The SCIP-school project is a two-year evidence-informed health intervention in compulsory school using a participatory and flexible approach with a systematic delivery based on the literature on factors influencing successful implementation . Fidelity to the programme, consisting of school self-assessment of health practices and environments, participation of staff in four workshops, four training sessions, writing of action plans and parent gatherings was almost complete, demonstrating feasibility. In contrast, fidelity to school’s own action plans was only 48%, yet positive impacts on self-reported school practices and environments, measured by the KEY, were seen in the modules physical activity, mental health and nutrition. Also, a tendency for a dose effect was found between low and high implementation schools in some of the modules. Our findings demonstrate that school staff had the will and the capacity to create their own solutions on the basis of a self-assessment and facilitation by external agents. The type and number of measures in the action plans varied, which we believe is an indication that local needs and interests were being considered, which is a success factor for implementation .
With regard to outcomes at student level, we could not show any improvements due to intervention with regard to diet, physical activity, self-esteem or weight status. No adverse effects on weight status, self-esteem or dieting were noted either. There might be several reasons for this apparent lack of intervention effect at student level. First, school action plans might have been insufficient due to lack of effective components. All components identified as part of effective interventions  were mentioned in the action plans, but not all schools included all components. Therefore, a likely explanation would be that action plans were not comprehensive enough and/or the degree of implementation was too low. On average schools fully implemented only 48% of the measures planned. In order to monitor implementation of each measure more closely, the quality and quantity ought to be assessed both with regard to the dose delivered and the dose received. In the implementation literature, a greater conceptual clarity in defining key implementation constructs has been called for , and we suggest that in future studies more emphasis is placed on specific and objective implementation indicators. Second, actions were not always relevant to students’ health needs. Results from the student’s questionnaires were not available at the time of writing of action plans. Therefore, the action plans probably reflected the interest of the health teams more than the needs of students, which is an important fact to consider for the future when using a participatory approach. Indeed, research has shown that programmes with a specific behavioural focus on e.g. vegetables are more effective than those addressing nutrition in general . Third, the health behaviour questionnaire, which covered the past week, might not have been sensitive enough to detect changes, although it was as valid and reliable as similar questionnaires used by others [37, 38]. Fourth, effects might have worn off after two years, because according to the KEY-scores, the programme was more intense at year 1. Fifth, the health behaviours of children in this middle-class municipality were already relatively good at the start of the programme and might be difficult to improve further. Compared to results in the WHO-study Health behaviours of school children, where 85% of Swedish children reported that they watched TV at most 3 hours on a week day, in the SCIP-cohort this was 93% . In the Health behaviours of school children study, 80% of 13-year old children had breakfast every week day whereas in the SCIP-cohort it was 86%. Also, the obesity prevalence was around 3%, which relatively low in an international comparison. In future interventions the needs assessment should be based on local data and not just general data for the country.
Other complex community-intervention projects targeting diet and physical activity in schools with a capacity-building, multi-component and flexible approach have been more successful. The Be Active Eat Well programme from Australia , a quasi-experimental study, was effective in slowing the rate of weight and waist gain in children by 0.1 units in BMIsds over 3 years. This comprehensive programme used multiple intervention strategies implemented to varying degrees in different schools, as in the present study. Advantages of such approach, mentioned by the authors, are flexibility and local adaptation, promotion of sustainability, the possibility of scaling up by external funding, and can lead to local health promoting policy development and decreasing health inequalities. Another school-based 4-year intervention from the USA, used the School Health Index as a tool for self-assessment and a planning guide with a participatory approach  very similar to our programme and showed reductions in child obesity among disadvantaged school children, which could be enhanced by addition of community actions. In both of these countries obesity prevalence among children is 2-3-fold higher than in Sweden, which increases the chance of a favourable outcome. A similar participatory and tailored approach is recommended in Canada and is called Comprehensive School Health involving both education and changes in the school environment . Using this approach in schools in socioeconomically disadvantaged areas has shown promising results with regard to healthy behaviours and obesity prevention . In each school a full-time school health facilitator was placed, who coordinated all actions. This is certainly an advantage but also costly for the community.
It seems to us and others  that a participatory approach based on local needs is the way forward with regard to school health promotion because it may lead to capacity-building and to potentially sustainable changes in the school environment. The will to participate in modifications to the school environment was also found in an interview study with principals and food service managers from the US . On the other hand this approach presents a number of challenges to the researcher with regard to planning and evaluation by allowing for choice and local autonomy. Furthermore, we have to acknowledge that student health is one priority area among multiple competing demands in schools, the most important being academic achievement. Therefore, initiatives should be framed in terms of their potential impact on academic achievement, if possible. Greater effort should be put into buy-in of the project among all school staff, not only headmasters or health teams. This is to ensure that all participants share the same vision, which should lead to higher fidelity to local action plans and long-term support for the programme . However, in spite of all our efforts action started to decline already after the first year of intervention, when the initial enthusiasm seems to have decreased suggesting that more support and guidance is needed in order to maintain the programme. Provided that extra resources can be found, we believe that the Canadian approach using school health facilitators in disadvantaged areas  could be a way forward also in Sweden. This would also demonstrate commitment to school health promotion at the community level, which is obviously needed for the sustainability of this work.
Second, health teams should receive stronger guidance in addressing health needs of students in their action plans, as well as on effective measures. We are currently working on a web-based system for student questionnaires, allowing a rapid feed-back of results to schools. Such local data collection and feed-back system has already been developed in Canada called SHAPES, where it has been widely disseminated . Regarding the Swedish context, we believe that school health care staff must play a central role in needs assessment, because they have the mandate and the health competence to collect and analyse such data, which could be used strategically in the schools’ health promotion work. In our experience, school staff like to develop their own measures. We have to find the right balance between this desire and guidance in working evidence-based by making the scientific literature available to the staff in an adequate format (written material or lectures) and guide the writing of action plans more strongly. The need for programmes that can be embedded into school routines and which do not demand too many external resources has been emphasised . School health teams should set their own goals but researchers should advise the strategies based on evidence. A way forward could be to use a stepwise approach to implementation of action plans and introduce and evaluate one component at the time, e.g. outdoor education or improved meal services, with regard to both process and outcome before introducing the next. Clearly such approach would require long-term commitment and monitoring of outcomes and randomisation of schools might not be possible.
Strengths and limitations
The strength of our approach is that it builds on implementation and sustainability research, and is applied in a “real-world” situation. After the intervention ended interviews were performed with school staff to analyse barriers and facilitators of implementation and analysis is on-going.
There are some limitations to our study. First, all outcomes at school and student level (except for body weight and height) were self-reported and as such prone to reporting bias. Fidelity and impacts at school level, as reported by health teams in interviews and with the KEY, could therefore have been biased in favour of the intervention. However, self-evaluation is part of an effective participatory approach , but could be substantiated through observations in schools. Second, the design was quasi-experimental, and there is a risk of selection bias in favour of more interested schools, which could explain the positive effects seen at school level. Third, the participatory approach resulting in tailored and distinct but complex school action plans is a strength with regard to ownership and capacity-building, but also a weakness with regard to evaluation, because the measures chosen and the dose varied between schools.