Health and economic outcomes of a universal early intervention for parents and children from birth to age five: evaluation of the Salut Programme using a natural experiment.

BACKGROUND: The aim of this study was to investigate the health and economic outcomes of a universal early intervention for parents and children, the Salut Programme, from birth to when the child completed five years of age. METHODS: This study adopted a retrospective observational design using routinely collected linked register data with respect to both exposures and outcomes from Västerbotten county, in northern Sweden. Making use of a natural experiment, areas that received care-as-usual (non-Salut area) were compared to areas where the Programme was implemented after 2006 (Salut area) in terms of: (i) health outcomes, healthcare resource use and costs around pregnancy, delivery and birth, and (ii) healthcare resource use and related costs, as well as costs of care of sick child. We estimated total cumulative costs related to inpatient and specialised outpatient care for mothers and children, and financial benefits paid to mothers to stay home from work to care for a sick child. Two analyses were conducted: a matched difference-in difference analysis using the total sample and an analysis including a longitudinal subsample. RESULTS: The longitudinal analysis on mothers who gave birth in both pre- and post-measure periods showed that mothers exposed to the Programme had on average 6% (95% CI 3-9%) more full-term pregnancies and 2% (95% CI 0.03-3%) more babies with a birth weight ≥ 2500 g, compared to mothers who had care-as-usual. Savings were incurred in terms of outpatient care costs for children of mothers in the Salut area ($826). The difference-in-difference analysis using the total sample did not result in any significant differences in health outcomes or cumulative resource use over time. CONCLUSIONS: The Salut Programme achieved health gains, as a health promotion early intervention for children and parents, in terms of more full-term pregnancies and more babies with a birth weight ≥ 2500 g, at reasonable cost, and may lead to lower usage of outpatient care. Other indicators point towards positive effects, but the small sample size may have led to underestimation of true differences.

Abnormal birth weights for gestational age in relation to maternal characteristics in Sweden: a five year cross-sectional study.

BACKGROUND: Abnormal birth weight - small for gestational age (SGA) and large for gestational age (LGA) - are important indicators for newborn health. Due to changes in lifestyle in recent decades, it is essential to keep up-to-date with the latest information on maternal factors linked to abnormal birth weight. The aim of this study is to investigate SGA and LGA in relation to maternal individual, lifestyle and socioeconomic characteristics. . METHODS: This is a register-based cross-sectional study. Self-reported data from Sweden's Salut Programme maternal questionnaires (2010-2014) were linked with records in the Swedish Medical Birth Register (MBR). The analytical sample comprised 5089 singleton live births. A Swedish standard method using ultrasound-based sex-specific reference curves defines the abnormality of birth weight in MBR. Univariable and multivariable logistic regressions were used to examine crude and adjusted associations between abnormal birth weights and maternal individual, lifestyle and socioeconomic characteristics. A sensitivity analysis, using alternative definitions of SGA and LGA under the percentile method, was undertaken. RESULTS: In multivariable logistic regression, maternal age and parity were associated with LGA (aOR = 1.05, CI = 1.00, 1.09) and (aOR = 1.31, CI = 1.09, 1.58). Maternal overweight and obesity were strongly associated with LGA (aOR = 2.28, CI = 1.47, 3.54) and (aOR = 4.55, CI = 2.85, 7.26), respectively. As parity increased, the odds of delivering SGA babies decreased (aOR = 0.59, CI = 0.42, 0.81) and preterm deliveries were associated with SGA (aOR = 9.46, CI = 5.67, 15.79). The well-known maternal determinants of abnormal birthweight, such as unhealthy lifestyles and poor socioeconomic factors, were not statistically significant in this Swedish setting. CONCLUSIONS: The main findings suggest that multiparity, maternal pre-pregnancy overweight and obesity are strong determinants for LGA babies. Public health interventions should address modifiable risk factors, especially maternal overweight and obesity. These findings suggest that overweight and obesity is an emerging public health threat for newborn health. This might also result in the intergenerational transfer of overweight and obesity. These are important messages for public health policy and decision making.

Self-rated health inequalities in the intersection of gender, social class and regional development in Spain: exploring contributions of material and psychosocial factors.

