A systematic review of school-based eHealth interventions targeting alcohol use, smoking, physical inactivity, diet, sedentary behaviour and sleep among adolescents: a review protocol
Champion et al. Systematic Reviews
A systematic review of school-based eHealth interventions targeting alcohol use, smoking, physical inactivity, diet, sedentary behaviour and sleep among adolescents: a review protocol
Katrina E. Champion 0 1
Nicola C. Newton 0
Bonnie Spring 1
Q. Eileen Wafford 2
Belinda J. Parmenter 3
Maree Teesson 0
0 NHMRC Centre of Research Excellence in Mental Health and Substance Use , NDARC, UNSW Sydney, Sydney, NSW , Australia
1 Department of Preventive Medicine, Northwestern University Feinberg School of Medicine , 680 N. Lake Shore Drive, Suite 1400, Chicago, IL 60611 , USA
2 Galter Health Sciences Library, Northwestern University Feinberg School of Medicine , Chicago, IL , USA
3 School of Medical Sciences, UNSW Sydney , Sydney, NSW , Australia
Background: Six key behavioural risk factors (risky alcohol use, smoking, poor diet, physical inactivity, sedentary behaviour and unhealthy sleep patterns) have been identified as strong determinants of chronic disease, such as cardiovascular disease, diabetes and cancers. School-based interventions targeting these multiple health risk behaviours among adolescents have the potential to halt the trajectory towards later disease, whilst online and mobile technology interventions offer advantages in terms of student engagement, reach and scalability. Despite this, the efficacy of eHealth school-based interventions targeting these six health risk behaviours among adolescents has not been evaluated. The proposed systematic review aims to address this by determining the nature and efficacy of existing eHealth school-based interventions targeting multiple health risk behaviours among adolescents. Methods: A systematic search of the MEDLINE, Embase, PsycINFO and Cochrane Library databases will be conducted to identify eligible published papers. Eligible studies will be randomised controlled trials, including cluster randomised controlled trials, of interventions targeting two or more of the following lifestyle risk behaviours: alcohol use, smoking, poor diet, physical inactivity, sedentary behaviour and sleep. Eligible studies will be those evaluating interventions delivered in a secondary school setting among participants 11-18 years of age, via an eHealth platform (Internet, computers of mobile technology). Two reviewers will independently screen studies for eligibility, extract data and assess the risk of bias. Study outcomes will be summarised in a narrative synthesis, and meta-analyses will be conducted where it is appropriate to combine studies. Discussion: It is anticipated that the results from this review will serve to inform the development of future eHealth multiple health behaviour interventions for adolescents by identifying common characteristics of effective programs and highlighting knowledge gaps in the evidence base. Systematic review registration: PROSPERO CRD42017072163
Prevention; Risk; School; Adolescence; Alcohol; Smoking; Diet; Physical inactivity; Sedentary behaviour; Sleep
Chronic diseases, such as cardiovascular diseases,
diabetes and cancers, are the leading cause of death
worldwide and are associated with significant costs and harms
]. It is well established that the major chronic diseases
share four common behavioural risks: poor diet, physical
inactivity, smoking and alcohol use [
]. In addition,
there is now evidence that associates emerging risk
behaviours, namely sedentary behaviour (i.e. sitting and
screen time) [
] and unhealthy sleep patterns (i.e. long
or short duration, poor quality) [
], with chronic disease
risk. Specifically, short sleep duration, poor quality and
sleep timing (late bedtime or wake-up time) have been
associated with poor health outcomes, such as obesity,
among children and adolescents [
] and risk for later
disease in adulthood [
]. Similarly, studies
investigating sedentary behaviour have demonstrated associations
between screen time and markers of adiposity and
cardiometabolic disease risk [
], mental health [
quality of life [
] in adolescents, and sedentary time has
been linked to increased risk of all-cause, cardiovascular
disease and cancer-related mortality, and incidence of
these diseases, in adults [
]. Sleep and sedentary
behaviour are also important risk factors to consider given
that they often co-occur, with other key risk behaviours
in adolescence [
10, 16, 17
]. Recent research has also
found a composite risk index encompassing these six
behaviours (alcohol use, smoking, poor diet, physical
inactivity, poor sleep and sedentary behaviour) to be highly
predictive of all-cause mortality . This association
reinforces the importance of considering all six lifestyle
risk factors in an effort to prevent future development of
Risk behaviours commonly co-occur as clusters, as
individuals engage in multiple risk behaviours
]. This has prompted the development of
multiple health behaviour change interventions [
in which shared risk factors are targeted together,
rather than in isolation. Many lifestyle risk behaviours
emerge and develop in adolescence and then persist
into adulthood; for example, dietary patterns
established in adolescence continue into adulthood and are
strongly associated with risk of heart disease later in
]. Conversely, research indicates that the
adoption of a healthy lifestyle in adolescence can have
protective effects against the onset of chronic disease
]. Although chronic disease prevention should
optimally occur at various stages across the life course,
adolescence provides a critical opportunity to
intervene before the onset of disease, thereby interrupting
the long-term trajectory towards poor adult health.
