Background
Health among Swedish children is in general good, with a relatively high proportion of children with high self-rated health and a low proportion of obesity, compared to other European countries [
1‐
3]. The home environment [
4‐
6] as well as parental styles and practices [
6,
7] play an important role in the development of children’s dietary and physical activity habits, and therefore the home is a crucial setting to promote healthy behaviours among children. Another important setting is the school, which has the potential to reduce social inequalities in health because it reaches all children. School-based programmes have shown some effectiveness in promoting health-related behaviours as well as preventing overweight and obesity [
8,
9], and the literature suggests that even better results may be obtained if parents are involved [
10,
11]. Counselling of parents can be an effective way to improve young children’s dietary habits [
12], whereas sending home information is not [
13,
14].
Based on this knowledge the programme ‘A Healthy School Start’ was developed with the aim to promote healthy dietary habits and physical activity among children through councelling through MI to parents in a school setting [
15]. MI was chosen as a counselling method as studies suggest that MI may increase parents’ motivation to improve their children’s health habits [
16,
17]. The programme resulted in a significant increase in vegetable intake in the children and the girls in the intervention group had higher total physical activity during the weekends compared to the children in the control group [
18].
In general there is a lack of research regarding barriers and facilitators of implementation of specific programmes [
19]. This is essential as even effective health promotion programmes will not make an impact if not implemented as intended.
When trying to implement health promotion programmes on a wider scale it is important to prepare the process thoroughly [
20]. By studying barriers to implementation it is possible to develop and select strategies to overcome difficulties [
21]. Factors identified to affect the implementation process in general, according to a systematic review by Durlak and DuPre [
22], include community level factors, provider characteristics, characteristics of the innovation, organizational capacity, and factors related to the prevention support system.
According to this review, ‘community level factors’ describe contextual aspects which can enhance or impede implementation, such as politics, policies and funding. ‘Provider characteristics’ refers to self-efficacy, skill proficiency and perceived needs among the providers. If the providers believe that a programme will produce desired benefits they are more likely to implement it with high fidelity. ‘Characteristics of the innovation’ concerns compatibility with values and goals of the organisation and adaptability of the intervention. A programme is much more likely to be implemented if it fits with the organisation’s existing priorities and if it is modifiable in accordance with local needs. ‘Organisational capacity’ deals with work climate, practices and leadership. Effective leadership within organisations and shared decision-making has been identified as crucial to implementation. Finally ‘factors related to the prevention support system’ includes training and technical assistance to providers. Training is needed to prepare providers for their task and technical assistance refers to the resources offered to providers once the intervention begins [
22].
Although there are many effectiveness studies regarding children’s dietary habits and physical activity to date, there is a lack of studies investigating factors of importance for large-scale implementation. The aim of this study was to explore the views of teachers and parents regarding factors influencing the implementation of a school-based parental support programme to promote physical activity and healthy diet.
Results
We identified an overarching theme at a latent level; Clear communication on roles and responsibilities, and five descriptive categories at a manifest level: 1) The programme; 2) the school; 3) family conditions; 4) group dynamics; and 5) the surrounding community. An overview of the results is given in Table
2.
Table 2
Factors influencing the implementation of a school-based parenting support programme, according to teachers and parents
Simplicity and flexibility | Management | Perceived need | Attitudes among children | Accessibility and availability |
Meaningful content | Resources | Life situation | Attitudes among parents | Attitudes in society |
Support for behavioural change | Work routines | Engagement and interest | | |
Information and feed-back | School-parent contact | Ability to change | | |
Theme: clear communication on roles and responsibilities
The overarching theme highlights the importance of communication between the project management, schools and parents during the implementation of the programme. It was of importance that both providers and participants knew from the start who was responsible for which part of the programme and what was expected from each and every one. Although the information given about the programme was perceived as clear there was a need for additional information. Both teachers and parents were positive towards the programme, but there were some unfulfilled expectations. For example, the parents expected more to happen in school, while teachers expected the parents to get more involved. According to this, clear communication and feedback is important to strengthen and motivate both teachers and parents in their efforts to promote healthy behaviours among children.
The programme
The programme was perceived as flexible and easy to implement. Parents described homework as non-burdensome and appreciated the flexible scheduling for the MI-sessions. The teachers particularly expressed appreciation for the ready-to-use material, which did not become an additional burden, but rather facilitated their daily work.
Just that everything was served to you, it was simply amazing. In this way you would do just as much as you wanted yourself, using these materials with books and everything. / Teacher
The programme was perceived as meaningful, dealing with important issues as well as including challenging tasks for children. Being part of a research project was mentioned as a facilitator. Both teachers and parents perceived that they received support from the programme for behaviour change in several ways. Professionalism was stressed, as well as the educational materials and personal contact with the research team. Not all parents interviewed felt that they had received support through the MI-sessions, but several parents expressed that these sessions were the most important part of the programme, helping them to articulate what changes they wanted to do and in which way.
