IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity (IMPROVE) - study protocol for a cluster-randomized trial.

BACKGROUND: IMPROVE aims to conduct a hybrid type 3 evaluation design to test the effectiveness of bundled implementation strategies on intervention fidelity of the Healthy School Start (HSS) program, while simultaneously monitoring effects on health outcomes of children and parents. The HSS is a 4-component family support program for children starting school (5-7 years of age) promoting healthy dietary habits and physical activity in the home environment to prevent childhood obesity and parents' risk of developing type 2 diabetes. METHODS: IMPROVE is a cluster-randomized controlled trial with two arms to evaluate and compare the effects of two different bundles of implementation strategies on intervention fidelity expressed as adherence and responsiveness at 12 and 24 months (primary outcomes). Thirty schools in two municipalities will participate in the study reaching about 1400 families per school year. In stakeholder workshops, key implementation determinants were identified according to the domains of the Consolidated Framework for Implementation Research. Through a consensus process with stakeholders, two bundles of implementation strategies were tailored to address context-specific determinants. Schools randomly assigned to group 1 will receive bundle 1 (Basic) and group 2 will receive bundle 1 + 2 (Enhanced). Bundle 2 consists of external facilitation, fidelity monitoring and feedback strategies. Secondary outcomes will include change in acceptability, appropriateness, feasibility, and organisational readiness as perceived by school staff. In addition, child weight status and diet, and parents' feeding practices and risk of type 2 diabetes will be monitored. Linear and ordinal regression analysis will be used to test the effect on the primary and secondary outcomes, taking clustering and covariates into consideration where needed. Process evaluation will be conducted through key stakeholder interviews to investigate experiences of the program and perceptions on sustainability. DISCUSSION: This systematic approach to investigating the effectiveness of two different bundles of implementation strategies tailored to context-specific determinants on the fidelity of the HSS intervention will provide new insight into feasible implementation strategies and external support needed for the HSS to be effective and sustainable. Results will help inform how to bridge the gap between the research on school-based health programs and routine practice in schools. TRIAL REGISTRATION: Registered prospectively at ClinicalTrials.gov ID: NCT04984421 , registered July 30, 2021.

Parental strategies for influencing the diet of their children - A qualitative study from disadvantaged areas.

BACKGROUND: A social gradient is evident in the prevalence of childhood overweight and obesity, to the disadvantage of children with low socioeconomic status (SES). Parents have a substantial influence on their children's dietary behaviours and weight development through the way they interact with the children around food. This study aims to explore the variation of how parents with low SES influence their child's dietary behaviours. METHODS: A phenomenographic design and analysis was used on 29 sessions of motivational interviewing with mothers and fathers participating in the Healthy School Start intervention study in 2012. The parents had a maximum of 12 years of education and resided in areas targeted for socioeconomic development. In the sessions, parents explored changes that they wanted to make in the home environment regarding their child's dietary behaviours. RESULTS: Five categories of guidance of children's dietary habits were found ranging from silently guiding to enforcement. The categories of guidance were structurally related to each other through positive to negative impact of parental recognition of responsibility for the child's behaviours, level of trust in the child's satiety response, and level of parental emotional distress. CONCLUSION: The results suggest that parents use situation-specific guidance with both negative and positive impacts on child behaviours. Depending on the type of guidance used, parents are in need of different supporting strategies to enhance positive parent-child interplay. Suggestions for intervention strategies are provided where specific focus on parental responsibility recognition, emotional self-regulation, increased responsiveness, and cooperation between parents are highlighted.

Low socio-economic status associated with unhealthy weight in six-year-old Swedish children despite higher levels of physical activity.

AIM: Socio-economic status is an important determinant of physical activity, sedentary behaviour and body mass index, but these associations are contradictory in younger children. We investigated the associations between parental socio-economic status, physical activity, sedentary behaviour and body mass index in six-year-old children, to identify possible differences in physical activity between socio-economic groups. METHODS: The study comprised 621 children from Stockholm suburbs, recruited from, A healthy school start, a cluster-randomised controlled intervention study. A cross-sectional study was performed using baseline data. Physical activity and sedentary behaviour were assessed by accelerometry, body weight and height were measured, and body mass index was calculated. Sedentary behaviour was also assessed using a questionnaire. RESULTS: We found that 12% of the study population were overweight and 9% were obese. Children from families with low socio-economic status were more physically active and slightly less sedentary, but were almost twice as likely to be overweight or obese than children from high socio-economic status, irrespective of the child's sex. CONCLUSION: Low socio-economic status was associated with higher physical activity, lower sedentary behaviour and an unhealthier weight status compared to high socio-economic status, suggesting a role of diet as a cause of the higher overweight and obesity prevalence.

Effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas, the Healthy School Start Study II, a cluster-randomised controlled trial.

BACKGROUND: There is increasing evidence for the effectiveness of parental support programmes to promote healthy behaviours and prevent obesity in children, but only few studies have been conducted among groups with low socio-economic status. The aim of this study was to develop and evaluate the effectiveness of a parental support programme to promote healthy dietary and physical activity habits and to prevent overweight and obesity in six-year-old children in disadvantaged areas. METHODS: A cluster-randomised controlled trial was carried out in disadvantaged areas in Stockholm. Participants were six-year-old children (n = 378) and their parents. Thirty-one school classes from 13 schools were randomly assigned to intervention (n = 16) and control groups (n = 15). The intervention lasted for 6 months and included: 1) Health information for parents, 2) Motivational Interviewing with parents and 3) Teacher-led classroom activities with children. Physical activity was measured by accelerometry, dietary intake and screen time with a questionnaire, body weight and height were measured and BMI standard deviation score was calculated. Measurements were conducted at baseline, post-intervention and at 5months follow-up. Group effects were examined using Mixed-effect Regression analyses adjusted for sex, parental education and baseline values. RESULTS: Fidelity to all three intervention components was satisfactory. Significant intervention effects were found regarding consumption of unhealthy foods (p = 0.01) and unhealthy drinks (p = 0.01). At follow-up, the effect on intake of unhealthy foods was sustained for boys (p = 0.03). There was no intervention effect on physical activity. Further, the intervention had no apparent effect on BMI sds for the whole sample, but a significant difference between groups was detected among children who were obese at baseline (p = 0.03) which was not sustained at follow-up. CONCLUSIONS: The Healthy School Start study shows that it is possible to influence intake of unhealthy foods and drinks and weight development in obese children by providing individual parental support in a school context. However, the effects were short-lived. Therefore, the programme needs to be prolonged and/or intensified in order to obtain stronger and sustainable effects. This study is an important contribution to the further development of evidence-based parental support programmes to prevent overweight and obesity in children in disadvantaged areas.

Longitudinal changes in health behaviours and body weight among Swedish school children--associations with age, gender and parental education--the SCIP school cohort.

BACKGROUND: In order to develop health promotion initiatives it is important to identify at what age gender and socioeconomic inequalities in health-related behaviours emerge. The aim of this longitudinal study was to analyse how health-related behaviours and weight status differed by age-group, gender, family socio-economic status and over time in three cohorts of school children. METHODS: All children in grades 2, 4 and 7 in a Swedish semi-urban municipality were invited to participate (n = 1,359) of which 813 (60%) consented. At baseline and after 2 years a health questionnaire was answered by all children. Height and weight was measured. Fourteen outcomes were analysed. The main and interaction effects of time, gender and parental educational level on the health-related behaviours, weight status and body mass index standard deviation score (BMIsds) were analysed by the Weighted Least Squares method for categorical repeated measures and Analysis of Variance. RESULTS: Nine of 12 health behaviours deteriorated over the two years: consumption of breakfast and lunch, vegetables and fruit, intake of sweetened drinks, TV viewing, club membership, being outdoors, and school recess activity; two behaviours were unchanged: intake of sweets, and active transport. Only sports participation increased with time. Girls consumed more vegetables, less sweetened drinks, performed less sports, were less physically active during recess, and had lower BMIsds, compared to boys. Those with more highly educated parents had more favourable or similar behaviours compared to those with less educated parents in 10 out of 12 health behaviours, the only exception being intake of sweets and being outdoors, and had lower BMIsds. CONCLUSIONS: This study adds to our knowledge regarding the temporal development of health behaviours and weight status in school children. Differences with regard to gender and socioeconomic status were seen already at a young age. These results contribute to our understanding of several important determinants of obesity and chronic diseases and may inform future interventions regarding how to decrease gender and social inequalities in health.

A participatory and capacity-building approach to healthy eating and physical activity- SCIP-school: a 2-year controlled trial.

