Gymnastik- och idrottshögskolan, GIH

BACKGROUND: A majority of adolescents do not meet the recommended levels of physical activity, while reported levels of mental health problems are increasing, and socioeconomic disparities in academic performance are widening. Many schools are implementing physical activity in different forms, but there is inconclusive evidence on what types of interventions improve mental health, cognitive functions, and academic performance and how to implement such interventions. There is a critical need for integrated, feasible, and equitable interventions. The objective of this study is to develop an effective multi-component school-based intervention that will target both physical activity and homework support during an extended school day and evaluate its effects on mental health, cognitive function and academic performance.

METHODS: The study is designed as a cluster-randomised controlled trial with 54 schools and approximately 2,700 students in grade 8 (age 14-15). The intervention includes three weekly 60-minute sessions: (1) Different types of physical activities (2), Homework support with short activity breaks, and (3) Walking and listening to audiobooks. This study will evaluate both outcome effects and implementation process. The primary outcome is anxiety, assessed using the Spence Children's Anxiety Scale (SCAS-S). Secondary outcomes include physical activity, sedentary time and behaviours measured by accelerometry and questionnaire, cognitive functions assessed by a computer-based test battery, mental health and sleep with questionnaires, and academic performance by grades. Process evaluation will include fidelity, dose, feasibility, acceptability and context, using structured documentation, interviews, focus groups, and observations. The effectiveness of outcomes between groups will be assessed using mixed-effects regression analysis, adjusting for relevant covariates. Process data will be analysed using descriptive statistics and content, and thematic analysis.

DISCUSSION: This study addresses key knowledge gaps in school-based health promotion by integrating physical activity and homework support within the school structure. The results will yield insights into both effectiveness and implementation, informing future policy and practice in schools to promote health and facilitate students' learning. The intervention targets youth in diverse socioeconomic contexts and is expected to contribute to reducing health and education inequalities.

TRIAL REGISTRATION: The trial was retrospectively registered on April 27, 2021. ISRCTN78666212.

BACKGROUND: Child obesity is a major global public health challenge. One way to reduce risk is through effective health promotion programs in schools that include parental involvement. However, programs often fail to be scaled up and sustained under real-world conditions. Therefore, it is necessary to study their implementation and study the perspective of decision-makers and school principals. The universal Healthy School Start (HSS) program, designed to promote healthy dietary and physical activity habits in children aged 5-7 years, was implemented in three municipalities in Sweden. This study aimed to identify and understand the success factors and barriers for scale-up and sustainment of the HSS program.

METHODS: This study used a qualitative explorative design. Individual semi-structured interviews were conducted with eight municipality leaders responsible for the school sector and eight school principals during 2023 and 2024. Data were analyzed using reflexive thematic analysis.

RESULTS: For a municipality to adopt and sustain the HSS program, dedicated leaders, in terms of health promotion, are crucial. Integrating the program into school routines and into the yearly quality assessment could support its sustainment. Barriers included challenges in prioritization of the HSS at the municipal level, perceived workload for school nurses, and staff and leadership turnover which could potentially reduce commitment to long-term program implementation. Facilitators and champions alleviated organizational challenges such as staff turnover. The feeling of support among staff was a key factor for successful implementation. To effectively promote health and prevent obesity, a multilevel and life-course approach involving several community actors was seen as necessary.

CONCLUSION: Success factors for scale-up and sustainment included the appointment of dedicated leaders in the municipality serving as program facilitators by providing consistent support and follow-up during the first year, while barriers such as lack of program prioritization, high workload and staff turnover posed a challenge to the implementation. Program integration into the yearly quality assessment might be the missing piece of the puzzle needed to achieve sustained implementation at scale. These findings are likely applicable in settings with a decentralized school system similar to Sweden's.

BACKGROUND: In Sweden, childhood overweight and obesity rates have risen significantly over the last decades, necessitating scalable interventions. The evidence-based Healthy School Start (HSS) program integrates school and family components to promote healthy habits and prevent overweight and obesity among children. The IMPROVE trial aimed to compare the effect of two tailored implementation strategy bundles (Basic and Enhanced) on fidelity to the HSS program.

METHODS: A hybrid type III cluster-randomized trial with two parallel arms was conducted in 45 schools (cluster) in three municipalities in Stockholm Sweden from August 2021 to June 2024. The program was implemented in two consecutive cohorts over two academic school years. Fidelity was measured with an adherence score (0-4) and parent's responsiveness (1-5) to the four intervention components (health brochure, motivational interviewing health talk, classroom module and type 2 diabetes risk test). Data were analyzed using mixed-effects linear and logistic regression models.

