Liselotte Schäfer Elinder

Purpose and aims The aim is to co-design and evaluate a novel model for family support (Co-fam) linking school and primary health care to effectively promote health and prevent and manage obesity among children 6-12 years. Two evidence-based family support programs, the universal Healthy School Start and the targeted More and Less will be adapted and combined and delivered in a municipality with high levels of childhood obesity. We hypothesize that Co-fam is effective and feasible to implement with high fidelity and acceptable to professionals and families. Project organization, timeplan and methods The project will be carried out over 4 years consisting of a preparation phase where the model will be co-designed with stakeholders and an implementation and evaluation phase based on an implementation framework. Evaluation will take place in a controlled hybrid type-2 effectiveness-implementation study using mixed methods. Quantitative data will be collected on child and parent level and on fidelity to the model, and costs. Interviews will be performed with personnel and parents to assess acceptability and feasibility. Significance Bridging the gap between school and primary health care to reduce obesity and health inequalities has been urgently requested in national guidelines and recommendations but is still not done. By combining a universal and a targeted program we will create a new model tailored to family needs leaving no child behind and with great potential to be scaled up.

Background Unhealthy diets, low physical activity and obesity are strong risk factors for chronic diseases. Schools are an ideal setting for implementing health promotion programs reaching all children. The universal Healthy School Start program (HSS) improves diet and physical activity of 6–7-year-old children and moderately reduces BMI in children with obesity. For younger children with overweight or obesity, the targeted parent support program More and Less (ML) effectively improves weight status and maintains effects long term. By combining and adapting the two evidence-based programs to older children, families with children 6-12 years can be offered a seamless family support program (Co-fam) tailored to individual needs and in line with national guidelines to improve child health and prevent future heart disease. Objectives Our hypothesis is that a family support program (Co-fam), co-designed between school and primary health care personnel and parents, is effective and feasible to implement with high fidelity, and acceptable by professionals and families. 1. Co-design a family support program for children 6-12 years including universal and targeted components together with school and primary health care to promote health, reduce overweight and obesity and prevent future CVD. 2. Evaluate the model in a case-control effectiveness-implementation study with health outcomes at child level, and fidelity and cost at organizational level. 3. A qualitative interview study with health professionals and parents to assess acceptability and feasibility of the model.

There is an urgent need for more knowledge on effective implementation strategies, as two-thirds of implementation efforts fail to achieve the intended change, and half have no effect on outcomes of interest. These implementation failures are partly due to the limited understanding of how implementation strategies work—the mechanisms of change through which implementation strategies affect implementation. This project will fill this research-gap by incorporating mediation analyses into a cluster randomized controlled trial that compares the effectiveness of two implementation strategies for implementing the Guideline for the prevention of mental ill-health at the workplace in schools. Schools are chosen as the setting for implementation given the high prevalence of mental ill-health among teachers. Moreover, they lack a structured approach to the prevention of mental ill-health. The aim of the project is to investigate how implementation strategies affect the defined mechanisms and guideline implementation. The mechanisms of the following implementation strategies will be compared: a discrete strategy that includes an educational meeting (control group) and a multifaceted strategy (intervention group) that combines the educational meeting with workshops, implementation teams and evaluative and iterative strategies (e.g. Plan-Do-Study-Act cycles). Our hypothesis is that schools that receive the multifaceted implementation strategy will show a greater increase in guideline adherence at follow-up than schools that only participate in an educational meeting. Mechanisms that will be tested include hypothesized mediators originating from the individual behavior change theory COM-B. The project will be conducted in primary schools (n=50) in four municipalities in Sweden. Adherence to the guideline will be assessed at baseline and 6, 12- and 24-months follow-up, and mediators at baseline and 3, 6, 9, 12- and 24-months follow-up. Mixed methods will be used.

The aim of IMPROVE is to test the scalability of the Healthy School Start Plus (HSSP) programme at the municipal level while maintaining positive effects on child health outcomes. Implementation strategies will be developed based on knowledge of barriers and facilitators and tested in a comparative effectiveness study with a hybrid type 3 design. HSSP is a family support programme in pre-school class in disadvantaged areas to prevent childhood overweight and obesity through improved diet and physical activity. It also includes a parental online test for risk of developing type 2 diabetes. The programme has been evaluated twice and shown effectiveness with regard to child dietary habits and some effect on obesity. A third intervention trial fully adapted to the school context ends in 2020. The aim of IMPROVE is to take the next step from research to practice and includes 3 work packages over 4 years. In WP1 stakeholder workshops will be held in municipalities with at least 20 participating schools each to collaboratively identify potential barriers and facilitators of implementation, guided by the Consolidated Framework for Implementation Research. Then, tailored implementation strategies will be developed, a basic bundle (Basic) and a basic and an additional bundle (Basic+) and schools will be randomized to either one. In WP2 effectiveness of the bundles will be compared after 1 and 2 years regarding intervention fidelity (primary outcome), acceptability, appropriateness, feasibility, penetration, organisational readiness, child weight status and parental risk of type 2 diabetes. In WP3 key stakeholders will be interviewed regarding what it would take to sustain the programme with high quality in the municipality and to establish a health data monitoring and feed-back system for professionals. The National Organisation for School Nurses has expressed interest in the HSSP indicating a strong implementation momentum and opportunity for long-term sustainability.