BACKGROUND: Inequalities in health across social class, gender and regional context in Spain are well-known; however, there is a lack of research examining how these dimensions of inequality interact. This study explores self-rated health (SRH) inequalities across intersectional positions of gender, social class and region, and the contribution of material and psychosocial factors to these inequalities. METHODS: Participants were drawn from the cross-sectional 2015 National Living Conditions Survey of Spanish residents aged 19-88 years (N = 27,215; 77% response rate). Eight intersectional positions were formed by combining dichotomous variables of gender, social class and regional development. Poisson regression was used to estimate intersectional inequalities in SRH as prevalence ratios, and the contributions of material and psychosocial factors. RESULTS: Results showed both cumulative and heterogeneous inequalities within and across intersectional positions. Inequalities in the intersection of social class and regional development were best explained by the joint contributions of material and psychosocial factors, while gender inequalities within non-manual social class were better explained by material factors alone. CONCLUSIONS: The results illustrate the complexity of interacting inequalities in health and their underpinnings in Spain. Local and national policies taking this complexity into account are needed to broadly improve equity in health in Spain.

Social-emotional problems among Swedish three-year-olds: an Item Response Theory analysis of the Ages and Stages Questionnaires: Social-Emotional.

BACKGROUND: There is enough evidence to believe that young children's social-emotional problems can have a long-term effect if extra support is not given early. Therefore, early identification of such problems and any differences between boys and girls are of importance. We utilized the 36-month interval of the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) among 3-year-olds aiming: 1) to report the normative values of social-emotional problems for Swedish boys and girls; 2) to identify ASQ:SE items that are most commonly endorsed by children with high level of social-emotional problems (high score on ASQ:SE); 3) to assess whether certain ASQ:SE items differ between boys and girls at the same level of social-emotional problems; and 4) to examine whether ASQ:SE performs well in identifying children with high level of social-emotional problems (high score on ASQ:SE). METHOD: During 2014-2017, data were collected from 7179 three-year-old children (boys = 3719, girls = 3460) through Child Health Care in the Region Västerbotten in the northern part of Sweden. Unidimensionality was assessed by Confirmatory Factor Analysis and goodness-of-fit was reported. Item Response Theory was used to answer the aims of the study. RESULTS: Items regarding interest in sexual words, too little sleep, disinterest in things around, unhappiness and self-injury were more commonly endorsed by children with high levels of social-emotional problems, as reported by their parents. For the same level of social-emotional problem, girls were more likely to demonstrate difficulties in occupying themselves, clinging behaviour and repetitive behaviour. On the other hand, boys were more likely to score high in items regarding destruction of things on purpose, difficulty to name friends and to express feelings. We have also found that the ASQ:SE is suitable for identifying children with high level of social-emotional problems. CONCLUSION: The salient point of our study was to increase knowledge about Swedish children's social-emotional problems at 3-years of age based on the psychometric characteristics of the ASQ:SE using Item Response Theory model. The gender differences as well as those items that occurred at high levels of social-emotional problems should be of concern for everyday practice in Child Health Care.

Health counselling in dental care for expectant parents: A qualitative study.

OBJECTIVES: Interventions during pregnancy and early childhood have been shown to impact dental health. Thus, Antenatal Care and Dental Care collaborated in an intervention called Health Counselling in Dental Care (HCDC). HCDC was offered free of charge to first-time expectant parents and was aimed at reducing the frequency of dental caries in children and their parents. However, the intervention reached less than 50% of the parents. The aim of this study was to explore facilitators of, barriers to, and suggestions for increased participation in HCDC. METHODS: Data were collected through semi-structured, face-to-face interviews with expectant parents. Participants were purposively sampled based on having been invited to HCDC and to achieve a variation in socio-demographics. Interviews were audio recorded, transcribed verbatim and analysed using conventional qualitative content analysis. RESULTS: In total, 16 interviews were conducted (10 women, 6 men). Six categories representing three facilitators and three barriers for participation emerged. The facilitators were the midwife's crucial role for disseminating information about HCDC and motivating participation, that the parents perceived HCDC as valuable for themselves and their offspring, and a desire for new or more knowledge. The barriers included a shortage of information regarding the counselling, a perceived lack of value for the parents and offspring, and the timing of the counselling during pregnancy. CONCLUSIONS: The midwives were crucial in providing information and motivation for HCDC participation. To increase attendance, sufficient information regarding the benefits of counselling is required, and the timing needs to be flexible and family-centred.

