Healthy School Start Research Articles

Effects of Universal School-Based Parental Support for Children’s Healthy Diet and Physical Activity—the Healthy School Start Plus Cluster–Randomised Controlled Trial

Health promotion from an early age is key to preventing unhealthy weight development in childhood, and parental involvement is essential. The school-based Healthy School Start intervention aims to promote healthy dietary and activity habits in the home environment and prevent child obesity through parental support. This study evaluated the effectiveness of the third iteration of the programme on children’s dietary and activity behaviours, and body composition through a cluster-randomised controlled trial. The trial included 17 schools (8 intervention) in disadvantaged areas in mid-Sweden with 353 families with 5- to 7-year-old children. The primary outcomes were intake of selected healthy and unhealthy foods and beverages measured using photography. Secondary outcomes were physical activity and sedentary time measured by accelerometry, and measured weight and height. All outcomes were assessed at baseline and post-intervention (8 months). Linear multi-level regression showed significant favourable effects of the intervention for intake of sweet beverages (b = − 0.17, p = 0.04), intake of healthy foods (b = 0.11, p = 0.04), and more time in moderate to vigorous physical activity during weekdays (b = 5.68, p = 0.02). An unfavourable sub-group effect of the intervention was found for children from families with low education regarding sedentary time on weekends (b = 23.04, p = 0.05). The results align with the previous two trials of the programme, indicating that school-based parental support is a useful approach for health promotion in young children in disadvantaged areas. Trial registration: ClinicalTrials.gov: No. NCT03390725, retrospectively registered on January 4, 2018, https://clinicaltrials.gov/ct2/show/NCT03390725.

Universal healthy school start intervention reduced the body mass index of young children with obesity.

To evaluate the effect of a universal, school-based family support programme on body mass index (BMI) of children aged 5-7 years, using pooled data from three trials. The programme has three to four components and is delivered during the first school year. It aims to promote healthy dietary and physical activity behaviours, and secondarily prevent unhealthy weight gain. Three cluster-randomised controlled trials were conducted between 2010 and 2018 in low and mixed socioeconomic status areas in Sweden. Weight and height were measured. Multiple mixed linear regression analysis was performed on the pooled data. In total, 961 children were included (50% girls, mean age 6.3 years). The post-intervention effect on BMI z-score in all children was small, but in those with obesity at baseline, we observed a significant, clinically relevant, decrease in BMI z-score (-0.21). This was most pronounced in children with a non-Nordic born parent (-0.24). Five to six months after the intervention, decreases were no longer statistically significant. The intervention resulted in changes in BMI comparable to obesity treatment programmes focusing on behaviour change. However, the effect attenuated with time suggesting the programme should be sustained and evaluated for a longer time.

Validation of the Comprehensive Feeding Practices Questionnaire among parents of 5- to 7-year-old children in Sweden

IntroductionParents’ behaviours towards food and mealtimes, also known as parental feeding practices, are important in the development of children’s eating habits. The Comprehensive Feeding Practices Questionnaire (CFPQ) was designed to measure parental feeding practices. The aim of this study was to evaluate the validity of the CFPQ in Sweden and to assess how it performs across different groups of people.MethodsData were from the baseline of a trial promoting children’s healthy dietary and physical activity behaviours, the Healthy School Start Plus intervention, conducted in 17 schools in the Stockholm region in Sweden. The CFPQ was completed by 263 parents (59% mothers) of 173 children, aged 5 to 7 years. Exploratory factor analysis and the omega reliability test were performed to identify the underlying factors in the data. Invariance testing was used to investigate the equivalence of these factors across parental sex, parental education and children’s weight status.ResultsFive factors were identified: monitoring of children’s food intake, pressure to eat, restriction of food, use of food for emotional regulation, and healthy eating guidance. All five factors were invariant across parental sex and education, though some questions were excluded to achieve invariance. The monitoring, pressure to eat and emotional regulation factors were invariant across children’s weight status.DiscussionThese results suggest that the CFPQ is valid for use in Sweden, amongst parents of children aged 5 to 7 years. The measurement invariance allows for comparisons of all five underlying factors across mothers and fathers and parental education levels, though across children’s weight status for only three factors. Due to the importance of parental feeding practices throughout childhood, this questionnaire should also be validated in other age groups in Sweden.