KEY FINDINGS: A total of 946 parents and 655 children participated. Overall fidelity, assessed as an adherence score, was around 75%, with most components implemented as expected. The adherence score in the Basic bundle showed no significant difference compared to the Enhanced implementation strategy bundle (β = 0.01, p = 0.95, 95% CI: -0.24, 0.25). Two of four Enhanced implementation strategies, educational outreach visits and networking between school and primary health care, did not happen mainly due to lack of interest and time among personnel. Parents born within the Nordic countries had twice the odds (p < 0.001, 95% CI: 1.14-3.43) of completing the motivational interviewing health talk compared to those born outside the Nordics.

DISCUSSION: Enhancing the Basic implementation bundle with additional strategies did not consistently improve adherence or responsiveness. However, improvements observed over time underscore the importance of targeted support during the initial implementation year. Additional motivational actions might be needed in schools with a high proportion of children whose parents are born outside the Nordic region. These findings highlight the complex interplay between context and implementation success, emphasizing the need to adapt strategies over time to optimize their effectiveness rather than merely adding more. Moreover, the essentially null findings also point to broader methodological challenges in implementation science, particularly how to prioritize among determinants, strategy selection and tailoring.

TRIAL REGISTRATION: ClinicalTrials.gov, Unique Protocol ID: NCT04984421. Registered July 30, 2021, https://register.

CLINICALTRIALS: gov/.

BACKGROUND: Digital interventions offering behaviour change support are warranted to prevent and treat non-communicable diseases, and have been evaluated rigorously in controlled settings. Effectivenss, factors influencing the uptake of scaled-up interventions-such as reach, received dose, usability and acceptability- and predictors and mediators of efficiency are rarely explored in research. The study described herein aims to evaluate the effectiveness of a personally tailored digital intervention (the app EviBody®), intended to support healthy and sustained lifestyle behaviours among the adult population, on well-being and behaviour change. Further aims are to explore context and uptake factors, predictors and mediators for behaviour change over 24 months.

METHODS: This is a real-world study, employing a quasi-experimental design and a process evaluation. EviBody® will be marketed and managed by its owner. A four-armed design will allow for comparison between three levels of intervention (basic, standard and premium) and a control group. Adults who sign up for the app will be invited to the research study including sharing app data and answering questionnaires at 0, 1, 3, 6, 12, 18, and 24 months. Study start is Autumn 2025. Controls (n = 200 to evaluate the primary endpoint well-being at 6 months) will be recruited through advertisements on social media and asked to answer the same questionnaires at 0 and 6 months provided by email. For predicting and mediating analyses the intention is to recruit 1500 app users. Well-being (measured with the WHO-5 Well-Being Index), goal achievement, physical activity, eating habits, mental health, mediators (motivation, self-efficacy, and perceived barriers), and demographics will be self-reported. Uptake will be collected using analytics and ratings of usability and acceptability, and described by demographics. Mixed models for repeated measures and structural equation modelling will be employed for data analysis.

DISCUSSION: Besides evaluating the effectivenss of a digital intervention, this study also applies a theory-based evaluation to understand which mediators are effective, for whom they are effective, and the specific conditions under which they are most beneficial.

TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT05973383 on 8 July 2023.

BACKGROUND: Early-life interventions are essential for improving public health since lifestyle behaviours are established already in childhood. Child healthcare (CHC) plays a crucial role in this context. The 'Saga Stories in health talk' (SSiHT) material includes a flipchart with colourful illustrations to facilitate CHC nurses' routine health talks with parents and their children, and a hand-out material kit to support healthy lifestyle behaviours in the families. Our aim was to evaluate the effectiveness of the SSiHT intervention at the 5-year routine visit at CHC on parental self-efficacy (primary outcome) and children's health-related behaviours (secondary outcomes). Implementation aspects for using the SSiHT material in routine practice for health talks at the 5-year visit were simultaneously evaluated.

METHODS: A hybrid type 1 effectiveness-implementation design was used to evaluate the intervention in six health regions across Sweden. A cluster-randomised controlled trial was conducted to evaluate effectiveness, where 40 CHC centres (98 nurses) were randomised into two arms: use the SSiHT material in routine care (intervention), or standard care (control). Parents (n = 698) of 5-year-olds were recruited. Outcome measures were assessed using digital questionnaires before the health talk (baseline), and two months later (follow-up). Linear mixed-effect models were used to contrast differences in outcomes between groups, in accordance with the study protocol. Acceptability, appropriateness, feasibility, fidelity, and adoption were evaluated using questionnaires and checklists to CHC nurses in the intervention group.