Multiple health behaviour change interventions have
the potential to achieve this in an efficient and timely
Secondary school is an ideal location for intervention
delivery as educators can engage large numbers of
students efficiently prior to risk behaviours becoming
entrenched. Outside of the family environment, the
school is the primary setting within which the
development of children and young people can be directed and
] and common school and peer influences
associated with lifestyle risk behaviours can be targeted
]. The World Health Organization [
that schools include education about nutrition, physical
activity and smoking to equip students with the
knowledge and skills needed to prevent and manage chronic
diseases, and the potential of the school environment for
cardiovascular disease prevention is well supported [
Given that teaching time is often limited in school
settings, interventions that can simultaneously address
multiple risk behaviours are particularly advantageous.
Additionally, eHealth interventions (i.e. those delivered
via the Internet, computers or mobile technology)
delivered in a school setting offer a number of potential
advantages over traditional prevention programs,
including increased student engagement, fidelity and scalability
]. Adolescents are extensive users of the Internet,
with an estimated 97% of 15- to 17-year-olds  and
98% of 12- to 14-year-olds in Australia [
the Internet regularly. Internet technology is also
becoming increasingly embedded in school education, with
86% of youth reporting using the Internet at school [
The use of mobile technology, such as smartphones, is
also a commonplace among adolescents [
], and there
is evidence to support the use of smartphone ‘apps’ to
improve health behaviours in youth [
Previous systematic reviews of multiple health
behaviour interventions have largely focused on adult
], with less evidence among
]. Of the literature that does exist is a
recent review by Hale and colleagues  which focused
on interventions addressing tobacco, alcohol and illicit
drug use; sexual risk behaviour; and aggressive behaviour
among youth but did not assess the domains of diet,
physical activity, sedentary behaviour or sleep. This
review concluded that multiple health behaviour
prevention programs are feasible and may be more efficient
than prevention strategies targeting risk factors in
isolation. The strongest effects were observed in relation to
substance use outcomes and school-based settings.
Another study [
] systematically reviewed interventions
targeting sexual risk behaviour and substance use
(alcohol, illicit drugs and tobacco) simultaneously among
adolescents. This review found few studies and
inconsistent effects, with multi-component school-based
interventions seemingly offering the most promise. A third
review of school-based multiple health behaviour
interventions encompassed a broader range of risk factors
including energy balance (diet, physical activity, screen
time) and addiction (alcohol, drug and tobacco use)
]; however, emerging risks, such as sleep
and sitting time, were not included, and published
literature beyond 2011 was not reviewed. Findings from this
review suggest that too few studies of school-based
multiple health behaviour interventions have been
conducted to be able to determine whether targeting
behaviours simultaneously has a synergistic effect.
Together, these reviews suggest that whilst there is a
possibility that universal multiple risk behaviour
interventions for young people are more efficient [
], there is not yet strong evidence regarding
whether they are effective and further research is needed.
Furthermore, whilst previous reviews have examined
eHealth interventions targeting various combinations of
lifestyle risk behaviours among adult [
] and youth
] populations, to our knowledge, there has been no
systematic review of school-based eHealth interventions
encompassing all six health risk behaviours in an
adolescent population. To avoid duplication with a previously
registered review protocol [
], and address gaps in the
field, the proposed review aims to systematically review
the literature on school-based eHealth interventions
designed to target two or more of the following lifestyle risk
behaviours among adolescents: alcohol use, smoking, poor
diet, physical inactivity, sedentary behaviour and sleep.
The specific objectives are to:
1. Determine the existence of school-based eHealth
multiple health behaviour change interventions
designed to target two or more of the six risk
behaviours of interest
2. Evaluate the efficacy of existing school-based
eHealth multiple health behaviour interventions in
preventing alcohol use, smoking, poor diet, physical
inactivity, sedentary behaviour and/or poor sleep
3. Identify intervention characteristics (including
duration, frequency, delivery mode, theoretical basis,
type and number of risk behaviours targeted
together) that are associated with effectiveness
A synthesis of the most recent evidence on eHealth
multiple health behaviour interventions for adolescents
will ideally guide the development of future
interventions by identifying which combinations of risk
behaviours have been effectively targeted simultaneously,
as well as the content and delivery components
associated with the effective interventions.