Social-emotional problems among three-year-olds differ based on the child's gender and custody arrangement.

AIM: The aim of this study was to investigate mental health with respect to social-emotional problems among three-year-olds in relation to their gender, custody arrangements and place of residence. METHODS: A cross-sectional population-based design was used, encompassing 7179 three-year-olds in northern Sweden during the period 2014-2017 from the regional Salut Register. Descriptive and comparative analyses were performed based on parents' responses on the Ages and Stages Questionnaires: Social-Emotional, supplemented with items on gender, custody arrangement and place of residence. RESULTS: Parental-reported social-emotional problems were found in almost 10% of the children. Boys were reported to have more problems (12.3%) than girls (5.6%; p < 0.001). Parents were most concerned about children's eating habits and interactions at mealtimes. Parents not living together reported more problems among their children than those living together (p < 0.001). When stratifying by custody arrangement, girls in rural areas living alternately with each parent had more problems compared to those in urban areas (p < 0.008). CONCLUSION: Gender and custody arrangements appear to be important factors for social-emotional problems among three-year-olds. Thus, such conditions should receive attention during preschool age, preferably by a systematic preventive strategy within Child Health Care.

Managing the initiation and early implementation of health promotion interventions: a study of a parental support programme in primary care.

BACKGROUND: Mental health problems are increasing among children and adolescents worldwide, and parental support programmes have been suggested as one preventive intervention. However, the actual impact and low rates of adoption and sustainability of prevention programmes have proven to be a concern, and thus, further studies on their implementation are needed. AIM: This study focused on the initial implementation of the International Child Development Programme (ICDP) in primary care. The aim was to investigate the involved actors' views on factors likely to affect implementation and the strategies used to manage them. DESIGN: A case study design with a mixed-methods approach combining quantitative and qualitative data from questionnaires and interviews was used. METHODS: Eighty-two professionals at different positions in the involved organisations participated. Directed content analysis was used for analyses, focusing on perceived levels of importance and the manifestation of implementation factors. FINDINGS: Interviews and questionnaires provided descriptions of factors influencing the initial ICDP implementation. Uncertainty on how to manage important factors and vague change strategies was reported. Discrepancies in the perceived levels of importance versus manifestation were found regarding several factors, including hands-on support, time and resources, communication and information, a comprehensive plan of action, follow-ups, and external and internal collaborations. Manifested factors were a need for change, motivation and the ICDP's compatibility with existing norms, values and practices. CONCLUSIONS: Implementing a parental support programme in a complex setting will benefit from being preceded by a thorough examination of the intervention and the target context and the development of clear implementation strategies based on the results of that examination. This study provides insights into how and by whom knowledge on implementation is applied during the launch of a health promotion programme, and these insights might help increase the rate of adoption and the use of such programmes and thereby increase their effectiveness.

Associations between toddlers' and parents' BMI, in relation to family socio-demography: a cross-sectional study.