When I wrote my goals, and then there was someone else listening to my goals. It was helpful; I’d still … disclose my problems. The interviewer, who I knew had listened to what I said … and believed that the goals were good. And then I felt some pressure to follow them up as well. / Parent 3
The importance of the face-to-face communication was emphasized, although some parents discussed the possibility of support via telephone or email. The teachers would have liked more time to reflect upon their work together with their colleagues and some parents asked for more concrete ideas on how to solve everyday issues. According to the teachers, it was important that the responsibility for the programme and its implementation was clearly defined. If the programme were not managed by a research team they thought that someone working in the municipality should take the lead. Although both teachers and parents stated that they received clear information about the programme, several parents requested more frequent feedback. They especially asked for feedback on the study results, both at an individual and at a group level. Some parents described how reminders about the programme would facilitate their motivation to engage in the programme, giving them the feeling that their contribution was important.
The school
According to the teachers, the school needed support from outside to manage the programme. Within school they asked for more interdisciplinary cooperation. Teachers emphasised that the school’s resources are limited and that the workload is high. The classroom component was perceived to be well adapted to the school setting, and easy to integrate into daily routines. Parents primarily perceived the programme as a school project, and several of them expressed a wish that more action would have taken place in the school to support the children. Both teachers and parents stressed the importance of good cooperation between the school and the parents. The parents felt that they received too little information, while some of the teachers felt they provided information to the parents without getting any response.
We sent out weekly newsletters every week. What we kind of wrote and, yes, the homework of the week and so on… We also reminded the parents, but it did not work that well after all. / Teacher
I just really did not know, had no follow-up from school, what … what had happened or what they were doing. Yes, because then we would have been able to be more supportive at home. If you know that this week we aim for this. Yes, fine, then … then we continue with it at home as well. / Parent 4
Family conditions
The perceived need for support regarding diet and physical activity varied among the families. Some described difficulties regarding vegetable consumption and watching TV, while others felt that their habits already were satisfactory. Even parents who did not experience needs for support appreciated the idea of paying attention to the children’s habits. The life situation of the parents, in terms of work and family constellation, affected their ability to get involved in the programme. Among divorced parents the information did not always reach both parents. Several parents also described a stressful life with a heavy workload, having more than one child and various leisure activities for them. Parents’ interest in the programme varied, while teachers stated that it was very important to involve the parents. Involving the children was also described as important, but not as difficult. Some parents described a strong self-efficacy in influencing the children’s lifestyles, while others felt more uncertain about their parental authority.
We’re pretty … very clear with our children. So they know what the rules are. And then we … we should not say that we are strict, but they know that when I say no then it’s no, then it’s not nagging twenty times. / Parent 9
You can change a little bit, but I’m not strong enough to say no, no candy. I cannot … I’m weaker. / Parent 7
Group dynamics
The children were influenced by attitudes among their peers, for example whether other children disliked vegetables or whether it was considered important to follow certain TV series.
And it’s not possible to turn it off either, because then it becomes … ‘why can’t I watch when my friends do’ and … Maybe they are talking about what happens in this series in school then. And the one who does not watch, he’s … he knows nothing (laughs). / Parent 8
The parents’ attitudes towards the programme and health behaviours were affected by other parents’ attitudes. Some parents mentioned that other parents’ rules mattered and others called for parental cooperation to agree on common rules.
Some of the parents mentioned factors in the environment affecting their ability to support their children towards healthy habits, such as climate, weather, food prices, exposure to healthy and less healthy foods, and accessibility to sport activities.
Because it is a problem today that perhaps children and even we, the adults, are more sedentary and we have been overly exposed to fast food. / Parent 1
Attitudes and focus in the media and in society were also perceived to have an impact. One of the parents discussed the impact of the food industry and the teachers mentioned that the health topic is “hot”.
Discussion
In this study we have explored the views of parents and teachers regarding the implementation of a school-based parental support programme targeting children’s dietary habits and physical activity. Our results show that there are a number of barriers which could potentially hinder successful implementation of the programme, as well as facilitators supporting the implementation process.
The results imply that clear communication between the research team, schools and parents is of major importance when implementing such programme in a school setting, as well as each and everyone’s expectations on their own and other people’s responsibilities. This conclusion is supported by earlier research regarding the implementation of alcohol and drug programmes in schools, which emphasises the importance of clear and mutually agreed upon definitions and expectations when schools are to be engaged [
26].
The programme was perceived as easy to implement by the teachers, because it included ready-to-use material and both the contents and the time scheduling of the classroom component was flexible. School programmes which are simple to conduct and do not involve too extensive changes from the current practice are known to be easier to implement [
26]. Already in 1995 Rogers pointed out that for effective implementation of a new programme this should be no more complex than existing services [
27]. This becomes a challenge, because such a programme might not be comprehensive enough to be effective [
28]. In this case the programme was perceived as relatively simple, because the teachers were thoroughly guided through each step of those routines although it did include new routines. However, it should be remembered that the person conducting the MI sessions was a member of the research team in this study, and mobilising this capacity in school might well turn out to be a barrier in the implementation of this programme, due to the need for extra resources.
