From leadership research to district action: “The missing piece in the puzzle” - Success factors and barriers for scale-up and sustainment of the Healthy School Start program

AI-assisted editorial implementation guide. Proposed district actions are separate from the original authors’ findings and recommendations. Independent peer review of this guide is not asserted.

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Evidence and transfer

Education-related source: verify which participants, institutions and outcomes were actually studied before district adoption. Source publication type: research-article. License and identity checks do not establish study quality or causality.

Original authors’ abstract, reproduced under the source license:

Abstract Background 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. Methods 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. Results 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. Conclusion 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. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-026-01835-0. Keywords: Implementation success, Scale-up, Sustainment, Health promotion, Parental support, Decision-makers, Children, Obesity, Overweight

Study methods

This study used a qualitative explorative design. Data were analyzed using reflexive thematic analysis within a constructivist paradigm [39], with the aim of capturing how stakeholders in leadership positions perceived program implementation [40]. This methodology allowed for an in-depth exploration and understanding of the participants’ perspectives, and subsequent identification of success factors and barriers, acknowledging how researchers participate in shaping knowledge in their interaction with participants and data [41]. Furthermore, the Theory of Organizational Readiness for Change [30] was applied. This approach provided insights that can assist practitioners and implementation scientists in operationalizing and applying our findings in similar settings. This study followed the Consolidated Criteria for Reporting Qualitative Studies Questionnaire (COREQ) (see Additional file 1) [42].

Limitations

A methodological strength of this study was the well-structured recruitment framework, which ensured transparency and rigor by inviting all municipality leaders and principals involved in the decision-making process and the implementation of the HSS program. This careful mapping and identification of potential participants contributed to the multivocality and supported credibility and dependability [70] in this study. This comprehensive approach in the data collection process is aligned with the Criteria for Excellent Qualitative Research [70]. Similarly, in line with ethical and rigorous qualitative research practices [70], efforts were made to include a group of stakeholders as diverse and broad as possible, despite some participants being unable or willing to participate in the interviews. The concept of information power was applied to determine our sample [49], thereby contributing to the study’s rich rigor [70]. Accordingly, the aim of this study is narrow, the sample specificity was dense, and the Theory of Organizational Readiness for Change [30], was applied which contributed to a higher information power by adding to the depth of the analysis and thereby supporting the generation of relevant and meaningful themes.

A 90-day district inquiry

Days 1–15 · Appraise. Read the source methods, recruitment, comparator, outcomes and limitations. Record how the study setting differs from your district and which claim the design can support.
Days 16–30 · Design. Choose one school improvement question with teachers. Protect a short shared planning cycle, agree an instructional change and use a common rubric for examining student work. Agree participation, privacy protections, baseline and stopping rules before starting.
Days 31–60 · Observe. Collect the pre-agreed measures, keep a log of implementation changes and invite confidential voluntary feedback. Preserve existing support for staff and learners.
Days 61–90 · Decide. Review implementation fidelity, teacher time and independently scored student work against a recorded baseline. Examine access differences and competing explanations before attributing changes to leadership. Make a dated decision to stop, revise or extend the inquiry.

Board decision brief

Present the local problem, source setting, evidence limits, intervention, responsible owner, total cost, measured changes and uncertainty. Separate staff perceptions, implementation measures and student learning outcomes.

Attribution and reuse

Jhon Álvarez Ahlgren; Kristi Sidney Annerstedt; Liselotte Schäfer Elinder; Susanne Andermo. “The missing piece in the puzzle” - Success factors and barriers for scale-up and sustainment of the Healthy School Start program. Archives of Public Health (2026-01-09). https://doi.org/10.1186/s13690-026-01835-0

Prepared 2026-11-07. Source authorship and DOI are preserved. The abstract and source passages are attributed extracts; this editorial guide is offered under the same CC BY 4.0 license.