BACKGROUND: It is well established that the pregnancy and the first years of life are important for future childhood health and body weight. Even though current evidence suggests that both parents are important for childhood health, the influence that parents' BMI and socio-demography has on toddlers' BMI has so far received little attention. This study aimed to increase our knowledge on the association between toddlers' and parents' BMI, in relation to family socio-demography. Further, the aim was to investigate the interaction between the mothers' and fathers' BMI in relation to their child's BMI. METHODS: A total of 697 children with a median age of 18 months (range 16-24 months) participated in the study along with their mothers (n = 697) and fathers (n = 674). As regards representability, our parental sample had a lower proportion of immigrants and the parents were more gainfully employed compared to parents in the rest of Sweden (when the child was 18 months old). The parents completed a questionnaire on parental and child health. Data on parental weight, height, and socio-demographics were recorded along with the child's weight and height measured at an ordinary child health care visit. We used the thresholds for children's BMI that were recommended for surveillance by the Royal College of Paediatrics and Child Health in 2012 based on the WHO reference population. RESULTS: Among the toddlers, 33 % had a BMI above the WHO 85(th) percentile and 14 % had a BMI above the WHO 95(th) percentile. The probability of a toddler having a BMI above the WHO 95(th) percentile was significantly increased if either the mother or father was overweight (BMI ≥ 25 kg/m(2)). Furthermore, we found a positive synergistic effect between the mother and father being overweight and their child having a BMI above the WHO 85(th) percentile. No associations were found between the toddlers' BMI and the family's socio-demographics, but there were associations between the parents' BMI and the family's socio-demographics. CONCLUSION: High BMI is common even in toddlers in this population. The risk increases if one parent is overweight, and it increases even more if both parents are overweight. The results in this study confirm the importance of considering familial risk factors when examining child health and BMI at ordinary child health care visits already at an early age.

"An on-going individual adjustment": a qualitative study of midwives' experiences counselling pregnant women on physical activity in Sweden.

BACKGROUND: In Sweden, midwives play prominent supportive role in antenatal care by counselling and promoting healthy lifestyles. This study aimed to explore how Swedish midwives experience the counselling of pregnant women on physical activity, specifically focusing on facilitators and barriers during pregnancy. Also, addressing whether the midwives perceive that their own lifestyle and body shape may influence the content of the counselling they provide. METHODS: Eight focus group discussions (FGD) were conducted with 41 midwives working in antenatal care clinics in different parts of Sweden between September 2013 and January 2014. Purposive sampling was applied to ensure a variation in age, work experience, and geographical location. The FGD were digitally recorded, transcribed verbatim, and analyzed using manifest and latent content analysis. RESULTS: The main theme--"An on-going individual adjustment" was built on three categories: "Counselling as a challenge"; "Counselling as walking the thin ice" and "Counselling as an opportunity" reflecting the midwives on-going need to adjust their counselling depending on each woman's specific situation. Furthermore, counselling pregnant women on physical activity was experienced as complex and ambiguous, presenting challenges as well as opportunities. When midwives challenged barriers to physical activity, they risked being rejected by the pregnant women. Despite risking rejection, the midwives tried to promote increased physical activity based on their assessment of individual needs of the pregnant woman. Some participants felt that their own lifestyle and body shape might negatively influence the counselling; however, the majority of participants did not agree with this perspective. CONCLUSIONS: Counselling on physical activity during pregnancy may be a challenging task for midwives, characterized by on-going adjustments based on a pregnant woman's individual needs. Midwives strive to find individual solutions to encourage physical activity. However, to improve their counselling, midwives may benefit from further training, also organizational and financial barriers need to be addressed. Such efforts might result in improved opportunities to further support pregnant women's motivation for performance of physical activity.

A population-based study of overweight and obesity in expectant parents: socio-demographic patterns and within-couple associations.

BACKGROUND: Overweight and obesity in pregnancy increase the risk of several adverse pregnancy outcomes. However, both mothers' and fathers' health play an important role for long-term health outcomes in offspring. While aspects of health and lifestyle of pregnant women have been reported, the health of expectant fathers and correlations of health variables within couples have received less attention. This study aimed to explore the prevalence and socio-demographic patterns of overweight and obesity in Swedish expectant parents, and to assess within-couple associations. METHODS: This population-based, cross-sectional study investigated self-reported data from 4352 pregnant women and 3949 expectant fathers, comprising 3356 identified couples. Data were collected in antenatal care clinics between January 2008 and December 2011. Descriptive, correlation and logistic regression analyses were performed. RESULTS: The self-reported prevalence of overweight (BMI 25.0-29.99) and obesity (BMI ≥ 30.0) was 29% among women (pre-pregnancy) and 53% among expectant fathers. In a majority of couples (62%), at least one partner was overweight or obese. The odds of being overweight or obese increased relative to partner's overweight or obesity, and women's odds of being obese were more than six times higher if their partners were also obese in comparison with women whose partners were of normal weight (OR 6.2, CI 4.2-9.3). A socio-demographic gradient was found in both genders in relation to education, occupation and area of residence, with higher odds of being obese further down the social ladder. The cumulative influence of these factors showed a substantial increase in the odds of obesity for the least compared to the most privileged (OR 6.5, CI 3.6-11.8). CONCLUSIONS: The prevalence of overweight and obesity in expectant parents was high, with a clear social gradient, and a minority of couples reported both partners with a healthy weight at the onset of pregnancy. Partner influence on health and health behaviours, and the role both mothers and fathers play in health outcomes of their offspring, underpin the need for a more holistic and gender inclusive approach to the delivery of pregnancy care and postnatal and child health services, with active measures employed to involve fathers.

