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

Success factors for scale-up and sustainment included the appointment of dedicated leaders in the municipality serving as program facilitators by providing consistent support and follow-up during the first year, while barriers such as lack of program prioritization, high workload and staff turnover posed a challenge to the implementation. Program integration into the yearly quality assessment might be the missing piece of the puzzle needed to achieve sustained implementation at scale. These findings are likely applicable in settings with a decentralized school system similar to Sweden's.