Screening for economic hardship at Child Health Care Centres: A qualitative study of stakeholders' perceptions and experiences of the Healthier Wealthier Families model in Sweden.

AIMS: The Healthier Wealthier Families model uses the child healthcare services as an access point to screen and connect parents experiencing economic hardship to municipal Budget and Debt Counselling services. This study aimed to explore the perceptions and experiences of the Healthier Wealthier Families model in a Swedish context. METHODS: Semi-structured interviews were conducted with three stakeholder groups: eligible parents who declined (n=10) and received (n=9) financial counselling; nurses (n=7); and financial counsellors (n=5). The data were analysed using thematic analysis. RESULTS: The analysis resulted in three main themes conveying the stigma of talking about finance, the connection between economic situation and family wellbeing, and the nuts and bolts of providing preventive financial counselling. CONCLUSIONS: A working model aiming to ameliorate child poverty in a societal service context needs to address the preconceptions and perceived mandate and role of the professionals, the prevalence of financial stigma in society, especially in relation to being a 'good' parent, and the current preoccupations and perceived financial needs and hopes of the families served.

Preschool-level socio-economic deprivation in relation to emotional and behavioural problems among preschool children in Sweden.

AIMS: The aim of this study was to explore the association between preschool-level socio-economic deprivation and emotional and behavioural problems among preschool children in Sweden using a multilevel approach. METHODS: In this cross-sectional study, we used data on 2267 children whose parents and preschool teachers had responded to items measuring individual-level socio-economic deprivation and the Strengths and Difficulties Questionnaire (SDQ) for assessment of emotional and behavioural problems. Further, the Socioeconomic Structure Compensation Index (SSCI), collected from Uppsala municipality, was used to assess preschool-level socio-economic deprivation. Unadjusted and adjusted multilevel logistic regression models were used to explore the relations between preschool-level socio-economic deprivation and emotional and behavioural problems. RESULTS: In unadjusted models, children who attended preschools classified as highly deprived had elevated odds for emotional symptoms (odds ratio (OR) 1.71) as rated by parents. However, this association did not remain significant after adjusting for individual-level socio-economic deprivation factors. In both unadjusted and adjusted models, children who attended preschools classified as moderately deprived had elevated odds for peer-relationship problems as rated by parents (OR 1.63; adjusted OR 1.48). There were no significant associations between preschool deprivation and emotional and behavioural problems as rated by preschool teachers. CONCLUSIONS: Swedish preschools may have a compensatory capacity in addressing children's emotional and behavioural problems, whereas preschool-level deprivation remained significantly associated with peer-relationship problems after controlling for individual-level socio-economic deprivation factors. This implies that peer-relationship problems in deprived preschools need to be addressed in a broader community context.

Child behaviour is a main concern for parents of 3-year-olds.

AIM: The aim of this study was to describe parental concerns about child health and behaviour and their sociodemographic predictors in 3-year-olds, in relation to the national guidelines of well-baby clinics. METHODS: The study included parents of 33 526 children in Stockholm who had completed a questionnaire prior to a routine visit to a well-baby clinic at age 3 years. Multivariate regression was used to analyse predictors for concerns. RESULTS: Child behaviour problems, defined as defiance and problem with adherence to daily routines, were the most common parental concerns (36.4%), with poor social skills and relations being second (21.8%). Regarding development, 9.6% had concerns about speech and 4.7% about motor development. Screen use (9.5%) and being underweight (6.3%) were other common parental concerns, while lifestyle concerns regarding physical activity and overweight were rare. Parents raised about twice as many concerns for first-born children compared with younger siblings. Child behaviour and developmental concerns were more frequent in families where the mother had primary education only and attended a well-baby clinic with a high Care Need Index. CONCLUSION: Parents' concerns reflected the national guidelines about child development and behaviour, but not its emphasis on a healthy lifestyle.

Training non-specialists in teaching recovery techniques (TRT) to help traumatised children in humanitarian settings: a qualitative analysis of experiences gained from 20 years of practice.

BACKGROUND: Although several manuals and guidelines have been developed to enhance the quality of task-sharing interventions, it remains challenging to train non-professional personnel in mental health and psychosocial support. Practitioners must translate general recommendations into practical applications to make them relevant in demanding contexts. However, limited research exists on practical experiences with standardised programmes in the field. AIM: To explore how experiences gained from the training of first-line health providers in a low-threshold intervention for children with trauma symptoms may guide implementation of such interventions in local communities in low-income countries. METHOD: We summarise 20 years of experience in the training of first-line health providers, teachers, and school counsellors in providing a low-threshold intervention. The intervention is called teaching recovery techniques (TRT), developed by the Children and War Foundation (CAW). Field notes containing notes from trainings and oral, informal feedback from participants are analysed using thematic analysis, a method well-suited for identifying, analysing, and reporting patterns, or themes, within data in qualitative research. FINDINGS: The analysis showed three main themes/ challenges: (1) Who can conduct the TRT intervention? (2) What form and content should the training take? (3) How can the intervention be used in a responsible way to follow the 'do no harm' principle? We discuss the implications of the findings for trainings in scalable interventions and further research.

Ameliorating epistemic injustice in practice: Communication strategies in a research project with refugee youth coresearchers.

