Managing Implementation of a Parental Support Programme for Obesity Prevention in the School Context: The Importance of Creating Commitment in an Overburdened Work Situation, a Qualitative Study.

Health-related behaviours in children can be influenced by parental support programmes. The aim of this study was to explore barriers to and facilitators for the implementation of a parental support programme to promote physical activity and healthy dietary habits in a school context. We explored the views and experiences of 17 coordinating school nurses, non-coordinating school nurses, and school principals. We based the interview guide on the Consolidated Framework for Implementation Research. We held four focus group discussions with coordinating and non-coordinating school nurses, and conducted three individual interviews with school principals. We analysed data inductively using qualitative content analysis. We identified "Creating commitment in an overburdened work situation" as an overarching theme, emphasising the high workload in schools and the importance of creating commitment, by giving support to and including staff in the implementation process. We also identified barriers to and facilitators of implementation within four categories: (1) community and organisational factors, (2) a matter of priority, (3) implementation support, and (4) implementation process. When implementing a parental support programme to promote physical activity and healthy dietary habits for 5- to 7-year-old children in the school context, it is important to create commitment among school staff and school nurses. The implementation can be facilitated by political support and additional funding, external guidance, use of pre-existing resources, integration of the programme into school routines, a clearly structured manual, and appointment of a multidisciplinary team. The results of this study should provide useful guidance for the implementation of similar health promotion interventions in the school context.

Motivational Interviewing to Prevent Childhood Obesity: A Cluster RCT.

OBJECTIVE: The objective was to evaluate a manualized theory-driven primary preventive intervention aimed at early childhood obesity. The intervention was embedded in Swedish child health services, starting when eligible children were 9 to 10 months of age and continuing until the children reached age 4. METHODS: Child health care centers in 8 Swedish counties were randomized into intervention and control units and included 1355 families with 1369 infants. Over ∼39 months, families in the intervention group participated in 1 group session and 8 individual sessions with a nurse trained in motivational interviewing, focusing on healthy food habits and physical activity. Families in the control group received care as usual. Primary outcomes were children's BMI, overweight prevalence, and waist circumference at age 4. Secondary outcomes were children's and mothers' food and physical activity habits and mothers' anthropometrics. Effects were assessed in linear and log-binominal regression models using generalized estimating equations. RESULTS: There were no statistically significant differences in children's BMI (ß = -0.11, 95% confidence interval [CI]: -0.31 to 0.08), waist circumference (ß = -0.48, 95% CI: -0.99 to 0.04), and prevalence of overweight (relative risk = 0.95, 95% CI: 0.69 to 1.32). No significant intervention effects were observed in mothers' anthropometric data or regarding mothers' and children's physical activity habits. There was a small intervention effect in terms of healthier food habits among children and mothers. CONCLUSIONS: There were no significant group differences in children's and mothers' anthropometric data and physical activity habits. There was, however, some evidence suggesting healthier food habits, but this should be interpreted with caution.

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.

Factors influencing the implementation of a school-based parental support programme to promote health-related behaviours--interviews with teachers and parents.

BACKGROUND: The 'Healthy School Start' programme was developed to promote healthy dietary habits and physical activity, targeting parents of 6-year-old children in pre-school class. Knowledge of barriers and facilitators of implementation is crucial before introducing this kind of programme on a larger scale. 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. METHODS: An inductive qualitative method was used to explore the experiences and views of teachers and parents involved in the programme. A group discussion was held with three teachers, and semi-structured interviews were conducted with 14 parents. Data were analysed using qualitative content analysis. RESULTS: Clear communication on roles and responsibilities was identified as an overarching theme, emphasising the importance of clear information and well-functioning cooperation between project management, schools and parents when implementing the programme in a school setting. Five categories at a manifest level described aspects influencing the implementation: 1) 'The programme' underlining the importance of flexibility and feed-back; 2) 'the school' referring to management and work routines; 3) 'family conditions', implying various life situations; 4) 'group dynamics' dealing with attitudes among children and parents; and 5) 'the surrounding community' including accessibility and attitudes within society. CONCLUSIONS: When implementing a parental support programme in a school setting it is important to facilitate communication and clearly define the division of responsibilities between project management, schools and parents. This emphasises the need for managerial support, and a professional prevention support system.

Effectiveness of universal parental support interventions addressing children's dietary habits, physical activity and bodyweight: A systematic review.

OBJECTIVES: The evidence regarding effectiveness of parental support interventions targeting children's health behaviours is weak. We aimed to review: 1) effectiveness of universal parental support interventions to promote dietary habits, physical activity (PA) or prevent overweight and obesity among children 2-18years and 2) effectiveness in relation to family socio-economic position. METHODS: Thirty five studies from 1990 to 2013 were identified from major databases. Quality was assessed by four criteria accounting for selection and attrition bias, fidelity to intervention, and outcome measurement methodology, categorizing studies as strong, moderate or weak. RESULTS: Four intervention types were identified: face-to-face counselling, group education, information sent home, and telephone counselling. Face-to-face or telephone counselling was effective in changing children's diet, while there was only weak evidence for improvement in PA. Sending home information was not effective. Concerning body weight, group education seemed more promising than counselling. Intervention effectiveness was generally higher in younger compared to older children. In groups with low socio-economic position, group-based approaches appeared promising. CONCLUSION: In the future efforts should be made to improve reporting of intervention content, include a power calculation for the main outcome, the use of high quality outcome assessment methodology, and a follow-up period of at least 6months.

