A Multi-Site Study of implementing a School-Based Health Promotion Intervention in Sweden – Changes in Readiness and Implementation Outcomes

A Multi-Site Study of implementing a School-Based Health Promotion Intervention in Sweden – Changes in Readiness and Implementation Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Multi-Site Study of implementing a School-Based Health Promotion Intervention in Sweden – Changes in Readiness and Implementation Outcomes Kristi Sidney Annerstedt, Lydia Kwak, Susanne Andermo, Emma Patterson, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8410429/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background : Effective implementation of evidence-based interventions is essential to reducing the disease burden. Contextual barriers can hinder implementation and reduce effectiveness. Assessing readiness early in the process may identify challenges and improve outcomes such as acceptability, appropriateness, and feasibility. This study examined changes in readiness and implementation outcomes among school staff implementing the Healthy School Start program in three Swedish municipalities M1, M2 and M3. Methods : Embedded in an implementation-effectiveness trial, validated questionnaires were used to assess readiness, acceptability (ACC), appropriateness (APP), and feasibility (FEAS) pre- and post-intervention. Data were collected from 39 school principals, 72 teachers, and 39 school nurses between September 2021 and May 2023. Summative scores were generated for each outcome using medians and interquartile ranges (IQR). Mixed-effects linear regressions were conducted to analyze change, adjusting for pre-intervention scores, professional group and clustering by school. Results : Adjusted analyses showed a significant increase in readiness post-intervention (β = 0.47, p < 0.001, 95% CI: 0.25–0.70) in the total sample. ACC, APP, and FEAS scores also increased significantly from pre- to post-intervention (ACC: β = 0.56, p < 0.001; APP: β = 0.45, p < 0.001; FEAS: β = 0.43, p = 0.001). While M3 showed significantly higher post-intervention readiness (β = 5.93, p = 0.014, 95% CI: 1.19–10.68) and FEAS compared to M1 (β = 2.67, p = 0.009, 95% CI: 0.67–4.66), no significant differences were found for ACC or APP between municipalities after adjustment. Across professional groups, school nurses reported lower feasibility pre-intervention compared to principals and teachers, but differences were not statistically significant after adjustment. Nearly half of participants in M2 scored in the “Low Readiness–Low Feasibility” quadrant, while over half in M1 and M3 scored in the “High Readiness–High Feasibility” quadrant. All M3 schools opted to continue the program into the subsequent year. Conclusion : This study provides novel empirical insight into school personnel’s preparedness to implement a new health program. Findings highlight that readiness and implementation outcomes can vary across settings, underscoring the need to address context-specific factors to strengthen implementation before starting the process. Trial registration: Registered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021 Readiness Acceptability Appropriateness Feasibility Hybrid type 3 study Implementation Schools Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Interventions to promote health and prevent obesity should start at an early age and target the whole family, and schools are an ideal setting for the delivery of health programs, particularly for children 6–12 years of age ( 1 , 2 ). Effective school-based programs are characterized by active parental involvement, especially for younger children ( 3 , 4 ). However, health promotion and prevention programs in schools involving parents can be challenging to implement since some school principals are uncertain about whether it is the role of the school to provide health guidance to parents ( 5 ) in addition to teaching children. Teachers describe barriers like the dense curriculum, lack of planning time, lack of support from principals and other personnel, and how projects come and go without feedback or sustainability ( 6 ), in addition to lack of parental engagement ( 5 ). In addition, while school nurses tend to see health promotion as their main obligation, they often feel overburdened and left alone with this task ( 5 ). Moreover, school resources are limited, and the workload is perceived to be high ( 5 , 7 ). While school is often considered to be a key setting for promoting healthy eating and physical activity for children, there appears to be a ‘responsibility conflict’ ( 8 ). Therefore, when planning to implement health promotion activities in the school setting, leadership and clear guidance from national and/or local government is needed to increase the readiness of the organization ( 9 , 10 ). When readiness is high, members are more likely to initiate change, and display more cooperative behavior, which overall results in more effective implementation of the proposed change ( 9 ). Important preconditions for success are that stakeholders have the same information, experience, and values before the start of an implementation process. Aarons and colleagues ( 11 ) emphasize four central factors for an organization to achieve readiness: 1) Employees must perceive the change as beneficial to themselves; 2) they must feel that they are capable of implementing the change; 3) they must believe that the change can lead to a desirable result; and 4) that both formal and informal leaders are committed to the change. Readiness has been proposed as a precursor of early implementation outcomes like acceptability (ACC), appropriateness (APP), and feasibility (FEAS) ( 12 ). A receptive context increases the likelihood of successful integration and adoption of a new program, ensuring their perceived ACC and APP within the organizational setting. However, while a program may be found acceptable by the stakeholders and appropriate for a given setting, it may not be feasible, typically due to lack of resources or competence of the providers. While conceptually distinct, evidence suggests that these implementation outcomes are highly correlated and could serve as proxies for each other ( 13 ). Understanding readiness, ACC, APP and FEAS early in the research process could help ensure that interventions and implementation strategies are optimized, fit with end-users’ preferences, can be scaled up and are sustainable. The present study was performed during the first year of scaling up the universal Healthy School Start (HSS) program in compulsory pre-school class or grade one within three different municipalities in the Stockholm region in Sweden ( 14 ). The HSS program is an evidence-based family support program to improve diet and physical activity and prevent or reduce obesity. The program has been evaluated at the school level in three separate cluster randomized controlled trials and shown effectiveness in improving dietary habits and physical activity ( 15 – 17 ), and in reducing BMI in children with obesity ( 18 ). These results are in line with other studies showing that school-based health promotion programs with direct parental involvement, especially for children up to 12 years which simultaneously address multiple behaviors in the school and home environments, can be effective ( 3 , 19 , 20 ). When designing the HSS program, great efforts were made to align the program with the Education Act and the National Curriculum which mandates health promotion as part of school responsibilities, and the Guidelines for School Health Services, in order to facilitate implementation. The field of organizational change, particularly in education and public sector settings, has long recognized that the successful adoption of new programs depends not only on program alignment with existing policies but also on broader system-level factors such as governance structures, leadership, and institutional capacity. In Sweden, most schools operate under local municipal governance and vary widely in resource allocation, socio-demographic profiles and staff qualifications. These contextual differences are known to play a critical role in implementation success within the school setting ( 10 , 21 , 22 ). The readiness for organizational change theory is well established and describes a shared psychological state in which organizational members feel committed to implementing an organizational change and confident in their collective abilities to do so ( 9 ). However, there remains limited empirical research that quantitatively assesses readiness for change in real-world school settings, particularly in relation to health promotion interventions ( 23 ). Specifically, there is a gap in studies that examine individual readiness for change and how this correlates with the individuals’ perception of ACC, APP, and FEAS of the intervention during early implementation. To address this gap, the present study assessed at the individual provider level the readiness and early implementation outcomes (ACC, APP, FEAS) before and after the delivery of a one-year family support intervention in three Swedish municipalities as part of a hybrid type 3 effectiveness-implementation study. This could contribute to new insights into how varying levels of pre-implementation readiness and context affect implementation outcomes, and what type of support or tailoring may be needed to enhance program adoption ( 24 ). The specific aims of this study were to 1) investigate changes in perceived readiness, ACC, APP and FEAS to implement the HSS program in the three municipalities and differences between professional groups (principals, teachers, school nurses), pre- and post-intervention; 2) to explore the correlation between perceived readiness and the three implementation outcomes. Methods Intervention The HSS program is implemented in schools by a team led by the principal or vice principal in collaboration with the school nurse and teachers. It includes four components: brochure with health information sent home to the parents, health talks using motivational interviewing given by the school nurse along with the parents, nine classroom lectures led by teachers with homework assignments to be completed with the child’s parents or guardians (henceforth referred to as parents), and an online risk test with eight questions for type 2 diabetes done by parents. The program was implemented in three municipalities in Stockholm County starting in 2021 in a hybrid type 3 implementation-effectiveness study called IMPROVE: IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity ( 14 ). The IMPROVE study is evaluating two bundles of implementation strategies (Basic and Enhanced) on the primary outcome of fidelity to the four program components after two years of implementation. A detailed study protocol including the SPIRIT checklist is published elsewhere ( 14 ). Study context In Sweden, schools are governed by the Education Act (§ 2010 − 800). Health promotion efforts are outlined in the National Guidelines for school health care ( 25 ) while the National Curriculum (Lgr22) sets the goals for learning. The guideline for school health care mandates that health promotion regarding healthy eating and physical activity should be included. The school nurse carries out a routine general health check with every child and their parents in either the compulsory preschool class (when the child is aged 6–7 years) or first grade (child aged 7–8 years). The HSS program was implemented in the same year as the routine health check with parents was scheduled: preschool class in Municipality 1 (M1) and Municipality 2 (M2) and in first grade in Municipality 3 (M3). Relevant characteristics of the three municipalities are shown in Table 1 . Table 1 Description of the population, schools and health in involved municipalities (M) Sweden M1 M2 M3 Population characteristics Number of inhabitants 1 10 400 000 113 951 50 273 101 209 Median income per year (SEK) 1 460 000 333 318 306 861 288 880 Proportion with employment (%) 1 68.8 79 77.3 75.3 Proportion unemployed (%) 1 7.4 7.4 9.1 11.4 Proportion with ≥ 3 years university education 25–64 years (%) 1 30.3 32.4 21.9 22.3 Proportion of inhabitants with ≤ 9 years of schooling 1 25–64 years (%) 10 10 14 17 Proportion of foreign-born inhabitants (year 2021) 1 (%) 20.0 30.8 36.2 42.4 School characteristics Proportion of teachers with certificate (%) 2 71.0 74.5 59.9 66.7 Number of eligible public primary schools Na 25 13 19 Number of schools adopting the program Na 15 13 19 School rank out of 290 municipalities (combination of teachers’ salary, teachers’ health and teacher density) 3 Na 214 219 Density of students per teacher (rank out of 290 municipalities) 3 Na 288 251 200 Health Indicators Overweight (not obesity) 4-year olds born 2017 (%) 4 10.9 9.4 11.7 11.4 Obesity 4-year olds born 2017 (%) 4 or 2016 5 2.9 4.1 5.3 5.1 3-year olds with caries born 2019 (%) 4 Na 3.7 5.4 3.3 Overweight and obesity in individuals ≥ 16 years (self-reported) (%) 6,7 51.0 51.3 53.5 56.1 Diabetes in individuals ≥ 16 years (self-reported) (%) 6,8 4.4–5 3.3 6 6.1 1 Central Bureau of Statistics – Statistiska Centralbyrån SCB. Kommuner i siffror [Internet]. Stockholm: SCB; 2021/2022; 2 Skolkollen.se 2023; 3 Swedish Teacher’s Union – Lärarförbundet. Bästa skolkommun - resultat och historik [Internet]. Stockholm: Lärarförbundet; 2021. The ranking is based on quality with determinants such as amount of resources, number of children in preschool class, educated and healthy teachers, teachers per student, and student gradings. Low number corresponds to high ranking. 4 Barnhälsovårdens Årsrapport 2022 (Yearly report Child Health Care), Region Stockholm. 