This systematic review has been registered with the
International Prospective Register of Systematic Reviews
(PROSPERO; CRD42017072163) and was written in
accordance with the Preferred Reporting Items for
Systematic Review and Meta-Analysis Protocols (PRISMA-P)
] as provided in Additional file 1. The
planned systematic review will also be conducted in line
with the PRISMA statement [
To be eligible for inclusion in the proposed systematic
review, published studies must target adolescents aged
between 11 and 18 years of age (i.e. those of secondary
school age); evaluate a multiple health behaviour
prevention program targeting two or more of the following
health risk behaviours: alcohol use, smoking (including
e-cigarette use), poor diet, physical inactivity, sedentary
behaviour and poor sleep (duration and quality); and be
primarily delivered via eHealth methods (including the
Internet, computers, tablet devices and mobile technology
such as smartphone ‘applications’ or text messages).
Interventions must be conducted in a secondary school setting;
however, school-based interventions incorporating
additional components (such as family- or
communitybased elements) will also be eligible. Eligible study designs
will be randomised controlled trials, including cluster
randomised controlled trials. Studies with a comparison
group that received no intervention, education as usual or
an alternate intervention, including offline and
face-toface interventions, will be included. Programs must be
universal in nature (i.e. delivered to all students regardless
of their level of risk). Interventions addressing other risk
behaviours in addition to two or more of the six
behaviours of interest, for example, illicit drug use, risky sexual
behaviour, sun protection habits and aggressive behaviour,
will be eligible for inclusion. Whilst data for these
additional outcomes will not be meta-analysed, studies and
results may be discussed within the paper qualitatively. As
recommended in the literature [
], Fig. 1 displays the
logic model for the proposed review.
A librarian will develop a database search strategy in
consultation with members of the review team.
Databases to be searched will include Ovid MEDLINE,
Embase (Elsevier), PsycINFO (EBSCOhost) and
Cochrane Library (Wiley; an example search strategy for
MEDLINE can be found in Additional file 2). The search
will be limited to human research and to studies
published between 2000 and 2017, given the focus on
eHealth interventions; however, no language restrictions
will be enforced. The search strategy will incorporate
filters to identify randomised controlled trials. All
papers identified in the search strategy will be exported
into a citation management system (Endnote) for
deduplication and uploaded to the Covidence online
software program for screening. The reference lists of
eligible papers will be reviewed to identify other
relevant studies, and recent related systematic reviews
will be consulted to identify any additional studies.
Grey literature, including clinical trial registries, will
also be searched for unpublished studies, and
conference proceedings/abstracts will also be reviewed.
Data extraction and screening
The titles and abstracts of identified articles will be
independently screened by two authors against the eligibility
criteria, with any disagreement resolved by a third
reviewer. Full-text copies of potentially relevant papers will
be assessed for eligibility by the two reviewers. Data
extraction will occur using a standardised extraction form,
which will be piloted by the two reviewers to assure that
it adequately captures trial data. Data will be extracted
by two reviewers and will include:
Publication details (study authors, year published)
Study characteristics (design, country, sample size,
Participant characteristics (e.g. age, gender, ethnicity,
Intervention characteristics (delivery method,
program duration, frequency of delivery, theoretical
basis, content and components, number and type of
specific lifestyle risk behaviours targeted)
Primary and secondary outcomes of interest across
all time points
Measurement tools employed (e.g. validated scales,
Details of the comparison group
Data to assess the risk of bias of each study and
process data will also be extracted to determine the
degree to which an intervention was implemented as
intended (e.g. attendance rates, fidelity, dosage, student
engagement). Where necessary, the corresponding
author of included studies will be contacted by email to
obtain any required data not presented in the published
paper. Data will be entered in the review manager
(RevMan) software for analysis.
Primary outcomes of interest will be the prevention,
delay in the onset, or reduction of any of the six lifestyle
risk behaviours targeted in the intervention: smoking,
alcohol use, physical inactivity, poor diet, poor sleep
patterns and sedentary behaviour. Data for outcomes at all
follow-up time points will be extracted and synthesised
for all eligible studies. It is anticipated that there may be
multiple measures of risk behaviours both across and
within studies, for example lifetime alcohol use and
binge drinking, and sleep duration and sleep quality. In
these instances, all types and units of measurement of
the lifestyle risk behaviour outcomes will be extracted.
