Abstract
BackgroundSchools 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.MethodsNine 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.ResultsProgramme 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.ConclusionsSchool 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.
Highlights
Schools can be effective settings for improving eating habits and physical activity, whereas it is more difficult to prevent obesity
Programme fidelity and action plans Each school formed local health teams consisting of 4–11 staff
The participatory approach resulting in tailored and distinct but complex school action plans is a strength with regard to ownership and capacity-building, and a weakness with regard to evaluation, because the measures chosen and the dose varied between schools. This model project showed a high degree of fidelity demonstrating feasibility of the SCIP-school programme with positive effects on school health practices and environments
Summary
Schools can be effective settings for improving eating habits and physical activity, whereas it is more difficult to prevent obesity. 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. The prevalence of obesity has been rising during the last two decades [3,4] a stabilisation seems to have occurred among children in Sweden at a level around 3% in 8–10 year olds [5,6,7,8]. There is mounting evidence that schools are effective settings for promoting healthy eating habits and physical activity in children and youth. The following measures have been included in beneficial programmes: Health education, physical education classes, food supply, supportive environments for healthy diets and physical activity, training of staff and capacity building, and parental involvement. There is evidence to suggest that girls are more responsive to educational strategies and boys to environmental changes [15,16], indicating that both types of strategies should be employed
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