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. 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. 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. 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.

Schools are a key setting for child health promotion, yet implementing school-based programs, particularly those involving parents, remains challenging. Organizational readiness and early implementation outcomes, acceptability (ACC), appropriateness (APP), and feasibility (FEAS), capture how stakeholders perceive the implementability of new interventions and engage with them. These perceptions may evolve during implementation, but evidence on how they change over time and relate to one another in real-world school settings is limited. This study examined these changes among school staff during the first year of implementing the Healthy School Start program in schools in three Swedish municipalities (M). Validated questionnaires were used to assess readiness, ACC, APP, and FEAS pre- and post-intervention to examine how these implementation variables varied with direct experience of the intervention. Data were collected from 39 school principals, 72 teachers, and 40 school nurses between September 2021 and June 2023. Multilevel linear regression models with random intercepts for school and individual examined pre-post changes and interactions by municipality and professional group. Readiness, ACC, and APP declined significantly from pre- to post-intervention in the total sample (readiness: β = −2.54, p = 0.032; ACC: β = −1.31, p = 0.004; APP: β = −1.12, p = 0.022), while FEAS remained stable (β = −0.30, p = 0.501). M2 schools reported lower baseline scores than M1 schools on ACC, APP, and FEAS. M1 schools showed significant declines across all four outcomes, while M3 schools remained stable. FEAS was the only outcome for which pre-post change differed significantly across municipalities (time × municipality interaction: χ²(2) = 9.56, p = 0.008), driven by a decline in M1. No significant differences were observed between professional groups, although school nurses reported the lowest readiness and feasibility scores. Baseline readiness was strongly correlated with ACC (ρ = 0.66), APP (ρ = 0.67), and FEAS (ρ = 0.73; all p < 0.001). Perceptions of implementability generally declined with feasibility remaining stable overall except for one municipality showing a significant decline. These findings run counter to assumptions that exposure alone improves implementation outcomes, and suggest that perceptions are shaped by organizational context, underscoring the importance of addressing contextual barriers both before and during implementation. Registered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021.

BACKGROUND:Many implementation studies focus on assessing the effectiveness of implementation strategies without investigating the mechanisms explaining their effects. This study investigates the specific mechanisms through which a multifaceted implementation strategy is hypothesized to improve guideline fidelity. This is done by tracing the specific mechanisms through which each discrete strategy achieved proximal outcomes that precede guideline fidelity. METHODS:Process tracing with comparative case studies was used to analyze qualitative data from a subsample of 16 implementers participating in a cluster-randomized controlled trial exploring the mechanisms by which a multifaceted strategy affects fidelity to a guideline for prevention of mental problems in schools. The study involved four steps: (1) Organizing a traceable process theory of change; (2) Gathering data to validate, modify, or expand the theory; (3) Coding data through qualitative content analysis; and (4) Causal analysis to articulate the theory's mechanisms, including temporal order and key contextual conditions that explain success or failure. The unit of analysis was implementers who were members of the schools' implementation teams, with each implementer representing a case. RESULTS:The analyses illuminated distinct pathways that explain how each of the five discrete strategies led to implementation success. (1) Organizing Implementation Teams enabled participation in implementation activities, as principals created an environment with dedicated resources, enabling social influences; (2) Educational meetings influenced the decision to implement the guideline through the educators' who promoted knowledge acquisition among the implementers and shaped their beliefs about the implementation; (3) Ongoing Training influenced the intention for implementation and enactment of activities through educators' engaged processes around ongoing acquisition and refinement of skills, which gradually built belief in implementation capability; (4) Small Cyclical Tests of Change influenced behavioral regulation as the workshops engaged repeated engagement in goal setting, action planning, reflection, and adjustment; (5) Facilitation supported implementers' goal setting and prioritization by creating an environmental context, enabling implementers' social influence through receiving social support from facilitators. Unsuccessful pathways for each strategy were also identified and explained. CONCLUSIONS:This study traced the specific sequences of actions and interactions through which five discrete implementation strategies contributed to guideline implementation. The findings illustrate how the mechanisms of the multifaceted strategy can be successfully engaged and why they may fail under certain conditions. TRIAL REGISTRATION:The trial was registered the 9th of August 2021 at Clinicaltrials.gov with Trial registration number: NCT05019937.

