Contextual factors in the implementation of the family support program A Healthy School Start in three municipalities in Sweden

Abstract 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