The Journal of School Nursing2021, Vol. 37(5) 363–373© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519879489journals.sagepub.com/home/jsn
Adolescence is a sensitive period in life and a time to redefine and learn new skills. In Norway, school health services provide individual health-promoting consultations with all eighth-grade students. As an aid to support these consultations, a dialogue tool called SchoolHealth was developed using a co-creation approach. SchoolHealth consists of a web-based health information form designed to be completed by the students and generates individual feedback reports to help the school nurses to prepare for the consultation and tailor it to the individual student’s need. Our aims were to evaluate the feasibility and user experiences of SchoolHealth among students and school nurses using a mixed methods approach. A total of 79 eighth-grade students (69% of those invited) and four school nurses from three schools participated. Analyses indicated that SchoolHealth was feasible, promoted reflection among students, and helped prepare students and school nurses for the consultation.
program development/evaluation, evidence-based practice, best practices/practice guidelines, middle/junior/high school, screening/risk identification, mental health, school-based clinics
Health in adolescence is influenced by prenatal and childhood development as well as by the specific biological and social-role changes that accompany puberty (Sawyer et al., 2012). Adolescence is a life phase in which future patterns of adult health are established. This life-course perspective reveals that determinants affecting health and health behavior in adolescents are crucial to the future health of this population and the economic development of nations (Viner et al., 2012).
Adolescence is also a sensitive period (Johnson, Blum, & Giedd, 2009; Sawyer et al., 2012). This sensitivity relates to the social embedding of developmental tasks and biological changes. The biological changes that take place in the body and the brain put the adolescent in a position to redefine and learn new skills to manage maturational tasks (Johnson et al., 2009; Sawyer et al., 2012). Recognized developmental tasks include adjusting to sexual changes, developing self-acceptance and a sense of identity, and achieving independence from parents (Shaffer & Kipp, 2014).
In adolescence, the importance and influence of peers increase as the adolescents strive for independence from parents. Schools are important social environments and provide opportunities to promote good relationships and healthy behaviors and to cope with stressful events or tasks. School nurses, teachers, and other health- and school-based personnel are important initiators when it comes to promoting healthy school environments and healthy behaviors. In addition, they may identify students who are at risk and need extra support.
The majority of adult mental health problems start in childhood and adolescence (Costello, Egger, & Angold, 2005; Jones, 2013; Kessler et al., 2009)—approximately 75% of adults with a mental health disorder experience the onset of the disorder before the age of 24 (Kessler et al., 2009). The high prevalence of mental health problems (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015) and the negative impact such health problems have on education (Sagatun, Heyerdahl, Wentzel-Larsen, & Lien, 2014), occupation (Sagatun, Heyerdahl, Wentzel-Larsen, & Lien, 2015), social functioning (Holen, Waaktaar, & Sagatun, 2018) and quality of life (Patel, Flisher, Hetrick, & McGorry, 2007), as well as their significant financial and societal costs (Kessler et al., 2009; Snell et al., 2013), show that there is a need for early identification and intervention as well as for prevention. However, there is a gap between the prevalence of mental health problems and treatment rates (O’Brien, Harvey, Howse, Reardon, & Creswell, 2016). One of the barriers to managing child and adolescent mental health problems is related to inadequate identification in primary care (O’Brien et al., 2016). In Norway, public health nurses (henceforth called school nurses) have called for an aid to help identify youths with such problems (Moen, 2018).
In Norway, the school health service is part of primary care and the municipal health services and aims to promote good health and to prevent disease. The service is located at the schools and is free for all students and aims to work on an individual, a group-based, and a universal level. On an individual level, the service aims to identify, as early as possible, those who struggle with life mastering and/or who live under disadvantaged circumstances, and to offer suitable help and refer them to specialist services when needed. Today, the resources and structures of the school health services, as well as what they offer, vary considerably between municipalities (Waldum-Grevbo, 2018; Waldum-Grevbo & Haugland, 2015). Partly because of this, a new national set of guidelines for the school health services was launched in 2017 (Helsedirektoratet [Norwegian Directorate of Health], 2019). These guidelines strongly recommend that the school nurses offer an individual consultation to all students in the eighth grade. The aim of this consultation is to promote healthy behavior and life skills. Based on the consultation, the school nurse is supposed to evaluate the need for further interventions on an individual level and on a group level.
In Denmark, a web-based dialogue tool called Skolesundhed.dk, which aims to support the Danish school nurses, has been developed over the past 10 years by local authorities together with researchers and professionals. The professional needs for public health nurses have been central in the development. It is currently used by more than 70 of the 98 municipalities in Denmark (more information about the Danish dialogue tool can be found at www.boernungeliv.dk.). Based on ideas and experiences from Skolesundhed.dk and the new guidelines for the school health service in Norway, “SchoolHealth” was developed as a web-based dialogue tool for use in the eighth-grade consultations. The tool is a result of co-creation between researchers and the school health services/school nurses. Co-creation is widely believed to increase successful implementation and research impact (Greenhalgh, Jackson, Shaw, & Janamian, 2016).