This study evaluates cost-neutral food tax reforms integrating climate and health objectives, compared with strictly climate-and health-focused reforms. Results indicate that a strict climate-focused reform risks negative health outcomes, while the strict health-focused reform achieves only 40 % of the climate benefit of the integrated reforms and adversely impacts animal welfare. Integrated tax reforms, however, could reduce Sweden's food carbon footprint by an amount equivalent to an 8 % reduction in passenger car emissions, alongside co-benefits such as decreased pesticide and fertilizer use and lower ammonia emissions. In addition, the healthier diets simulated as a result of the integrated reforms are estimated to save more than twice as many lives as those lost to road traffic fatalities. Furthermore, the strict climate-and health-focused reforms lead to higher food costs, disproportionately affecting low-income groups. The integrated reforms were designed to be cost-neutral by applying subsidies in the form of VAT exemptions on healthy foods or through the redistribution of tax revenues to all citizens. This study demonstrates that it is possible to design food tax reforms to achieve substantial environmental and health improvements while avoiding additional financial burdens on consumers, suggesting a promising pathway for policy development.

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. 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. This 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. 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. 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.

Occupational guidelines exist to support workplaces with the prevention of mental health problems (MHP) among their staff. However, knowledge of effective implementation strategies to support their implementation is limited. This study experimentally tested whether a multifaceted implementation strategy – comprising an educational meeting, five workshops, implementation teams, small cyclical tests of change, and facilitation – improves fidelity to a guideline for preventing MHP in a school setting through the pathway of change of the Capability Opportunity Motivation-Behavior (COM-B)-model. To gain a more granular understanding of the mechanisms of change, the Theoretical Domains Framework (TDF) was used to specify mediators related to capability, opportunity, and motivation. This study tested whether the multifaceted strategy versus a discrete strategy (1) improves fidelity, (2) enhances capability, opportunity, and motivation over time, and (3) if the strategy’s effect on fidelity is mediated by capability, opportunity, and motivation. Fifty-five schools were randomly assigned to a multifaceted strategy or a discrete strategy. Fidelity was measured by questionnaires at baseline and 12 months, while capability, opportunity, and motivation were assessed three times within this period (directly after the educational meeting and at three and nine months). The Determinants of Implementation Behavior Questionnaire was used to assess TDF hypothesized mediators corresponding to the COM-B components. Separate pathways were analyzed for each mediator. Linear Mixed Modeling was employed to test the strategy’s effect on fidelity, and mediation analyses were conducted using the PROCESS Macro. The multifaceted strategy led to improved fidelity at 12 months (B = 2.81, p < .001). Multifaceted schools reported higher scores for all mediators after nine months compared to schools receiving the discrete strategy. The effect of the multifaceted strategy on fidelity was partially mediated by all TDF mediators (p = < .05) except for beliefs about consequences. Capability-related mediators, including skills (Proportion-mediated = 41

AIM:To describe the current approaches to surveillance and use of data on children's growth in the Nordic countries and to reach consensus on how this can be improved. METHODS:Members of the Promoting Healthy Weight in Children (PromoKids) network and additional public health professionals from five Nordic countries described their respective national growth surveillance systems. The various approaches to data collection and consolidation were analysed and compared. RESULTS:In Finland, Denmark, Norway, Sweden and Iceland, all children's weight and height are measured repeatedly at different intervals from birth by child and school health services. However, the data are not consistently registered centrally in all countries for use in public health planning, policymaking and research. Finland and Denmark had the most mature systems for data collection. CONCLUSION:A consensus was reached that surveillance of body weight and height should be a mandatory element of national action plans to prevent and manage growth disorders including obesity, and to identify susceptible population groups. Surveillance protocols should be designed to prevent stigmatisation of children with overweight. Nordic countries should collaborate to accomplish comprehensive data coverage to uncover social inequalities and evaluate societal actions to prevent obesity in children.