RESULTS: No statistically significant intervention effects were found on parental self-efficacy to promote healthy lifestyle behaviours in their children (-0.61 score on a scale 0-160; p = 0.56), nor children's intake of vegetables, fruits/berries, and sweet drinks or screen time (p > 0.05 for all). However, CHC nurses overall reported that the SSiHT material was feasible and appropriate to use in the health talks with families, and they used it in 83% of their health talks.

CONCLUSION: Although the SSiHT material was well accepted by the CHC nurses, there was no intervention effect on parental self-efficacy (primary outcome) nor health-related behaviours in children when evaluated in Swedish CHC. This warrants further research to better understand how to effectively empower parents through CHC health talks.

TRIAL REGISTRATION: Registered 2 February 2022 at Clinicaltrials.gov NCT05237362; https://www.

CLINICALTRIALS: gov/study/NCT05237362 .

Background

Schools are important settings for universal child health promotion. Understanding the experiences of providers of interventions targeting both children and their parents is crucial for designing feasible and sustainable school-based health promotion programs.

Aim

The aim of this study was to explore school nurses' perceptions and experiences of delivering a health-promotion program focusing on healthy lifestyle habits in primary schools in Sweden.MethodsThis study employed an explorative qualitative design with an inductive approach. Interviews were conducted with school nurses using a semi-structured interview guide. The data were audio-recorded, transcribed and analysed using thematic analysis.

Results

School nurses had insights regarding the acceptability and appropriateness of the program as well as reflections regarding implementation and perceived impact. School nurses appreciated the evidence-based content and structure of the program and experienced improved collaboration with teachers. Moreover, positive changes were noted in relation to both children and parents such as improved knowledge and relations. Declining interest from school principals over the school year and lack of involvement among some parents were highlighted as implementation challenges.

Conclusion

This study sheds light on the complexities faced by school nurses in delivering health-promotion interventions in collaboration with teachers in primary schools. Evidence-based practices, sustained leadership support and culturally sensitive strategies are essential for successful health promotion within schools. Our findings underscore the critical role of school nurses as health advocates, educators, and facilitators.

Introduction: There is an association between physical activity and both health and academic performance. However, there is still a lack of consensus on how to engage adolescents in physical activity interventions in secondary schools. One approach to better understand the activities and strategies supporting effective implementation is to involve school staff and adolescents in the early stages of planning and preparing for interventions. Therefore, the aim of this study is to explore how multiple stakeholders, including school staff, students, and experts, perceive the barriers and facilitators for implementing a school-based intervention that extends the school day with additional physical activity in Sweden.

Material and methods: This inductive explorative qualitative study involved 16 participants. Three focus groups with school staff, including principals (n = 3), teachers (n = 6), and students (n = 4), and three interviews with experts were conducted. The planned intervention and its components were presented to the participants in the focus group and interviews to discuss them based on their previous experiences and thoughts of implementing physical activities or health promotion programmes in their schools or with adolescents. Data were analysed using qualitative content analysis.

Results: Three categories emerged: (1) “types of activities offered”, highlighting the importance of designing activities that are fun, inclusive and unusual; (2) “integration of the activities into school curriculum” to promote sustainability of the intervention and incorporate physical activity throughout the school day and across school subjects, and (3) “Management support and funding” referring to the funded time and facilities that teachers leading the activities need to facilitate implementation.

Conclusions: Before implementing extra physical activity in a school setting, it is important to understand what activities enhance students' motivation and the type of support teachers need from the school principal and administration. This includes funding for teachers' time, appropriate scheduling of the activities, and access to facilities.

BACKGROUND: Current evidence suggests that even in high-income countries such as Sweden, there are socioeconomic differences in children's participation in physical activity. While family-based programmes appear promising to encourage physical activity, there is a lack of knowledge on how to engage families in such programmes, particularly in socioeconomically disadvantaged areas. The Open Health-Promoting Activities programme was launched to promote physical activity outdoors and health equity for children and their families in these areas. This study aims to explore parents' experiences with the Open Health-Promoting Activities programme in socioeconomically disadvantaged areas, focusing on family engagement in physical activity and perceived changes in family dynamics.