Secondary outcomes will include knowledge, attitudes,
future intentions and self-efficacy to engage/not engage
in the lifestyle risk behaviours, as well as mental (e.g.
anxiety, depression, suicide or self-harm) and physical
health outcomes (e.g. obesity, type II diabetes, premature
mortality), educational attainment and employment.
Risk of bias
Two reviewers will independently assess the risk of bias
of the included studies using a modified version of the
Cochrane Collaboration’s tool for assessing the risk of
]. This tool covers a range of domains of
potential bias, including sequence generation; allocation
concealment; blinding of participants, personnel and
outcome assessors; incomplete outcome data; selective
outcome reporting; and any other threats to the validity
of the trials (e.g. recruitment bias, baseline imbalance,
incorrect analyses). Any discrepancies between the raters
will be resolved by a third reviewer. Scores will be
summed across the six domains to give a total score of
the risk of bias for each study. Studies with a higher
score will be deemed to be of higher quality; however,
rather than focussing on just the scores, the quality of
each study will be assessed by whether or not points
were given for individual quality criterion. With
randomisation already being a necessary criterion, studies
that have points allocated for allocation concealment,
blinding of participants and outcome assessors, and
intention to treat analysis and are free of any other bias
will be deemed to be of higher quality and therefore
lower risk of bias.
We will conduct a narrative synthesis on all available
data. A qualitative synthesis of the following study
aspects will be conducted: intervention content (i.e. risk
behaviours targeted), delivery method, intervention
frequency and duration, and sample characteristics (e.g.
age). A quantitative analysis of all primary outcomes
where enough data is available will also be conducted.
We anticipate that there is likely to be a high degree of
heterogeneity with respect to participant age,
intervention types/lengths, reporting of outcomes and outcome
measurements. Therefore, if it is appropriate to combine
studies, we will conduct an inverse variance
randomeffects analysis on each of the outcomes. The
randomeffects analysis may then account for any differences in
outcome measure results and sample size across the
studies. Inconsistency between groups will be quantified
using Higgins I2, with scores ranging from 0 to 100%.
Higgins I2 represents the total variation that is attributed
to the true difference between the studies, with values >
50% possibly representing substantial heterogeneity. The
significance of any heterogeneity identified will be
examined using the Cochran’s Q (chi2) test with p < 0.05
indicating significant heterogeneity. If significant
heterogeneity is present, then a sub-analysis on outcomes by
elements of the interventions (e.g. type of eHealth
intervention: online, smartphone, other; duration/setting of
intervention; number and type of behaviours targeted;
gender; age of participants; and low/high-income
countries) may be warranted to identify sources of
heterogeneity. Sensitivity analyses may be used to restrict
analyses to studies at low risk of bias, lower age groups,
socioeconomic status and/or where other issues suitable
for sensitivity analysis have been identified during the
review process. In addition, funnel plots will be visually
examined for publication bias. We will use the Grading
of Recommendations Assessment, Development and
Evaluation (GRADE) framework to assess the quality of
the body of evidence [
The proposed systematic review will be the first to
evaluate the efficacy of eHealth school-based multiple
health behaviour interventions designed to prevent,
delay the onset or reduce six key lifestyle risk behaviours
among adolescents: alcohol use, smoking, diet, physical
inactivity, sedentary behaviour and poor sleep. A
systematic review of the most recent evidence will serve to
inform the development of future eHealth interventions
addressing multiple risk behaviours among secondary
school students. Interventions designed to address these
lifestyle risk factors among adolescents, which are
rendered scalable and engaging through their Internet- or
mobile-based delivery, have the potential to produce
short-term improvement in young peoples’ health and
also to reduce the accumulation of risk for later chronic
disease in adulthood.
Additional file 1: PRISMA-P checklist. This document entails a completed
PRISMA-P checklist. (DOCX 29 kb)
Additional file 2: Search strategy. This document provides an example
search strategy. (DOCX 15 kb)
GRADE: Grading of Recommendations Assessment, Development and
Evaluation; PRISMA-P: Preferred Reporting Items for Systematic Review and
Meta-Analysis Protocols; PROSPERO: International Prospective Register of
We thank Dr. Emily Stockings for her consultation regarding the preliminary
methodology and search strategy for this protocol.
This review is funded by an Australian National Health and Medical Research
Council Early Career Fellowship awarded to KC (APP1120641). The funders
played no role in the design of this study, collection, analysis and
interpretation of the data or in writing this manuscript.
Availability of data and materials
KC led the systematic review design and completed the PROSPERO
registration. EW developed the example search strategy and BP developed
the meta-analysis plan. NN, BS, EW, BP and MT contributed to the review
methodology and manuscript preparation. All authors read and approved
the final manuscript.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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