Overweight and lifestyle among 13-15 year olds: a cross-sectional study in northern Sweden.

AIM: To increase knowledge of self-rated health and lifestyle in relation to overweight/obesity among 13-15 year olds in northern Sweden. METHODS: All 6768 13-15 year olds in nine out of 15 municipalities in Västerbotten County were asked to complete a cross-sectional school-based on-line survey in 2007. Eighty-two per cent participated in the study. Responses were considered reliable for 74% of the participants (2517 boys/2470 girls). The survey addressed demography, self-rated health, self-reported weight, height, and lifestyle characteristics. Simple and multiple logistic regression analyses were used. RESULTS: Overweight/obesity (ISO body mass index ≥25 kg/m(2)) was more prevalent among boys (20%) than girls (11%), but more girls (19%) than boys (9%) reported fair or bad health. Overweight/obese boys and girls were more often physically inactive. For the boys, overweight/obesity was also associated with skipping breakfast, insufficient tooth brushing, and using snuff. For the girls, overweight/obesity was also associated with living with one parent and more television watching. Boys reported healthier habits concerning sleep duration, physical activity, eating breakfast, and smoking compared to the girls. On the other hand, girls reported better dietary and tooth brushing habits. CONCLUSIONS: This study uncovered two alarming findings: a fifth of the boys were overweight/obese and a fifth of the girls reported fair or bad health. Girls living with a single parent and boys and girls with unhealthy lifestyles were more likely to be overweight. Our findings emphasise the need for developing and implementing effective health promotion strategies for school-aged children to prevent an overweight and obesity epidemic that could continue into adulthood.

Improving child health promotion practices in multiple sectors - outcomes of the Swedish Salut Programme.

BACKGROUND: To improve health in the population, public health interventions must be successfully implemented within organisations, requiring behaviour change in health service providers as well as in the target population group. Such behavioural change is seldom easily achieved. The purpose of this study was to examine the outcomes of a child health promotion programme (The Salut Programme) on professionals' self-reported health promotion practices, and to investigate perceived facilitators and barriers for programme implementation. METHODS: A before-and-after design was used to measure programme outcomes, and qualitative data on implementation facilitators and barriers were collected on two occasions during the implementation process. The sample included professionals in antenatal care, child health care, dental services and open pre-schools (n=144 pre-implementation) in 13 out of 15 municipalities in a Swedish county. Response rates ranged between 81% and 96% at the four measurement points. RESULTS: Self-reported health promotion practices and collaboration were improved in all sectors at follow up. Significant changes included: 1) an increase in the extent to which midwives in antenatal care raised issues related to men's violence against women, 2) an increase in the extent to which several lifestyle topics were raised with parents/clients in child health care and dental services, 3) an increased use of motivational interviewing (MI) and separate 'fathers visits' in child health care 4) improvements in the supply of healthy snacks and beverages in open pre-schools and 5) increased collaboration between sectors. Main facilitators for programme implementation included cross-sectoral collaboration and sector-specific work manuals/questionnaires for use as support in everyday practice. Main barriers included high workload, and shortage of time and staff. CONCLUSION: This multisectoral programme for health promotion, based on sector-specific intervention packages developed and tested by end users, and introduced via interactive multisectoral seminars, shows potential for improving health promotion practices and collaboration across sectors. Consideration of the key facilitators and barriers for programme implementation as highlighted in this study can inform future improvement efforts.

The Ages and Stages Questionnaire: Social-Emotional-What Is the Optimal Cut-Off for 3-Year-Olds in the Swedish Setting?