Our aims here were to evaluate the feasibility of and user experiences of SchoolHealth among students and school nurses using a mixed methods approach including both quantitative and qualitative methods. We also explored the participating services’ reflections about the further development of SchoolHealth.
To evaluate feasibility and user experiences of School-Health, we used a mixed methods approach. Both students and school nurses completed questionnaires about their experiences with the dialogue tool (Figure 1, dotted dark gray boxes). To get more in-depth information on feasibility, experiences, adaptions, and reflections relevant to the further development of SchoolHealth, both individual and focus group interviews were conducted among students and school nurses (Figure 1). Additionally, an experience seminar was organized after the eighth-grade consultations were completed. The study was approved by the Norwegian Center for Research Data (I. D. No. 54731).
School nurses and their leaders, The Professional Interest Group of Public Health Nurses in Norway, schools (teachers and students), researchers, and technical personnel developed the first version of SchoolHealth over several workshops during 2017–2018. The first version of SchoolHealth consisted of a web-based health information form to be completed at school by the students before the consultation with the school nurse, individual feedback reports for the school nurse, a consultation guide, implementation routines, a 1-day training seminar for the school nurses, and ongoing support.
The web-based health information form covered topics highlighted in the national guideline for the consultations, including mental and physical health, health behavior, quality of life, relationships, school environment, as well as violence and other potential traumatic experiences. As far as possible, standardized questionnaires were used including the Strengths and Difficulties Questionnaire (SDQ; Youthin-mind, 2012), health-related quality of life (Haraldstad & Richter, 2014), and Children’s Somatic Symptoms Inventory (Walker, Beck, Garber, & Lambert, 2009). Questions about potential traumatic events including violence and abuse were adapted from the KATE-B, a Norwegian self-report measure (NKVTS [Norwegian Centre for Violence and Traumatic Stress Studies], 2015) based on the Child and Adolescent Trauma screen (Sachser et al., 2017). Behaviors affecting health such as physical activity, screen use, sleep, eating habits, and bullying were measured through questions used in large-scale population-based studies in Norway (The Hunt Study, HUNT4, The Oslo Health Study—the Youth part [UNGHUBRO], and The Pupil Survey administered by The Norwegian Directorate for Education and Training). The health information form consisted of about 200 questions/items. Prior to the pilot study, the health information form was tested out twice in small groups of adolescents (n = 7 and 8). The purpose of these “pre-pilot” studies was to get an idea of how much time it would take to fill out the form and whether the adolescents understood the questions. One of the “pre-pilot” groups consisted solely of ethnic minority students.
An individual feedback report for each student was generated based on their answers on the health information form. These feedback reports, available for the school nurses only, had color codes based on agreed cutoffs (green, yellow, and red). The purpose of the colors was to make it easier to identify the student’s resources and challenges before the consultation and thus help the school nurse tailor the consultation to the individual’s needs and to determine the order in which students would be scheduled.
The consultation guide included practical suggestions on how to carry out the consultations and recommendations on how to use instruments included in the health information form (SDQ, Kidscreen, and KATE-B). In addition, supportive communication techniques building on the existing competencies of the school nurses were described. In the Norwegian school nurse education, Antonovsky’s (1979) salutogenetic framework, which focuses on factors that support human health and well-being is a central part of the curriculum. Antonovsky emphasized health before sickness and was concerned to identify factors promoting health. Sense of coherence consists of at least three dimensions: comprehensibility, manageability, and meaningfulness (Antonovsky, 1979). Empowerment, as a process through which people gain mastery over their lives, is also emphasized (Rappapon, 1984). In this context, “empowerment” refers to the school nurses’ professional support, which enables students to overcome their sense of powerlessness and to recognize and use their own resources. The format and choice of topics covered in the guide were based on the school nurses’ experiences.
The implementation plan included suggested routines for how to administer the web-based health information form. At schools where more than one class of students participated, the health information form and the following consultations were carried out class-wise. Routines were based on existing practice and recommendations in the new national guidelines. A 1-day training seminar for the school nurses and their leaders covering use of the technical solution, the consultation guide, and routines for administering the health information form was provided. In addition, continuous support concerning technical aspects and use of the dialogue tool was available by telephone.
School health services and schools from three different municipalities in and close to Oslo (Norway) were invited to participate in the pilot study. More specifically, four school nurses and five eighth-grade classes from three schools (N = 118 students) were invited. One school had two school nurses, while the other two schools had one each. The recommended minimum norm of school nurses at junior high schools (eighth to tenth grade) in Norway is one 100% position (37.5 hr per week) per 550 students. This norm was met at the participating schools.