Parents’ experiences of participating in the Healthy School Start Plus programme – a qualitative study

BackgroundThe rise in overweight and obesity among children is a global problem and effective prevention interventions are urgently required. Parents play an important role in children’s lifestyle behaviours and body weight development and therefore there is a great need to investigate how to involve parents effectively in health promotion and prevention programmes. The aim of the study was to describe parents’ experiences of barriers and facilitators of participating in the Healthy School Start Plus (HSSP) intervention study.MethodsHSSP is a parental support programme, conducted in Sweden, with the aim to promote a healthy diet, physical activity and preventing obesity in 5-7-year-old children starting school. In total 20 parents from 7 schools participated in semi-structured telephone-based interviews. The data was analysed using qualitative content analysis, with a deductive approach based on the Consolidated Framework for Implementation Research (CFIR).ResultsParental experiences of barriers and facilitators informing the implementation of the HSSP intervention were identified within all five domains of the CFIR. Two additional constructs, not included in the CFIR were identified: Social factors and Cooperation. The findings of parental experiences of barriers and facilitators related to the importance of (1) adaptation of the intervention to fit the abilities of the parents with different social and cultural backgrounds; (2) the need for continuous delivery of information related to healthy behaviours; (3) the commitment and efforts of the deliverers of the intervention; (4) the need for repetition of information related to healthy behaviours given by the deliverers of the intervention; (5) encouragement and facilitation of the involvement of the family and key people around them through the intervention activities and by the deliverers of the intervention; (6) awareness of unexpected impacts and social and cultural conditions complicating the execution of the intervention and; (7) cooperation and a well-functioning interaction between parents and school staff.ConclusionsBarriers and facilitators indicated by the parents highlighted that interventions like the HSSP need to be adapted to fit the parents’ abilities, with reminders, follow-ups and delivery of relevant information. Variations in social and cultural conditions need to be taken into consideration. The commitment of the school and the interaction between the school staff and the family as well as key people around them appears to be important.Trial registrationThe Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Impact of Changing School Start Times on Teacher Sleep Health and Daytime Functioning.

The benefits of delaying school start times for secondary students are well-established. However, no previous study has considered how changing school start times impacts sleep and daytime functioning for K-12 teachers. Teachers in a large suburban school district completed 3 annual surveys (pre-change n=1687, post-change n=1857, follow-up n=1812) assessing sleep and daytime functioning. With delayed start times, high school teachers had later rise times (high school [HS]: 28 minutes, middle school [MS]: 14 minutes), increased sleep duration (HS: 22 minutes, MS: 13 minutes), and improved daytime functioning. Improvements for middle school teachers were noted but were not statistically significant. With earlier start times, elementary teachers reported earlier bedtimes (9minutes) and wake times (9minutes), with no changes in sleep duration or daytime functioning. Today's school health policies often focus on wellness. Findings from this study reveal that the policy of healthy school start times can have a significant, positive impact on adults who teach in later-starting secondary schools. Later school start times for secondary teachers provide greater parity with their elementary colleagues in terms of sleep opportunity. This study extends previous findings on how the policy of later secondary school start times improves the health and well-being of adolescents, highlighting that healthy start times contribute to increased sleep opportunity for MS and HS teachers and improved daytime functioning for HS teachers, with changed start times having no significant negative effect on elementary school teachers.

Changing school start times: Impact on extracurricular activities and employment

Sufficient sleep duration is associated with student health and wellbeing, but early secondary school start times limit students' sleep opportunity. Despite recommendations that all middle and high schools adopt a healthy school start time policy, one barrier to policy implementation is concerns about the impact on student participation in activities and employment. This study examined student extracurricular activity participation and employment before and after the implementation of healthy secondary school start times. Approximately 24,000 students/year (grades 3–11) completed three annual surveys (pre-change, post-change, follow-up) measuring sleep-wake patterns, extracurricular activity participation, and employment. Following the implementation of an earlier school start time, before-school activity participation decreased for elementary school students, but after-school participation was similar across years. Following the implementation of later school start times, there was a small decrease in after-school activity participation for middle and high school students (~3–4%). Equally important, middle and high school students reported significantly increased sleep duration with later start times, regardless of participation in before- or after-school activities and employment. Study findings support the recommendation for healthy school start time policies.

