School Health Program Research Articles

MENSTRUAL HYGIENE KNOWLEDGE, PRACTICES AND INTERVENTIONS AMONG JUNIOR HIGH SCHOOL GIRLS IN THE KROBO AREA OF GHANA

Purpose –– This study was conducted to assess the menstrual hygiene knowledge and practices of adolescent girls in the Krobo area of Ghana. Methods –– It adopted a cross-sectional study where 245 Junior High School girls from eight schools in two municipal districts of Ghana were studied. Findings –– The study identified that only 35% of students frequently change pads, although 96% of them use sanitary pads. It was also detected that girls avoid school when they are menstruating for reasons such as severe bleeding, fear of stains, painful periods and a lack of facilities at school which impacts their academic performance negatively. Conclusion & Recommendations –– The study revealed that the majority of the girls do not change pads or dispose of them while in school due to inadequate facilities. Therefore, it is highly recommended that schools give proper education and provide appropriate facilities for girls’ academic advancement, good health and well-being. Keywords –– Menstrual hygiene, Water, Sanitation and Health, Adolescent girls, School health programme

Methodologies of sexual health education intervention for high school students' knowledge and attitudes: A systematic review

Background & Aim: Providing adolescents with information to understand their sexual health is critical to promote healthy sexual development, reducing the negative consequences of risky sexual behaviors, and creating a foundation for healthy adulthood. This study aimed to identify the recent empirical evidence on new methodologies for improved sexual health outcomes among adolescents.
 Methods & Materials: A systematic review of randomized controlled trials guided the PICO question, "What knowledge and attitudes do high school students obtain when confronted with new methodologies for teaching sexuality compared to traditional teaching?" regardless of geographic location, race/ethnicity, or gender criteria, concerning adolescents, was conducted. The databases CINAHL, MEDLINE, PsycINFO, SCOPUS, and Cochrane Central Register of Controlled Trials, were searched in December 2022. The Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews were used to assess methodological quality. Data were synthesized across studies and presented narratively.
 Results: Thirteen articles were included for review, involving 11.262 participants. The duration of the interventions with new methodologies ranged from a few hours to three months. New methodologies on sexual health education to improve high school student's knowledge and attitudes were divided into four types: digital and Internet-based intervention, curriculum-based intervention, training-based intervention, and peer group bonding-based intervention.
 Conclusion: These results provide healthcare professionals with additional strategies that may be integrated into school health programs regarding sex education.

Programmatic Approach to Hearing Health in Low- and Middle-Income Countries

Programmatic Approach to Hearing Health in Low- and Middle-Income Countries

Comparative Analysis of the Status of Implementation of School Health Services in Public and Primary Schools in Owerri Municipal, Imo State, Nigeria.

Effective school health service helps to reduce ill health, increase school attendance, academic performance, decrease school dropout rates, and additionally plays a role in identifying children with emotional, behavioural, and mental health problems for proper assessment and appropriate interventions. To assess the status of the school health services in selected public and private primary schools within Owerri Municipal Local Government Area, Imo State. A cross sectional descriptive study was carried out from March to April 2017. Out of the 48 government approved primary schools, 36 (12 public and 24 private) schools within Owerri Municipal LGA were assessed. Relevant data was obtained from school head teachers and direct observation was done where applicable. The responses were scored using a validated School Health Programme evaluation scale. The overall mean score for School Health Services in Owerri Municipal LGA was 13.14 with the mean scores of 14.42 for private and 10.58 for public schools which were significantly lower than the minimum acceptable score of 19. The private schools performed better than public schools in practice of School Health Services and their mean difference was statistically significant (p=0.012). School health personnel were available in fourteen (38.9%) schools, out of which one (8.3%) public school had health personnel. All (100%) schools had first aid boxes, but none of the schools had the boxes completely stocked. School health clinics were available in one (8.3%) public school and 5 (20.8%) private schools. School meals were served in six (25%) private but none in public schools. The overall status of school health services in primary schools within Owerri Municipal LGA is poor. The private schools performed comparatively better than public schools. These findings therefore portray the need for implementation of the National School Health Policy by the State Ministries of Education and Health. Keywords: Implementation, School Health Services, Public and Primary Schools.

