Background
Because health-related behaviours and obesity track from childhood to adolescence and adulthood, it is highly important to promote and establish healthy eating habits and physical activity among children (Biddle, Pearson, Ross, & Braithwaite,
2010; Craigie, Lake, Kelly, Adamson, & Mathers,
2011; Singh, Mulder, Twisk, van Mechelen, & Chinapaw,
2008; Telama,
2009). The health of children in Sweden is relatively good, as compared to other countries, but there is a steep social gradient in the prevalence of overweight and obesity among children from families with low socioeconomic status (SES; Elinder, Heinemans, Zeebari, & Patterson,
2014; Magnusson, Hulthen, & Kjellgren,
2005; Moraeus et al.,
2012; Sundblom, Petzold, Rasmussen, Callmer, & Lissner,
2008). Low parental education has been associated with a higher intake of unhealthy foods and a lower intake of vegetables among children (Safsten, Nyberg, Elinder, Norman, & Patterson,
2016), as well as with less participation in organised sports and more time spent watching TV (Hesketh, Crawford, & Salmon,
2006; Moraeus et al.,
2012). According to a study of health behaviours among Swedish school children, those whose parents had attained higher levels of education had more favourable health-related behaviours than those with less educated parents in seven out of 12 health behaviours related to diet and physical activity (Elinder et al.,
2014). It is therefore important to develop and implement health interventions that are effective among disadvantaged groups, and do not widen the socioeconomic health gap.
The World Health Organization has released an action plan called “Ending childhood obesity” that includes six main recommendations, in which the role of parents, families, caregivers, and educators in encouraging healthy behaviours among children is strongly emphasised (World Health Organization,
2016). Parents can make healthy foods and activities accessible to their children (Ferreira et al.,
2007), and employ parenting styles and practices to support and encourage healthy habits (Collins, Duncanson, & Burrows,
2014; Davison, Cutting, & Birch,
2003; Seabra et al.,
2013; Ventura & Birch,
2008; Vollmer & Mobley,
2013). A majority of obesity prevention interventions in children are school-based (Lobstein et al.,
2015). Evidence has accumulated that health promotion in schools can enhance children’s physical activity and healthy dietary habits, although the effects achieved are usually small and short-lived (Brown & Summerbell,
2009; Dobbins, Husson, DeCorby, & LaRocca,
2013; Peirson et al.,
2015; Waters et al.,
2011) and should therefore be complemented by program components that target parents. A systematic review of parental support programmes has showed that merely sending home information is ineffective, whereas parental counselling, either face-to-face or by telephone, is effective in changing children’s diet but not physical activity (Kader, Sundblom, & Elinder,
2015). Some weak effects on body mass index (BMI) have been obtained by group-based interventions (Kader et al.,
2015). Furthermore, effectiveness was generally higher in studies targeting parents of preschool age children (2–5 years) than those targeting parents of older children.
The parental support programme “A Healthy School Start” (HSS) was developed and evaluated with the aim of promoting physical activity and healthy dietary habits and prevent obesity, especially among children in disadvantaged areas where the prevalence of overweight and obesity is high (Nyberg et al.,
2015; Nyberg, Norman, Sundblom, Zeebari, & Elinder,
2016). This universal programme, which targets 6 year olds and their parents regardless of the weight status of their children, is described in detail elsewhere (Nyberg, Sundblom, Norman, & Elinder,
2011). Briefly, the programme comprises three components: (1) a brochure containing health information for the parents, (2) two individual sessions of Motivational Interviewing (MI) for the parents, and (3) ten 30-min teacher-led classroom activities for the children. All three components target the parents: the first two directly and the third indirectly through the children’s homework. MI is a client-centred and goal-steering method to support an individual in behaviour change ( Miller & Rollnick,
2013). During the first MI session the parents choose some aspect of their child’s diet, physical activity, or sleep that they want to change, and during the second session they explore their efforts towards achieving this goal. The MI sessions should preferably be conducted by MI-trained staff. For classroom activities, the teachers are provided with a manual and a tool-box with pedagogic materials regarding diet, physical activity, and sleep, and the children receive homework assignments to carry out together with their parents at home.
The HSS programme has been evaluated within the context of two cluster randomised controlled trials (Nyberg et al.,
2015,
2016). The mean age of the children in the first trial was in 6.2 years and 6.3 years in the second trial. Outcomes were in both trials measured before and after intervention, and at follow-up after 5 months. Results from the first study, carried out in an area with low to medium SES in Stockholm, Sweden, showed positive intervention effects on vegetable intake and physical activity among girls during weekends (Nyberg et al.,
2015).