All students participating in the study were invited to be interviewed. Those who wanted to participate contacted the school nurse who decided together with the teacher which students should be interviewed individually and which ones should participate in the focus group interviews. The participants were equally distributed between genders, and the ethnic background reflected the study population. A total of 38 students from all three schools participated in qualitative interviews. There were six individual interviews and four focus group interviews with eight participants in each group. The interviews lasted approximately 45 min and took place at school. The participating students received a free movie ticket for the inconvenience. Three school nurses were interviewed individually; in addition, all four school nurses participated in a focus group interview. Three of the authors acted as moderators, and the interviews were recorded on audio tape and later transcribed verbatim, as recommended by Krueger and Casey (2000).
School nurses and their leaders, head of the Professional Interest group of Public Health Nurses in Norway, one principal, and one school counselor from the participating schools as well as the researchers attended the experience seminar. The aim of the seminar was to discuss experiences and further development of SchoolHealth, with a special focus on aggregated feedback reports as a tool to promote collaboration between the school health service and the schools.
Quantitative data. Questionnaires concerning feasibility and experiences were answered by the students at two points: (1) at the end of the health questionnaire and (2) immediately after the consultation (see dotted dark gray boxes in Figure 1). The students were informed that their individual answers to these questions were blinded to the school nurses. The first questionnaire consisted of tailored questions about the health form’s clarity, relevance, and acceptability, as well as the participant’s willingness to answer the questions about the topics covered. The second evaluation questionnaire consisted of 10 items covering competence, user involvement, satisfaction, and experiences based on the work by Sjetne (2009). The school nurses filled out a questionnaire evaluating every consultation in terms of time spent, topics covered, main topic for their consultation, whether their impression after the consultation was in line with the individual feedback report, and whether any follow-up was planned.
Qualitative data. All the interviews were conducted after the consultations and were carried out separately for students and school nurses (see dark gray boxes in Figure 1). The interview guides contained open-ended questions about experiences both with the health information form and the consultation. The individual and focus group interview guides covered similar topics (see interview guide in Online Appendices 1 and 2). The interview guides for the school nurses were similar to the students’ interview guides, except for a greater focus on feasibility and further development and the school nurses’ experiences with having the individual feedback reports before the consultations. The students were also asked whether some of the questions on the health information form were difficult to understand, and if they felt that other questions should have been included.
Quantitative data on the time the students spent filling out the health form and the length of the consultations with the school nurse along with questions on competence, user involvement, satisfaction, and topic covered in the consultation were analyzed with descriptive statistics using IBM SPSS Statistics (v. 23; IBM Corp., Armonk, NY). Results were presented as the mean [± standard deviation (SD)] or number and prevalence (n and %). Qualitative analyses, exploring both students and school nurses’ experiences, were performed by three researchers reading and rereading the text of all the transcribed interviews to obtain an overall understanding of the text, then dividing the text into themes and subthemes. The data were analyzed according to the guidelines set down in Kvale and Brinkman’s qualitative method that employs a phenomenological and hermeneutical framework and three levels of interpretation: self-understanding, critical understanding based on common sense, and theoretical understanding (Kvale, Brinkmann, Anderssen, & Rygge, 2015).
Before the students could participate, informed written consent forms were collected from their parents. All parents were informed about the study by the researchers and school nurses at parents’ meetings at the beginning of the semester. In addition, written information was sent by email. Students received information from the school nurse along with written information. The students themselves consented to participate by filling out the health information form. Students not participating in the study were offered regular assistance by the school health service. In addition, informed written consent was provided by the four participating school nurses.
After a description of the participants, the quantitative and qualitative findings are presented together, sorted by topic: implementation, the health information form, the consultation, and further development.
For the invited eighth graders (N = 118), 67% (n = 79) of the parents gave informed consent to their child’s participation. Of these, 96% (n = 76) of the students completed the health information form, and 88% (n = 70) completed the consultation with the school nurse. Of those filling out the health information form, 58% (n = 44) reported that they and both parents and were born in Norway, and 46% (n = 35) were boys. All the school nurses were ethnic Norwegians and female.
All participating school nurses also participated in the training seminar. The three school health services contacted the project staff twice for technical support, and the school nurses who were working alone also called to discuss use of the SDQ instrument once.
In the individual and focus group interviews, all school nurses reported having read the consultation guide and finding it useful. They found SchoolHealth somewhat time-consuming and some of the consultations demanding. Partly because of this and in order to be able to maintain an open-door policy for a few hours a day, the school nurses considered three or four consultations with students to be sufficient for 1 day. Overall, they found that SchoolHealth was easily integrated with other routines in the school health service. Two of the services had already asked the students questions prior to the consultation using a locally developed paper-based questionnaire. In the interviews, students emphasized the importance of talking with the school nurse as soon as possible after completing the health form and at least within the following weeks or month.