BackgroundAlthough the management of psychosocial risks in the work environment represents an evidence-based approach to the prevention of mental health problems, its implementation is limited, including in schools, and knowledge on how to support better implementation is scarce. This study compares the effectiveness of a multifaceted vs. a discrete implementation strategy on fidelity to an occupational guideline for the prevention of mental health problems. Dual perspectives were used to assess fidelity, an important aspect of the measurement agenda.Methods A cluster-randomized controlled trial was conducted among 55 schools in Sweden. A multifaceted strategy (educational meeting, implementation teams, ongoing training, Plan-Do-Study-Act cycles, and facilitation) was compared with a discrete strategy (teams participating in the educational meeting). Fidelity to the guideline's recommendations from the recipients' perspective was measured by questionnaire (Baseline n = 2276; 12 months n = 1891). Fidelity from the implementers' perspective (n = 54) was assessed via a checklist at 12 months. Linear mixed modeling was used. A qualitative approach was applied to analyze the open-ended responses to the checklist.Results Absolute changes in recipient fidelity were observed in all three indicators of the guideline's recommendation 1 (Multifaceted: 13.2 to 19.5%, Discrete: 10.4 to 13.2%). A statistically significant effect was found favoring the multifaceted strategy (d = 0.16). The indicator of recommendation 2 also supported the effect of the multifaceted strategy (Multifaceted: 9.2%, Discrete: 5.0%; d = 0.16). The largest difference between the strategies was observed for recommendation 3, for six indicators (Multifaceted: 0.7 to 13.9%, Discrete:-3.2 to 0.0%; d = 0.19 to 0.41). Convergence was observed between the two perspectives in support of the multifaceted strategy's favorable effect on guideline fidelity compared to the discrete strategy. The findings complemented each other, with implementers describing the activities that were enacted and recipients quantifying the change in fidelity over time.ConclusionsThe multifaceted strategy was more effective than the discrete strategy in fidelity attainment after 12 months. Assessing fidelity from the implementer and recipient perspectives provided an understanding of the contextual functioning of the strategies, highlighting the variation in fidelity and the importance of examining the need for adaptations of strategies during the implementation process.Trial registrationThe trial was registered the 9th of August 2021 at Clinicaltrials.gov with Trial registration number: NCT05019937.

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. 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. A total of 946 parents and 655 children participated. Overall fidelity, assessed as an adherence score, was around 75

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 .

Background: Effective implementation and sustainability of evidence-based public health interventions is vital to reducing the burden of chronic diseases. Suboptimal implementation due to contextual barriers reduce effectiveness and can be difficult to identify and predict. The aim of this study was to investigate the change in readiness and implementation outcomes of school staff implementing the universal family support program A Healthy School Start pre- and post-intervention in three municipalities in Sweden. Methods: Embedded in a hybrid type 3 implementation-effectiveness trial, validated questionnaires were used to assess readiness and implementation outcomes (acceptability, appropriateness, feasibility) at two time points. Data was collected from 39 school principals (implementation leader), 72 teachers (providing a classroom component to children) and 39 school nurses (providing a health talk with parents) between September 2021 – May 2023. A summative score was created for the outcomes. Median and interquartile ranges (IQR) were presented. Results: Readiness scores of all personnel were positively correlated with the acceptability (0.66), appropriateness (0.70), and feasibility (0.71) pre-intervention scores in the municipalities. Three distinct patterns were found in the implementation outcomes in the municipalities (M). In M1, all three implementation outcomes were high pre-intervention (16 IQR:14-19, 16 IQR:15-18, 16 IQR:14-18). Post-intervention acceptability and feasibility significantly decreased (12.5 IQR:9-17 and 15 IQR:9-17). In M2, implementation outcomes were low (12 IQR:10-16, 12.5 IQR:10-16.5, and 12 IQR:8-16) pre-intervention and remained low post-intervention. In M3, all three outcomes were high pre-intervention (16 IQR:14-18, 16 IQR:14-18, 16 IQR:13.5-17.5) and remained unchanged. School personnel in M3 experienced higher readiness and acceptability (53%) than in M1 (45%) and M2 (23%). School nurses scored lower (p=0.059) than principals and teachers regarding their perception of the feasibility of the program both pre- and post- implementation. Conclusion: This study provides useful insights into the implementation of a new school-based family support program in three municipalities. Further studies are needed to identify factors at school and municipality level which may have influenced the school personnel’s readiness to implement the program. A combined pre-implementation assessment of readiness, and acceptability, appropriateness and feasibility could be one way to identify organizations which are not yet ready to adopt a new program. Trial registration: Registered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021