BACKGROUND: Schools can be effective settings for improving eating habits and physical activity, whereas it is more difficult to prevent obesity. A key challenge is the "implementation gap". Trade-off must be made between expert-driven programmes on the one hand and contextual relevance, flexibility, participation and capacity building on the other. The aim of the Stockholm County Implementation Programme was to improve eating habits, physical activity, self-esteem, and promote a healthy body weight in children aged 6-16 years. We describe the programme, intervention fidelity, impacts and outcomes after two years of intervention. METHODS: Nine out of 18 schools in a middle-class municipality in Sweden agreed to participate whereas the other nine schools served as the comparison group (quasi-experimental study). Tailored action plans were developed by school health teams on the basis of a self-assessment questionnaire called KEY assessing strengths and weaknesses of each school's health practices and environments. Process evaluation was carried out by the research staff. Impacts at school level were assessed yearly by the KEY. Outcome measures at student level were anthropometry (measured), and health behaviours assessed by a questionnaire, at baseline and after 2 years. All children in grade 2, 4 and 7 were invited to participate (n=1359) of which 59.8% consented. The effect of the intervention on health behaviours, self-esteem, weight status and BMIsds was evaluated by unilevel and multilevel regression analysis adjusted for gender and baseline values. RESULTS: Programme fidelity was high demonstrating feasibility, but fidelity to school action plans was only 48% after two years. Positive and significant (p<.05) impacts were noted in school health practices and environments after 2 years. At student level no significant intervention effects were seen for the main outcomes. CONCLUSIONS: School staff has the capacity to create their own solutions and make changes at school level on the basis of self-assessment and facilitation by external agents. However these changes were challenging to sustain over time and had little impact on student behaviours or weight status. Better student outcomes could probably be attained by a more focused and evidence-based approach with stepwise implementation of action plans.

A healthy school start - parental support to promote healthy dietary habits and physical activity in children: design and evaluation of a cluster-randomised intervention.

BACKGROUND: Childhood obesity is multi-factorial and determined to a large extent by dietary habits, physical activity and sedentary behaviours. Previous research has shown that school-based programmes are effective but that their effectiveness can be improved by including a parental component. At present, there is a lack of effective parental support programmes for improvement of diet and physical activity and prevention of obesity in children. METHODS/DESIGN: This paper describes the rationale and design of a parental support programme to promote healthy dietary habits and physical activity in six-year-old children starting school. The study is performed in close collaboration with the school health care and is designed as a cluster-randomised controlled trial with a mixed methods approach. In total, 14 pre-school classes are included from a municipality in Stockholm county where there is large variation in socio-economic status between the families. The school classes are randomised to intervention (n = 7) and control (n = 7) groups including a total of 242 children. The intervention is based on social cognitive theory and consists of three main components: 1) a health information brochure; 2) two motivational interviewing sessions with the parents; and 3) teacher-led classroom activities with the children. The primary outcomes are physical activity in the children measured objectively by accelerometry, children's dietary and physical activity habits measured with a parent-proxy questionnaire and parents' self-efficacy measured by a questionnaire. Secondary outcomes are height, weight and waist circumference in the children. The duration of the intervention is six months and includes baseline, post intervention and six months follow-up measurements. Linear and logistic regression models will be used to analyse differences between intervention and control groups in the outcome variables. Mediator and moderator analysis will be performed. Participants will be interviewed. DISCUSSION: The results from this study will show if it is possible to promote a healthy lifestyle and a normal weight development among children from low-income districts with relatively limited efforts involving parents. Hopefully the study will provide new insights to the further development of effective programmes to prevent overweight and obesity in children. TRIAL REGISTRATION: ISRCTN: ISRCTN32750699.

Obesogenic environments--aspects on measurement and indicators.

BACKGROUND: The focus in understanding the causes of and preventing obesity has broadened from the individual level to include the obesogenic environment. Proving a causal relationship between environmental factors and eating patterns poses a great challenge because randomised controlled trials are seldom possible or feasible to conduct. Interactions between the environment and individuals are beginning to be explored in multilevel studies and qualitative and sociological research. AIM: The aim is to give an overview of the wider environmental determinants of diet such as the national food supply, food availability and accessibility in different settings as well as the economic food environment and in relation to socio-economic status. RESULTS: The indicators suggested are based on the amount of data available in the scientific literature and the potential for intervention. They can be used to monitor societal interventions or evaluate 'natural' changes in the food environment. The indicators are of relevance to the Second WHO European Action Plan for Food and Nutrition Policy 2007-2012. CONCLUSION: The relatively weak empirical evidence does not imply the absence of causal relationships between environmental factors and diet. Potentially relevant factors have not been evaluated due to the complexity of the task and to lack of political will to change the food environment in a more healthy direction by use of legislation or economic instruments. Future intervention research, targeting the wider environmental determinants of diet, will give us better evidence to propose societal actions to counteract obesity and to strike the right balance between individual and societal action.