Results from the second study, carried out in an area with low SES and a high prevalence of overweight and obesity, showed positive intervention effects, e.g., lower consumption of unhealthy foods and unhealthy drinks, as well as lower BMI z-scores, among children who were obese at baseline (Nyberg et al.,
2016). No effect could be seen on physical activity for the whole group in either of the studies. This was probably due to the fact that the majority of the children in both studies had already reached the recommendations for physical activity at baseline. However, as physical activity levels among children peak at the age of 5–6 and decrease rapidly thereafter (Cooper et al.,
2015), it is still important to promote physical activity from an early age. The positive effect of vegetable intake was sustained among boys at 5 months follow-up in the first study, and the beneficial effect on the consumption of unhealthy food was sustained among boys at 5 months follow-up in the second study, while other effects tended to wear off. Thus, the results of the two trials are in agreement with the international literature, according to which diet—and to a lesser extent BMI—can be positively influenced through parental counselling (Kader et al.,
2015), while physical activity is more difficult to influence at this age. However, the effects of the programme levelled off after 5 months, and we have therefore reasoned that the HSS programme may have to be extended and/or intensified if we are to enhance and sustain its effectiveness.
In both trials, the programme was conducted with substantial support from the research team, and the MI sessions were conducted by MI-trained external staff (Nyberg et al.,
2015,
2016). In order for this programme to be implemented on a broader scale it has to be fully integrated into the school context, and the most realistic solution is that school nurses should provide the parental counselling, which means that they have to be competent in MI. Health promotion is emphasised in the Swedish guidance to school health services (The National Board of Health and Welfare & The Swedish National Agency for Education,
2016). School guidelines state that “student health care should mainly work with health promotion and prevention” and that the schools have the potential to support healthy diet and physical activity, for example by “giving parental support that encourages healthy dietary habits, physical activity and less sedentary behaviour” (pp. 27 and 98).
No matter how effective a programme might be, it will only result in health changes at a population level if widely and well implemented. The aim of this study was to explore barriers to and facilitators for the implementation of a parental support programme aimed at promoting physical activity and healthy dietary habits in the school context and carried out by school staff, as perceived by school nurses and school principals. The HSS programme was used as an example of such a programme.
Discussion
In this study, we explored barriers to and facilitators for the future implementation of a parental support programme in school addressing diet and physical activity, as perceived by school nurses and school principals. The overarching theme that emerged was that it is important to create commitment among all staff members in school and student health care to successfully implement a parental support programme in a context where the workload is generally high. We identified four categories at a manifest level, which we have also attempted to refer back to CFIR (see Table
1). This is recommended by the developers of CFIR in order to promote the ability to compare research over time and across contexts (Kirk et al.,
2016).
Table 1Correspondence between results from inductive analysis and consolidated framework for implementation research (CFIR) domains and constructs
Community and organisational factors | Inner setting | Structural characteristics |
Network and communication |
Culture |
Implementation climate |
Readiness for implementation |
Leadership engagement |
Available resources |
Outer setting | External policy and incentives |
Characteristics of individuals | Other personal attributes (such as motivation and competence) |
A matter of priority | Inner setting | Implementation climate |
Tension for change |
Compatibility |
Relative priority |
Outer setting | Patients’ needs and resources |
Implementation support | Intervention characteristics | Complexity |
Design, quality and packaging |
Cost |
Process | External change agent |
Implementation process | Process | Engaging |
Formally appointed internal implementation leaders |
External change agents |
Reflecting and evaluating |
Both school nurses and school principals reported that their schools’ resources are limited, and that the workload is heavy, which in CFIR terms relates to the domain ‘Inner setting’ of the schools. This was also stressed by teachers in a previous implementation study of the HSS programme (Bergstrom et al.,
2015). Limited resources for school health professionals have also been described in a study from the United Kingdom, where lack of capacity, among other things, constituted a barrier for health promotion activities (Turner et al.,
2016). In this overburdened work situation, it is a challenge for the staff to engage in and commit to a programme that requires time and effort. Therefore, to be able to implement a programme like HSS with high fidelity, additional resources would be needed. On the positive side, the existing organisation offers great opportunities, such as engagement, competence, and structures for cooperation and communication between different professions both within and among schools, all of which could facilitate commitment among the staff. High quality formal communication and peer collaboration are known to contribute to effective implementation in general (Damschroder et al.,
2009). Multidisciplinary collaborative approaches and professional networks have also been highlighted as one of five enablers regarding implementation of the health-promoting school concept (Hung, Chiang, Dawson, & Lee,
2014). Networks and pre-existing teams might form a solid basis for shared decision-making, which is important not only for a successful implementation but also for program sustainability (Durlak & DuPre,
2008).