Effectiveness of a universal parental support programme to promote healthy dietary habits and physical activity and to prevent overweight and obesity in 6-year-old children: the Healthy School Start Study, a cluster-randomised controlled trial.

OBJECTIVE: 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 Swedish children. METHODS: A cluster-randomised controlled trial was carried out in areas with low to medium socio-economic status. Participants were six-year-old children (n = 243) and their parents. Fourteen pre-school classes were randomly assigned to intervention (n = 7) and control groups (n = 7). 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 and physical activity habits and parental self-efficacy through a questionnaire. Body weight and height were measured and BMI standard deviation score was calculated. Measurements were conducted at baseline, post-intervention and at 6-months follow-up. Group differences were examined using analysis of covariance and Poisson regression, adjusted for gender and baseline values. RESULTS: There was no significant intervention effect in the primary outcome physical activity. Sub-group analyses showed a significant gender-group interaction in total physical activity (TPA), with girls in the intervention group demonstrating higher TPA during weekends (p = 0.04), as well as in sedentary time, with boys showing more sedentary time in the intervention group (p = 0.03). There was a significantly higher vegetable intake (0.26 servings) in the intervention group compared to the control group (p = 0.003). At follow-up, sub-group analyses showed a sustained effect for boys. The intervention did not affect the prevalence of overweight or obesity. CONCLUSIONS: It is possible to influence vegetable intake in children and girls' physical activity through a parental support programme. The programme needs to be intensified in order to increase effectiveness and sustain the effects long-term. These findings are an important contribution to the further development of evidence-based parental support programmes to prevent overweight and obesity in children. TRIAL REGISTRATION: Controlled-trials.com ISRCTN32750699.

Understanding the Implementation Process of a Multi-Component Health Promotion Intervention for Adults with Intellectual Disabilities in Sweden.

BACKGROUND: There is a need to better understand implementation processes of health interventions. This study describes the implementation of a multicomponent intervention to improve diet and physical activity among adults with intellectual disabilities, viewed from the perspectives of staff and managers. MATERIALS AND METHODS: All health ambassadors (n = 12), appointed among staff and managers (n = 5) taking part of a health intervention in community residences in Sweden, were interviewed with a focus on barriers and facilitators regarding implementation of the intervention. Data were analysed using content analysis. RESULTS: The overarching theme describes the importance of supporting motivation for change among managers, caregivers and residents. The experiences of the implementation process are described in four main categories: intervention characteristics, individual commitment, organizational capacity and societal factors. CONCLUSION: The implementation can be facilitated by a programme meeting perceived needs, a flexible and participatory approach, external input and an extensive preparation phase.

Stuck in a vicious circle of stress. Parental concerns and barriers to changing children's dietary and physical activity habits.

INTRODUCTION: Dietary habits and physical activity are often the focus of obesity prevention programmes and involving parents in such programmes has proven to be effective. The aims of this study were to describe parents' concerns about their children's diet and physical activity habits and to describe barriers to change. RESULTS: The study used archival data gathered unobtrusively in the form of memos taken after sessions of Motivational Interviewing as part of the parental support programme, A Healthy School Start. The 74 MI-sessions were conducted from October 2010 to April 2011 with either a mother or father or both, all with children in pre-school class. Thematic analysis was applied. Three themes were identified regarding children's dietary habits: amount of food consumed influenced by behaviour in the family, eating situations influenced by stressful everyday life and family interplay, and food choices influenced by stressful everyday life and family interplay. One theme appeared regarding physical activity: physical activity influenced by stressful everyday life and family interplay. CONCLUSION: Family interplay appears to be an important link between the work-life stress perceived by parents and less healthy food and physical activity habits in the home. Both lack of parental cooperation and negative parent-child interactions may act as barriers to healthy eating and physical activity and should be addressed in future intervention studies on health-related behaviours of children.

Primary prevention of childhood obesity through counselling sessions at Swedish child health centres: design, methods and baseline sample characteristics of the PRIMROSE cluster-randomised trial.