O3-6 The Healthy School Start Plus Study - A parental support programme to promote healthy behaviours and prevent childhood obesity in disadvantaged areas

BackgroundThe rise in childhood overweight and obesity worldwide demands effective health promotion and obesity prevention programmes, especially targeting socially disadvantaged areas. The aim of this study is to examine the effectiveness of a revised parental support programme, promoting physical activity and a healthy diet, and on preventing overweight and obesity among children in disadvantaged areas.MethodsThe effectiveness of this programme will be compared to standard school routines in a parallel group cluster randomised controlled trial. The 6-month programme included: 1) A health information brochure; 2) School nurses conducting motivational interviewing with parents; 3) Classroom activities and home assignments for children; 4) A self-test for type-2 diabetes risk for parents. Seventeen schools were enrolled including 352 six-year-old children (155 intervention/197 control). Physical activity and sedentary time were measured by accelerometry. Dietary intake was assessed by a newly developed mobile phone-based photo method. Weight and height were measured by trained researchers. All outcomes were measured at baseline and at 6 and 18 months post baseline. Parental level of education was self-reported, and the highest level achieved by either parent was used as an indicator of socioeconomic position (SEP). A mixed-effect regression analysis will be performed to evaluate the effectiveness of the programme.ResultsAfter the intervention, when adjusting for sex and parental education, the intervention group showed 6.4 mins more moderate to vigorous physical activity (MVPA) during weekdays than the control group (p = 0.03). No significant effect on MVPA was detected during weekends (p = 0.47). Further, no significant effect was detected on time spent sedentary during weekdays (p = 0.12) nor during weekends (p = 0.78).According to IOTF classifications, 9.6% of the children had obesity, 16.4% overweight, 4.4% underweight and 69.6% normal weight. Results on changes in BMI, and dietary intake at 6 months will be presented.ConclusionsThe results from the evaluation of this parental support programme will add to the knowledge and advance intervention and implementation research in the Swedish/Nordic context relating to prevention of overweight and obesity in childhood.

“Sometimes It Felt Great, and Sometimes It Just Went Pear-Shaped”: Experiences and Perceptions of School Nurses’ Motivational Interviewing Competence: A Convergent Mixed-Methods Study

In this convergent mixed-methods study, the aim was to explore how objective and subjective quality ratings of school nurses’ motivational interviewing (MI) correlate whilst also considering the perceptions of delivering and participating in the same MI sessions. Quantitative and qualitative data were derived from seven intervention schools participating in the Healthy School Start Plus parenting support intervention. School nurses were trained in MI and conducted an MI session with parents of 6–7-year-old children to discuss children’s physical health and development. Quantitative data comprised objective ratings of school nurses’ MI competence using the Motivational Interviewing Treatment Integrity 4.2 [MITI-4] protocol, as well as parents’ and school nurses’ subjective ratings of the MI sessions. Qualitative data comprised semi-structured interviews with parents and school nurses about their perceptions of the MI sessions. First, quantitative data were analysed using Spearman’s rank correlation, and qualitative data were analysed using content analysis. Next, quantitative and qualitative findings were merged. Our findings suggest that school nurses’ MI performances were rated and perceived as valuable and family-centred by both school nurses and parents who had left the meeting feeling motivated and empowered to promote their children’s healthy behaviours. Nonetheless, school nurses were critical to their own MI technical performance, and they found that reflections were easier to deliver and to self-rate. Overall, MITI ratings were the lowest and parents’ ratings were the highest. Future studies should focus on relating clients’ subjective ratings of MI with clients’ behavioural outcomes.

Relationships between Physical Activity Parenting Practices and Children's Activity Measured by Accelerometry with Children's Activity Style as a Moderator-A Cross Sectional Study.

The objective was to examine the associations between physical activity parenting practices (PAPP) and children’s levels of moderate-to-vigorous physical activity (MVPA), and time spent sedentary (SED) during non-school time in weekdays and weekends when children’s activity style was taken into account. Study participants were 88 children (mean age 6.3 (SD 0.3) years); 51.0% girls) and their parents who took part in A Healthy School Start Plus in Sweden. The independent variables included PAPPs Structure, Neglect/control, and Autonomy promotion and children’s activity style as moderator, assessed through validated parent questionnaires. Dependent variables were the MVPA and SED in minutes, measured by accelerometry. Structural equation modeling was used to examine the associations between PAPPs and children’s MVPA and SED with children’s activity style as a moderator. No significant associations between the PAPPs Structure, Neglect/control, and Autonomy promotion and measures of physical activity were found (p > 0.13). The moderating role of activity style improved the model fit and the final model had a reasonable fit to the data. Our results suggest that in future studies, with the aim to explore the relationship between PAPP and children’s physical activity, the activity style of the children should be included as a moderator.