5 Miregård et al. Acta Paediatrica 2023 6 Folkhälsokollen.se, Region Stockholm, 7 Public Health Agency of Sweden, 8 Diabetics Association in Sweden Table 1 : Description of the population, schools and health in involved municipalities (M) Pre-implementation phase In 2020, the research team contacted eight municipalities with a high prevalence of childhood obesity among 4-year-old children in Region Stockholm to explore their interest in participating in the IMPROVE study. Three central administrative leaders from the municipalities expressed interest. After an introduction to the program, two municipalities agreed to participate while the third delayed their participation by one year due to the COVID-19 pandemic. Table 2 provides a timeline of the stakeholder engagement activities after recruitment at the municipality and school level and training of school personnel. One of the aims of the program ( 14 ) was to strengthen collaboration between school and primary health care. Therefore, primary health care staff were involved in the initial workshops to identify barriers and facilitators and develop suitable implementation strategies. Table 2 Pre-implementation activities and timeline in the three municipalities Activity Date Stakeholder 1st online workshop to identify barriers and facilitators to implementation Fall 2020 School and primary health care representatives from M1 and M2 2nd online workshop to discuss and decide implementation strategies based on barriers and facilities from the 1st workshop Spring 2021 School representatives from M1 and M2 Introduction of each professional group to the HSS program and IMPROVE study by research team Spring 2021 Principals, teachers, and school nurses M1 and M2 Online 2-day training in Motivational Interviewing (MI) adapted for the HSS program Spring 2021 School nurses in M1 and M2 Onsite 2-day MI training in Motivational Interviewing adapted for the HSS program Spring 2022 School nurses in M3 Introduction of each professional group to the HSS program and IMPROVE study by research team Spring 2022 Principals, teachers, and school nurses from M3 Table 2 : Pre-implementation activities and timeline in the three municipalities School principals were informed about the municipality’s intention to implement the program in all public schools, which they then communicated to their personnel. If a school had special reasons or circumstances such as staff shortages, the principal had the possibility to decline participation. A written agreement was signed between the municipalities and Karolinska Institutet to conduct the IMPROVE study during 2021 to 2024. All introductory meetings were given online for about one hour separately for each professional group (principals, teachers and school nurses) and participants were given the opportunity to ask questions. A website was developed for the program in Swedish and included all necessary information and program materials. Lectures in public health for school personnel given by experts in the area were available on the website. The program material including the implementation manual and the teacher’s manual was made available to school personnel two to three months before the start of the program. Study participants The total number of participating schools was 15 (60%) in M1, 13 (100%) in M2 and 19 (100%) in M3. All school personnel working with the HSS program were invited to participate in the IMPROVE study. We used data collected from school leadership (i.e., principals and vice principals), school nurses and teachers, all referred to as school personnel henceforth ( 14 ). We used an open cohort design since some teachers and a few school nurses started or ended their employment during the study period. In addition, in M3 the teacher implementing the classroom component changes each year (i.e., the teacher stays with students up to grade 3), thus in M3 each school year a new group of teachers entered the IMPROVE study. Data collection and instruments used Acceptability (ACC) is the perception among implementation stakeholders that a given intervention or innovation is agreeable, palatable, or satisfactory. Appropriateness (APP) expresses the perceived fit, relevance, or compatibility of the intervention for a given setting, provider, or consumer; and/or perceived fit of the intervention to address a particular problem. Feasibility (FEAS) is defined as the extent to which a new intervention can be successfully carried out within a given setting ( 26 ). ACC, APP, and FEAS were assessed with a short and validated tool ( 13 ) translated to Swedish (Additional file 1). Each outcome consists of four items answered on a 5-point Likert scale with a total score between 4 to 20 points per outcome. Readiness was assessed with a modified version of the Organizational Readiness for Implementing Change (ORIC) tool developed by Shea et al. ( 27 ) and adapted into a Leader Readiness to Implement Tool (LRIT) answered by school principals and a Staff Readiness to Implement Tool (SRIT), answered by school nurses and teachers (Additional file 2). The scales have been validated in the Swedish context (A Toropova et al., submitted for publication). The respondent answers for him/her-self instead of on behalf of the school (all items start with “I who work here…” instead of “People who work here...”) as in the original scale. LRIT and SRIT consisted of 13 items each answered on a 5-point Likert scale as follows: 1 = Disagree, 2 = Somewhat disagree, 3 = Neutral, 4 = Somewhat agree, and 5 = Agree. The tools were translated to Swedish and back translated to check for accuracy and minor adjustments were made. Data collection was performed by electronic questionnaires using the secure web platform Research Electronic Data Capture (REDCap) between September 2021 and June 2023. An informational email was sent to all invited school personnel detailing the study and consent to participate. A link to the survey was included at the end of the email. The survey had three parts: a section with sociodemographic questions, the ACC, APP, and FEAS questionnaires, and lastly the LRIT and SRIT questionnaires. School personnel answered the questionnaires individually online during working hours at their school. Responses were collected after the HSS program had been introduced to the school personnel, but before the implementation had started in September-October and again post-intervention in May-June the following year. Automatic reminders were scheduled and sent weekly through REDCap up to three times after the initial invitation. Organizational changes in the school were documented. This included changes within the school leadership (principal or vice principal), school nurse, teachers or other school reorganizations. The data was collected during visits made to each school in April-May 2022 (in M1 and M2) and April-May 2023 (M3) to review the performance of implementation strategies and through consultations with the municipality administration. It was hypothesized that organizational changes could impact on the outcomes of interest. Organizational instability per school was defined as any change to school personnel implementing the HSS program. The school was coded as 1 if there was school personnel turnover and 0 if there was no school personnel turnover. Statistical analysis A summative score was created for readiness (leadership and staff together) and ACC, APP, FEAS respectively at pre- and post-intervention time points. Descriptive statistics were presented as median and interquartile range (IQR). The data was tested for normal distribution using the Shapiro–Wilk normality test. Boxplots graphs were presented and included the median, IQR, minimum and maximum values for readiness, ACC, APP and FEAS. Mixed-effects linear regression models were used to assess changes in post-intervention readiness, ACC, APP, and FEAS between municipalities, adjusting for pre-intervention scores and accounting for clustering at the school level. The model was also adjusted for profession of school personnel. Robust standard errors were applied to improve the reliability of estimates in the presence of mild non-normality. P-value < than 0.05 was considered statistically significant. Model assumptions, including normality of residuals and homoscedasticity, were assessed through visual inspection of Q-Q plots and residuals vs. fitted values. There were 44 clusters (schools) and the average cluster size was 2.2. Correlation coefficients were presented for ACC, APP, and FEAS in relation to the readiness score. A scatter plot graph was used to display the correlation between FEAS median and readiness with leadership and staff represented in the same graph. Four quadrants were created based on the median values of the FEAS and Readiness scores as follows: Quadrant I: FEAS 4–14 and Readiness 10–37 deemed “Low FEAS and Readiness”; II: FEAS 4–14 and Readiness 38–52 deemed “Low FEAS and High Readiness”; III: FEAS 15–20 and Readiness 10–37 deemed “High FEAS and Low Readiness”; IV: FEAS 15–20 and Readiness 38–52 deemed “High FEAS and Readiness”. Results A total of 57 schools were eligible for inclusion; 10 schools in Municipality 1 (M1) declined participation, citing organizational changes or staff shortages. Figure 1 illustrates the flow of school and personnel enrollment across the study period. Of the 229 eligible individuals, 150 (66%) completed the pre-intervention survey. Characteristics of school personnel by municipality are presented in Table 3 . The only significant difference between municipalities was years of work experience, which was higher in M1 than in M2 and M3 (p = 0.02). Organizational instability affected more than half of the schools in M2 (7/13, 54%), compared with 40% in M1 (6/15) and 16% in M3 (3/19). Table 3 Characteristics of school personnel pre-intervention by municipality. Participant characteristics Total n = 150 Municipality 1 n = 45 Municipality 2 n = 41 Municipality 3 n = 64 P-value Age mean years (SD) 46.4 (9.7) 48.5 (6.3) 46.4 (9.9) 44.9 (11.2) 0.16 * Female n (% in municipality) 140 (93) 41 (91) 39 (95) 60 (94) 0.39 ** Professional title Principal/Vice-Principal n a 39 ( 26 ) 11 ( 24 ) 11 ( 27 ) 17 ( 27 ) 0.86 ** Teachers n (%) 72 (48) 23 (51) 17 (41) 32 (50) School Nurses n (%) 39 ( 26 ) 11 ( 24 ) 13 ( 32 ) 15 ( 23 ) Work experience in the field median years (IQR) 7 ( 3 , 15 ) 11 ( 4 , 20 ) 5 ( 2 , 15 ) 6 (2,10.5) 0.02 † Work experience in the current school median years (IQR) 4 ( 2 , 6 ) 4 ( 2 , 6 ) 4 ( 2 , 8 ) 3 ( 1 , 6 ) 0.50 † SD: standard deviation; IQR: Interquartile range. Organizational instability per school was defined as any change to school personnel implementing the HSS program. *ANOVA; **Pearson’s Chi-Squared test; †Kruskal-Wallis Figure 1 : Flow chart describing the process of enrolling schools and personnel in the three municipalities . Table 3 . Characteristics of school personnel pre-intervention by municipality. Changes in Readiness, Acceptability, Appropriateness, and Feasibility Readiness The median readiness score among all personnel was 38 (IQR: 26,43) pre-intervention and decreased to 33 (IQR: 25,41) post-intervention. When looking at the change in each municipality separately, three different pictures emerged. Readiness declined in both M1 (from 38 to 30) and M2 (from 29 to 27), with the largest decrease in M1 (Fig. 2 ). In contrast, M3 showed no change (median 39 at both time points). Figure 2 : Boxplot graph of Readiness to Implement (RIT) score from pre-intervention to post-intervention in the three municipalities. In the adjusted model (Table 4 ), readiness increased significantly from pre- to post-intervention (β = 0.47, p < 0.001, 95% CI: 0.25,0.70) (Table 4 ). Furthermore, M3 reported significantly higher readiness post-intervention compared with M1 (β = 5.93, p = 0.014, 95% CI: 1.19,10.68). Table 4 Difference in readiness (model 1), acceptability (model 2), appropriateness (model 3) and feasibility (model 4) from pre- to post-intervention and between municipalities. Outcome N Β p-value 95% CI Model 1: Readiness 91 0.47 0.000 0.25,0.70 M1 Reference M2 1.48 0.6 -4.06,7.02 M3 5.93 0.014 1.19,10.68 Model 2: Acceptability 101 0.56 0.000 0.33,0.78 M1 Reference M2 0.28 0.819 -2.10,2.66 M3 1.53 0.085 -0.21,3.28 Model 3: Appropriateness 98 0.45 0.000 0.24,0.66 M1 Reference M2 -0.67 0.602 -3.18,1.84 M3 0.61 0.545 -1.38,2.61 Model 4: Feasibility 98 0.43 0.001 0.17,0.69 M1 Reference M2 1.09 0.403 -1.46,3.64 M3 2.67 0.009 0.67,4.66 M = municipality; adjusted for pre-intervention scores and professional groups. Β – beta coefficient. CI- confidence interval. Models were adjusted for pre-intervention scores, clustering at the school level and the type of profession of school personnel. Table 4 : Difference in readiness (model 1), acceptability (model 2), appropriateness (model 3) and feasibility (model 4) from pre- to post-intervention and between municipalities 1 . Acceptability (ACC) The median pre-intervention total ACC score was 15 (IQR: 12,18) and decreased to 14 (IQR:10,17). At pre-intervention, M2 reported lower median ACC (12, IQR:10,16) compared to M1 (16, IQR:14,19) and M3 (16, IQR:14,18) (Fig. 3 ).The post-intervention scores decreased for M1 (12, IQR:9,16) and M2 (11.5, IQR:10,16) but stayed the same in M3 (16, IQR:13,18). In the total sample after adjustment, ACC increased significantly post-intervention (β = 0.56, p < 0.001, 95% CI: 0.33,0.78), with no remaining differences between municipalities (Table 4 ). Figure 3 : Boxplot graph of Acceptability (ACC) score from pre-intervention to post-intervention in the three municipalities Appropriateness (APP) The median pre-intervention total APP score was 16 (IQR: 12.5,18) and decreased to 14 (IQR:11,17). At pre-intervention, M2 (12.5, IQR:10,16.5) again showed lower scores than M1 (16, IQR:15,18) and M3 (16, IQR: 14,18) (Fig. 4 ). Post-intervention scores remained stable in M1 and M3 ( 16 ), while increasing slightly in M2 (13.5, IQR:9.5,15). In the total sample after adjustment (Table 4 ) showed an increase in APP from pre- to post-intervention (β = 0.45, p < 0.001, 95% CI: 0.24,0.66) with no significant municipal