SCHOOL HEALTH PROGRAMME FOR STUDENTS, TEACHERS, AND PARENTS IN ELEMENTARY TO IMPROVE ORAL HEALTH KNOWLEDGE IN MALANG

Dental and oral health has an important role in supporting the health of the human body. Diseases and disorders of the teeth in school-age children between 7-15 years are disturbances in growth and development. However, many factors still influence the occurrence of dental and oral problems. One of them is the lack of attention and knowledge. At the age of children, parents and teachers have an important role in guiding, providing understanding, reminding and providing facilities to maintain healthy teeth and mouth. Therefore, all three of them need to know to underlie the formation of behaviors that support children adopting a healthy lifestyle. Based on these conditions, we conducted community service to increase this knowledge through the School Health Program, which was implemented in 7 elementary schools in Malang City. In this activity, education was carried out for students, parents and teachers with a total of 325 participants. The results of this program show an increase in knowledge by students, teachers and parents. The knowledge conveyed included basic dental care recommendations such as brushing teeth twice a day with fluoride toothpaste, managing good eating habits, staying away from bad habits that damage teeth and preventing dental caries as early as possible. After completing this activity, participants can adopt a healthy lifestyle to prevent problems with their teeth and mouth

School Health Policies in the World: A Scoping Review

Context: School health refers to a set of measures implemented to diagnose, provide, and improve the physical, mental, social, and spiritual health of students and those staff who are in some way in contact with students. In this regard, various school health policies and programs are developed, each presenting a different aspect of school health. Therefore, the present study aims to review the scope of existing school health policies worldwide. Evidence Acquisition: This scoping review study was conducted in 2022 following the PRISMA-ScR reporting guideline. In this regard, PubMed, Scopus, Web of Science, ProQuest, and Google Scholar databases were searched from 2000 to 2022 for English documents using the keywords of policy, program, and school health. Finally, the related data were extracted by two reviewers independently and analyzed using thematic content analysis. Results: Based on the initial search, 16,439 records were retrieved, and 24 articles were eligible to be included in the study. Most of these studies were conducted in 2014, 2018, and 2020; three were conducted in 2021. Eleven studies employed the literature review method, nine were conducted in the United States, and 18 focused on presenting a comprehensive school health policy in all aspects. The most important aspects of school health policy include school nutrition policies, school environmental health, school, home, and community cooperation, comprehensive health education, provision of health services in school, physical activity, counseling, social and psychological services, and promoting the health of the working environment of school employees. Most of these articles had good quality. Conclusions: This review shows that the number of school health policies is low globally, and each country must prepare a comprehensive school health policy regarding their economic, social, cultural, environmental, and political conditions.

Overview and Methods for the Youth Risk Behavior Surveillance System — United States, 2021

The Youth Risk Behavior Surveillance System (YRBSS) is the largest public health surveillance system in the United States, monitoring a broad range of health-related behaviors among high school students. The system includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate school-based YRBSs conducted by states, tribes, territories, and local school districts. In 2021, these surveys were conducted during the COVID-19 pandemic. The pandemic underscored the importance of data in understanding changes in youth risk behaviors and addressing the multifaceted public health needs of youths. This overview report describes 2021 YRBSS survey methodology, including sampling, data collection procedures, response rates, data processing, weighting, and analyses. The 2021 YRBS participation map, survey response rates, and a detailed examination of student demographic characteristics are included in this report. During 2021, in addition to the national YRBS, a total of 78 surveys were administered to high school students across the United States, representing the national population, 45 states, two tribal governments, three territories, and 28 local school districts. YRBSS data from 2021 provided the first opportunity since the onset of the COVID-19 pandemic to compare youth health behaviors using long-term public health surveillance. Approximately half of all student respondents represented racial and ethnic minority groups, and approximately one in four identified as lesbian, gay, bisexual, questioning, or other (a sexual identity other than heterosexual) (LGBQ+). These findings reflect shifts in youth demographics, with increased percentages of racial and ethnic minority and LGBQ+ youths compared with previous YRBSS cycles. Educators, parents, local decision makers, and other partners use YRBSS data to monitor health behavior trends, guide school health programs, and develop local and state policy. These and future data can be used in developing health equity strategies to address long-term disparities so that all youths can thrive in safe and supportive environments. This overview and methods report is one of 11 featured in this MMWR supplement. Each report is based on data collected using methods presented in this overview. A full description of YRBSS results and downloadable data are available (https://www.cdc.gov/healthyyouth/data/yrbs/index.htm).