METHODS: A qualitative design with an ethnographic approach was employed. In line with an ethnographic approach, the research team conducted 15 participant observations of the programme sessions on Saturdays during Spring 2022. Field notes were compiled during the observations, which provided contextual information for individual interviews with 12 programme participants. These interviews were conducted after the researchers attended the programme. The participants were adults/parents who participated in the programme with one or more of their children. An inductive reflexive thematic analysis was used to analyse the field notes and interviews.

RESULTS: The analysis identified three main themes: (1) prioritising children's equal engagement in physical activity, (2) helping parents promote children's healthy lifestyles, and (3) improving family dynamics through engagement in physical activity. Each theme captures an aspect of the programme that parents perceived as essential to facilitating their family's engagement in the programme. All the themes are interconnected and form the basis for improving family dynamics.

CONCLUSION: To develop tailored family-based programmes in socioeconomically deprived communities, it is crucial to understand parents' experiences and perceptions of aspects that facilitate their children's engagement in physical activity. The findings suggest that emphasising equal opportunities, a safe space approach and participation are essential for increasing family engagement in physical activity. These elements also supported increasing parents' awareness of their children's need to be active and have fun together.

Background

Healthy lifestyle habits, such as performing physical activity and having healthy eating habits, are cornerstones of primary and secondary prevention of noncommunicable diseases, such as type 2 diabetes. Mobile health (mHealth) services may effectively promote healthy lifestyle habits, but more research focusing on users' perspectives of health-promoting mHealth services is needed to adapt them to user's needs and preferences. This study aimed to explore perceptions of an mHealth service to support physical activity, healthy eating habits, and mental health among adult individuals with type 2 diabetes. In this qualitative study, individual interviews were conducted with 10 people with type 2 diabetes in Sweden who were using an mHealth service providing digital coaching to support physical activity, healthy eating habits, and mental health for four weeks. Qualitative content analysis with an inductive approach was used to analyze the data.

Results

Six subcategories and two categories were identified in the data. The participants emphasized the importance of an interactive design, including a user-friendly layout, meaningful and varied functions, and a design promoting motivation and goal setting. Additionally, they highlighted the importance of user-centered content, such as a holistic approach, a setting tailored to the user, and diabetes-specific information. These factors were seen as crucial for optimizing support for healthy lifestyle habits and ensuring that the content of the mHealth service effectively reaches users.

Conclusion

Adult individuals with type 2 diabetes highlighted the importance of an interactive design that incorporates user-centered content in mHealth services to facilitate daily usage and promote behavioral change. This study contributes to the understanding of users' perceptions with mHealth services, which have been confirmed to be important when developing person-centered digital interventions.

INTRODUCTION AND AIM: Ethnically diverse neighborhoods encounter pronounced inequalities, including housing segregation and limited access to safe outdoor spaces. Residents of these neighborhoods face challenges related to physical inactivity, including sedentary lifestyles and obesity in adults and children. One approach to tackling health inequalities is through family-based programs tailored specifically to these neighborhoods. This study aimed to investigate parents' experiences and perceptions of the family-based Open Activities, a cost-free and drop-in program offered in ethnically diverse and low socioeconomic neighborhoods in Sweden.

METHODS: Researchers' engagement in 15 sessions of the Open Activities family-based program during the spring of 2022, and individual interviews with 12 participants were held. Data were analyzed using reflexive thematic analysis.

RESULTS: The analysis resulted in three main themes and seven sub-themes representing different aspects of the program's meaning to the participants as parents, their families, and communities. The main themes describe how parents feel valued by the program, which actively welcomes and accommodates families, regardless of cultural differences within these neighborhoods. The themes also show how cultural norms perceived as barriers to participation in physical activity can be overcome, especially by mothers who express a desire to break these norms and support girls' physical activity. Additionally, the themes highlight the importance of parents fostering safety in the area and creating a positive social network for their children to help them resist criminal gang-related influences.

CONCLUSIONS: The program's activities allowed parents to connect with their children and other families in their community, and (re)discover physical activity by promoting a sense of community and safety. Implications for practice include developing culturally sensitive activities that are accessible to and take place in public spaces for ethnically diverse groups, including health coordinators that can facilitate communication between groups. To enhance the impact of this program, it is recommended that the public sector support the creation of cost-free and drop-in activities for families who are difficult to reach in order to increase their participation in physical activity, outreach, and safety initiatives.