differences. Figure 4 : Boxplot graph of Appropriateness (APP) score from pre-intervention to post-intervention in the three municipalities Feasibility (FEAS) The median pre-intervention total FEAS score was 15 (IQR: 12,17) and remained the same post-intervention (IQR:10,18). Pre-intervention FEAS scores were lowest in M2 (12, IQR:8,16), compared with M1 (16, IQR:14,18) and M3 (16, IQR:13.5,17.5) (Fig. 5 ). Post-intervention, FEAS increased slightly in M1 (15, IQR:9,17) and M2 (13 (IQR:9,16.5), while remained stable in M3 (16, IQR:14,19.5). Adjusted models indicated a total significant increase in FEAS post-intervention (β = 0.43, p < 0.001, 95% CI: 0.17,0.69). Between the municipalities, M3 reported significantly higher FEAS than M1 post-intervention (β = 2.67, p = 0.009, 95% CI: 0.67,4.66). Figure 5 : Boxplot graph of Feasibility (FEAS) score from pre-intervention to post-intervention in the three municipalities Differences Between Professional Groups School nurses reported the lowest median readiness score at both time points (pre: 33.5, IQR: 23–41; post: 28.5, IQR: 24–40). Differences in ACC, APP, and FEAS across groups were small (Table 5 ). School nurses had a slightly lower FEAS score pre-intervention (14, IQR:10,16) compared with principals (16, IQR:14,18) and teachers (16, IQR:12,18), a pattern that persisted post-intervention (Table 5 ). Table 5 Median score of ACC, APP, FEAS for pre- and post-intervention and the change among professional groups n Principal/VP n Teacher n School Nurse Readiness Pre-intervention Score, median (IQR) 37 38 (29,42) 68 39 (26,45) 40 33.5 (23,41) Readiness Post-intervention Score, median (IQR) 26 37 (25,40) 47 36 (25,44) 30 28.5 (24,40) ACC Pre-intervention Score, median (IQR) 39 15 ( 12 , 18 ) 72 16 (12.5,18) 39 15 ( 10 , 16 ) ACC Post-intervention Score, median (IQR) 26 15.5 ( 11 , 18 ) 44 14 ( 10 , 17 ) 30 14.5 ( 11 , 16 ) APP Pre-intervention Score, median (IQR) 38 16 ( 14 , 17 ) 71 16 ( 12 , 18 ) 39 16 ( 12 , 17 ) APP Post-intervention Score, median (IQR) 25 16 ( 12 , 19 ) 44 15 ( 13 , 17 ) 29 14 ( 10 , 16 ) FEAS Pre-intervention Score, median (IQR) 38 16 ( 14 , 18 ) 71 16 ( 12 , 18 ) 39 14 ( 10 , 16 ) FEAS Post-intervention Score, median (IQR) 25 16 ( 12 , 20 ) 44 16 (12.5,19) 29 13 ( 9 , 16 ) ACC = Acceptability, APP = Appropriateness, FEAS = Feasibility, IQR = Interquartile range, VP = Vice Principal; Table 5 . Median score of ACC, APP, FEAS for pre- and post-intervention and the change among professional groups After adjustment, school nurses had a lower readiness score than teachers post-intervention, although this difference was not statistically significant (β = − 3.77, p = 0.101, 95% CI: − 8.28 to 0.74). Correlations Between Readiness and Implementation Outcomes Pre-intervention readiness scores were positively correlated with ACC (r = 0.66), APP (r = 0.69), and FEAS (r = 0.71) across all municipalities. Figure 6 presents the relationship between readiness and FEAS. Nearly half of M2 personnel (46%) were classified in quadrant I (“Low Feasibility–Low Readiness”), compared with 27% in M1 and 30% in M3. In quadrant IV (“High Feasibility–High Readiness”), 52% of personnel in M1 and M3 were represented, compared with only 19% in M2. Similar patterns for ACC-Readiness and APP-Readiness correlations are shown in Additional Files 3 and 4. All schools in M3 opted to continue the HSS program after year one, unlike M1 and M2. Figure 6 : Correlation (r = 0.66) between pre-intervention Feasibility (FEAS) and Readiness scores for all school personnel. The dotted lines indicate the median value of each variable. LRIT; Leader Readiness to Implement Tool, SRIT: Staff Readiness to Implement Discussion This study demonstrated increases in readiness and in the implementation outcomes ACC, APP, and FEAS after adjusting for pre-intervention scores, clustering at the school level and profession suggesting that the program was overall positively received by school personnel. However, across the three municipalities, patterns in readiness and implementation outcomes differed at both baseline and follow-up. M3 consistently reported high readiness and implementation outcomes and was the only municipality in which all schools continued the program into the following year. Distinct patterns in implementation outcomes between municipalities One important contextual difference between the municipalities that may help explain these differences was that implementation started in August 2021 during the COVID-19 pandemic in M1 and M2, while M3 started one year later. No primary schools were closed in Sweden during the pandemic. However, parents were strongly encouraged not to enter school buildings (e.g., classrooms, cafeteria or other administrative buildings) ( 28 ). School personnel in M1 and M2 were therefore implementing a new program (HSS) under highly constrained and unprecedented conditions. In M3, where schools started to implement the program in August 2022, work routines had resumed to more usual conditions. In addition, the schools in M3 experienced higher organizational stability than in M1 and M2, which might also have contributed to the higher proportion of participants reporting high feasibility and readiness. This aligns with previous Swedish research linking organizational stability to implementation success ( 29 ). Despite greater socioeconomic disadvantage and poorer health indicators, M3 demonstrated the most positive and stable implementation outcomes. Nevertheless, it had the highest teacher density per student of the three municipalities, which could have contributed to greater stability in readiness and more favorable implementation outcomes. It will be important to continue to monitor organizational changes as research shows that implementation strategies are more likely to succeed in a stable organization that are able to retain senior leaders and staff that are knowledgeable and motivated to continue delivering health promotion over time ( 30 ). Readiness appears embedded in structural conditions, including funding, workforce stability, policy environments, and population health needs ( 9 ). Political leadership is important as it can effectively prioritize and create conditions which favor the implementation of health promotion programs like the HSS as illustrated by M3. This could help reduce inequalities in health within and between municipalities. Implementation outcomes between school personnel Although overall readiness increased from pre- to post-intervention across the full sample, the adjusted model showed that school nurses had slightly lower post-intervention readiness than teachers. Meaning that both groups improved over time, but teachers showed slightly greater gains. The difference was not statistically significant, indicating no clear evidence of meaningful differences in readiness between professions. School nurses also reported slightly lower feasibility scores compared to other school personnel after the first year. This may reflect the demands of delivering in-person health talks using motivational interviewing, particularly during the pandemic in M1 and M2. For example, school nurses in Sweden had to adapt their work to support students and families digitally during this period ( 32 ). More broadly, the Swedish school health teams operate under variable staffing ratios and time constraints. We also found in a separate study that while health promotion is included in national guidelines, mandatory tasks such as health checks and vaccinations are prioritized over other preventive activities (under review). Our previous studies with school nurses participating in the HSS found that mastering motivational interviewing was initially challenging, but with practice, they appreciated its ability to promote a more equal power balance with parents ( 31 ). Teachers, by contrast, engage with content closely aligned with the curriculum, though classroom components require preparatory work. Process evaluations of the HSS program indicate that teachers value the program for strengthening their own health competence ( 33 ) and collaboration with parents ( 6 ). Implementation outcomes and readiness were correlated While not surprising, there was a strong positive correlation between pre-intervention readiness and the implementation outcomes ACC, APP and FEAS. This suggests consistency in how individuals perceive readiness and early implementation outcomes. School personnel in quadrant I (Fig. 6 ) did not find the HSS very feasible and perceived low readiness, while those in quadrant IV perceived the intervention to be feasible and that they were ready for change. Smaller groups fell into mixed-perception quadrants (II and III). These discrepancies may reflect individual or role-specific contextual factors. Although barriers and facilitators to the implementation of HSS were explored qualitatively ( 14 ), their relative importance was not ranked. Different perceptions of barriers could be one explanation why some of the participants from the same municipality ended up in different quadrants. Another study also found a high correlation between readiness and implementation outcomes and suggested that readiness is a precursor of early implementation outcomes like ACC, APP and FEAS ( 12 ). These authors warned against implementing a service in an organization receiving a low appropriateness score without engaging in a process to improve readiness. This underscores the need to better understand how readiness shapes later implementation processes. Strategies could be developed to engage or prepare staff depending on the quadrant they score in. This may support more strategic timing and resource-efficient implementation. In the CFIR Outcomes Addendum readiness, ACC, APP and FEAS have been classified as antecedent assessments on the pathway between implementation determinants and outcomes and thus predictors of more distal implementation outcomes like fidelity ( 34 ). Future analyses could examine how readiness is associated with fidelity over time. Strengths and weaknesses To our knowledge, this is one of the first school-based implementation studies to use the validated questionnaire by Weiner et al. on implementation outcomes ( 13 ). While previous studies have relied primarily on mixed methods to examine acceptability, appropriateness, and feasibility, often in rural school settings ( 35 )( 36 ), the present study applies a standardized, theory-informed quantitative instrument in an urban school-based implementation context. Moreover, we have recently validated the readiness instrument in the Swedish context (A Toropova et al., submitted for publication). In contrast to the ORIC instrument on which it is based, the readiness scales used in this study ask for a personal appraisal of readiness instead of an assessment of organizational readiness as a whole. Assessing organizational readiness may be challenging for individual staff members, and in this sense, the readiness scales capture individual perceptions of readiness to implement the HSS program, rather than the organization’s readiness per se. The same individual-level perspective applies to the instrument used to assess implementation outcomes. A key limitation of this study is the relatively small sample size within professional subgroups, combined with potential selection bias, as only 66% (150/229) of eligible personnel participated and 73% of these (110/150) completed the post-intervention survey. The limited statistical power may explain the absence of statistically significant differences in readiness scores between professional groups. Nonetheless, the inclusion of principals, teachers, and school nurses offers important triangulation across professional roles and provides insight into the additional workload and stress experienced by school nurses when delivering the MI component for the first time. Future studies with larger samples or qualitative approaches could further explore higher-level organizational and systematic barriers and facilitators to implementation at scale. Conclusion This study identified three distinct patterns across municipalities in terms of readiness and early implementation outcomes during the first year of implementing the Healthy School Start (HSS) intervention. These findings suggest that perceptions of implementability of the same intervention vary across local contexts. Importantly, when the majority of school personnel perceive low readiness or feasibility, additional implementation support or preparation time may be required addressing the identified barriers before full-scale implementation is initiated. By capturing pre- and post-intervention data on readiness and implementation outcomes, this study provides novel empirical insight into personnels’ preparedness to implement a new health program by combining different validated implementation measures. Abbreviations ACC Acceptability APP Appropriateness FEAS Feasibility HSS Healthy School Start IMPROVE IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity IQR Interquartile Range LRIT Leader Readiness to Implement Tool M Municipality ORIC Organizational Readiness for Implementing Change REDCap Research Electronic Data Captur SRIT Staff Readiness to Implement Tool Declarations Ethics approval and consent to participate The study was conducted in accordance with the principles of the Declaration of Helsinki. Participation was voluntary, and informed consent was obtained from all participants. All participants were aged 18 years or older at the time of survey completion. Ethical approval for the study was granted by the Swedish Ethical Review Authority (protocol number 2021-02267). Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Funding for this study has been received from the Swedish Research Council for Health, Working Life and Welfare (FORTE) grant number 2020-01198. Swedish Research Council FORTE, Box 38084, SE-100 64 Stockholm, Sweden. The funder has no role in the study. Authors' contributions KSA, LK, SA, EP, ÅN, NSS and LSE conceptualized the study. LSE, SA, EP, ÅN and NSS participated in the pre-intervention workshops where barriers and facilitators were identified. KSA collected the data and performed the data analysis. KSA and LSE drafted the initial manuscript, while LK, SA, EM, ÅN, SR and NSS provided critical feedback. All authors read and approved the final manuscript. 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School Ment Health. 2015;7(4):273–86. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additionalfile2v2.docx Additionalfile3.docx Additionalfile4.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 15 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers invited by journal 13 Jan, 2026 Editor assigned by journal 13 Jan, 2026 Editor invited by journal 08 Jan, 2026 Submission checks completed at journal 08 Jan, 2026 First submitted to journal 08 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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08:43:50","extension":"xml","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":140906,"visible":true,"origin":"","legend":"","description":"","filename":"43f12ceeae3f464da683071dd7940b351structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/559fad11ae50db7d0712cf3e.xml"},{"id":100594703,"identity":"d7b1fd31-41f8-4a91-bdd4-bdcb8ef867f4","added_by":"auto","created_at":"2026-01-19 13:44:05","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":152676,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/fe50fa12d771af19d3cda89a.html"},{"id":100560731,"identity":"4e9647af-c931-46bd-bdef-d7228501d28a","added_by":"auto","created_at":"2026-01-19 08:43:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47611,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow chart describing the process of enrolling schools and personnel in the three municipalities\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/eed7f05733b550a1f55e9da6.jpg"},{"id":100560453,"identity":"6871a862-1fcd-401f-a570-6b1018fd6dbe","added_by":"auto","created_at":"2026-01-19 08:43:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":340561,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot graph of Readiness to Implement (RIT) score from pre-intervention to post-intervention in the three municipalities.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/e543bc23870c65d5244c57d7.jpg"},{"id":100560344,"identity":"8e6aabc7-69e9-4e65-9d91-e163e2ffacf5","added_by":"auto","created_at":"2026-01-19 08:43:40","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":381012,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot graph of Acceptability (ACC) score from pre-intervention to post-intervention in the three municipalities\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/cbd78cb3b681f878b2eacdc2.jpg"},{"id":100595277,"identity":"f1b79395-8604-4181-abf6-37886fe16256","added_by":"auto","created_at":"2026-01-19 13:48:07","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":379923,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot graph of Appropriateness (APP) score from pre-intervention to post-intervention in the three municipalities\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/77b8b0f01434a92f683f0956.jpg"},{"id":100559891,"identity":"caef6412-d889-42b8-bbb7-d2ec03ec520a","added_by":"auto","created_at":"2026-01-19 08:43:37","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":387266,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot graph of Feasibility (FEAS) score from pre-intervention to post-intervention in the three municipalities\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/314c7affda638c1a17d7c6ce.jpg"},{"id":100560306,"identity":"3c233a04-78b1-47e9-8945-fd5621b6a69e","added_by":"auto","created_at":"2026-01-19 08:43:40","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":33844,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation (r=0.71) between pre-intervention Feasibility (FEAS) scores and combined Readiness scores for all school personnel. The dotted lines indicate the median value of each variable. LRIT; Leader Readiness to Implement Tool, SRIT: Staff Readiness to Implement\u003c/p\u003e","description":"","filename":"Picture6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/9e6d9cf13563a7498454d114.jpg"},{"id":100857738,"identity":"9c923788-0525-490d-85f7-3ad71437a512","added_by":"auto","created_at":"2026-01-22 07:21:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3237384,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/abfed438-4f0f-4eef-91fa-239f5a59cad7.pdf"},{"id":100560464,"identity":"1090bcfa-bfcc-4fbb-868d-fd0259ad5470","added_by":"auto","created_at":"2026-01-19 08:43:41","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":64239,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/738f80c49f46cad89100f066.docx"},{"id":100560035,"identity":"46b48de4-69d7-455f-bd15-cdf62e24b229","added_by":"auto","created_at":"2026-01-19 08:43:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":65963,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2v2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/174c7af45dcb31bdf14113bc.docx"},{"id":100595501,"identity":"c98d7bb6-205f-43c8-a637-9f391d49eaa6","added_by":"auto","created_at":"2026-01-19 13:48:37","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":74863,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/da966805dd1f1d4e99368832.docx"},{"id":100560846,"identity":"9ee57e4e-9cc5-4550-8974-1fe34d5ff600","added_by":"auto","created_at":"2026-01-19 08:43:51","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":74523,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-8410429/v1/f38470222b96af4ab364aac0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Multi-Site Study of implementing a School-Based Health Promotion Intervention in Sweden – Changes in Readiness and Implementation Outcomes","fulltext":[{"header":"Background","content":"\u003cp\u003eInterventions to promote health and prevent obesity should start at an early age and target the whole family, and schools are an ideal setting for the delivery of health programs, particularly for children 6\u0026ndash;12 years of age (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Effective school-based programs are characterized by active parental involvement, especially for younger children (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, health promotion and prevention programs in schools involving parents can be challenging to implement since some school principals are uncertain about whether it is the role of the school to provide health guidance to parents (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) in addition to teaching children. Teachers describe barriers like the dense curriculum, lack of planning time, lack of support from principals and other personnel, and how projects come and go without feedback or sustainability (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), in addition to lack of parental engagement (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In addition, while school nurses tend to see health promotion as their main obligation, they often feel overburdened and left alone with this task (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Moreover, school resources are limited, and the workload is perceived to be high (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). While school is often considered to be a key setting for promoting healthy eating and physical activity for children, there appears to be a \u0026lsquo;responsibility conflict\u0026rsquo; (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Therefore, when planning to implement health promotion activities in the school setting, leadership and clear guidance from national and/or local government is needed to increase the readiness of the organization (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). When readiness is high, members are more likely to initiate change, and display more cooperative behavior, which overall results in more effective implementation of the proposed change (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImportant preconditions for success are that stakeholders have the same information, experience, and values before the start of an implementation process. Aarons and colleagues (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) emphasize four central factors for an organization to achieve readiness: 1) Employees must perceive the change as beneficial to themselves; 2) they must feel that they are capable of implementing the change; 3) they must believe that the change can lead to a desirable result; and 4) that both formal and informal leaders are committed to the change. Readiness has been proposed as a precursor of early implementation outcomes like acceptability (ACC), appropriateness (APP), and feasibility (FEAS) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A receptive context increases the likelihood of successful integration and adoption of a new program, ensuring their perceived ACC and APP within the organizational setting. However, while a program may be found acceptable by the stakeholders and appropriate for a given setting, it may not be feasible, typically due to lack of resources or competence of the providers. While conceptually distinct, evidence suggests that these implementation outcomes are highly correlated and could serve as proxies for each other (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Understanding readiness, ACC, APP and FEAS early in the research process could help ensure that interventions and implementation strategies are optimized, fit with end-users\u0026rsquo; preferences, can be scaled up and are sustainable.\u003c/p\u003e \u003cp\u003eThe present study was performed during the first year of scaling up the universal Healthy School Start (HSS) program in compulsory pre-school class or grade one within three different municipalities in the Stockholm region in Sweden (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The HSS program is an evidence-based family support program to improve diet and physical activity and prevent or reduce obesity. The program has been evaluated at the school level in three separate cluster randomized controlled trials and shown effectiveness in improving dietary habits and physical activity (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), and in reducing BMI in children with obesity (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These results are in line with other studies showing that school-based health promotion programs with direct parental involvement, especially for children up to 12 years which simultaneously address multiple behaviors in the school and home environments, can be effective (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen designing the HSS program, great efforts were made to align the program with the Education Act and the National Curriculum which mandates health promotion as part of school responsibilities, and the Guidelines for School Health Services, in order to facilitate implementation. The field of organizational change, particularly in education and public sector settings, has long recognized that the successful adoption of new programs depends not only on program alignment with existing policies but also on broader system-level factors such as governance structures, leadership, and institutional capacity. In Sweden, most schools operate under local municipal governance and vary widely in resource allocation, socio-demographic profiles and staff qualifications. These contextual differences are known to play a critical role in implementation success within the school setting (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe readiness for organizational change theory is well established and describes a shared psychological state in which organizational members feel committed to implementing an organizational change and confident in their collective abilities to do so (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, there remains limited empirical research that quantitatively assesses readiness for change in real-world school settings, particularly in relation to health promotion interventions (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Specifically, there is a gap in studies that examine individual readiness for change and how this correlates with the individuals\u0026rsquo; perception of ACC, APP, and FEAS of the intervention during early implementation. To address this gap, the present study assessed at the individual provider level the readiness and early implementation outcomes (ACC, APP, FEAS) before and after the delivery of a one-year family support intervention in three Swedish municipalities as part of a hybrid type 3 effectiveness-implementation study. This could contribute to new insights into how varying levels of pre-implementation readiness and context affect implementation outcomes, and what type of support or tailoring may be needed to enhance program adoption (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The specific aims of this study were to 1) investigate changes in perceived readiness, ACC, APP and FEAS to implement the HSS program in the three municipalities and differences between professional groups (principals, teachers, school nurses), pre- and post-intervention; 2) to explore the correlation between perceived readiness and the three implementation outcomes.