Students. The mean time used by the students to fill out the web-based health information form was 29.7 min (SD ± 7.1 min). When students were asked how satisfied they were with the questionnaire, 78% (n = 58) scored it 4 or better on a scale of 1–6, where 6 was best (mean = 4.69, SD ± 1.5). Most (88%, n = 67) reported that they could answer all questions sincerely. However, 12% (n = 9) of the students reported that they were uncomfortable answering some questions. In addition, 3% (n = 2) stated that several questions were hard to understand.
In the interviews, students reported that they had enjoyed completing the health information form and that it covered many important topics. They liked that it included questions both on what happened at home and on what happened at school. Filling out the form also made them aware of topics the school nurse was likely to address. Some students mentioned that answering the questions promoted reflection and awareness of their own habits and situations. One boy said: “I got more aware of how many hours I use on the Internet and social media after filling out the form.”
Some students also found a few questions uncomfortable, especially questions covering topics such as violence and bullying. They knew that their answers on the health information form were seen by the school nurse and used to prepare their consultation. This made it difficult for the students to answer some of the questions honestly. At the same time, they emphasized the importance of being honest. In the focus groups, it was pointed out that some of the questions on the health information form seemed to overlap and that the form was too long. On the other hand, the students would have liked more questions about the school environment and their friends. The students also emphasized the importance of having friends and a positive school environment.
Students. Students completed a questionnaire after the consultation with the school nurse, and 95.6% (n = 65) of the students reported that they had talked about topics that mattered to them, and 97% (n = 65) felt that the school nurse tailored the consultation to their needs. Overall, 74.4% (n = 54) of the students responded that it was useful or very useful to fill out the web-based health form before the consultation.
During the interviews, students also reported that they appreciated talking with the school nurse after completing the health information form. The students appreciated that the school nurse “knew” them before the consultation and emphasized that it was easier to talk about sensitive topics when these were addressed directly by the school nurse and the students were prepared. One boy said: “It is easier to talk about difficult subjects when you have filled out the questionnaire before meeting the school nurse.”
School nurses. On average, the consultations lasted for 28.8 min (SD ± 10.6). Around seven topics were covered per consultation (mean = 6.94, SD ± 3.2). The frequencies of topics covered are presented in Figure 2. The school nurses were also asked to report the main topic for the consultation. The most frequent main topics were physical symptoms and pain (20%, n = 14); family (18.6%, n = 13); on-screen activities (11.4%, n = 8); and violence, abuse and adverse life-events (11.4%, n = 8). The school nurses’ impression of the students’ strengths and challenges changed after the individual consultation in 27 of 70 cases (36%). In 6 of these 27 consultations, the school nurses became more concerned for the students. A follow-up plan was made for 15 students (20%), which primarily involved a second consultation with the school nurse.
In the interviews, the school nurses reported that the health form was of great help in obtaining a wider perspective of a student’s resources and challenges before the individual consultation. The color codes in the individual feedback reports helped structure the consultations and determine the order in which student would be called for a consultation. The individual report provided important information on the student’s overall situation and helped the school nurse target relevant topics during the consultation. This information included social resources and risk factors, general and mental health, and health habits. One said: “Before, I used the consultation to find out what problems the students have. Now I was more prepared and able to use the consultation for the student’s needs.”
The school nurses also appreciated that the form included questions related to the students’ home situation. One said: “I feel this health form covers relationships at home and I like it. It gives me a broader impression of the student’s situation.” For students who were reporting symptoms of mental and/or social problems, the school nurses thought it could be useful to have a questionnaire for the parents in order to get their opinion and compare it with the student’s responses. When talking about follow-up, the school nurses reported that they collaborated with the teachers if students reported having problems with friends at school. Furthermore, they reported that aggregated feedback reports would be beneficial for obtaining a good overview of the student population and collaboration with teachers at a group level.
At the seminar, which was arranged after the school nurses had conducted the consultations (see Figure 1), experiences with and further development of SchoolHealth were discussed. Personnel from the schools were also present, and ideas on how to use aggregated student reports to plan teaching and interventions were discussed. The need for flexibility in the reports concerning both topics and relevant comparisons of answers was highlighted. In addition, a report describing the average length of the consultations, topics talked about during the consultations, and the number and type of follow-up agreements were viewed as useful information for the leader of the school health service. Another development task suggested by the school nurses was that the health information in SchoolHealth should be dynamically linked with the school health services’ digital1 journal system in the future.
The overall response was that SchoolHealth was easily integrated into existing routines in the school health service. Both the school nurses and the eighth-grade students found it useful and liked it. The health information form promoted reflection among students and helped prepare both students and school nurses for the consultation.
