEST) was con-structed, which contained questions about experi-ences of well-being related to stress (Table 1). Thequestions were based on the research group’s ownexperience in the areas of public health, pedago-

gical and medical science. Moreover, previousresearch focusing on pupils’ sense of well-beingrelated to stress from a holistic perspective thattook their life environments (i.e. school, leisuretime and home) into account was reviewed; wheresuch research was lacking, adult data were usedinstead.1,6,14,33,34 The items were designed on anordinal scale level as a four-point Likert scale, andexamined by the research group for contentvalidity. A pilot study was conducted in four classesof a school that was not taking part in the study(n ¼ 90). An explorative factor analysis in accor-dance with principal component analysis, Varimaxrotation was performed on 33 items. The cumula-tive loading variance was 58% at the start of theacademic year and 61% at the end of the academicyear. Factors with an Eigenvalue 41 and variablecorrelations 40.5 were included in the analysis,which resulted in 23 items distributed across sixfactors of well-being related to stress: self-reli-ance; leisure time; being an outsider; general andhome satisfaction; school satisfaction; and schoolenvironment. Internal consistency reliability inaccordance with Cronbach’s alpha was measuredfor each factor and for the entire instrument(0.86). As can be seen in Table 1, five factors, eachwith four questions, resulted in a total valuebetween 4 (lowest value, indicating the highestlevel of well-being) and 16 (highest value, corre-sponding to the lowest level of well-being).Another factor consisted of three questions, whichresulted in a total value between 3 and 12. Valuesup to and including 8, comprising the responsealternatives ‘Always/very often’ or ‘Often’, weredeemed to be very good or good well-being relatedto stress (Table 2). In addition, four backgroundquestions (sex, country of origin, living with one orboth parents and class) and a question aboutphysical activity (exercising in leisure time two tothree times/week or more) were included.

Data collection

Data were collected on two occasions, namely thestart of the school year (Autumn 2003) and the endof the school year (Spring 2004). An independentresearch assistant distributed and collected thequestionnaires during class time in both schools.

Statistical procedure and analysis

The Statistical Package for the Social Sciences, Version13 was used to analyse data.35 Chi-squared test,Student’s t-test and the Mann–Whitney U-test wereused for comparison at baseline. For pre- and post-test

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Table 1 Tests of the ‘Adolescents’ sense of well-being related to stress’ questionnaire on two measurementoccasions in terms of construct validity and internal consistency reliability calculated by explorative factor analysisand Cronbach’s alpha.

At start of academic year At end of academic year

F I F II F III F IV F V F VI a F I F II F III F IV F V F VI a

Self-reliance 0.81 0.85Okay the way you are F1 0.73 0.79Satisfied with one’s appearance F2 0.74 0.80Level of self-confidence F3 0.70 0.75Satisfied with oneself F4 0.73 0.81

Leisure time 0.79 0.82Sufficient time for homework F5 0.59 0.60Sufficient time for leisure activities F6 0.72 0.72Sufficient time for one’s friends F7 0.84 0.84Sufficient time for fun things F8 0.80 0.85

Being an outsider 0.72 0.77Feeling lonely F9 0.74 0.77A feeling of being excluded F10 0.74 0.72Pupils don’t want to be with you F11 0.72 0.74Feeling bullied at school F12 0.61 0.73

General and home satisfaction 0.70 0.73There are adults that I can trust F13 0.65 0.65Peace and quiet at home F14 0.64 0.59Enjoy being at home F15 0.70 0.82Happy with my life right now F16 0.55 0.51

School satisfaction 0.55 0.56Participating in school rules F17 0.54 0.63Help is available at school F18 0.58 0.55Know what school day will be like F19 0.63 0.57School work is meaningful F20 0.65 0.64

School environment 0.64 0.63School breaks too rough F21 0.78 0.80School dinner too rough F22 0.77 0.78Noise level too high F23 0.71 0.61

(0.86) (0.86)

Kaiser–Meyer–Olkin measure of sampling adequacy: 0.87 and 0.86 at start and end of the academic year, respectively.Bartlett’s test of shericity: Po0.0001.Eigenvalues41.Cumulative loading variance ¼ 58% and 61% at start and end of the academic year, respectively.