Two programme characteristics that have been related to implementation are ‘compatibility’ , which refers to the extent to which the intervention fits with the priorities and values of the organisation and ‘adaptability’ , which refers to the extent to which the programme can be adapted to local needs [
22]. Programmes that are congruent with existing norms are more likely to be successfully implemented [
22]. School programmes also need to be designed with enough flexibility to have local relevance [
19]. This programme was perceived as contextually appropriate while at the same time being flexible regarding time and content, which might have been especially important because the workload in schools was described as high. The MI-sessions for the parents allowed for individual tailoring, which has been pointed out as an important facilitator for parental engagement in parenting programmes [
28].
The programme was perceived as meaningful, and even more so because it was a research project. This aspect has to be considered, because it implies that this kind of programme might be viewed as less important when scaled up and implemented without support from a research team. To maintain the perception of importance it might be necessary to give continuous feedback on the progress made, which points to the need for external leadership. The importance of personal contact, especially regarding MI-sessions, was emphasised by some of the parents. Telephone-based interventions can have effect on children’s dietary habits [
29‐
31], but according to some parents in this study support via telephone or email would lack an important dimension.
According to the teachers the classroom component fitted well into existing school routines and was easy to implement. This indicated a high feasibility and possibilities for successful integration of this component in the school setting [
32]. It became clear that if it was not run by a research team, someone else would have to provide external support for the programme. Effective leadership is crucial to implementation [
22] and lack of leadership support has been identified as a barrier to implementation for other school-based programmes [
33]. Our findings suggest that it is essential to designate a project leader within the municipality, such as a health coordinator.
The importance of good cooperation between the school and the parents was stressed, but there were obvious challenges relating to the dissemination of information. This kind of difficulty in school-parent communication has been described previously [
34]. As communication and clarity in the division of responsibilities is important, this underlines the need to find well-functioning communication channels. In a qualitative study from four countries parents expressed a preference for informal personal contact above written communication through letters, websites and diaries [
35].
Perceived needs and family conditions affected the parents’ motivation and ability to engage in the programme. This category relates to ‘provider characteristics’ [
22], although parents could be viewed both as providers and target group in this programme. Providers who believe that a programme will produce desired benefits, feel confident in their ability to do what is expected and, being proficient, are more likely to implement the programme as intended [
22]. This would be applicable to both teachers and parents. A challenging family situation might be a barrier though. Competing demands on parent’s time and resources has been described as a barrier for engagement [
28] as also described by the parents during the MI sessions [
36].
Group dynamics among the children and the parents affected the attitudes towards the programme as well as towards behaviour change. Some parents called for parental cooperation, which could be one way of strengthening the parental engagement. Because some of the parents experienced high stress as a barrier to be as engaged as they would like to, they might have hoped for parental cooperation as a way to reduce this stress. Previous research confirms that high work-life stress has a negative impact on parents’ possibilities to create an environment that stimulates healthy dietary and physical activity habits [
36‐
39].
The surrounding community, including the social as well as the physical environment, affected the families and their perceived possibilities to change behaviour. Factors in the home and in the school environment have shown strong correlations with physical activity and dietary habits in children [
6,
40]. To be able to create this supportive home environment the parents might be supported or hindered by attitudes in society as well as accessibility to a supportive environment or lack thereof. Other community level factors, mentioned by Durlak and DuPre, regard politics, funding and policy [
22]. These factors were not taken up by parents or teachers but are nevertheless important to consider while planning further implementation.
Strengths and weaknesses
This study contributes valuable knowledge when implementing a parental support programme in a school setting. Data was collected from both teachers and parents, which increases the credibility of the study [
23]. Illustrative citations and intersubjective agreement in the coding and analysis of the data increases the trustworthiness as well [
23]. The setting and the intervention are described in detail and therefore the results should be transferable to similar programmes and contexts. It is a limitation that the the perspective of the children was not covered, but would be useful to investigate in future studies. Because the MI-sessions were delivered by the research team it was not possible to realistically evaluate the implementation of this component, which might be seen as a limitation. In the future we hope to be able to integrate the programme into school health care services, which means that school nurses or other staff will be responsible for the delivery of the MI. A relatively small number of informants were included, but the teachers represented different schools and the parents were purposefully sampled and therefore represented a wide variation in experiences. The relatively small number of teachers participating may however limit the transferability of the study.
Conclusion
When implementing a parental support programme in a school setting it is important to facilitate communication between project management, schools and parents. This emphasises the need for managerial support, and a prevention support system. The implementation can be facilitated by clear information to everyone involved prior to start, a flexible programme allowing some adaptation to local needs, a programme content perceived as meaningful, face-to-face communication and support characterised by professionalism. To further facilitate motivation among teachers and parents, results should be reported back, together with other relevant reminders. Barriers found included limited resources and high workload within the schools, stressed family situations, and lack of support within the physical and social environment. Future research should identify the best way to provide MI-sessions for parents when the programme is implemented on a wider scale.
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Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
LSE, GN, ES and ÅN contributed to the design of the study and acquisition of funding; UH collected the data with assistance from HB; HB conducted the data analysis in continuous discussion with ES, ÅN and UH; and HB drafted the manuscript. All authors have contributed to drafting and given final approval of the manuscript.