In addition to being easily integrated into existing routines, SchoolHealth could be completed within, on average, about 30 min, which is the estimated time for a consultation in the national guidelines (Helsedirektoratet [Norwegian Directorate of Health], 2019). The school nurses were also pleased with the 1-day training seminar, and the available telephone assistance, which was used only a few times. According to the Expert Recommendations for Implementing Change (Powell et al., 2015; Waltz et al., 2015), the highest ranked strategies for implementation include developing stakeholder interrelationships and organizational readiness, adapting and tailoring interventions to context, and providing ongoing support and consultation. By using a co-creation approach that included both school nurses and leaders, the aim was to ensure that the intervention/consultation was tailored to the service. The approach ensured knowledge of the dialogue tool and probably also increased the services’ readiness. This might have reduced the need for the ongoing support and assistance offered. However, in a broader evaluation and scale-up, it might be necessary to have a more comprehensive implementation plan including a more thorough introduction to the content and tailoring of procedures to the local contexts. Additionally, the dialogue tool operationalizes recommendations stated in the new national guidelines for the school health service, which may have increased organizational readiness and stakeholder engagement.
Students found the health information form relevant, and the majority were comfortable answering it as it made them aware of their health behavior and present situation. The health form also gave them an idea of what topics the school nurse might take up and prepared them for the consultation. There was also some feedback suggesting that the health information form was somewhat repetitive and too long. At the same time, some topics were missed or reported not to be sufficiently explored. We included instruments covering related topics such as mental health and health-related quality of life (SDQ and Kidscreen), which might explain the comments on repetitive/overlapping questions. However, considering the time used by the student to fill out the health form consisting of around 200 items (30 min on average), it seems like a feasible number of items, on the condition that all the information is needed. However, it is necessary to explore the benefits of the included instruments and questions for revision and further development of SchoolHealth.
One of the aims for the consultation, outlined in the guidelines, is to promote life skills and healthy choices for each student (Helsedirektoratet [Norwegian Directorate of Health], 2019). Students becoming more aware of their own behavior through completing a health information form could be a step toward reaching this goal. The transtheoretical model of change (Prochaska & Velicer, 1997) combines several theories and describe six stages of behavior change. Once you determine which stage of change you are at, suitable actions can be taken. An early, and necessary, stage is the acknowledgment that there is an issue that needs to be addressed and beginning to think about changing it. The health information form in SchoolHealth may promote such reflections before the consultation with the school nurse. Thus, the consultation can be used to elaborate further and motivate for the next step: preparing for actions. In this regard, the health form may be viewed as an intervention, facilitating a health-promoting consultation with the school nurse. However, this hypothesis of possible mechanisms and effects need further explorations in a study with a randomized design.
To offer a service tailored to the particular student’s need is a goal for the school health service in Norway (Helsedirektoratet [Norwegian Directorate of Health], 2019). The approach described in the current study seems to be useful in this regard. The school nurses reported that basing the consultation on the individual feedback report helped to gain a broader view of the students’ personal, social, and environmental strengths and challenges, which may put the nurses in a good position to identify vulnerable students and support them in gaining a “sense of coherence” (Antonovsky, 1979). The school nurse might function as a resistant resource enabling students to make sense of and to manage developmental tasks and stressful events such as being bullied (Kvarme et al., 2019). One finding that supports this claim is that students report being able to talk about topics important to them, which suggests that they felt that they were seen and accepted when talking to the school nurse—a good starting point for the nurse when trying to identify disadvantaged students, help students understand events and their meaning, giving relevant evidence-based information, and/or motivate change when needed.
In the present study, one of the most frequent main topics during consultations was family-related issues. An important developmental task of adolescence is to achieve independence from parents (Shaffer & Kipp, 2014). As such, the school nurse may play the role of an adult outside the family with whom the students can talk during this sensitive period of their lived. The school nurse may have the skills to empower the adolescents in ways that promote a sense of coherence and coping in their situation.
The students also pointed out that it was easier to talk about sensitive topics, perhaps including violence and abuse, when the school nurse asked them direct questions. In the guidelines for the Norwegian school health service, it is strongly recommended that all eighth-grade students are asked about domestic violence and abuse (Helsedirektoratet [Norwegian Directorate of Health], 2019). The background for this recommendation comes in part from research on pregnant women that found that direct questions from health personnel regarding domestic violence identified more cases than regular practice (Jahanfar, Howard, & Medley, 2014; O’Doherty et al., 2015). In Norway, about 20% of children have reported physical punishment from their parents, and 6% more severe violence (Mossige & Stefansen, 2016). However, a study among public health and school nurses in Norway revealed that they seldom asked questions directly about domestic violence or neglect (Silje, 2013). The students highlighted the importance of direct questions from the nurse on sensitive topics, in line with the recommendation in the guidelines. However, there is a need for more research on the potential benefits of routinely asking all students about violence and abuse.