K.S. Haraldsson et al.28

comparisons within the groups, a non-parametric test,Wilcoxon’s matched-pairs signed-ranks test, was used.The level of significance was set at 0.05.

Results

Baseline data

At baseline, no significant differences were foundbetween the IS and the NIS in terms of backgroundor physical activity. Nor were there any sex

differences between the schools (P ¼ 0.061). Themajority (98%) of both the IS and the NIS pupilswere born in Sweden (P ¼ 0.542), and 84% in the ISand 81% in the NIS (P ¼ 0.749) were living with bothparents. There were no significant differencesbetween classes; in the IS, 39% were in Class 6,28% in Class 7 and 33% in Class 8, while in the NIS,38% were in Class 6, 39% in Class 7 and 23% in Class 8(P ¼ 0.169). With regard to the level of physicalactivity, most pupils exercised at least two to threetimes/week in their leisure time (79% in the IS and78% in the NIS; P ¼ 0.231). In terms of well-beingrelated to stress, the majority reported satisfactory

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Table 2 Sense of well-being related to stress at baseline in the two schools.

Intervention school Non-intervention school P-value

Mean SD Median Min. Max. Mean SD Median Min. Max.

BoysSelf-reliance 7.1 2.1 7.0 4 14 7.0 1.9 7.0 4 12 0.767Leisure time 7.3 2.3 7.0 4 13 7.0 2.1 7.0 4 14 0.320Being an outsider 5.7 1.6 5.0 4 12 5.5 1.6 5.0 4 12 0.328General and home satisfaction 5.6 1.6 5.0 4 10 5.6 1.6 5.0 4 10 0.885School satisfaction 8.2 1.8 8.0 4 14 8.3 1.9 8.0 5 14 0.750School environment 6.2 1.6 6.0 3 12 6.3 1.5 6.0 3 12 0.544

GirlsSelf-reliance 7.9 2.6 8.0 4 15 8.0 2.3 8.0 4 15 0.524Leisure time 7.7 2.7 8.0 4 14 7.3 2.4 7.0 4 14 0.399Being an outsider 5.5 1.7 5.0 4 12 5.8 1.6 6.0 4 12 0.136General and home satisfaction 6.2 2.2 6.0 4 13 5.9 1.9 6.0 4 13 0.422School satisfaction 8.0 2.0 8.0 4 14 7.8 1.7 8.0 4 12 0.682School environment 6.0 1.7 6.0 3 11 6.6 1.5 7.0 3 10 0.016

Lower values indicate a higher level of well-being.Mann–Whitney U-test was used for comparison between the two schools.

Health promotion programme for adolescents 29

well-being at baseline (Table 2). No significantdifferences were observed between girls and boysin the IS or the NIS at baseline within the six areasof well-being related to stress, with the exceptionof girls in the area of school environment(P ¼ 0.016) (Table 2).

Data within the schools

A pre- and post-test comparison was made withineach school for well-being related to stress in theareas of self-reliance, leisure time, being anoutsider, general and home satisfaction, schoolsatisfaction and school environment. It was foundthat IS boys had maintained their very good or goodsense of well-being in all areas, while the IS girls’sense of well-being was maintained in five areasand deteriorated in the area of school environ-ment. The NIS boys maintained their very good orgood sense of well-being in four areas anddeteriorated in two areas; leisure time and schoolenvironment. The NIS girls maintained their senseof well-being in two areas and deteriorated in fourareas; leisure time, school satisfaction, being anoutsider and school environment (Table 3).

Discussion

Methodological issues

The choice of arena for the intervention wasimportant. According to the Ottawa Charter for

health promotion, schools play a particular role inhealth promotion.28,29 It is essential to identify anddesign new interventions to strengthen adoles-cents’ health and well-being,32 as they are at asensitive age when their future health behaviour isbeing shaped.2 Another reason is that traditionalhealth education has only resulted in minor changesin attitudes to health behaviours.30 In the presentstudy, the intervention was conducted as a schoolsubject in its own right. An alternative could be tointegrate health promotion into all other subjects,so that, for example, the school day starts withmate-to-mate massage or relaxation training,irrespective of subject and teacher.