Impact of changing school start times on parent sleep

ObjectiveTo examine the impact of changing school start times on sleep in parents of students in elementary, middle, and high school. MethodsAnnual surveys were completed by parents of K-12 students (n = 8190-10,592 per year) before (pre-change) and for 2 years (post-change, follow-up) after implementation of new school start times (elementary school [ES]: 60 minutes earlier, middle school [MS]: 40-60 minutes later, high school [HS]: 70 minutes later), providing parent self-reported weekday bedtime and wake time, sleep quality, and feeling tired. ResultsSignificant level-by-year interactions were found for parent bedtime, wake time, and sleep duration (all p < .0001). Post hoc analyses show ES parents reporting earlier bedtimes and wake times at post-change, with no change in sleep duration, while MS and HS parents reported later post-change wake times. Post-change, more MS and HS parents reported sufficient sleep duration (p < .0001) and good sleep quality (p < .0001), with fewer HS parents reporting feeling tired (p < .0001). ConclusionsThis is the first study to consider the impact of a policy change aimed at improving child sleep on parent sleep. Healthy school start times has a significantly positive downstream effect on secondary school parents’ sleep and daytime functioning, with minimal impact reported by parents of elementary school students.

IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity (IMPROVE) \u2013 study protocol for a cluster-randomized trial

BackgroundIMPROVE 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.MethodsIMPROVE 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.DiscussionThis 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 registrationRegistered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021

Variations in perceptions of parenting role related to children\u2019s physical activity and sedentary behaviours \u2013 a qualitative study in a Northern European context

BackgroundThe aim of the study was to increase understanding of the variation in parental perceptions of their roles and responsibilities in relation to children’s physical activity and sedentary behaviours.MethodsThis qualitative study was based on data from the Healthy School Start intervention study II, in the form of recorded motivational interviewing (MI) sessions with mothers and fathers participating in the intervention. Forty-one MI sessions where parents discussed physical activity and/or sedentary behaviour were selected for analysis. Data analysis was performed using a phenomenographic approach.ResultsThree categories describing a structural relationship of parents’ different views on their own role in relation to their child’s habits were identified: 1) The parent decides – Child physical activity according to my beliefs and views as a parent and where I, as a parent, decide, 2) Parent-child interaction – child physical activity is formed in interaction between me as a parent and my child or 3) The child/someone else decides – The child or someone other than me as a parent decides or has the responsibility for my child’s physical activity. All three categories included four subcategories of specific activities: organised activity, activity in everyday life, being active together and screen time, describing practical approaches used in each of the three categories.ConclusionsThis study found variation in mothers’ and fathers’ perceptions of their roles and responsibilities for their child’s physical activity and sedentary behaviours related to specific types of activities. The results indicate areas where parents need support in how to guide their children and how parental responsibility can have a positive influence on children’s physical activity and sedentary habits.

Children\u2019s experiences of participating in a school-based health promotion parental support programme \u2013 a qualitative study

BackgroundChildren’s voices are seldom heard in process evaluations concerning health promotion programmes. A Healthy School Start Plus (HSSP) is a parental support programme, conducted in Sweden, with the aim of promoting healthy diet, physical activity and preventing obesity in preschool class children. The 6-month programme includes: (1) Health information to parents; (2) Motivational Interviewing with parents by school nurses; (3) Classroom activities and home assignments for children; (4) A self-test of type-2 diabetes risk for parents. We aimed to describe children’s experiences of the third component regarding barriers and facilitators of participating in and learning from the classroom activities in the HSSP.MethodsIn total 36 children from 7 schools in Sweden, mean age 6 years, participated in 7 focus group discussions. Purposeful sampling with maximum variation was used to collect the data. The focus groups were audio-recorded, transcribed and analysed using qualitative content analysis.ResultsFour categories were identified; (1) Time available to work on intervention activities; (2) Others’ interest; (3) Abilities and interests in intervention activities; and (4) Practicing the concept of health.ConclusionsThe findings may improve the HSSP and other similar interventions that include classroom-based learning regarding health by highlighting the following points to consider: aiming for homework to be an integrated part of the school-setting to enhance parental involvement; using flexible material, tailored to the children’s abilities and giving children adequate time to finish the intervention activities; and making teachers and parents aware of the importance of verbal and body language regarding intervention activities.Trial registrationThe Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Maintaining Regular Sleep-Wake Schedule During Pandemic May Help Adolescents