OBJECTIVE: Expressions of emotional and behavioral symptoms in preschool age can predict mental health problems in adolescence and adulthood. The Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) has been successful in detecting social and emotional problems in young children in some countries but had not been tested in Sweden. The objective of this study was to determine the optimal cut-off for the ASQ:SE instrument when administered to 3-year-old children in a northern Swedish setting, using the Strengths and Difficulties Questionnaire (SDQ) as the reference. METHODS: The ASQ:SE (36-month interval, first edition) was administered at routine 3-year-olds' visits to Child Health Care centers in Region Västerbotten, Sweden. During the study period (September 2017 to March 2018) parents were invited to also fill out the SDQ (2-4 year version). In the final analyses 191 children fulfilled the criteria for inclusion in the study sample. Non-parametric Receiver Operating Characteristic analysis was performed to quantify the discriminatory accuracy of ASQ:SE based on SDQ. RESULTS: The Pearson correlation between ASQ:SE and SDQ indicated strong correlation between the two instruments. The Receiver Operating Characteristic curve showed good accuracy of ASQ:SE in relation to SDQ. However, our results suggest that the existing ASQ:SE cut-off score of 59 was not optimal in the Swedish context. Changing the cut-off from 59 to 50 would allow us to detect 100% (n = 14) of children with problems according to SDQ, compared to 64% (n = 9) when the cut-off was 59. However, the proportion of false positives would be higher (9% compared to 3%). CONCLUSION: The main finding was that for 3-year-olds in Sweden a decreased ASQ:SE cut-off score of 50 would be optimal. This would increase the detection rate of at-risk children according to SDQ (true positive), thus prioritizing sensitivity. Our conclusion is that, although this change would result in more false positives, this would be justifiable.

Maternal and paternal self-rated health and BMI in relation to lifestyle in early pregnancy: the Salut Programme in Sweden.

AIM: This study's aim was to increase knowledge about maternal and paternal self-rated health and body mass index in relation to lifestyle during early pregnancy. METHODS: Study subjects were expectant parents visiting antenatal care (2006-07) as part of the Salut Programme in northern Sweden. During early pregnancy, 468 females and 413 male partners completed questionnaires. The questions addressed sociodemography, self-rated general health, weight and height, satisfaction with weight, and lifestyle, such as dietary habits, physical activity, sleeping pattern, and alcohol, tobacco, and drug use. RESULTS: Most rated their general health as good, very good, or excellent, although women less often than men (88% and 93%). The sex difference was more prominent when restricting the comparison to self-rated health being very good or excellent--49% of the women compared to 61% of the men. Being overweight or obese was common (53% of the men and 30% of the women). Few participants fulfilled the national recommendations with respect to a health-enhancing lifestyle; this was somewhat more common for women than men. Expectant parents with normal body mass index and vigorous physical activity were more likely to have very good or excellent self-rated health. CONCLUSIONS: Most expectant parents perceived their general health as good, although this perception was less for women than men. Being overweight and having a non-health-enhancing lifestyle were more common for men than women. Thus, there is need for more powerful health-promoting interventions for expectant parents.

Giving offspring a healthy start: parents' experiences of health promotion and lifestyle change during pregnancy and early parenthood.

BACKGROUND: There are good opportunities in Sweden for health promotion targeting expectant parents and parents of young children, as almost all are reached by antenatal and child health care. In 2005, a multisectoral child health promotion programme (the Salut Programme) was launched to further strengthen such efforts. METHODS: Between June and December 2010 twenty-four in-depth interviews were conducted separately with first-time mothers and fathers when their child had reached 18 months of age. The aim was to explore their experiences of health promotion and lifestyle change during pregnancy and early parenthood. Qualitative manifest and latent content analysis was applied. RESULTS: Parents reported undertaking lifestyle changes to secure the health of the fetus during pregnancy, and in early parenthood to create a health-promoting environment for the child. Both women and men portrayed themselves as highly receptive to health messages regarding the effect of their lifestyle on fetal health, and they frequently mentioned risks related to tobacco and alcohol, as well as toxins and infectious agents in specific foods. However, health promotion strategies in pregnancy and early parenthood did not seem to influence parents to make lifestyle change primarily to promote their own health; a healthy lifestyle was simply perceived as 'common knowledge'. Although trust in health care was generally high, both women and men described some resistance to what they saw as preaching, or very directive counselling about healthy living and the lack of a holistic approach from health care providers. They also reported insufficient engagement with fathers in antenatal care and child health care. CONCLUSION: Perceptions about risks to the offspring's health appear to be the primary driving force for lifestyle change during pregnancy and early parenthood. However, as parents' motivation to prioritise their own health per se seems to be low during this period, future health promoting programmes need to take this into account. A more gender equal provision of health promotion to parents might increase men's involvement in lifestyle change. Furthermore, parents' ranking of major lifestyle risks to the fetus may not sufficiently reflect those that constitute greatest public health concern, an area for further study.