Schools are continually offered various kinds of programmes and must prioritise, due to limited resources and a heavy workload. To implement a programme like HSS, schools must recognise a need, which in this case is closely connected to the prevalence of overweight and obesity among the students (CFIR domain ‘Outer setting’). Providers who recognise a specific need for a programme will also be more likely to implement it with higher fidelity (Durlak & DuPre,
2008). The decision as to whether or not to introduce a programme is strongly influenced by whether the staff believe it can actually be integrated into school routines, as they do not want to put effort and time into something that cannot be sustained (CFIR domain ‘Intervention Characteristics’). The HSS programme is designed for pre-school classes of 5–7 years old children but, as the nurses and school principals in our study pointed out, the attitudes and ideas can be supported by all school professionals during all grades. Teachers, school nurses and meal staff could contribute to implementing and sustaining such a whole-school programme by acting as role models, initiating discussions and offering healthy alternatives.
Participants in this study had to come to terms with the circumstance that in a future implementation study MI would have to be carried out by the school nurses themselves, and not by an outside expert as in our previous studies (CFIR domain ‘Intervention Characteristics’). As our study’s school nurses already perceived their workload as overburdened, their main focus was on feasibility. Therefore, using MI as a component may require additional resources in terms of time, money and training.
MI has been found effective in promoting healthy diet and physical activity behaviours in adults (Hardcastle, Taylor, Bailey, Harley, & Hagger,
2013; Martins & McNeil,
2009). The technique has previously been used in programmes that involve parental support (Dawson et al.,
2014; Schwartz et al.,
2007) and it is often appreciated by parents. Being client-centred, MI is a flexible method that can be adapted to the severity of the concern, degree of motivation, and wishes of the specific parent. A Danish study concerning the use of MI in school health services revealed that the school nurses perceived it as useful in working with both parents and children to prevent overweight and obesity (Bonde, Bentsen, & Hindhede,
2014). The majority of school nurses in our study had training and some experience in MI already. However, previous studies show that in general, the MI conducted within health care services does not meet recommended standards for MI competence (Ostlund, Kristofferzon, Haggstrom, & Wadensten,
2015). MI is generally learnt over time and both practice and supervision are essential (Miller, Yahne, Moyers, Martinez, & Pirritano,
2004). Hence, although many school nurses in Sweden already have some basic training in MI, additional practice with supervision and feedback on audio-recorded MI sessions would be needed if they are to attain full MI competence. This, in turn, is costly, but as MI appears effective in health promotion, such training could be cost-effective.
One argument against introduction of a programme like HSS was uncertainty about whether it is the role of the school to provide support to parents, and school nurses asked for policy guidance in this regard (CFIR domain ‘Outer setting’). The same uncertainty about the boundary between parents’ and schools’ responsibility when it comes to healthy eating and sufficient physical activity has previously been noted in the international literature (Clarke, Fletcher, Lancashire, Pallan, & Adab,
2013) and might lead to lack of appropriate action. As a matter of fact, the Swedish guideline for school health care from 2014, and updated in 2016, does encourage schools to support parents (The National Board of Health and Welfare & The Swedish National Agency for Education,
2016). But because of the high workload there is still uncertainty about whether or not it is right to focus on supporting parents. A policy decision on health promotion and parental support, preferably including additional funding, could provide a further incentive for schools when they must prioritise actions. This finding is in line with a study by Clarke et al. (
2017), who interviewed head teachers regarding obesity prevention in English primary schools. Like our respondents, school leaders expressed a need for support through resources and government policy in order to fulfil this role. It is our impression that the school food environment in Sweden is conducive to health due to policies at the local and national levels to improve school meal quality (Patterson & Elinder,
2015) and remove unhealthy food products from primary schools. In addition, the government decided to add extra hours of physical education to the curriculum in primary schools as of 2019. Furthermore, the Swedish government has made additional funding available for student health care staff since 2016, with no prioritisation regarding the focus area.