Maintaining Regular Sleep-Wake Schedule During Pandemic May Help Adolescents

0993 Impact Of Changing School Start Times On Parent Sleep

Abstract Introduction No studies have previously considered how healthy school start times impact parents. Since parent and child sleep schedules, in particular wake time, are associated, we examined whether changing school start times would impact parent sleep (elementary school [ES] 9:00am to 8:00am, middle school [MS] 8:00am to 8:50am, high school [HS] 7:10am to 8:20am). Methods Parents of students (grades K-12) completed online surveys pre-change, one-year, and two-years post-change (2017 n=11,579; 2018 n=8,884; 2019 n=8,796), reporting weekday bedtime and wake time (sleep duration calculated bedtime to wake time). Four PROMIS sleep questions asked about sleep “quality”, feeling “alert” upon waking, feeling “tired” during the day, and “daytime problems” because of sleep. Finally, parents were asked one-year post-change how happy they were about the new school start times. Results Parents with only ES students reported earlier bedtimes and wake times (10 and 13 minutes). Parents with &amp;gt;1 HS student woke later (HS only: 22 minutes; MS and HS: 25 minutes; ES and HS: 10 minutes; all 3 levels: 14 minutes) and slept longer (HS only: 19 minutes; MS and HS: 21 minutes; ES and HS: 12 minutes; all 3 levels: 18 minutes), with changes maintained two years. Similarly, parents of only ES students reported no change in sleep quality/impairment. Post-change, more parents with &amp;gt;1 MS or HS student reported good sleep quality (average increase=6.9%), feeling alert (average increase=5.8%), not feeling tired (average increase=5.0%), and having few daytime problems (average increase=4.2%), with benefits maintained two-years post-change. Across levels, parents who were “very happy” about start time changes slept longer than “very unhappy” parents (12-30 minutes); however, across levels, child sleep did not differ between happy and unhappy parents. Conclusion This is the first study to examine the impact of changing start times on parents of students in grades K-12. Study results show no significant impact on parents of elementary students. However, similar to students, parents of middle/high school students reported later wake times and increased sleep duration. Notably, parents’ happiness with start time changes was related to parent, but not student, sleep duration. Support Robert Wood Johnson Foundation’s Evidence for Action Grant

School-based obesity prevention for busy low-income families-Organisational and personal barriers and facilitators to implementation.

Little research has targeted multiple-level barriers and facilitators in school-based parental support programmes. This qualitative study aims to describe barriers and facilitators, at organisational and personal levels, that teachers and parents in disadvantaged settings in Sweden perceived as influencing the implementation of the Healthy School Start II (HSS II) intervention. Data collection, analysis and interpretation were guided by the Consolidated Framework for Implementation Research (CFIR). Focus groups and interviews were conducted with 14 parents and ten teachers within the HSS II trial. Data were analysed using qualitative content analysis in a deductive step using the three CFIR domains-inner and outer setting, and personal characteristics-followed by an inductive analysis. The theme 'being on the same page-getting burdened teachers and parents to work on common ground' was found. Among teachers, barriers and facilitators were related to the structure of the schoolwork and curriculum, involvement from other staff and school management, the practical school workday, perception of high family needs but low parental interest, insufficient resources in the families, and teacher's personal knowledge, interests, and opinions about health and food. For parents, barriers and facilitators were related to the perceived family needs and resources, parents' health knowledge, consensus about healthy behaviours and ability to cooperate, and school involvement in health issues and the intervention. Interventions should facilitate parents' and teachers' work on common ground, with activities suitable for a stressful and burdensome workday and everyday life. This could be achieved by integrating evidence-based practices within school routines, and including activities that are practicable despite parents' stressful lives, and that increase parental consensus about promoting health. Strategies to increase involvement of parents in families with high needs are necessary. Also, this study suggests an expansion of the CFIR to capture the interface between different micro-level organisations, and account for several delivering/receiving organisations.