BACKGROUND: Childhood obesity is a growing concern in Sweden. Children with overweight and obesity run a high risk of becoming obese as adults, and are likely to develop comorbidities. Despite the immense demand, there is still a lack of evidence-based comprehensive prevention programmes targeting pre-school children and their families in primary health care settings. The aims are to describe the design and methodology of the PRIMROSE cluster-randomised controlled trial, assess the relative validity of a food frequency questionnaire, and describe the baseline characteristics of the eligible young children and their mothers. METHODS/DESIGN: The PRIMROSE trial targets first-time parents and their children at Swedish child health centres (CHC) in eight counties in Sweden. Randomisation is conducted at the CHC unit level. CHC nurses employed at the participating CHC received training in carrying out the intervention alongside their provision of regular services. The intervention programme, starting when the child is 8-9 months of age and ending at age 4, is based on social cognitive theory and employs motivational interviewing. Primary outcomes are children's body mass index and waist circumference at four years. Secondary outcomes are children's and mothers' eating habits (assessed by a food frequency questionnaire), and children's and mothers' physical activity (measured by accelerometer and a validated questionnaire), and mothers' body mass index and waist circumference. DISCUSSION: The on-going population-based PRIMROSE trial, which targets childhood obesity, is embedded in the regular national (routine) preventive child health services that are available free-of-charge to all young families in Sweden. Of the participants (n = 1369), 489 intervention and 550 control mothers (75.9%) responded to the validated physical activity and food frequency questionnaire at baseline (i.e., before the first intervention session, or, for children in the control group, before they reached 10 months of age). The food frequency questionnaire showed acceptable relative validity when compared with an 8-day food diary. We are not aware of any previous RCT, concerned with the primary prevention of childhood obesity through sessions at CHC that addresses healthy eating habits and physical activity in the context of a routine child health services programme. TRIAL REGISTRATION: ISRCTN16991919.

Validity and Reliability of a Parental Self-Efficacy Instrument in the Healthy School Start Prevention Trial of Childhood Obesity.

INTRODUCTION: Measures of parental self-efficacy (PSE) for healthy dietary or physical activity (PA) behaviors in children have been used in several studies; however, further psychometric validation of PSE for these behaviors is needed. The purpose of the present study was to evaluate the psychometric properties of a new PSE instrument. METHODS: Mothers (n = 162) of 6-year-old children in the Healthy School Start prevention trial of childhood obesity responded to the instrument and a parent-report questionnaire on diet and PA in children. In addition, PA was objectively assessed by accelerometry. RESULTS: Exploratory factor analysis yielded a structure composed of three factors of PSE for dietary and PA behaviors in children, and PSE was associated with parent-report of these behaviors. Internal consistency was good. DISCUSSION: Preliminary support of the validity and reliability of the PSE instrument was provided. The measure may be useful in prevention and treatment trials of childhood obesity.

Trajectories of weight disturbances during adolescence in relation to gender in a Swedish cohort.

AIM: To explore developmental trajectories among adolescents of thinness and overweight in relation to gender. METHODS: A group-based procedure was used to determine patterns of weight disturbances in a school-based sample of 3020 Swedish adolescents followed from age 11 to 18. A sensitivity analysis was performed to compensate for an increasing number of missing height and weight data after grade 8. RESULTS: Six trajectories represented the best description of developmental weight disturbances with the exception of thinness among boys, which was best described by four trajectories. Concerning thinness, 5.9% of girls and 4.2% of boys developed this condition during the study period, while 1.9% of girls and 3.0% of boys recovered from their initial thinness. For overweight, (including obesity) 1.5% of girls and 3.1% of boys developed this weight disturbance during the study period, while 10.1% of girls and 9.3% of boys recovered from overweight/obesity. Non-reporting of height and weight was biased towards an underestimation of the true prevalence of overweight and obesity in girls and of thinness in boys. CONCLUSIONS: Developmental trajectories provide a novel method to describe the dynamics of weight disturbances during adolescence. Similar patterns were found for overweight and thinness in boys and girls but group sizes varied between genders. Non-reporting of height and weight was found in a gender-specific pattern.

Low physical activity is a predictor of thinness and low self-rated health: gender differences in a Swedish cohort.

PURPOSE: To examine the relationship between leisure time physical activity in 15-year-old students, and weight status and self-rated health 3 years later. METHODS: Data were used from two follow-up waves, one in 2002 (grade 9, age 15 years) and one in 2005 (grade 12, age 18 years) of a cohort of approximately 2,500 adolescents. Adolescents reported height and weight, health behaviors, and self-rated health by a questionnaire at both occasions. Age and gender-specific body mass index cut-off points for thinness, overweight, and obesity were used to assess weight status. Logistic regression analyses were performed with weight status and self-rated health as the outcomes and level of leisure time physical activity as the independent variable. Adjustments were made for parental years of education, student's current smoking habits, and baseline body mass index. RESULTS: As compared with students who were active for more than 4 hours per week during leisure time, being active 2-4 hours (odds ratio [OR]: 4.15, confidence interval [CI]: 1.62-10.60) and <2 hours (OR: 3.92, CI: 1.30-11.78) predicted thinness in boys. In girls, the risk was smaller and became significant at <2 hours per week (OR: 2.57, CI: 1.38-4.77). Overweight or obesity was not significantly predicted by physical activity. A significant risk of low self-rated health was found at follow-up in boys active for <4 hours per week compared with those active for >4 hours per week. CONCLUSION: Physical activity is important to maintain a healthy body weight and for future self-rated health in boys.

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.