Teachers assessment of asthma-friendliness of primary schools in Abuja

Introduction: Children should be protected and safe in school. An important disease like asthma, the leading chronic respiratory disease among children globally, should occupy a place of priority in a school’s health programme. Therefore, the aim of thestudy was to determine how asthma-friendly schools are in Abuja, Nigeria from a teacher’s perspective.
 Materials and Methods: This was a cross sectional, questionnaire- based survey carried out among andomly selected teachers in public primary schools. Asthmafriendliness of schools was assessed using the “How asthmafriendly is your school” questionnaire.
 Results: Of the 403 teachers who participated in the study, majority were females 249(61.8%), mean age was 35 years SD ±8 years, school settings were mainly urban 14 (58.3%) and majority teachers located in urban settings 251 (62.3%). The teachers scored the schools poorly on questions about availability of school policies on asthma care for the children in or out of emergency situations, quick access to asthma medications at school, availability of a full-time nurse or responsible personnel for children with asthma, training of teachers on asthma and monitoring of Air Quality Index. Adherence was scored high on questions referring to recommendations about keeping the school environment tobacco smoke free and preventing exposures to asthma triggers such as excessive dust. Majority of the schools had a poor asthmafriendliness level 300 (74.4%) based on the teachers report.
 Conclusion: Given the importance of asthma among children, concerted efforts should be made to ensure that schools in Abuja, Nigeria are asthma-friendly. This can be achieved by strengthening school health programmes.

KNOWLEDGE AND INDEPENDENCE IN THE CARE OF COMMUNITY DENTAL AND ORAL HEALTH TO TEACHERS AND PARENTS OF ELEMENTARY SCHOOL STUDENTS

Dental and oral health in Indonesia is still a health problem that needs attention. Based on the Riskesdas 2018, it was reported that the prevalence of dental and oral problems in Indonesia is still very high. As many as 57.6 percent of Indonesians have dental and mouth problems. The most concerning thing is that as many as 93% of school-age children experience dental and mouth problems. This activity is intended as a comprehensive school program in Indonesia, which consists of a 21-day dental and oral health program for children at school. Implementation of the School Health Program uses an online system through the zoom application. The target participants are 5 parents and 5 teachers at SD Hangtuah 6 Surabaya. The location and time of implementation is Saturday, November 5 2022, 08.30 – 11.00 WIB by using a zoom meeting. The results of the statistical analysis used a paired sample t-test with a significance value of 0.000, this means that there is a significant difference in the level of knowledge of maintaining dental and oral health among teachers and parents of students at SD Hangtuah 6 before being given DHE material and after being given DHE through "Training of Trainers”. Teachers and parents can become pioneers in disseminating knowledge and how to maintain oral health for school-level children, as well as changing behavior in maintaining dental and oral health for the better.

Barriers to Mental and Social Health Programs in Schools: A Qualitative Study.

Objective: In order to achieve development goals, in addition to providing students with physical health, their mental and social health should be considered as a necessity and priority in development programs. This program, called the Nemad Project in Iran was formally established in 2015. This study aims to explore the challenges of the Nemad project in Iranian schools based on stakeholders' views. Method : The present qualitative study, with a contractual content analysis approach, was conducted on 21 experts in the field of social harm prevention and mental health promotion at the senior, intermediate, and operational levels in educational institutions and schools, Ministry of Health, the Judiciary and the Planning and Budget Organization. These experts also included project technical officers. Participants were selected using snowball and purposeful sampling methods. Data were collected through semi-structured interviews and analyzed by coding, classification, and extraction of the main themes. Results: Six main themes were derived that included inefficiency in resource management (with subcategories of inadequate facilities and equipment, inadequate human resource management, and information management system deficiencies), weakness in program organization (with subcategories of poor cross-sectoral and weak inter-sectoral subgroups), challenges of laws/regulations/policies (with sub-categories of defective protocols and guidelines and lack of specific task descriptions), barriers and challenges to implementation of policies (with macro and school policy implementation subcategories), structural factors (with subcategories of financial resources allocation problems, inconsistency in managerial levels, and deficiencies in decision-making principles), weaknesses in educational processes (with subcategories of inadequate teacher education, weaknesses in parenting courses, and weaknesses in student education), and ultimately, weaknesses in monitoring and evaluation (with the subcategory of lack of a monitoring and evaluation system). Conclusion: According to experts, implementation of mental and social programs in schools is not in a desirable situation and is faced with certain challenges. To enhance the management of the Nemad project in Iranian schools, it is necessary to compile flowcharts of service delivery and inter-device communication, allocate resources to meet the expectations of each organization, do performance-based budgeting, take a comprehensive look at parental issues, and design a system of monitoring and evaluating the requirements.