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003eThe HSS program is implemented in schools by a team led by the principal or vice principal in collaboration with the school nurse and teachers. It includes four components: brochure with health information sent home to the parents, health talks using motivational interviewing given by the school nurse along with the parents, nine classroom lectures led by teachers with homework assignments to be completed with the child\u0026rsquo;s parents or guardians (henceforth referred to as parents), and an online risk test with eight questions for type 2 diabetes done by parents. The program was implemented in three municipalities in Stockholm County starting in 2021 in a hybrid type 3 implementation-effectiveness study called IMPROVE: IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The IMPROVE study is evaluating two bundles of implementation strategies (Basic and Enhanced) on the primary outcome of fidelity to the four program components after two years of implementation. A detailed study protocol including the SPIRIT checklist is published elsewhere (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudy context\u003c/p\u003e \u003cp\u003eIn Sweden, schools are governed by the Education Act (\u0026sect;\u0026nbsp;2010\u0026thinsp;\u0026minus;\u0026thinsp;800). Health promotion efforts are outlined in the National Guidelines for school health care (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) while the National Curriculum (Lgr22) sets the goals for learning. The guideline for school health care mandates that health promotion regarding healthy eating and physical activity should be included. The school nurse carries out a routine general health check with every child and their parents in either the compulsory preschool class (when the child is aged 6\u0026ndash;7 years) or first grade (child aged 7\u0026ndash;8 years). The HSS program was implemented in the same year as the routine health check with parents was scheduled: preschool class in Municipality 1 (M1) and Municipality 2 (M2) and in first grade in Municipality 3 (M3). Relevant characteristics of the three municipalities are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescription of the population, schools and health in involved municipalities (M)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePopulation characteristics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of inhabitants\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026nbsp;400 000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113 951\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e101 209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian income per year (SEK)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e460 000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e333\u0026nbsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e306\u0026nbsp;861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e288 880\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion with employment (%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion unemployed (%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion with \u0026ge;\u0026thinsp;3 years university education 25\u0026ndash;64 years (%)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion of inhabitants with \u0026le;\u0026thinsp;9 years of schooling\u003csup\u003e1\u003c/sup\u003e 25\u0026ndash;64 years (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion of foreign-born inhabitants (year 2021)\u003csup\u003e1\u003c/sup\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSchool characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion of teachers with certificate (%)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of eligible public primary schools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of schools adopting the program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool rank out of 290 municipalities (combination of teachers\u0026rsquo; salary, teachers\u0026rsquo; health and teacher density)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDensity of students per teacher (rank out of 290 municipalities)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth Indicators\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight (not obesity) 4-year olds born 2017 (%)\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObesity 4-year olds born 2017 (%)\u003csup\u003e4\u003c/sup\u003e or 2016\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3-year olds with caries born 2019 (%)\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight and obesity in individuals\u0026thinsp;\u0026ge;\u0026thinsp;16 years (self-reported) (%)\u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes in individuals\u0026thinsp;\u0026ge;\u0026thinsp;16 years (self-reported) (%)\u003csup\u003e6,8\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.4\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e1\u003c/sup\u003eCentral Bureau of Statistics \u0026ndash; Statistiska Centralbyr\u0026aring;n SCB. Kommuner i siffror [Internet]. Stockholm: SCB; 2021/2022; \u003csup\u003e2\u003c/sup\u003eSkolkollen.se 2023; \u003csup\u003e3\u003c/sup\u003eSwedish Teacher\u0026rsquo;s Union \u0026ndash; L\u0026auml;rarf\u0026ouml;rbundet. B\u0026auml;sta skolkommun - resultat och historik [Internet]. Stockholm: L\u0026auml;rarf\u0026ouml;rbundet; 2021. The ranking is based on quality with determinants such as amount of resources, number of children in preschool class, educated and healthy teachers, teachers per student, and student gradings. Low number corresponds to high ranking. \u003csup\u003e4\u003c/sup\u003eBarnh\u0026auml;lsov\u0026aring;rdens \u0026Aring;rsrapport 2022 (Yearly report Child Health Care), Region Stockholm. \u003csup\u003e5\u003c/sup\u003eMireg\u0026aring;rd et al. Acta Paediatrica 2023 \u003csup\u003e6\u003c/sup\u003eFolkh\u0026auml;lsokollen.se, Region Stockholm, \u003csup\u003e7\u003c/sup\u003ePublic Health Agency of Sweden, \u003csup\u003e8\u003c/sup\u003eDiabetics Association in Sweden\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cb\u003eDescription of the population, schools and health in involved municipalities (M)\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePre-implementation phase\u003c/p\u003e \u003cp\u003eIn 2020, the research team contacted eight municipalities with a high prevalence of childhood obesity among 4-year-old children in Region Stockholm to explore their interest in participating in the IMPROVE study. Three central administrative leaders from the municipalities expressed interest. After an introduction to the program, two municipalities agreed to participate while the third delayed their participation by one year due to the COVID-19 pandemic. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides a timeline of the stakeholder engagement activities after recruitment at the municipality and school level and training of school personnel. One of the aims of the program (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) was to strengthen collaboration between school and primary health care. Therefore, primary health care staff were involved in the initial workshops to identify barriers and facilitators and develop suitable implementation strategies.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre-implementation activities and timeline in the three municipalities\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStakeholder\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st online workshop to identify barriers and facilitators to implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFall 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchool and primary health care representatives from M1 and M2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd online workshop to discuss and decide implementation strategies based on barriers and facilities from the 1st workshop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpring 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchool representatives from M1 and M2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntroduction of each professional group to the HSS program and IMPROVE study by research team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpring 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrincipals, teachers, and school nurses M1 and M2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnline 2-day training in Motivational Interviewing (MI) adapted for the HSS program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpring 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchool nurses in M1 and M2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnsite 2-day MI training in Motivational Interviewing adapted for the HSS program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpring 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchool nurses in M3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntroduction of each professional group to the HSS program and IMPROVE study by research team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpring 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrincipals, teachers, and school nurses from M3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: \u003cb\u003ePre-implementation activities and timeline in the three municipalities\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSchool principals were informed about the municipality\u0026rsquo;s intention to implement the program in all public schools, which they then communicated to their personnel. If a school had special reasons or circumstances such as staff shortages, the principal had the possibility to decline participation. A written agreement was signed between the municipalities and Karolinska Institutet to conduct the IMPROVE study during 2021 to 2024. All introductory meetings were given online for about one hour separately for each professional group (principals, teachers and school nurses) and participants were given the opportunity to ask questions. A website was developed for the program in Swedish and included all necessary information and program materials. Lectures in public health for school personnel given by experts in the area were available on the website. The program material including the implementation manual and the teacher\u0026rsquo;s manual was made available to school personnel two to three months before the start of the program.\u003c/p\u003e \u003cp\u003eStudy participants\u003c/p\u003e \u003cp\u003eThe total number of participating schools was 15 (60%) in M1, 13 (100%) in M2 and 19 (100%) in M3. All school personnel working with the HSS program were invited to participate in the IMPROVE study. We used data collected from school leadership (i.e., principals and vice principals), school nurses and teachers, all referred to as school personnel henceforth (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). We used an open cohort design since some teachers and a few school nurses started or ended their employment during the study period. In addition, in M3 the teacher implementing the classroom component changes each year (i.e., the teacher stays with students up to grade 3), thus in M3 each school year a new group of teachers entered the IMPROVE study.\u003c/p\u003e \u003cp\u003eData collection and instruments used\u003c/p\u003e \u003cp\u003eAcceptability (ACC) is the perception among implementation stakeholders that a given intervention or innovation is agreeable, palatable, or satisfactory. Appropriateness (APP) expresses the perceived fit, relevance, or compatibility of the intervention for a given setting, provider, or consumer; and/or perceived fit of the intervention to address a particular problem. Feasibility (FEAS) is defined as the extent to which a new intervention can be successfully carried out within a given setting (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). ACC, APP, and FEAS were assessed with a short and validated tool (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) translated to Swedish (Additional file 1). Each outcome consists of four items answered on a 5-point Likert scale with a total score between 4 to 20 points per outcome. Readiness was assessed with a modified version of the Organizational Readiness for Implementing Change (ORIC) tool developed by Shea et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and adapted into a \u003cem\u003eLeader Readiness to Implement Tool\u003c/em\u003e (LRIT) answered by school principals and a \u003cem\u003eStaff Readiness to Implement Tool\u003c/em\u003e (SRIT), answered by school nurses and teachers (Additional file 2). The scales have been validated in the Swedish context (A Toropova et al., submitted for publication). The respondent answers for him/her-self instead of on behalf of the school (all items start with \u0026ldquo;I who work here\u0026hellip;\u0026rdquo; instead of \u0026ldquo;People who work here...\u0026rdquo;) as in the original scale. LRIT and SRIT consisted of 13 items each answered on a 5-point Likert scale as follows: 1\u0026thinsp;=\u0026thinsp;Disagree, 2\u0026thinsp;=\u0026thinsp;Somewhat disagree, 3\u0026thinsp;=\u0026thinsp;Neutral, 4\u0026thinsp;=\u0026thinsp;Somewhat agree, and 5\u0026thinsp;=\u0026thinsp;Agree. The tools were translated to Swedish and back translated to check for accuracy and minor adjustments were made.\u003c/p\u003e \u003cp\u003eData collection was performed by electronic questionnaires using the secure web platform Research Electronic Data Capture (REDCap) between September 2021 and June 2023. An informational email was sent to all invited school personnel detailing the study and consent to participate. A link to the survey was included at the end of the email. The survey had three parts: a section with sociodemographic questions, the ACC, APP, and FEAS questionnaires, and lastly the LRIT and SRIT questionnaires. School personnel answered the questionnaires individually online during working hours at their school. Responses were collected after the HSS program had been introduced to the school personnel, but before the implementation had started in September-October and again post-intervention in May-June the following year. Automatic reminders were scheduled and sent weekly through REDCap up to three times after the initial invitation.