Discussion
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REGRESSION, SECONDARY
This study expanded the work of Thirsty? Choose Water! into regional and remote secondary schools within two NSW LHD. Where practicable, this study mirrored the parent study, but some changes to study implementation and evaluation were required, necessitated by funding timelines. Consequently, the vaccination intervention was not implemented, and student data were only collected at two time points, rather than three. The study also weathered challenges including the impacts of COVID-19 and issues that arose due to school locality. Nevertheless, these regional and remote schools achieved similar levels of acceptability and outcomes as the parent study.Within schools that received the BI, there was positive feedback from teachers on the training to deliver the intervention and the intervention components themselves. Eighty-six per cent of teachers reported the lesson content to be useful to very useful, with all teachers reporting the Thirsty? Choose Water! website to be ‘useful’ to ‘very useful.’ The environmental intervention also had a high level of acceptability. Within these schools, staff reported that the CWS were well utilised and appreciated by students, particularly in hot weather. Schools within the study also made some changes to their policies regarding water, such as including information about bringing water on excursion notes and promoting water within sports and school newsletters.Regarding student outcomes, the within-group analysis demonstrated several statistically significant changes in knowledge, water behaviours and consumption. Students receiving the combined intervention had a statistically significant change from baseline to follow-up on water behaviours, such as bringing a bottle to school, filling it up at school and drinking from the bubbler. Students in both the environmental intervention and control reported a statistically significant increase in water consumption. Students across all groups showed a significant decrease in SSB consumption. Statistically significant changes were also noted in several variables for the control group, which could be explained by the hawthorn effect, whereby the very nature of being involved in a study may influence behaviour change. The smaller sample size in this study may also not have had the power to withstand these sorts of effects.Like the parent study, this study used logistic regression to examine the impacts of the individual and combined effect of the interventions on both water and SSB consumption. Like the parent study, these outcomes showed that odds for increasing water consumption or reducing SSB consumption all moved in a positive direction, although only some were statistically significant. In terms of decreasing SSB consumption, both the environmental intervention alone and the combined interventions had a statistically significant effect. However, none of the interventions (either alone or combined) produced a statistically significant effect on increasing water consumption.This study adds to a growing literature regarding interventions in school settings to increase water consumption and decrease SSB consumption among students. To effectively address this issue, there are calls for multicomponent interventions in schools that address the environment, the individual or bothThere were several challenges for this study, with the impacts of distance, natural disasters and COVID-19 combined impacting study implementation and evaluation. While the regionality and remoteness of schools did not impact the acceptability of the interventions, it did present some issues for the rigour of the evaluation of the research and its outcomes. For example, the utility of the data loggers as an objective measure of water consumption within this study is questionable and cannot be used to its full potential. This was because in some regional/remote locations, schools did not have good internet connectivity. This meant that data loggers were often ‘offline’, being unable to connect to the internet and log data. Therefore, the dataset is incomplete. Similarly, internet connectivity impacted other aspects of the study evaluation to some degree.At the commencement of the study (Spring 2019; September–November), bushfire emergencies arose in both study regions. This impacted the usual running of some schools and had a knock-on effect on study implementation, delaying baseline data collection for some schools and therefore CWS installation. The emergence of COVID-19 in early 2020 also presented further challenges to study. Although most schools in the BI groups had delivered the programme before the first COVID-19 lockdown in March 2020, some schools had not. Subsequently, the project team acted swiftly to ensure that the programme could be delivered online whilst students were homeschooling. Although teachers provided positive feedback about this, we are aware that some students had issues with accessing online platforms and internet connectivity. This is consistent with other research that examine the impact of COVID-19 on the delivery of health promotion interventions in schools and some students’ inability to connect with the remote learning aspectsThe study’s strengths are that it extended both an intervention and study design that had been implemented effectively previously. One limitation of the parent study was the inability to detect changes in water consumption due to the blunt nature of the Likert scale that gathered that data. In this study, we attempted to overcome that, even with limited success. While we asked about water consumption as a continuous variable, we could not incorporate that data field into the logistic regression, as the SSB consumption had been measured as a categorical variable. Therefore, despite attempts to address this limitation, we had to revert to the categorical data for water consumption when it came to include variables into the logistical regression.Overall, the results of this study continue to mirror the findings of the parent and pilot studies. That being that schools are willing and ready to address this issue, that it aligns well within their PDHPE curriculum and that they appreciate access to chilled water. Regarding water and SSB consumption outcomes, the interventions appear to have had a positive effect in the direction of the desired change. This would warrant further investigation into the translation of intervention components more broadly into school settings. To support this in secondary school settings in NSW, a range of Thirsty? Choose Water! resources were developed and can be accessed at 