Sustainable practice change: professionals' experiences with a multisectoral child health promotion programme in Sweden.

BACKGROUND: New methods for prevention and health promotion and are constantly evolving; however, positive outcomes will only emerge if these methods are fully adopted and sustainable in practice. To date, limited attention has been given to sustainability of health promotion efforts. This study aimed to explore facilitators, barriers, and requirements for sustainability as experienced by professionals two years after finalizing the development and implementation of a multisectoral child health promotion programme in Sweden (the Salut programme). Initiated in 2005, the programme uses a 'Salutogenesis' approach to support health-promoting activities in health care, social services, and schools. METHODS: All professionals involved in the Salut Programme's pilot areas were interviewed between May and September 2009, approximately two years after the intervention package was established and implemented. Participants (n = 23) were midwives, child health nurses, dental hygienists/dental nurses, and pre-school teachers. Transcribed data underwent qualitative content analysis to illuminate perceived facilitators, barriers, and requirements for programme sustainability. RESULTS: The programme was described as sustainable at most sites, except in child health care. The perception of facilitators, barriers, and requirements were largely shared across sectors. Facilitators included being actively involved in intervention development and small-scale testing, personal values corresponding to programme intentions, regular meetings, working close with collaborators, using manuals and a clear programme branding. Existing or potential barriers included insufficient managerial involvement and support and perceived constraints regarding time and resources. In dental health care, barriers also included conflicting incentives for performance. Many facilitators and barriers identified by participants also reflected their perceptions of more general and forthcoming requirements for programme sustainability. CONCLUSIONS: These results contribute to the knowledge of processes involved in achieving sustainability in health promotion initiatives. Facilitating factors include involving front-line professionals in intervention development and using small scale testing; however, the success of a programme requires paying attention to the role of managerial support and an overall supportive system. In summary, these results emphasise the importance for both practitioners and researchers to pay attention to parallel processes at different levels in multidisciplinary improvement efforts intended to ensure sustainable practice change.

Social-Emotional Problems Among 3-Year-Olds Are Associated With an Unhealthy Lifestyle: A Population-Based Study.

Introduction: Little attention has been paid to the association between preschool children's social-emotional problems and lifestyle at the population level. Objective: This study aimed to overcome this knowledge gap by investigating to what extent children's social-emotional problems are associated with their lifestyle and if there are any gender differences. Methods: This cross-sectional, population-based study used data from the regional Salut Register in northern Sweden, including 7,179 3-year-olds during 2014-2017. Parents responded to a questionnaire including the 36-month interval of the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) and questions regarding family and lifestyle characteristics. Single and multiple logistic regression were used to assess the association between children's social-emotional problems and multiple family lifestyle characteristics. Results: More reports of social-emotional problems were found among children who did not have parents living together or had markers of an unhealthy lifestyle. Children who ate vegetables less frequently, whose parent/-s brushed their teeth less often and did not read to them regularly were more likely to have social-emotional problems. Playing outdoors <3 h during weekdays and >1 h of sedentary screen time during weekends increased the risk of social-emotional problems among boys only, while >1 h of sedentary screen time during weekdays increased the risk among girls. When it comes to lifestyle and gender differences, a high proportion of the 3-year-olds had an unhealthy lifestyle, more so for boys than for girls. The dietary quality and tooth brushing were somewhat more adequate for the girls than for the boys, but boys spent more time playing outdoors compared to the girls. Conclusions: This study provides us with an important overview picture of the family life situation of three-year-olds, including those with social-emotional problems. Such problems were significantly associated with markers of unhealthy lifestyle, with significant gender differences. Therefore, this study suggests that in order to maintain children's social-emotional ability and support children at risk of problems, public health intervention programs should have a broader perspective on improving children's lifestyle rather than merely focusing on their social and emotional problems, and the gender differences found may be taken in account.