Liselotte Schäfer Elinder Before the COVID-19 pandemic, the prevalence of overweight and obesity in children had continually increased for four decades, reaching a high but relatively stable level in northwestern Europe.1 However, during and after the pandemic, obesity levels have continued to rise,2, 3 calling for strong preventive action from early childhood to adult age. The scoping review by Starnberg and Renström4 on the issue of obesity prevention in children from birth to 7 years of age in the Nordic countries is a welcome contribution to the literature with the potential to guide further action. The Nordic countries have similar prevalences of overweight and obesity in all age groups, and their health care systems are therefore largely comparable. Out of 414 identified papers, 14 randomised and non-randomised studies involving some type of family support were included. While most studies showed improvements in reported diet, some saw effects on physical activity, but none of them reported significant beneficial effects on the overall Body mass index (BMI) z-score in the children. This led the authors to conclude that there is limited evidence for obesity prevention in children in the Nordic countries, that future studies should focus on risk groups, and that interventions should last over several years. Is this conclusion justified? Yes, the evidence for effective obesity prevention among children from birth to 7 years is limited. A global Cochrane review including a meta-analysis on randomised controlled trials of obesity prevention in children 0–5 years5 reported that combined diet and physical activity interventions versus control for preventing obesity led to a small but significant reduction of BMI z-score (mean difference −0.07 kg/m2, 95% CI −0.14 to −0.01) in children aged 0–5 years. The children's mean BMI z-score ranged from 0.15 to 0.98 in the 16 included studies, with a total of over 6000 participants. However, it is not clear if this reduction in BMI occurred over the whole BMI spectrum and thus prevented children from becoming obese or whether the effect was due to a reduction in BMI z-score in children with overweight or obesity, as seen in a study from Sweden.6 Therefore, the Cochrane review does not really answer the question whether obesity was prevented, lowered or both. So even if the evidence on obesity prevention is limited, there is evidence that BMI can be lowered in children in this age group. As pointed out by Starnberg and Renström, we need larger sample sizes and probably more intense interventions to demonstrate the prevention of obesity, such as population-based studies at the national or regional level with long-term follow-up. Only by examining effects on BMI in different weight categories over time, rather than looking at the average change in BMI, can we say for sure if an intervention is preventing or reducing obesity. However, such studies are difficult for researchers to perform on their own considering the need for individual consent from all parents, the risk of selection bias, the high rate of attrition and the need for long-term funding. A more feasible approach would be to gather all data collected regularly by child and school health care in a national registry to be used for research purposes. Finland is the only Nordic country that has succeeded with this so far. Since 2018, Finland has run the national registry FinChildren, covering the ages 2–16 years and including children's height and weight data collected by local child and school health care and transferred to a national registry. The data are used for regular monitoring at the national, regional and municipality levels and also for research purposes, for example, to investigate child obesity in relation to parents' socioeconomic status based on data from 200 000 children.7 Norway has recently started to build a similar system. Thus, the relatively small-scale studies, of which most included less than 500 individuals in the review by Starnberg and Renström, are not able to answer the question if obesity was prevented. On the other hand, most of the included studies could demonstrate improvements in diet and some even a reduction in the BMI in children with obesity, which is a desirable result. After all, we do not want children with underweight or normal weight to decrease their BMI, while we do want all children to improve their diet and metabolic risk factors. With the availability of surveillance data, public health interventions to promote healthy weight could be evaluated on a population basis to see if they work or not. No, in my opinion, there are four strong arguments why we should perform universal interventions in addition to treating obesity in affected children, like the study by Derwig et al.6 First, in children around 6 years of age, the prevalence of obesity is around 5 percent and doubles by the time children are 10 years old in Sweden.8 By only intervening in children believed to be at higher risk today, we would miss out on a high number of children who are at higher risk tomorrow. Second, by selecting only children at higher risk, possibly already overweight, there is a risk of stigmatisation of both parents and children,9 thus contributing to the perception of obesity as a problem caused by the individual. This argument is supported by findings in the Healthy School Start programme, where parents highly appreciated a universal approach.10 Third, all children and their families can benefit from guidance on healthy diets and physical activity with the prospect of lowering their future risk of cardiovascular diseases, type 2 diabetes and several forms of cancer. Therefore, it would be unethical to withhold this information from low-risk children and their families. Fourth, by targeting the whole population in more disadvantaged communities, there is a chance that the focus will fall on the obesogenic environment, leading to multi-level interventions as well. Based on the results from several systematic reviews to prevent childhood obesity, it is fair to conclude that it is possible to reduce the BMI through universal and targeted health promotion and prevention interventions. However, it is challenging to prove this in the Nordic context simply because we have a relatively low prevalence of obesity in children up to 7 years and often limited sample sizes in the studies. Moreover, effects tend to wear off after the intervention ends, underlining the need for continued efforts and long-term follow-up. Establishment of a national registry for children's height and weight based on data that are regularly collected in child and school health care would make it possible to monitor growth and other conditions related to weight and height in different regions and groups in the population and to evaluate large-scale and long-term interventions. But this is not enough. The obesity epidemic will not end without policy changes, as also noted by Starnberg and Renström.4 Regulatory measures will be required to counteract the tsunami of unhealthy foods and drinks that children and their parents are exposed to every day, as also emphasised by the World Health Organization.11 There is hope that things will improve in Sweden in the coming years. The Swedish government's 2023 budget bill calls for an increased focus on health promotion and disease prevention to reach equality in health, prioritising children and youth. In addition, the Swedish Board of Health and Welfare and other national agencies have been assigned to develop a national health programme for children and young people up to the age of 20 years to be finalised in 2026. In summary, let us continue our efforts to improve health-related behaviours among all children and their families and reduce BMI in children with obesity. At the same time, we must pass on the ball to decision-makers to establish a national registry for child health with Finland as a role model, regulate marketing to children and create a healthy and sustainable environment for all to prevent obesity. Liselotte Schäfer Elinder: Conceptualization; writing – review and editing. The author has no conflicts of interest to declare.