After the consultation, the school nurses changed their impression of 27 of 70 students based on the individual reports; for six of these, the school nurses expressed greater concern. This illustrates that SchoolHealth is a “dialogue tool” consisting of a health information form with a following dialogue/consultation for all students. Use of the health form to identify students with possible problems prior to consultation needs further exploration.
The new guidelines for the school health services emphasize the need for cooperation between school health services and the schools. Moreover, the Norwegian Directorate for Education and Training is currently developing a new national curriculum where life skills is included as a compulsory subject. Life skills in this curriculum operationalized in ways that resemble the topics that are to be covered in the eighth-grade consultation: physical and mental health, screen-based activities, living habits, sexuality, substance abuse, and positive relationships. Useful cooperation between the two services should therefore be within reach, and it might be promoted using SchoolHealth. The aggregated reports may be a common basis for adjusting teaching and planning appropriate actions for each school.
The school nurses, leaders, and school personnel acknowledged the need for relevant aggregated reports and for procedures on how to use these reports in different settings. However, discussions during the experience seminar revealed different opinions and needs and thus highlighted the need for a flexible solution. Another aspect that was discussed was the need for anonymity. These issues need further consideration before creating the aggregated reports.
In the current study, we needed to obtain parental consent since students were invited to participate in a research project and 23% of the students did not participate because parental consent was missing. This selection might limit the generalizability of the findings if the nonparticipating students differ systematically from those who took part (Szklo, 2007). Because of a lack of resources, the written information form was available only in Norwegian. We know that parents with poor Norwegian and English language skills were overrepresented in the group not giving their consent. Thus, students not participating might differ from those who did in terms of integration into the Norwegian culture/society, and they might have experienced SchoolHealth differently. Nevertheless, several ethnic minority students participated in the study. In a larger evaluation, it is important to give information to parents in several languages and maybe also consider developing a health information form in English. Another possible limitation is information bias and social disability bias in particular (Szklo, 2007). A further limitation is that three of the four school nurses participating in the pilot also took part in the development phase. Co-creation is crucial for several aspects of the study, but in turns of dependency the school nurses did in a sense evaluate their own tool. It helps that the researchers interviewing the school nurses were different from the researcher leading the co-creation teams, but in later evaluations, it will be interesting to see whether the evaluation differs between those who participated in the development process and those who did not.
It is not possible to rule out the possibility that this study might have been influenced by selection and/or informant biases but based on concurrent and supplementary findings using method triangulation—that is, by combining qualitative and quantitate data from both students and school nurses—we assume that the findings are reliable (Foss & Ellefsen, 2002).
Implementing SchoolHealth in the school health service in Norway is feasible. A normal population of students in their early teens liked answering questions about their health and health behavior prior to an individual consultation with the school nurse. Filling out the web-based health form helped prepare them for the consultation. The school nurse felt that this approach provided a broad view of the students’ resources and challenges and helped tailor the consultations to the students’ individual needs. The feasibility and levels of satisfaction encourage further evaluation of the dialogue tool for the effects on quality of life and the identification of vulnerable students. It also encourages further development of the content and use of various types of aggregated reports.
This project is a response to expressed needs among practitioners in the school health service in Norway. It was developed in line with the national guideline for the service using a co-creation approach. We believe that the close collaboration between users, practitioners, stakeholders, and researchers has been important for the promising results. The active role of the school nurses in all parts of the process was probably crucial for the outcome. The systematic approach in the development, including evaluation and further development, may be used elsewhere to develop similar tools.
Åse Sagatun, Lisbeth Gravdal Kvarme, Mia C. Myhre, Solveig Holen, and Nina Misvær contributed to the conception/design of the manuscript, while Åse Sagatun, Lisbeth Gravdal Kvarme, and Solveig Holen drafted the manuscript. All authors contributed to the acquisition of data and analysis, critically revised the text, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The authors thank the adolescents for their participation. We are also grateful for the contribution by the school health services and schools in the development and evaluation of SchoolHealth. Special thanks to Kristin Sofie Waldum-Grevboe, head of the Professional Interest Group of Public Health Nurses in Norway, for valuable contributions and support. Last, but not least, we would like to thank professor Carsten Obel and his colleagues at Skolesundhed.dk, Mette Laub Larsen, and Mia Juul Christensen. Your sharing is deeply appreciated.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Åse Sagatun, PhD, PHN, MSc https://orcid.org/0000-0002-4205-6729
Lisbeth Gravdal Kvarme, PhD, PHN https://orcid.org/0000-0002-8779-7512
Supplemental material for this article is available online.