Parental support in promoting children\u2019s health behaviours and preventing overweight and obesity \u2013 a long-term follow-up of the cluster-randomised healthy school start study II trial

BackgroundEffects of obesity prevention interventions in early childhood are only meaningful if they are sustained over time, but long-term follow-up studies are rare. The school-based cluster-randomised Healthy School Start (HSS) trial aimed at child health promotion and obesity prevention through parental support was carried out in 31 pre-school classes (378 families) in disadvantaged areas in Sweden during 2012–2013. Post-intervention results showed intervention effects on intake of unhealthy foods and drinks, and lower BMI-sds in children with obesity at baseline. This study aimed to evaluate the long-term effectiveness 4 years post-intervention.MethodsData were collected from 215 children in March–June 2017. Child dietary intake, screen time, and physical activity were measured through parental-proxy questionnaires. Child height and weight were measured by the research group. Group effects were examined using Poisson, linear, logistic, and quantile regression for data on different levels. Analyses were done by intention to treat, per protocol, and sensitivity analyses using multiple imputation.ResultsNo between-group effects on dietary intake, screen time, physical activity, or BMI-sds were found for the entire group at the four-year follow-up. In girls, a significant subgroup-effect was found favouring intervention compared to controls with a lower intake of unhealthy foods, but this was not sustained in the sensitivity analysis. In boys, a significant sub-group effect was found where the boys in the intervention group beyond the 95th percentile had significantly higher BMI-sds compared to boys in the control group. This effect was sustained in the sensitivity analysis. Analyses per protocol showed significant intervention effects regarding a lower intake of unhealthy foods and drinks in the children with a high intervention dose compared to controls.ConclusionsFour years after the intervention, only sub-group effects were found, and it is unlikely that the HSS intervention had clinically meaningful effects on the children. These results suggest that school-based prevention programmes need to be extended for greater long-term effectiveness by e.g. integration into school routine practice. In addition, results showed that children with a high intervention dose had better long-term outcomes compared to controls, which emphasises the need for further work to increase family engagement in interventions.Trial registration ISRCTN, ISRCTN39690370, retrospectively registered March 1, 2013, http://www.isrctn.com/ISRCTN39690370.

A Healthy School Start Plus for prevention of childhood overweight and obesity in disadvantaged areas through parental support in the school setting - study protocol for a parallel group cluster randomised trial

BackgroundSystematic reviews conclude that interventions to prevent overweight and obesity in children obtain stronger effects when parents are involved. Parenting practices and parent-child interactions shape children’s health-related behaviours. The Healthy School Start Plus intervention aims to promote healthy dietary habits and physical activity and prevent obesity in children through parental support in disadvantaged areas with increased health needs, delivered by teachers and school nurses. This protocol describes the design, outcome and process evaluation of the study.MethodsEffectiveness of the intervention is compared to standard care within school health services. The 6-month programme, based on Social Cognitive Theory, consists of four components: 1) Health information to parents regarding the child; 2) Motivational Interviewing with the parents by the school nurse concerning the child; 3) classroom activities for the children by teachers; and 4) a web-based self-test of type-2 diabetes risk by parents. Effects will be studied in a cluster randomised trial including 17 schools and 352 six-year old children. The primary outcome is dietary intake of indicator foods, and secondary outcomes are physical activity, sedentary behaviour and BMI. Outcomes will be measured at baseline, at 6 months directly after the intervention, and at follow-up 18 months post baseline. Statistical analysis will be by mixed-effect regression analysis according to intention to treat and per protocol. Mediation analysis will be performed with parental self-efficacy and parenting practices. Quantitative and qualitative methods will be used to study implementation in terms of dose, fidelity, feasibility and acceptability. The hypothesis is that the programme will be more effective than standard care and feasible to perform in the school context.DiscussionThe programme is in line with the cumulated evidence regarding the prevention of childhood obesity: That schools should be a focal point of prevention efforts, interventions should involve multiple components, and include the home environment. If effective, it will fill a knowledge gap concerning evidence-based health promotion practice within school health services to prevent obesity, and in the long term reduce social inequalities in health.Trial registrationThe trial was retrospectively registered on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

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

BackgroundA 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. MethodsA 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. ResultsFive 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. ConclusionThe 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.

A Healthy School Start – parental support for prevention of obesity in disadvantaged areas in Sweden

A Healthy School Start – parental support for prevention of obesity in disadvantaged areas in Sweden