\u003c/p\u003e \u003cp\u003eOrganizational changes in the school were documented. This included changes within the school leadership (principal or vice principal), school nurse, teachers or other school reorganizations. The data was collected during visits made to each school in April-May 2022 (in M1 and M2) and April-May 2023 (M3) to review the performance of implementation strategies and through consultations with the municipality administration. It was hypothesized that organizational changes could impact on the outcomes of interest. Organizational instability per school was defined as any change to school personnel implementing the HSS program. The school was coded as 1 if there was school personnel turnover and 0 if there was no school personnel turnover.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eA summative score was created for readiness (leadership and staff together) and ACC, APP, FEAS respectively at pre- and post-intervention time points. Descriptive statistics were presented as median and interquartile range (IQR). The data was tested for normal distribution using the Shapiro\u0026ndash;Wilk normality test. Boxplots graphs were presented and included the median, IQR, minimum and maximum values for readiness, ACC, APP and FEAS.\u003c/p\u003e \u003cp\u003eMixed-effects linear regression models were used to assess changes in post-intervention readiness, ACC, APP, and FEAS between municipalities, adjusting for pre-intervention scores and accounting for clustering at the school level. The model was also adjusted for profession of school personnel. Robust standard errors were applied to improve the reliability of estimates in the presence of mild non-normality. P-value\u0026thinsp;\u0026lt;\u0026thinsp;than 0.05 was considered statistically significant. Model assumptions, including normality of residuals and homoscedasticity, were assessed through visual inspection of Q-Q plots and residuals vs. fitted values. There were 44 clusters (schools) and the average cluster size was 2.2.\u003c/p\u003e \u003cp\u003eCorrelation coefficients were presented for ACC, APP, and FEAS in relation to the readiness score. A scatter plot graph was used to display the correlation between FEAS median and readiness with leadership and staff represented in the same graph. Four quadrants were created based on the median values of the FEAS and Readiness scores as follows: Quadrant I: FEAS 4\u0026ndash;14 and Readiness 10\u0026ndash;37 deemed \u0026ldquo;Low FEAS and Readiness\u0026rdquo;; II: FEAS 4\u0026ndash;14 and Readiness 38\u0026ndash;52 deemed \u0026ldquo;Low FEAS and High Readiness\u0026rdquo;; III: FEAS 15\u0026ndash;20 and Readiness 10\u0026ndash;37 deemed \u0026ldquo;High FEAS and Low Readiness\u0026rdquo;; IV: FEAS 15\u0026ndash;20 and Readiness 38\u0026ndash;52 deemed \u0026ldquo;High FEAS and Readiness\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 57 schools were eligible for inclusion; 10 schools in Municipality 1 (M1) declined participation, citing organizational changes or staff shortages. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the flow of school and personnel enrollment across the study period. Of the 229 eligible individuals, 150 (66%) completed the pre-intervention survey. Characteristics of school personnel by municipality are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The only significant difference between municipalities was years of work experience, which was higher in M1 than in M2 and M3 (p\u0026thinsp;=\u0026thinsp;0.02). Organizational instability affected more than half of the schools in M2 (7/13, 54%), compared with 40% in M1 (6/15) and 16% in M3 (3/19).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of school personnel pre-intervention by municipality.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;150\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMunicipality 1 n\u0026thinsp;=\u0026thinsp;45\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMunicipality 2 n\u0026thinsp;=\u0026thinsp;41\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMunicipality 3 n\u0026thinsp;=\u0026thinsp;64\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e mean years (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.4 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.4 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.9 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.16\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u0026nbsp;n (% in municipality)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 (94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.39\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional title\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrincipal/Vice-Principal n a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.86\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeachers n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool Nurses n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork experience in the field\u003c/b\u003e median years (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (2,10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.02\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork experience in the current school\u003c/b\u003e median years (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.50\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSD: standard deviation; IQR: Interquartile range. Organizational instability per school was defined as any change to school personnel implementing the HSS program. *ANOVA; **Pearson\u0026rsquo;s Chi-Squared test; \u0026dagger;Kruskal-Wallis\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cb\u003eFlow chart describing the process of enrolling schools and personnel in the three municipalities\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. \u003cb\u003eCharacteristics of school personnel pre-intervention by municipality.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eChanges in Readiness, Acceptability, Appropriateness, and Feasibility\u003c/p\u003e\n\u003ch3\u003eReadiness\u003c/h3\u003e\n\u003cp\u003eThe median readiness score among all personnel was 38 (IQR: 26,43) pre-intervention and decreased to 33 (IQR: 25,41) post-intervention. When looking at the change in each municipality separately, three different pictures emerged. Readiness declined in both M1 (from 38 to 30) and M2 (from 29 to 27), with the largest decrease in M1 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In contrast, M3 showed no change (median 39 at both time points).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: \u003cb\u003eBoxplot graph of Readiness to Implement (RIT) score from pre-intervention to post-intervention in the three municipalities.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn the adjusted model (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), readiness increased significantly from pre- to post-intervention (β\u0026thinsp;=\u0026thinsp;0.47, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI: 0.25,0.70) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Furthermore, M3 reported significantly higher readiness post-intervention compared with M1 (β\u0026thinsp;=\u0026thinsp;5.93, p\u0026thinsp;=\u0026thinsp;0.014, 95% CI: 1.19,10.68).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifference in readiness (model 1), acceptability (model 2), appropriateness (model 3) and feasibility (model 4) from pre- to post-intervention and between municipalities.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΒ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 1: Readiness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.25,0.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-4.06,7.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.19,10.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 2: Acceptability\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.33,0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.10,2.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.21,3.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 3: Appropriateness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.24,0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-3.18,1.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.38,2.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 4: Feasibility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.17,0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.46,3.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67,4.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eM\u0026thinsp;=\u0026thinsp;municipality; adjusted for pre-intervention scores and professional groups. Β \u0026ndash; beta coefficient. CI- confidence interval. Models were adjusted for pre-intervention scores, clustering at the school level and the type of profession of school personnel.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: \u003cb\u003eDifference in readiness (model 1), acceptability (model 2), appropriateness (model 3) and feasibility (model 4) from pre- to post-intervention and between municipalities\u003c/b\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eAcceptability (ACC)\u003c/h3\u003e\n\u003cp\u003eThe median pre-intervention total ACC score was 15 (IQR: 12,18) and decreased to 14 (IQR:10,17). At pre-intervention, M2 reported lower median ACC (12, IQR:10,16) compared to M1 (16, IQR:14,19) and M3 (16, IQR:14,18) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).The post-intervention scores decreased for M1 (12, IQR:9,16) and M2 (11.5, IQR:10,16) but stayed the same in M3 (16, IQR:13,18). In the total sample after adjustment, ACC increased significantly post-intervention (β\u0026thinsp;=\u0026thinsp;0.56, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI: 0.33,0.78), with no remaining differences between municipalities (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e: \u003cb\u003eBoxplot graph of Acceptability (ACC) score from pre-intervention to post-intervention in the three municipalities\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003eAppropriateness (APP)\u003c/h3\u003e\n\u003cp\u003eThe median pre-intervention total APP score was 16 (IQR: 12.5,18) and decreased to 14 (IQR:11,17). At pre-intervention, M2 (12.5, IQR:10,16.5) again showed lower scores than M1 (16, IQR:15,18) and M3 (16, IQR: 14,18) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Post-intervention scores remained stable in M1 and M3 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), while increasing slightly in M2 (13.5, IQR:9.5,15). In the total sample after adjustment (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) showed an increase in APP from pre- to post-intervention (β\u0026thinsp;=\u0026thinsp;0.45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI: 0.24,0.66) with no significant municipal differences.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: \u003cb\u003eBoxplot graph of Appropriateness (APP) score from pre-intervention to post-intervention in the three municipalities\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003eFeasibility (FEAS)\u003c/h3\u003e\n\u003cp\u003eThe median pre-intervention total FEAS score was 15 (IQR: 12,17) and remained the same post-intervention (IQR:10,18). Pre-intervention FEAS scores were lowest in M2 (12, IQR:8,16), compared with M1 (16, IQR:14,18) and M3 (16, IQR:13.5,17.5) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Post-intervention, FEAS increased slightly in M1 (15, IQR:9,17) and M2 (13 (IQR:9,16.5), while remained stable in M3 (16, IQR:14,19.5). Adjusted models indicated a total significant increase in FEAS post-intervention (β\u0026thinsp;=\u0026thinsp;0.43, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI: 0.17,0.69). Between the municipalities, M3 reported significantly higher FEAS than M1 post-intervention (β\u0026thinsp;=\u0026thinsp;2.67, p\u0026thinsp;=\u0026thinsp;0.009, 95% CI: 0.67,4.66).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e: \u003cb\u003eBoxplot graph of Feasibility (FEAS) score from pre-intervention to post-intervention in the three municipalities\u003c/b\u003e\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDifferences Between Professional Groups\u003c/h2\u003e \u003cp\u003eSchool nurses reported the lowest median readiness score at both time points (pre: 33.5, IQR: 23\u0026ndash;41; post: 28.5, IQR: 24\u0026ndash;40). Differences in ACC, APP, and FEAS across groups were small (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). School nurses had a slightly lower FEAS score pre-intervention (14, IQR:10,16) compared with principals (16, IQR:14,18) and teachers (16, IQR:12,18), a pattern that persisted post-intervention (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMedian score of ACC, APP, FEAS for pre- and post-intervention and the change among professional groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrincipal/VP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTeacher\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSchool Nurse\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReadiness\u003c/b\u003e Pre-intervention Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (29,42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39 (26,45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.5 (23,41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReadiness\u003c/b\u003e Post-intervention Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (25,40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (25,44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.5 (24,40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eACC\u003c/b\u003e Pre-intervention Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (12.5,18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eACC\u003c/b\u003e Post-intervention Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.5 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAPP\u003c/b\u003e Pre-intervention Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAPP\u003c/b\u003e Post-intervention Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFEAS\u003c/b\u003e Pre-intervention Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFEAS\u003c/b\u003e Post-intervention Score, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (12.5,19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eACC\u0026thinsp;=\u0026thinsp;Acceptability, APP\u0026thinsp;=\u0026thinsp;Appropriateness, FEAS\u0026thinsp;=\u0026thinsp;Feasibility, IQR\u0026thinsp;=\u0026thinsp;Interquartile range, VP\u0026thinsp;=\u0026thinsp;Vice Principal;\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. \u003cb\u003eMedian score of ACC, APP, FEAS for pre- and post-intervention and the change among professional groups\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAfter adjustment, school nurses had a lower readiness score than teachers post-intervention, although this difference was not statistically significant (β = \u0026minus;\u0026thinsp;3.77, p\u0026thinsp;=\u0026thinsp;0.101, 95% CI: \u0026minus;\u0026thinsp;8.28 to 0.74).