# “The missing piece in the puzzle” - Success factors and barriers for scale-up and sustainment of the Healthy School Start program

## TL;DR

This study explores what helps or hinders the long-term success of a school-based program to prevent child obesity in Sweden.

## Contribution

Identifies success factors and barriers for scaling up and sustaining a health promotion program in schools.

## Key findings

- Dedicated leaders and program integration into school routines support program sustainment.
- Barriers include lack of prioritization, high workload, and staff turnover.
- Program integration into yearly quality assessments may help achieve long-term success.

## Abstract

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.

The online version contains supplementary material available at 10.1186/s13690-026-01835-0.