Evaluating the Efficacy of School Mental Health Promotion Program in Iranian Schools: A Qualitative Study

Objectives Considering the importance of identifying the mental health problems among school students and their proper management by offering specialized services to them, the present study aims to evaluate the efficacy of school mental health (SMH) program in Iranian schools, identify its shortcomings and provide recommendations for it improvement. Methods This is a qualitative study using conventional content analysis method. A semi-structured in-depth interview was used to collect information from 35 participants who included teachers, principals, and developers of the SHM Program in Iran. Results Based on the results, four themes (strengths, weaknesses, barriers, and recommendations) and 14 subthemes were extracted. Overall, 50 codes were obtained. The results showed the effectiveness of the SMH program. Conclusion The SMH program is effective and has opened a new perspective to school-based interventions. However, expecting the full implementation and continuation of this program in the short term and with limited resources does not seem logical. Therefore, it is first recommended to improve the infrastructure for implementing this program, use trained personnel, upgrade the counseling departments of schools, and remove the time limit of teachers and legal limitations. Then, this project should be implemented at the national level for all schools in Iran.

Improving the Participation of Preschool Children’s Mothers in Fluoride Varnish Program: An Educational Intervention

Introduction: Tooth decay is the most prevalent chronic childhood disease. Fluoride tooth restoration is a common method of controlling tooth decay, but common misconceptions in this area prevent family involvement. Therefore, the aim of this study was to determine the effect of educational interventions on the participation of preschool children’s mothers in the fluoride varnish program. Methods: This was an interventional study performed on 176 mothers of preschool children in Yazd in 2020. Participating mothers were randomly selected and divided into intervention and control groups. The research tool was a researcher-made questionnaire with confirmed validity and reliability. It included demographic variables and 4 sections of awareness, facilitators, barriers, and behavior. Intervention and control groups completed the questionnaires before and two months after the intervention. Chi-square, Mann-Whitney, Kruskal-Wallis, and Spearman correlation tests, as well as repeated measures analysis of variance and the generalized estimating equations model were used for data analyses. Results: The proportion of people who participated in the fluoride varnish program before the study was the same in both intervention and control groups (35.2 and 37.5), but after the intervention, the percentage of people whose children participated in this program was more in the intervention group (88.6 and 51.1, P<0.0001). Conclusion: The findings of this study confirmed the positive effect of the educational intervention on increasing the participation of mothers in the fluoride varnish program. To better cooperate and involve families with oral health programs in schools, thinkers in the field should be fully justified in the program to provide timely training and interventions.

School-based health and nutrition interventions addressing double burden of malnutrition and educational outcomes of adolescents in low- and middle-income countries: A systematic review.

School system is a promising platform for addressing all forms of malnutrition in adolescents. However, little is known about the impact of integrated school health and nutrition programmes on adolescent nutrition and educational outcomes in low- and middle-income countries (LMICs). This systematic review sought to characterize school-based health and nutrition interventions among adolescents in LMICs and analyze their effects on nutritional status and educational outcomes. Four databases were searched for studies evaluating school-based health and nutrition interventions for adolescents in LMICs, reporting changes in either nutritional status or educational outcomes. A narrative synthesis was used to analyze and describe the evidence. Our review included 68 articles evaluating 58 interventions, of which a third had moderate to strong methodological quality. Forty-two studies evaluated single-domain interventions, while 26 evaluated multi-component interventions. A third of all interventions were based on a theoretical framework. Three-fourths of the interventions were shorter than 11 months, which may make identifying their effect difficult. The results of the effectiveness of these interventions were mixed and inconsistent across intervention types. Sixteen out of 21 studies evaluating multi-component interventions and 12 out of 23 studies evaluating nutrition education reported improving nutritional or diet-related outcomes. One out of six studies reported positive effects on educational outcomes. Our review has identified that research needs include: a greater inclusion of theory-based approaches to guide the implementation of interventions; more studies of integrated interventions that involve parents and the wider community in LMICs; and extension of outcomes beyond nutritional status to include educational outcomes.