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCorrelations Between Readiness and Implementation Outcomes\u003c/h3\u003e\n\u003cp\u003ePre-intervention readiness scores were positively correlated with ACC (r\u0026thinsp;=\u0026thinsp;0.66), APP (r\u0026thinsp;=\u0026thinsp;0.69), and FEAS (r\u0026thinsp;=\u0026thinsp;0.71) across all municipalities. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e presents the relationship between readiness and FEAS. Nearly half of M2 personnel (46%) were classified in quadrant I (\u0026ldquo;Low Feasibility\u0026ndash;Low Readiness\u0026rdquo;), compared with 27% in M1 and 30% in M3. In quadrant IV (\u0026ldquo;High Feasibility\u0026ndash;High Readiness\u0026rdquo;), 52% of personnel in M1 and M3 were represented, compared with only 19% in M2. Similar patterns for ACC-Readiness and APP-Readiness correlations are shown in Additional Files 3 and 4.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAll schools in M3 opted to continue the HSS program after year one, unlike M1 and M2.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e: \u003cb\u003eCorrelation (r\u0026thinsp;=\u0026thinsp;0.66) between pre-intervention Feasibility (FEAS) and Readiness scores for all school personnel.\u003c/b\u003e The dotted lines indicate the median value of each variable. LRIT; Leader Readiness to Implement Tool, SRIT: Staff Readiness to Implement\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated increases in readiness and in the implementation outcomes ACC, APP, and FEAS after adjusting for pre-intervention scores, clustering at the school level and profession suggesting that the program was overall positively received by school personnel. However, across the three municipalities, patterns in readiness and implementation outcomes differed at both baseline and follow-up. M3 consistently reported high readiness and implementation outcomes and was the only municipality in which all schools continued the program into the following year.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDistinct patterns in implementation outcomes between municipalities\u003c/h2\u003e \u003cp\u003eOne important contextual difference between the municipalities that may help explain these differences was that implementation started in August 2021 during the COVID-19 pandemic in M1 and M2, while M3 started one year later. No primary schools were closed in Sweden during the pandemic. However, parents were strongly encouraged not to enter school buildings (e.g., classrooms, cafeteria or other administrative buildings) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). School personnel in M1 and M2 were therefore implementing a new program (HSS) under highly constrained and unprecedented conditions. In M3, where schools started to implement the program in August 2022, work routines had resumed to more usual conditions.\u003c/p\u003e \u003cp\u003eIn addition, the schools in M3 experienced higher organizational stability than in M1 and M2, which might also have contributed to the higher proportion of participants reporting high feasibility and readiness. This aligns with previous Swedish research linking organizational stability to implementation success (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Despite greater socioeconomic disadvantage and poorer health indicators, M3 demonstrated the most positive and stable implementation outcomes. Nevertheless, it had the highest teacher density per student of the three municipalities, which could have contributed to greater stability in readiness and more favorable implementation outcomes. It will be important to continue to monitor organizational changes as research shows that implementation strategies are more likely to succeed in a stable organization that are able to retain senior leaders and staff that are knowledgeable and motivated to continue delivering health promotion over time (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReadiness appears embedded in structural conditions, including funding, workforce stability, policy environments, and population health needs (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Political leadership is important as it can effectively prioritize and create conditions which favor the implementation of health promotion programs like the HSS as illustrated by M3. This could help reduce inequalities in health within and between municipalities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eImplementation outcomes between school personnel\u003c/h2\u003e \u003cp\u003eAlthough overall readiness increased from pre- to post-intervention across the full sample, the adjusted model showed that school nurses had slightly lower post-intervention readiness than teachers. Meaning that both groups improved over time, but teachers showed slightly greater gains. The difference was not statistically significant, indicating no clear evidence of meaningful differences in readiness between professions.\u003c/p\u003e \u003cp\u003eSchool nurses also reported slightly lower feasibility scores compared to other school personnel after the first year. This may reflect the demands of delivering in-person health talks using motivational interviewing, particularly during the pandemic in M1 and M2. For example, school nurses in Sweden had to adapt their work to support students and families digitally during this period (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMore broadly, the Swedish school health teams operate under variable staffing ratios and time constraints. We also found in a separate study that while health promotion is included in national guidelines, mandatory tasks such as health checks and vaccinations are prioritized over other preventive activities (under review).\u003c/p\u003e \u003cp\u003eOur previous studies with school nurses participating in the HSS found that mastering motivational interviewing was initially challenging, but with practice, they appreciated its ability to promote a more equal power balance with parents (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Teachers, by contrast, engage with content closely aligned with the curriculum, though classroom components require preparatory work. Process evaluations of the HSS program indicate that teachers value the program for strengthening their own health competence (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and collaboration with parents (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplementation outcomes and readiness were correlated\u003c/h2\u003e \u003cp\u003eWhile not surprising, there was a strong positive correlation between pre-intervention readiness and the implementation outcomes ACC, APP and FEAS. This suggests consistency in how individuals perceive readiness and early implementation outcomes. School personnel in quadrant I (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) did not find the HSS very feasible and perceived low readiness, while those in quadrant IV perceived the intervention to be feasible and that they were ready for change. Smaller groups fell into mixed-perception quadrants (II and III). These discrepancies may reflect individual or role-specific contextual factors. Although barriers and facilitators to the implementation of HSS were explored qualitatively (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), their relative importance was not ranked. Different perceptions of barriers could be one explanation why some of the participants from the same municipality ended up in different quadrants. Another study also found a high correlation between readiness and implementation outcomes and suggested that readiness is a precursor of early implementation outcomes like ACC, APP and FEAS (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These authors warned against implementing a service in an organization receiving a low appropriateness score without engaging in a process to improve readiness. This underscores the need to better understand how readiness shapes later implementation processes. Strategies could be developed to engage or prepare staff depending on the quadrant they score in. This may support more strategic timing and resource-efficient implementation.\u003c/p\u003e \u003cp\u003eIn the CFIR Outcomes Addendum readiness, ACC, APP and FEAS have been classified as antecedent assessments on the pathway between implementation determinants and outcomes and thus predictors of more distal implementation outcomes like fidelity (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Future analyses could examine how readiness is associated with fidelity over time.\u003c/p\u003e \u003cp\u003eStrengths and weaknesses\u003c/p\u003e \u003cp\u003eTo our knowledge, this is one of the first school-based implementation studies to use the validated questionnaire by Weiner et al. on implementation outcomes (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). While previous studies have relied primarily on mixed methods to examine acceptability, appropriateness, and feasibility, often in rural school settings (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), the present study applies a standardized, theory-informed quantitative instrument in an urban school-based implementation context. Moreover, we have recently validated the readiness instrument in the Swedish context (A Toropova et al., submitted for publication). In contrast to the ORIC instrument on which it is based, the readiness scales used in this study ask for a personal appraisal of readiness instead of an assessment of organizational readiness as a whole. Assessing organizational readiness may be challenging for individual staff members, and in this sense, the readiness scales capture individual perceptions of readiness to implement the HSS program, rather than the organization\u0026rsquo;s readiness per se. The same individual-level perspective applies to the instrument used to assess implementation outcomes.\u003c/p\u003e \u003cp\u003eA key limitation of this study is the relatively small sample size within professional subgroups, combined with potential selection bias, as only 66% (150/229) of eligible personnel participated and 73% of these (110/150) completed the post-intervention survey. The limited statistical power may explain the absence of statistically significant differences in readiness scores between professional groups. Nonetheless, the inclusion of principals, teachers, and school nurses offers important triangulation across professional roles and provides insight into the additional workload and stress experienced by school nurses when delivering the MI component for the first time. Future studies with larger samples or qualitative approaches could further explore higher-level organizational and systematic barriers and facilitators to implementation at scale.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identified three distinct patterns across municipalities in terms of readiness and early implementation outcomes during the first year of implementing the \u003cem\u003eHealthy School Start\u003c/em\u003e (HSS) intervention. These findings suggest that perceptions of implementability of the same intervention vary across local contexts. Importantly, when the majority of school personnel perceive low readiness or feasibility, additional implementation support or preparation time may be required addressing the identified barriers before full-scale implementation is initiated. By capturing pre- and post-intervention data on readiness and implementation outcomes, this study provides novel empirical insight into personnels\u0026rsquo; preparedness to implement a new health program by combining different validated implementation measures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAPP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAppropriateness\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFEAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFeasibility\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthy School Start\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIMPROVE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLRIT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeader Readiness to Implement Tool\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMunicipality\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eORIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOrganizational Readiness for Implementing Change\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eREDCap\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eResearch Electronic Data Captur\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRIT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStaff Readiness to Implement Tool\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki. Participation was voluntary, and informed consent was obtained from all participants. All participants were aged 18 years or older at the time of survey completion. Ethical approval for the study was granted by the Swedish Ethical Review Authority (protocol number 2021-02267).