The pupils were aged between 12 and 15 years.However, it is possible that the intervention shouldhave included younger pupils, as the earlier thatschool health promotion is introduced, the greaterthe satisfaction in later life.36 Furthermore, pupilswho are satisfied with school assimilate a healthpromotion message more readily and reject riskbehaviour to a greater extent.37,38 The question-naire used should have a health promotionapproach based on a holistic perspective, withfocus on well-being related to stress in theadolescents’ different life environments, namelyschool, leisure time and home. The holisticperspective is essential, as massage and mentaltraining can have a long-term influence on thepupil’s sense of well-being in all his/her lifeenvironments. Designing a health promotion ques-tionnaire for adolescents may seem hazardous.However, a health questionnaire has been shown to

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Table 3 Sense of well-being related to stress in the pre- and post-intervention tests in the two schools.

Boys Girls

N za P-value n za P-value

Intervention schoolSelf-reliance 85 �0.99 0.323 57 �1.70 0.089Leisure time 85 �0.88 0.380 59 �0.89 0.373Being an outsider 83 �0.47 0.635 58 �1.89 0.059General and home satisfaction 80 �0.55 0.585 59 �0.95 0.342School satisfaction 85 �1.93 0.054 60 �1.74 0.083School environment 86 �0.95 0.342 62 �2.04 0.042

Non-intervention schoolSelf-reliance 137 �0.59 0.552 142 �1.54 0.124Leisure time 136 �3.79 o0.0001 138 �3.53 o0.0001Being an outsider 137 �0.62 0.538 144 �1.97 0.049General and home satisfaction 129 �1.76 0.078 134 �1.73 0.083School satisfaction 133 �0.93 0.352 138 �4.37 o0.0001School environment 135 �3.10 0.002 140 �3.75 o0.0001

Wilcoxon’s matched-pairs signed-ranks test was used for comparison within the schools.aThe higher the numerical z-value, the lower the level of well-being.

K.S. Haraldsson et al.30

provide reliable results in pupils as young as 8–11years.39 Several stress questionnaires intended foradolescents are available but these are linked tosymptoms, diseases, crucial life events and coping.Measurements of health and well-being by means ofquestionnaires in order to study ill health andmorbidity are common. However, the ADWESTquestionnaire focuses on factors connected towell-being in relation to different types of stress.As it is difficult to capture all dimensions ofsignificance for well-being related to stress on thefirst occasion that an instrument is used, furtherstudies are necessary in order to develop thequestionnaire. Nevertheless, the questionnairewas tested with regard to content and constructvalidity by a pilot study, and two factor analyseswere found to have acceptable figures. Internalconsistency reliability measured by Cronbach’salpha exceeded the recommended 0.70 based onthe Nunnally criterion.40

Result issues

At baseline, no significant difference was foundbetween the adolescents in the IS and the NIS interms of background factors. This is important asfamily structure, i.e. living with one or twoparents, and the family’s socio-economic statusplay a role in well-being.12,13,41,42 Physical activityis also associated with well-being,43 but no sig-nificant difference in physical activity was foundbetween the schools.

IS girls maintained their sense of well-beingrelated to stress in most areas, while that of NISgirls deteriorated during the academic year. This issupported by other studies in which ill healthincreased in line with age.1,4 In the IS, thebeneficial effect of the intervention was seen forboth sexes in most areas. Massage and mentaltraining may have had an impact on all areas byinfluencing the pupils’ feelings and thoughts lead-ing to increased well-being,21,22 and by generallyhaving a calming and strengthening effect.17,18