PEER SEXUAL BEHAVIOURS, AS CORRELATE OF SECONDARY SCHOOL ADOLESCENTS’ SEXUAL RISKY BEHAVIOURS IN ANAMBRA STATE

Adolescence is an important developmental period when they get involved in sexual activities with their peers, which have the tendency to expose the parties involved to risky sexual behaviours. This study investigated peer sexual behaviours as a correlate of secondary school adolescents’ sexually risky behaviours in Anambra State. One research question guided the study, while one null hypothesis was formulated and tested at the 0.05 level of significance. The design for the study was correlational survey research. The sample comprised 1,200 students drawn from a population of 19,048 SS2 adolescents in public secondary schools. A standard instrument, the "Adolescent Sexual Behaviour Index," developed by Hansen, Paskett, and Carter (1999), was used for data collection. The internal consistency reliability coefficient for the instrument was 0.86. Data was collected through direct delivery of the instrument to the respondents and analysed using the Statistical Package for Social Sciences (SPSS). The research question was answered using Pearson Product Moment Correlation Coefficients, while the null hypothesis was tested using a t-test for significant correlation. The findings of the study revealed that there is a low positive relationship between sexual behaviour and sexual risk behaviours among public secondary school students in Anambra State. The findings further revealed that the relationship existing between peer sexual behaviour and sexual risk behaviours of secondary school adolescents in Anambra State is significant. Based on the findings of the study, it was recommended that school management set up school health programmes that can help young people adopt lifelong sexual behaviours that support their health and well-being, including behaviours that can reduce their risk for HIV and other STDs. KEYWORDS: peer, sexual behaviours, sexual risky behaviours, adolescents, correlate

Health Risks Management Program in Schools: An Operational Study in Türkiye.

This study was carried out to improve the quality of school health services with the operational epidemiology method. The study aimed to describe the current status of the School Health Protection and Improvement Program (SHPIP), the difficulties experienced during its implementation, to develop evidence-based solution methods, and to test the proposed solutions, in a district with a population of 400,513, 20.4% of which is of school age between the ages of 5-19. The "Health Risk Management Program at Schools", which consists of the stages of putting the results into practice by sharing the results with the relevant parties, wasdeveloped. In this study, a cross-sectional research design was employed using questionnaire forms, while qualitative data were collected through the use of the phenomenological analysis method, specifically through the conduct of focus group interviews. SHPIP year-end evaluation forms of 191 schools were reviewed retrospectively, questionnaires were applied to 554 school staff and 146 family health center staff between 21 October 2019 and 21 November 2019 using the probabilistic sampling (simple random) method, and semi-structured focus group interviews were conducted with 10 school health study executives. The most common health risks in schools and the risks identified during the execution of school health services were identified. In order to eliminate the lack of in-service training, training modules for "School Health Management Teams" were developed and impact analyses were conducted. After the intervention, a significant difference was found in the compliance of schools with SHPIP, and the application of all components of the school health program increased from 10.0% to 65.6% (p < 0.05). The program has been integrated into the "School Health Protection and Improvement Program" (SHPIP) with the decisions of the District School Health Board and District Hygiene Council.

Caregivers' health-seeking behaviour for children participating in an integrated school health programme in KwaZulu-Natal, South Africa.

Caregivers are active members of the healthcare team, and the uniqueness of their role in caring for a sick child is holistic, as no other healthcare team member is consistently aware of all the facets of the child's life. The integrated school health programme (ISHP) aims to improve access to healthcare services and promote equity for school-going children by delivering comprehensive healthcare services. However, not much attention has been paid to understanding caregivers' health-seeking experiences within the context of the ISHP. This study sought to understand caregivers' health-seeking behaviour for their children participating in the ISHP. Three low-resource communities were chosen within the eThekwini District of the KwaZulu-Natal province, South Africa. This study utilised a qualitative research design. We recruited 17 caregivers using purposive sampling. Semistructured interviews were conducted, and the data were analysed using thematic analysis. Caregivers explored multiple means of care, ranging from managing the children's health conditions based on previous experiences to visiting traditional healers and administering traditional medicines. Caregivers delayed health seeking due to low literacy levels and financial barriers. Although ISHP has expanded its coverage and the range of services provided, the study suggests the need to implement interventions focused on providing support to caregivers of sick children within the ISHP context.Contribution: The findings of the study highlight the need to develop potential schemes to address transportation barriers to accessing healthcare services for school-going children.