AIM: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. METHODS: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. RESULTS: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. CONCLUSION: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.

Food security is of vital importance for human existence. Yet, global food production has huge environmental impacts which increasingly threaten food security. Today, food production occupies around 40% of all ice-free land surface, contributes about 25x0025; of all human-induced greenhouse gas emissions, and is the largest driver of deforestation. Moreover, it accounts for about 70% of the Earth’s freshwater withdrawals and is driving nitrogen and phosphorus eutrophication and acidification of the Earth’s ecosystems.

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.

The 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. HSSP 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). Parental 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. Barriers 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. The 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.

Objectives This study aimed to compare the effectiveness of the multifaceted implementation strategy (multi-faceted group) versus a discrete implementation strategy (discrete group) for implementing the Swedish Guide-line for the Prevention of Mental Ill-health Problems at the Workplace on the primary intervention outcome - exhaustion - and secondary outcomes of stress, health, recovery, psychosocial safety climate, and social and organizational risk factors. Another aim was to examine whether the primary and secondary outcomes differed on the basis of guideline adherence levels, irrespective of the group. Methods A cluster-randomized waiting-list controlled trial with 6-and 12-months follow-up was conducted among 19 Swedish public schools. Primary and secondary outcomes as well as guideline adherence were assessed by self-reported questionnaire. Linear mixed modeling was used to compare differences in outcomes between the groups from baseline to 6 and 12 months, and in relation to different adherence levels. Results The trial comprised 698 employees (83.1%) participated. There were no differences between groups in the primary and secondary outcomes at 6 months, while at 12 months differences were observed for some outcomes to the advantage of the discrete group. Better guideline adherence was associated with improvements in exhaustion at 12 months and the secondary outcomes of psychosocial safety climate, work organization and job content, interpersonal relations and leadership, and recovery over 6 and 12 months. Conclusion The multifaceted implementation strategy was no more effective than the discrete strategy in improv-ing health outcomes or organizational and social work environment. However, higher adherence to the guideline was associated with larger improvements in health outcomes and organizational and social work environment, irrespective of the implementation strategy used.

Background and objectivesCurrent dietary habits have substantial negative impacts on the health of people and the planet. This study aimed to develop a novel approach for achieving health-promoting and climate-friendly dietary recommendations for a broad range of consumers.Subjects and methodsHierarchical clustering analysis was combined with linear programming to design nutritionally adequate, health-promoting, climate-friendly and culturally acceptable diets using Swedish national dietary data (n = 1797). Diets were optimised for the average consumption of the total population as well as for the dietary clusters.ResultsThree dietary clusters were identified. All optimised diets had lower shares of animal-source foods and contained higher amounts of plant-based foods. These dietary shifts reduced climate impacts by up to 53% while leaving much of the diet unchanged. The optimised diets of the three clusters differed from the optimised diet of the total population. All optimised diets differed considerably from the food-group pattern of the EAT-Lancet diet.ConclusionsThe novel cluster-based optimisation approach was able to generate alternatives that may be more acceptable and realistic for a sustainable diet across different groups in the population.

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