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study has been received from the Swedish Research Council for Health, Working Life and Welfare (FORTE) grant number 2020-01198. Swedish Research Council FORTE, Box 38084, SE-100 64 Stockholm, Sweden. The funder has no role in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKSA, LK, SA, EP, ÅN, NSS and LSE conceptualized the study. LSE, SA, EP, ÅN and NSS participated in the pre-intervention workshops where barriers and facilitators were identified. KSA collected the data and performed the data analysis. KSA and LSE drafted the initial manuscript, while LK, SA, EM, ÅN, SR and NSS provided critical feedback. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank all participating school personnel in the IMPROVE study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWaters E, de Silva-Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011;12:CD001871.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Report of the commission on ending childhood obesity. World Health Organization; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBleich SN, Vercammen KA, Zatz LY, Frelier JM, Ebbeling CB, Peeters A. Interventions to prevent global childhood overweight and obesity: a systematic review. The lancet Diabetes \u0026amp; endocrinology; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGori D, Guaraldi F, Cinocca S, Moser G, Rucci P, Fantini MP. Effectiveness of educational and lifestyle interventions to prevent paediatric obesity: systematic review and meta-analyses of randomized and non-randomized controlled trials. Obes Sci Pract. 2017;3(3):235\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBergstrom H, Sundblom E, Elinder LS, Norman A, Nyberg G. Managing Implementation of a Parental Support Programme for Obesity Prevention in the School Context: The Importance of Creating Commitment in an Overburdened Work Situation, a Qualitative Study. J Prim Prev. 2020;41(3):191\u0026ndash;209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman A, Nyberg G, Berlin A. School-based obesity prevention for busy low-income families-Organisational and personal barriers and facilitators to implementation. PLoS ONE. 2019;14(11):e0224512.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurner GL, Owen S, Watson PM. Addressing childhood obesity at school entry: Qualitative experieces of school health professionals. J Child Health Care. 2016;20(3):304\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClarke J, Fletcher B, Lancashire E, Pallan M, Adab P. The views of stakeholders on the role of the primary school in preventing childhood obesity: a qualitative systematic review. Obes Rev. 2013;14(12):975\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner BJ. A theory of organizational readiness for change. Implement Sci. 2009;4:67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArmenakis BA. Organizational Change: A Review of Theory and Research in the 1990s. J Manag. 1999;25(3):293\u0026ndash;315.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAarons G, Horowitz J, Dlugosz L, Ehrhart M. The role of organisational processes in dissemination and implementation research. In: Brownson RC, Colditz GA, Proctor EK, editors. Dissemination and implementation research in healthTranslating science to practice. New York: Oxford University Press; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLivet M, Blanchard C, Richard C. Readiness as a precursor of early implementation outcomes: an exploratory study in specialty clinics. Implement Sci Commun. 2022;3(1):94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElinder LS, Wiklund CA, Norman \u0026Aring;, Stattin NS, Andermo S, Patterson E, et al. IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity (IMPROVE) \u0026ndash; study protocol for a cluster-randomized trial. BMC Public Health. 2021;21(1):1630.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman A, Malek ME, Nyberg G, Patterson E, Elinder LS. Effects of Universal School-Based Parental Support for Children's Healthy Diet and Physical Activity-the Healthy School Start Plus Cluster-Randomised Controlled Trial. Prev Sci. 2024;25(6):963\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyberg G, Norman A, Sundblom E, Zeebari Z, Elinder LS. Effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas, the Healthy School Start Study II, a cluster-randomised controlled trial. Int J Behav Nutr Phys Act. 2016;13(1):4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyberg G, Sundblom E, Norman A, Bohman B, Hagberg J, Elinder LS. Effectiveness of a Universal Parental Support Programme to Promote Healthy Dietary Habits and Physical Activity and to Prevent Overweight and Obesity in 6-Year-Old Children: The Healthy School Start Study, a Cluster-Randomised Controlled Trial. PLoS ONE. 2015;10(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatterson E, Nyberg G, Norman A, Schafer Elinder L. Universal healthy school start intervention reduced the body mass index of young children with obesity. Acta Paediatr. 2024;113(9):2119\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown T, Moore TH, Hooper L, Gao Y, Zayegh A, Ijaz S, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2019;7(7):CD001871.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerjans-Janssen SRB, van de Kolk I, Van Kann DHH, Kremers SPJ, Gerards S. Effectiveness of school-based physical activity and nutrition interventions with direct parental involvement on children's BMI and energy balance-related behaviors - A systematic review. PLoS ONE. 2018;13(9):e0204560.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStouten JRD, De Cremer D. Successful Organizational Change: Integrating the Management Practice and Scholarly Literatures. Acad Manag Ann. 2018;12(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyon AR, Bruns EJ. From evidence to impact: Joining our best school mental health practices with our best implementation strategies. School Ment Health. 2019;11(1):106\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang T, OD F, Chen P. Creating individual and organizational readiness for change: conceptualization of system readiness for change in school education. Int J Leadersh Educ. 2023;26(6):1037\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOreg SVM, Achilles Armenakis. Change Recipients\u0026rsquo; Reactions to Organizational Change. J Appl Behav Sci. 2011;47(4):461\u0026ndash;524.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eV\u0026auml;gledning f\u0026ouml;r elevh\u0026auml;lsan (Guideline for school health services) Stockholm. National Board of Health and Welfare \u0026amp; Swedish National Agency for Education; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing change: a psychometric assessment of a new measure. Implement Sci. 2014;9:7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLudvigsson JF. The first eight months of Sweden's COVID-19 strategy and the key actions and actors that were involved. Acta Paediatr. 2020;109(12):2459\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToropova A, Bjorklund C, Bergstrom G, Elinder LS, Stigmar K, Wahlin C, et al. Effectiveness of a multifaceted implementation strategy for improving adherence to the guideline for prevention of mental ill-health among school personnel in Sweden: a cluster randomized trial. Implement Sci. 2022;17(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerlitz L, MacIntyre H, Osborn T, Bonell C. The sustainability of public health interventions in schools: a systematic review. Implement Sci. 2020;15(1):4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoberg M, Lindqvist H, Andermo S, Norman A. Sometimes It Felt Great, and Sometimes It Just Went Pear-Shaped: Experiences and Perceptions of School Nurses' Motivational Interviewing Competence: A Convergent Mixed-Methods Study. Clin Pract. 2022;12(3):333\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinsson E, Garmy P, Einberg EL. School Nurses' Experience of Working in School Health Service during the COVID-19 Pandemic in Sweden. Int J Environ Res Public Health. 2021;18(13).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBergstrom H, Haggard U, Norman A, Sundblom E, Elinder LS, Nyberg G. Factors influencing the implementation of a school-based parental support programme to promote health-related behaviours-interviews with teachers and parents. BMC Public Health. 2015;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamschroder LJ, Reardon CM, Opra Widerquist MA, Lowery J. Conceptualizing outcomes for use with the Consolidated Framework for Implementation Research (CFIR): the CFIR Outcomes Addendum. Implement Sci. 2022;17(1):7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalvert HG, McQuilkin M, Havlicak A, Lewis T, Turner L. Acceptability, appropriateness, and feasibility of Rural School Support Strategies for behavioral interventions: a mixed methods evaluation over two years of a hybrid type 3 implementation-effectiveness trial. Implement Sci Commun. 2023;4(1):92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyon AR, Bruns EJ, Ludwig K, Stoep AV, Pullmann MD, Dorsey S, et al. The Brief Intervention for School Clinicians (BRISC): A mixed-methods evaluation of feasibility, acceptability, and contextual appropriateness. School Ment Health. 2015;7(4):273\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Readiness, Acceptability, Appropriateness, Feasibility, Hybrid type 3 study, Implementation, Schools","lastPublishedDoi":"10.21203/rs.3.rs-8410429/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8410429/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Effective implementation of evidence-based interventions is essential to reducing the disease burden. Contextual barriers can hinder implementation and reduce effectiveness. Assessing readiness early in the process may identify challenges and improve outcomes such as acceptability, appropriateness, and feasibility. This study examined changes in readiness and implementation outcomes among school staff implementing the\u003cem\u003e Healthy School Start\u003c/em\u003eprogram in three Swedish municipalities M1, M2 and M3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Embedded in an implementation-effectiveness trial, validated questionnaires were used to assess readiness, acceptability (ACC), appropriateness (APP), and feasibility (FEAS) pre- and post-intervention. Data were collected from 39 school principals, 72 teachers, and 39 school nurses between September 2021 and May 2023. Summative scores were generated for each outcome using medians and interquartile ranges (IQR). Mixed-effects linear regressions were conducted to analyze change, adjusting for pre-intervention scores, professional group and clustering by school.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Adjusted analyses showed a significant increase in readiness post-intervention (β = 0.47, p \u0026lt; 0.001, 95% CI: 0.25–0.70) in the total sample. ACC, APP, and FEAS scores also increased significantly from pre- to post-intervention (ACC: β = 0.56, p \u0026lt; 0.001; APP: β = 0.45, p \u0026lt; 0.001; FEAS: β = 0.43, p = 0.001). While M3 showed significantly higher post-intervention readiness (β = 5.93, p = 0.014, 95% CI: 1.19–10.68) and FEAS compared to M1 (β = 2.67, p = 0.009, 95% CI: 0.67–4.66), no significant differences were found for ACC or APP between municipalities after adjustment. Across professional groups, school nurses reported lower feasibility pre-intervention compared to principals and teachers, but differences were not statistically significant after adjustment. Nearly half of participants in M2 scored in the “Low Readiness–Low Feasibility” quadrant, while over half in M1 and M3 scored in the “High Readiness–High Feasibility” quadrant. All M3 schools opted to continue the program into the subsequent year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This study provides novel empirical insight into school personnel’s preparedness to implement a new health program. Findings highlight that readiness and implementation outcomes can vary across settings, underscoring the need to address context-specific factors to strengthen implementation before starting the process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e Registered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021\u003c/p\u003e","manuscriptTitle":"A Multi-Site Study of implementing a School-Based Health Promotion Intervention in Sweden – Changes in Readiness and Implementation Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 08:25:49","doi":"10.21203/rs.3.rs-8410429/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-16T04:00:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T16:01:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T08:20:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229208213816169563304877090135921552848","date":"2026-01-15T20:10:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297070315353030867196294851798122408872","date":"2026-01-15T13:24:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T10:12:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T09:08:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-08T10:32:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-08T10:03:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-08T09:50:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"754025ee-7570-4509-afab-c25c5bb593c0","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T04:09:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-19 08:25:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8410429","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8410429","identity":"rs-8410429","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}