Strengthening Dental Health through School Health Program: A Call for Prevention of Dental Caries among Indian School children

Strengthening Dental Health through School Health Program: A Call for Prevention of Dental Caries among Indian School children

The Relationship Between Food Insecurity and Food Assistance Program Participation in Families of Preschool Children in the Rio Grande Valley

ABSTRACT The South Texas Early Prevention Study-PreK, a cluster randomized trial, explored the Bienestar Coordinated School Health Program’s influence on health variables in South Texas children. Factors associated with food insecurity (FI) were analyzed. Income-to-poverty ratio, income, and food assistance (FA) program participation were all associated with FI. Forty percent of families (257/643) reporting FI did not utilize FA. Of those families with FI, but who reported no FA participation, 31.8% were FA eligible. Families experiencing FI may underutilize FA programs, despite eligibility. Curtailing obstacles preventing FA program participation and matching those who are eligible with FA programs are crucial.

Knowledge and Uptake of Human Papillomavirus Vaccine among Female Adolescents in Port Harcourt. A Call for Urgent Intervention

Background: Infection with high-risk types of the Human Papillomavirus (HPV) has been associated with the development of cancers in both genders, affecting the genital, oropharyngeal and anal regions. Safe and effective vaccines are available against high-risk types which are responsible for majority of cases of cervical cancer. This study was conducted to assess the level of knowledge and uptake of the HPV vaccine among female adolescents in Port Harcourt, Nigeria.&#x0D; Methodology: A descriptive cross-sectional survey conducted among in-school female students of both public and private secondary schools in Port Harcourt metropolis, aged 9 - 19 years. A total of 328 participants were recruited using multi-stage sampling. Information on socio-demographics, sexual history, knowledge of HPV, its vaccine and vaccine uptake were collected using a self-administered, semi-structured questionnaire. Data was analyzed using SPSS version 23. Descriptive and analytical tests were performed to determine associations and predictors of vaccine uptake.&#x0D; Results: The level of knowledge of the availability, protective role, and schedule for administration of the HPV vaccine was poor (≤36%). Only 2.1% of girls interviewed were vaccinated with 42.9% of these having taken only one dose, thus being incompletely vaccinated. The mean age at vaccine uptake was 13.4±1.2 years. The most common reason given for not having taken the vaccine, is unawareness of the vaccine (322/328). Uptake of the vaccine was better among students at public schools.&#x0D; Conclusion: Social mobilization towards primary prevention of HPV infection should also focus on adolescents. Social media and school health programs/ clubs should be exploited/ improved to provide detailed and adolescent-friendly information necessary to stimulate improved uptake of the vaccine and thus reduce the devastating potential consequences of infection with the HPV.

Implementing Adolescent Wellbeing and Health Programs in Schools: Insights from a Mixed Methods and Multiple Informant Study.

Determining the factors that influence implementation of school-based wellbeing and health programs is essential for achieving desired program effects. Using a convergent mixed-methods, multiple informant design, this study considered factors that influence implementation of health programs for ninth grade students and in what ways implementation is differentially perceived by multiple informants (i.e., participants, instructors, and independent observers). Two types of programs-mindfulness and health education-were implemented with ninth graders (N = 70) in three schools situated in low-resourced urban neighborhoods. Study outcomes were derived from four data sources: (1) focus group participants (N = 45); (2) program instructor fidelity ratings; (3) independent observer fidelity ratings and notes; and (4) instructor open-ended session responses. Using thematic and mixed methods integration analyses, we identified themes related to implementation promoting or challenging factors. Theme names differed when data sources were separately analyzed by informant. Mixed methods integration analysis indicated that four themes were common across all informant groups: (1) competent, attentive, and engaging instructors are essential; (2) programs should involve interactive components (e.g., physical activities, applied learning opportunities); (3) adequate time for program delivery is key for student exposure and engagement; and (4) students' availability and preferences should guide program scheduling. A fifth theme, unique to instructor and observer perspectives, was that program implementation was negatively impacted by distractions from multiple sources, including instructors, students, and settings. Recommendations from students, instructors, and observers for implementation optimization are discussed.