1. In the School health services in Norway, the individual student’s journal is digitalized.
Antonovsky, A. (1979). Health, stress, and coping. San Francisco, CA: Jossey-Bass.
Costello, E. J., Egger, H. L., & Angold, A. (2005). The developmental epidemiology of anxiety disorders: Phenomenology, prevalence, and comorbidity. Child and Adolescent Psychiatric Clinics of North America, 14, 631–648, vii.
Foss, C., & Ellefsen, B. (2002). The value of combining qualitative and quantitative approaches in nursing research by means of method triangulation. Journal of Advanced Nursing, 40, 242–248.
Greenhalgh, T., Jackson, C., Shaw, S., & Janamian, T. (2016). Achieving research impact through co-creation in community-based health services: Literature review and case study. Milbank Quarterly, 94, 392–429.
Haraldstad, K., & Richter, J. (2014). Psychometric properties of the Norwegian version of KIDSCREEN. PsykTestBarn, 2, 1. doi:10.21337/0032
Helsedirektoratet [Norwegian Directorate of Health]. (2019). Nasjonal faglig retningslinje for det helsefremmende og fore-byggende arbeidet i helsestasjon, skolehelsetjeneste og helses-tasjon for ungdom. [The Norwegian guideline for health promoting and preventing work in the child and youth health clinics and the school health service]. Retrieved from https://helsedirektoratet.no/retningslinjer/helsestasjons-og-skolehelsetjenesten
Holen, S., Waaktaar, T., & Sagatun, Å. (2018). A chance lost in the prevention of school dropout? Teacher-student relationships mediate the effect of mental health problems on noncompletion of upper-secondary school. Scandinavian Journal of Educational Research, 62, 737–753.
Jahanfar, S., Howard, L., & Medley, N. (2014). Interventions for preventing or reducing domestic violence against pregnant women. Cochrane Database of Systematic Reviews, 11, CD009414.
Johnson, S. B., Blum, R. W., & Giedd, J. N. (2009). Adolescent maturity and the brain: The promise and pitfalls of neuroscience research in adolescent health policy. Journal of Adolescent Health, 45, 216–221.
Jones, P. B. (2013). Adult mental health disorders and their age at onset. British Journal of Psychiatry, 202, s5–s10. doi:10.1192/bjp.bp.112.119164
Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J.,… Wang, P. S. (2009). The global burden of mental disorders: An update from the WHO World Mental Health (WMH) surveys. Epidemiologia e Psichiatria Sociale, 18, 23–33.
Krueger, R. A., & Casey, M. A. (2000). Focus groups: A practical guide for applied research (3rd ed.). Thousand Oaks, CA: Sage.
Kvale, S., Brinkmann, S., Anderssen, T. M., & Rygge, J. (2015). Det kvalitative forskningsintervju [The qualitative research interview] (3rd ed., 2nd printing). Oslo, Norway: Gyldendal Akademisk.
Kvarme, L. G., Misvær, N., Valla, L., Myhre, M. C., Holen, S., & Sagatun, Å. (2019). Bullying in school: Importance of and challenges involved in talking to the school nurse. Journal of School Nursing. doi:10.1177/1059840519846649
Moen, L. Ø. (2018). Helsesøsters utfordringer med psykisk uhelse i skolen [The school nurse’s challenges related to mental health in school]. Sykepleien forskning. doi:10.4220/Sykepleiens.2017.64615
Mossige, S., & Stefansen, K. (2016). Vold og overgrep mot barn og unge: omfang og utviklingstrekk 2007–2015 [Violence and abuse of children and young people: Scope and development 2007–2015] (Vol. 5). Oslo, Norway: Norsk institutt for forskning om oppvekst, velferd og aldring.
NKVTS [Norwegian Centre for Violence and Traumatic Stress Studies]. (2015). KATE-Barn: Kartlegging av traumeerfaringer [KATE-Barn: Mapping of trauma experiences]. Oslo, Norway: Author.
O’Brien, D., Harvey, K., Howse, J., Reardon, T., & Creswell, C. (2016). Barriers to managing child and adolescent mental health problems: A systematic review of primary care practitioners’ perceptions. British Journal of General Practice, 66, e693–e707.
O’Doherty, L., Hegarty, K., Ramsay, J., Davidson, L., Feder, G., & Taft, A. (2015). Screening women for intimate partner violence in healthcare settings. Cochrane Database of Systematic Reviews, 7, CD007007.
Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: A global public-health challenge. The Lancet, 369, 1302–1313.
Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56, 345–365.
Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., …Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10, 21.
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American. Journal of Health Promotion, 12, 38–48
Rappapon, J. (1984). Studies in empowerment: Introduction to the issue. Prevention in Human Services, 3, 1–7.