Research problem and hypothesisThis project aims to co-design and evaluate a novel model for family support (Co-fam) linking school and primary health care to promote healthy lifestyle and prevent and manage overweight and obesity among children 6-12 years. Two evidence-based family support programs, the universal Healthy School Start (HSS) and the targeted More and Less (ML) will be combined and delivered in a municipality with a high level of childhood obesity. We hypothesize that Co-fam is effective and feasible to implement with high fidelity and acceptable to professionals and families.Data and methodThe project will be carried out in two phases. In phase 1, the research team together with school and primary health care personnel and parents will co-design the model based on the implementation framework EPIS (Exploration, Preparation, Implementation, Sustainment). We will define referral criteria, identify barriers and facilitators of implementation, and design suitable implementation strategies. Adaptations will be made in both programs to children 6-12 years. Phase 2 consists of an 18-month controlled hybrid type 2 effectiveness-implementation study using mixed methods. Quantitative data will be collected on child and parent level and on fidelity to the model components and costs. Interviews will be performed with key personnel to assess acceptability and feasibility.Societal relevance and utilization The high prevalence of unhealthy behaviors, overweight and obesity among children underlines the societal relevance of this project. Combining a universal and a targeted program creates a new synergistic model tailored to all children’s and families’ needs with potential to be scaled up, lacking today. Bridging the gap between school and primary health care to reduce health inequalities has been urgently requested in national guidelines and recommendations.Plan for project realizationThis project will be performed by skilled intervention and implementation researchers in collaboration with personnel from schools, primary health care and parents. HSS, launched in 2022 in the municipality in collaboration with the education administration, is well-established in all public schools. A primary health care unit in the municipality, partner in this project, has started to implement ML with parents of pre-school age children. This means that the project partners are in the starting blocks and highly motivated to participate in this study.

The purpose of the project is to develop a training and implementation support package to enhance the uptake and impact of the evidence-based Healthy School Start (HSS) family support programme. Family support is recommended in national guidelines for the prevention and treatment of unhealthy behaviours in children aged 6-12 years but is not provided routinely in Sweden today. In a series of randomised-controlled trials in areas with high health needs we have developed, implemented and evaluated this programme, which has shown beneficial effects on child diet, physical activity and weight development. Several school organisations are now interested in establishing the HSS permanently but need training and implementation support to get started. The ongoing IMPROVE implementation study, financed by Forte, is in its final stage and will provide essential knowledge on the type and level of implementation support needed for high fidelity, making this project very timely.Based on our extensive experience of the school context we will develop and provide a central training and implementation support package in collaboration with Karolinska Institutet Executive and Professional Education (KI-EPE) on the online platform Canvas. KI-EPE has a high level of credibility as a training provider for professionals. The target groups for the educational package are school administration personnel, school principals, teachers and school nurses. KI-EPE reaches a wide range of individuals in the health sector, schools, municipalities, school organisations and regions, providing an excellent opportunity to spread information about the training to a broad and relevant audience.This package will offer continuous technical support for implementation throughout Sweden at a reasonable cost for stakeholders. KI-EPE holds high quality and has the necessary competence to perform this training package successfully together with the researchers behind the programme.

Purpose and aimsThe aim is to co-design and evaluate a novel model for family support (Co-fam) linking school and primary health care to effectively promote health and prevent and manage obesity among children 6-12 years. Two evidence-based family support programs, the universal Healthy School Start and the targeted More and Less will be adapted and combined and delivered in a municipality with high levels of childhood obesity. We hypothesize that Co-fam is effective and feasible to implement with high fidelity and acceptable to professionals and families.Project organization, timeplan and methodsThe project will be carried out over 4 years consisting of a preparation phase where the model will be co-designed with stakeholders and an implementation and evaluation phase based on an implementation framework. Evaluation will take place in a controlled hybrid type-2 effectiveness-implementation study using mixed methods. Quantitative data will be collected on child and parent level and on fidelity to the model, and costs. Interviews will be performed with personnel and parents to assess acceptability and feasibility.SignificanceBridging the gap between school and primary health care to reduce obesity and health inequalities has been urgently requested in national guidelines and recommendations but is still not done. By combining a universal and a targeted program we will create a new model tailored to family needs leaving no child behind and with great potential to be scaled up.

Background Unhealthy diets, low physical activity and obesity are strong risk factors for chronic diseases. Schools are an ideal setting for implementing health promotion programs reaching all children. The universal Healthy School Start program (HSS) improves diet and physical activity of 6 7-year-old children and moderately reduces BMI in children with obesity. For younger children with overweight or obesity, the targeted parent support program More and Less (ML) effectively improves weight status and maintains effects long term. By combining and adapting the two evidence-based programs to older children, families with children 6-12 years can be offered a seamless family support program (Co-fam) tailored to individual needs and in line with national guidelines to improve child health and prevent future heart disease. Objectives Our hypothesis is that a family support program (Co-fam), co-designed between school and primary health care personnel and parents, is effective and feasible to implement with high fidelity, and acceptable by professionals and families. 1. Co-design a family support program for children 6-12 years including universal and targeted components together with school and primary health care to promote health, reduce overweight and obesity and prevent future CVD. 2. Evaluate the model in a case-control effectiveness-implementation study with health outcomes at child level, and fidelity and cost at organizational level. 3. A qualitative interview study with health professionals and parents to assess acceptability and feasibility of the model. Work plan Year 1: Co-design workshops facilitated by the research team to define the components of Co-fam and adapt it to the age group 6-12 years. Implementation strategies will be developed based on an analysis of barriers and facilitators. Year 2-3: An 18-month effectiveness-implementation study in disadvantaged areas in Region Stockholm. Interviews will be held with health professionals and participating parents. Significance Two evidence-based programs will be combined to create an urgently needed model counteracting the increase in unhealthy eating, physical inactivity and obesity in children, all risk factors for CVD. This unique family support model is ready to be developed and implemented in a relatively short time. Bridging the gap between school and primary health care to reduce social inequalities in health has been urgently requested in recent governmental enquiries.