Massaging and being massaged can also be a way ofpromoting and strengthening friendship. Youngpeople have reported that the most importantsocial qualities are the ability to support one’sfriends and to encourage and stand up for eachother.44 This finding has a bearing on several of theareas in this study. When it comes to bullying andbeing excluded, which is inherent in being anoutsider, massage has a beneficial effect as itprevents bullying and inhibits aggression.20 Thisstudy observed a deterioration in the area of beingan outsider within the NIS but not within the IS.Massage can also have a bearing on the schoolenvironment. Up to 40% of differences in healthproblems between school classes are attributableto the psychosocial environment.8 Being the victimof bullying as a child can lead to anxiety and socialphobia in adulthood,9 or cause emotional andbehavioural problems.10 This study showed thatonly IS boys maintained their sense of well-being inthe area of school environment. Well-being in thearea of school satisfaction deteriorated in the NIS

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Health promotion programme for adolescents 31

girls, while all pupils in the IS maintained theirsense of well-being. School satisfaction meansbeing allowed to participate and feeling involvedin school activities, experiencing school as mean-ingful, and receiving social support from teachersin the event of difficulty. This is in line with theWHO guidelines for health promotion in schools29

and the SOC components.14,16 Relationships existbetween well-being and stress, self-efficacy, socialsupport from teachers and school conditions.12,45 Ithas been shown that health is strengthened andlearning improved in schools that work in accor-dance with the guidelines.46,47 In addition, theparental attitude to school plays a role in thechild’s satisfaction with school. When parents,especially the mother, do not like school, the childwill not like it either.42 Poor relationships withparents, friends and teachers and a negativeattitude to school can also lead to poor health.42

A deterioration in the sense of well-being related tostress was found in both boys and girls within theNIS in the area of leisure time, while the IS pupilsmaintained their sense of well-being. Adolescentsconsidered having time for active and meaningfulpursuits as positive for well-being,48 as well asleading to attachment to parents, friends andschool as well as self-perceived strengths.49

In the areas of self-reliance, and general andhome satisfaction, all pupils at the IS and the NISmaintained their sense of well-being related tostress. The high level of self-reliance is positive, asa person’s self-image is an important predictor ofhealth promotion behaviour.11 The adolescents0

descriptions of the importance of family for well-being included a comfortable home, an emotionallywarm atmosphere, open communication and possi-bilities for external relationships.13 One possiblereason why the differences within the schools werenot very pronounced is the time aspect related tothe intervention and follow-up. In order for mentaltraining to have an effect, at least one 15-minsession is required each day for a longer period oftime.21,22 In line with this, a study involving adultsand employing daily mental training reported amore positive mood, a lower level of stress andincreased well-being after 14 months.50 In thepresent study, the pupils received mental trainingonce a week for one academic year (i.e. 8 months).In future studies, mental training should be givenmore time in order to achieve a better outcome. Inthis study, the basic elements of mental trainingwere focused upon, which is necessary for learningthe technique.51 However, for further improve-ment, more time needs to be devoted to imagetraining than was the case in this study. In view ofthe fact that the results of health promotion

interventions usually only become visible in thelong term, a longer follow-up period is necessary.Furthermore, in several of the areas discussed, theentire school needs to be involved in order toachieve a higher level of well-being among thepupils. This is also in line with the Ottawa Charterfor health promotion in schools,28,29 which under-lines the importance of collaboration both withinand outside school as well as with the family andsociety in general. By working with health promo-tion, efforts are concentrated on strengtheningadolescents before problems arise, based on aholistic perspective and taking account of their lifeenvironments.52,53

Conclusions and implications

Massage and mental training for adolescents helpedto maintain their well-being related to stress forone academic year. It is hoped that this type ofintervention can form a natural part of the healthpromotion concept in schools. A questionnaire withacceptable validity and reliability was developedand tested in order to evaluate the health promo-tion approach. However, there is a need for furtherstudy to develop both the intervention and thequestionnaire for young people.

Acknowledgement

The authors would like to thank all pupils andteachers who participated in the study. The authorsalso wish to express their gratitude to the late PiaJohansson, Registered Physiotherapist, who sadlydied as a result of an accident, for her exemplarycontribution to the intervention.

Ethical approval

Ethics committee of Goteborg University, Sweden.

Funding

Halland County Council.

Competing interests

None.

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