The equity impact of a universal child health promotion programme.

BACKGROUND: Real-world evaluations of complex interventions are scarce. We evaluated the effect of the Salut Programme, a universal child health promotion intervention in northern Sweden, on income-related inequalities in positive birth outcomes and healthcare utilisation up to 2 years after delivery. METHODS: Using the mother's place of residence at delivery, the child and the mother were classified as belonging to either the control area (received care-as-usual) or the intervention area (where the intervention was implemented from 2006) and either the premeasure (children born between 2002 and 2004) or the postmeasure (children born between 2006 and 2008) period. Parents' earned income was used as the socioeconomic ranking variable. The Relative Concentration Index was computed for six binary birth outcome indicators and for inpatient and day patient care for children and their mothers. Changes in inequality over time were compared using a difference-in-difference approach. RESULTS: Income-related inequalities in birth outcomes and child healthcare utilisation were absent, except that full-term pregnancies were concentrated among the poor at premeasure in the intervention area. In contrast, mothers' healthcare utilisation was significantly pro-poor in the control area. The extent of inequality changed differentially between premeasure and postmeasure for two birth outcomes: full-term pregnancies and infants with normal birth weight. Inequalities in healthcare utilisation did not change significantly in either area over time. CONCLUSION: In northern Sweden, income-related inequalities in birth outcomes and child healthcare utilisation are largely absent. However, relative inequalities in mothers' healthcare utilisation are large. We found no evidence that the Salut Programme affected changes in inequality over time.

Is there an association between pregnant women's experience of violence and their partner's drinking? A Swedish population-based study.

OBJECTIVE: Pregnancy is a time of heightened vulnerability for women, especially for experiencing violence in their close and intimate relationships. Alcohol misuse by a male intimate partner is a known contributor to increased risk and severity of intimate partner violence generally, however less is known about the relationship between partner drinking patterns and women's experience of violence in their relationship, and particularly in early pregnancy. This study aimed to explore these associations in a large, population-based sample of Swedish expectant parents. DESIGN, SETTING AND PARTICIPANTS: Data for this cross-sectional study were drawn from 11 461 couples (22 922 participants) enrolled in Salut, a child health promotion programme in Västerbotten County Council, Sweden. Data were collected at women's antenatal care visits during the first trimester of pregnancy. MEASUREMENTS: Questionnaires included male partners' self-reported drinking patterns using AUDIT (Alcohol Use Disorders Identification Test) and pregnant women's reports of violence. Descriptive and logistic regression analyses were undertaken to examine prevalence of reported violence and association with partner drinking patterns. FINDINGS: There was a strong association between male partner alcohol misuse and the odds of pregnant women experiencing violence in general, experiencing violence since becoming pregnant, and fear for their own safety at the time of enrolment in ANC. The odds of having experienced being controlled or physically hurt in a relationship, or having ever experienced sexual violence, were higher with more serious alcohol misuse by the male partner. Most striking was that women whose partners reported hazardous drinking or alcohol dependence had nearly nine times higher odds of experiencing being physically hurt by a partner since becoming pregnant, compared to women whose partners reported non-harmful alcohol use (OR 8.50, CI 2.39-30.17, p = 0.001). Fearing for current safety was also strongly linked to more severe alcohol use by their current male partner (OR 7.65, CI 1.02-57.24, p = 0.048). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This study contributes population-level evidence that the risk for women of experiencing violence in general or in early pregnancy is exacerbated when a male partner drinks in harmful ways. Health professionals and those supporting pregnant women should pay attention to the role of risk factors such as partner alcohol use. Ensuring the health of pregnant women and safety in their relationships is important for maternal, foetal and infant health and family functioning.