Another interesting result of the study concerns the issue of whether a top
–down decision to conduct a health programme would help or impede implementation (‘Implementation process’ in CFIR). On the one hand, study participants reported that a top
–down decision may disengage staff. Earlier research shows that school staff pressured to offer new programmes do not implement them very effectively, probably because they are not committed enough (Durlak & DuPre,
2008). Our previous implementation study of HSS also supports this observation. Teachers who were told to carry out the programme felt they were being forced, which affected their engagement in the programme negatively (Norman, Nyberg, Elinder, & Berlin,
2016). To avoid opposition, staff should be actively involved in detailed planning regarding when and how the programme should be implemented. According to a systematic review on implementation of the concept of health-promoting schools, enthusiasm among staff is maintained if they have a sense of ownership, which can be achieved by letting them play an important role in strategic planning and decision-making (Hung et al.,
2014).
It became clear that to create commitment among staff and implement the obesity prevention intervention with high fidelity, the staff should be offered training and opportunities to discuss the content of the programme. Our second trial showed that teachers’ time for making the necessary preparations for the intervention and doing so before finalising their plans for the school year, influenced their engagement in the programme (Norman et al.,
2016). Furthermore, the results of this study demonstrated that lack of parental engagement is a barrier to securing parental support. Both process evaluations from the earlier trials confirm that successful implementation to a large extent relies on good cooperation between home and school. The importance of facilitating communication and clearly defining the division of responsibilities between project management (i.e., researchers), schools, and parents is emphasized (Bergstrom et al.,
2015). It is also important to tailor the intervention to the abilities of the target group to increase participant engagement (Norman et al.,
2016).
To support implementation, participants desired a kick-off meeting with an inspirational person from outside the organisation. This kind of ‘external change agent” is described in CFIR as individuals affiliated with an outside entity, who influence or facilitate the implementation (Damschroder et al.,
2009). Such a kick-off meeting could function to engage parents as well as school staff and contribute to enhancing cooperation between school and parents regarding the programme.
Strengths and Weaknesses
Prior to implementing a programme, capacity and needs assessment must be carried out to identify potential barriers and facilitators from the perspective of the individuals involved in the implementation (Damschroder et al.,
2009). However, the participants in this study had no prior experience of the programme, except reading the manual 1 week before the interview. On the other hand, they had knowledge and experience from the setting where the programme is to be implemented, which we considered important. We collected data from three different groups of professionals, which increases the trustworthiness of the study (Patton,
2015). Trustworthiness was also increased by illustrative quotes and intersubjective agreement in the coding and analysis of the data (Patton,
2015).
We asked each participating municipality to aim at including participants from areas representing variations in SES. However, a purposive sampling of schools with maximum variation (Patton,
2015) with regard to area SES would have been more appropriate to make sure that full range of this characteristic was represented. This was not possible because of a restricted time frame and difficulties recruiting enough informants, due to the fully booked schedules of school nurses and school principals. Another weakness was the limited number of participants in one of the focus groups.
As the setting is described in detail, and the results are referred back to the guiding framework (CFIR), the results of this study should provide useful guidance for implementation of similar health promotion interventions in the school context.
Conclusions
When implementing a parental support programme to promote physical activity and healthy dietary habits for children within a school context, it is crucial to create commitment among all staff. The resources available to schools are scarce, and in order for staff members to prioritise such a programme, it should be based on needs, have policy support, be integrated into routine school practice, and seek to improve both health and learning for the children. Barriers to implementation included financial and time constraints, other health needs competing for resources, and challenges in engaging parents. To summarise, the implementation of a parental support programme in school can be facilitated by factors external and internal to the organisation, and intervention characteristics. The external factors comprise support from decision-makers through policies, guidelines and financial incentives as well as access to external support by phone or email, and expert guidance through an inspirational kick-off meeting. Important intervention characteristics were found to facilitate implementation such as a clearly structured manual including detailed information and checklists, and information materials to use when presenting the programme to parents.
Internal factors facilitating implementation include use of pre-existing resources, such as competent and engaged staff, multidisciplinary health care teams, web-based systems for documentation and communication, municipality networks, and local experts. Other important internal factors for effective implementation include the integration of the programme into the school routines and creating awareness among all staff as well as appointment of a multidisciplinary team and an implementation leader at each school, to carry out detailed planning and time management.
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