Sachser, C., Berliner, L., Holt, T., Jensen, T. K., Jungbluth, N., Risch, E., …Goldbeck, L. (2017). International development and psychometric properties of the Child and Adolescent Trauma Screen (CATS). Journal of Affective Disorders, 210, 189–195.
Sagatun, Å., Heyerdahl, S., Wentzel-Larsen, T., & Lien, L. (2014). Mental health problems in the 10th grade and noncompletion of upper secondary school: The mediating role of grades in a population-based longitudinal study. BMC Public Health, 14, 16.
Sagatun, Å., Heyerdahl, S., Wentzel-Larsen, T., & Lien, L. (2015). Medical benefits in young adulthood: A population-based longitudinal study of health behaviour and mental health in adolescence and later receipt of medical benefits. BMJ Open, 5, e007139.
Sawyer, S. M., Afifi, R. A., Bearinger, L. H., Blakemore, S. J., Dick, B., Ezeh, A. C., & Patton, G. C. (2012). Adolescence: A foundation for future health. The Lancet, 379, 1630–1640.
Shaffer, D. R., & Kipp, K. (2014). Developmental psychology: Childhood and adolescence (9th ed.). Belmont, CA: Wadsworth Cengage Learning.
Silje, B. (2013). Tåler noen barn mer juling? En kartlegging av hjelpeapparatets håndtering av vold mot barn i minoritetsfamilier [Can some children tolerate more beating? A study on the response of Norwegian Child Welfare Services to violence in ethnic minority families]. Oslo, Norway: Save the Children Norway.
Sjetne, I. S. (2009). Pasienterfaringer i spesialisthelsetjenesten: et generisk, kort spørreskjema [Patient experiences in the specialist health service: A generic, short questionnaire]. Oslo, Norway: Notat fra Kunnskapssenteret.
Snell, T., Knapp, M., Healey, A., Guglani, S., Evans-Lacko, S., Fernandez, J. L.,… Ford, T. (2013). Economic impact of childhood psychiatric disorder on public sector services in Britain: Estimates from national survey data. Journal of Child Psychology and Psychiatry, 54, 977–985.
Szklo, M. (2007). Epidemiology: Beyond the basics. Sudbury, MA: Jones & Bartlett.
Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. The Lancet, 379, 1641–1652.
Waldum-Grevbo, K. S. (2018). Helsesøster: Folger du de nye, nasjonale anbefalingene? [School nurse: Do you follow the new national guidelines?]. Sykepleien Fag. doi:10.4220/Sykepleiens.2018.70773
Waldum-Grevbo, K. S., & Haugland, T. (2015). En kartlegging av helsesøsterbemanningen i skolehelsetjenesten. [A mapping of the school nurse staffing in the school health service]. Sykepleien Forskning, 10, 352–360.
Walker, L. S., Beck, J. E., Garber, J., & Lambert, W. (2009). Children’s somatization inventory: Psychometric properties of the revised form (CSI-24). Journal of Pediatric Psychology, 34, 430–440. doi:10.1093/jpepsy/jsn093
Waltz, T. J., Powell, B. J., Matthieu, M. M., Damschroder, L. J., Chinman, M. J., Smith, J. L.,…Kirchner, J. E. (2015). Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: Results from the Expert Recommendations for Implementing Change (ERIC) study. Implementation Science, 10, 109.
Youthinmind. (2012). Information for researchers and professionals about the Strengths & Difficulties Questionnaires. Retrieved from http://www.sdqinfo.com/
Åse Sagatun, PhD, PHN, MSc, is a researcher at the Regional Center for Child and Adolescent Mental Health, Oslo, Norway.
Lisbeth Gravdal Kvarme, PhD, PHN, is a professor at the Oslo Metropolitan University, Oslo, Norway.
Nina Misvær, PHN, is an associate professor at the Oslo Metropolitan University, Oslo, Norway.
Mia Myhre, PhD, Dr.Med, is a researcher at the Norwegian Center for Violence and Traumatic Stress Studies, Oslo, Norway.
Lisbeth Valla, PhD, PHN, is a researcher at the Regional Center for Child and Adolescent Mental Health, Oslo, Norway, and also an associate professor at the Oslo Metropolitan University, Oslo.
Solveig Holen, PhD, MSc, is a researcher at the Regional Center for Child and Adolescent Mental Health, Oslo, Norway.
1 Regional Center for Child and Adolescent Mental Health, Oslo, Norway
2 Oslo Metropolitan University, Oslo, Norway
3 Norwegian Center for Violence and Traumatic Stress Studies, Oslo, Norway
Corresponding Author:Åse Sagatun, Regional Center for Child and Adolescent Mental Health, P.O. Box 4623 Nydalen, 0405 Oslo, Norway.Email: aase.sagatun@r-bup.no