INTRODUCTION: Many researchers want to include seldom involved groups, such as refugees and youth, in patient and public involvement (PPI), but experience a number of barriers. The PPI research community calls for critical evaluations that are prospective, data-based and conducted by researchers and public contributors together. In this study, we conducted a longitudinal evaluation of a core activity in all collaborations: communication strategies. The aim was to evaluate the communication strategies adopted throughout a research project with refugee youth coresearchers. METHODS: This article is based on the evaluation of a project where refugee youth were involved in the online adaptation of a group-based programme for youth with posttraumatic stress. Behavioural observations and field notes collected during the project were analysed with qualitative content analysis and a readability index, and discussed through the lens of epistemic injustice. The article was cowritten by researchers and refugee youth. FINDINGS: Four manifest categories were identified: Facilitating engagement through coplanning and circumstantial flexibility; Different needs require different channels; It's not just about the channel-facilitation skills matter; Finding a common language opens a communicative flow. In addition, a latent underlying theme reflecting the role of trust was identified: Interactive moments facilitate trust-trust facilitates richer involvement. CONCLUSION: At the core of the identified communication strategies were strengthening relationship-building and actively facilitating involvement. Establishing trusting relationships enabled refugee youth to share input. The communication strategies increased hermeneutical justice by contributing to a common understanding; thus, taking a step towards ameliorating epistemic injustice. PATIENT OR PUBLIC CONTRIBUTION: This article is a participatory analysis of a PPI process; it was written in collaboration between researchers and refugee youth coauthors, who were all previously involved in the evaluated project.

Perceptions of the COVID-19 pandemic as demonstrated in drawings of Swedish children aged 4-6 years.

AIM: To explore the perceptions of the COVID-19 pandemic, as expressed in the drawings of Swedish children aged 4-6 years. METHODS: We analysed 91 drawings with associated descriptions submitted to the Swedish Archive of Children's Art from April 2020 to February 2021. RESULTS: The visual and text analysis resulted in three themes. First, illustrating the virus and embodying the danger showed that young children understood the invisible enemy, combining realistic elements of the virus particle with fantasies of the 'virus monster' that needs to be fought off. Second, life has changed for the worse describes the profound effect the pandemic had on young children's lives also in Sweden, with comparatively mild restrictions and no school closures. Third, the virus spreads across the world, affects people and infects their bodies conveys young children's understanding of the pandemic as an existential challenge affecting the whole world. Children displayed surprisingly high levels of health literacy related to COVID-19, including contagion routes and the importance of hand hygiene. CONCLUSION: The drawings of Swedish children aged 4-6 years demonstrated the profound, practical and emotional effects of the pandemic on their lives. Drawings also illuminated young children's level of health literacy regarding COVID-19.

Adolescent co-researchers identified the central role of social media for young people during the pandemic.

AIM: To test the method of engaging co-researcher adolescents in data collection and explore stated motives for their selection of social media material related to COVID-19. METHODS: Twenty-three adolescents, 13-19-years old, in Sweden participated as co-researchers collecting material from their social media related to COVID-19. Specifically, they motivated their selection of social media material in field notes. Their motives were explored using content analysis. RESULTS: Adolescent co-researchers understood and performed the task well, providing insight into the social media exchanges of adolescents during the pandemic. An overarching theme for the motivation for their selection emerged: Social media is an important tool for adolescents' communication and information exchange during COVID-19. Four categories were identified: Keeping track of the talk of the town; Recognition of personally relevant topics; Adolescents as information consumers; Social media as a means for expressing feelings, advice and existential reflections. Co-researchers reported challenges relating to the quality of pandemic-related information available to adolescents. CONCLUSION: Including young people as co-researchers on matters relevant to them was successful. This study also underlines the need to consider the role of social media in information exchange during crises and to co-produce health communication with adolescents to meet their specific needs.

Promoting positive development among refugee adolescents.

Of the estimated 35.3 million refugees around the world (UNHCR, Figures at a Glance, 2022), approximately 50% are children under the age of 18. Refugee adolescents represent a unique group as they navigate developmental tasks in an unstable and often threatening environment or in resettlement contexts in which they often face marginalization. In addition to physiological, social, and psychological changes that mark adolescence, refugee youth often face traumatic experiences, acculturative stress, discrimination, and a lack of basic resources. In this consensus statement, we examine research on refugee adolescents' developmental tasks, acculturative tasks, and psychological adjustment using Suárez-Orozco and colleague's integrative risk and resilience model for immigrant-origin children and youth proposed by Suárez-Orozco et al. Finally, we discuss recommendations-moving from proximal to more distal contexts.

'Feeling down one evening doesn't count as having mental health problems'-Swedish adolescents' conceptual views of mental health.

AIMS: To explore Swedish adolescents' conceptual views of mental health and mental health problems. DESIGN: A qualitative descriptive study design. METHODS: Semi-structured focus group interviews and individual interviews were conducted with, in total, 32 Swedish adolescents (15-18 years old) in October-November 2020. Data were analysed using systematic text condensation. RESULTS: Three themes were identified through the analysis: Mental health is about how we feel; One's mental health depends on one's situation, thoughts and ways of coping; and Mental health problems should be taken seriously and can get severe. CONCLUSION: The results indicate that adolescents understand the complexity and holistic nature of mental health and mental health problems. According to the participating adolescents, positive mental health and mental health problems should be considered simultaneously to understand a young person's mental health state. Good health was described as having both absence of mental health problems and high levels of well-being: feeling well. Mental health problems were defined as something other than normal difficulties in life, but ranging from minor difficulties to more severe conditions. However, all kinds of mental health problems were termed as feeling unwell. The results suggest that adolescents are in need of support to cope with normal difficulties in life rather than lectures about life sometimes being challenging. In addition, the results highlight the need to prevent school-related stress and offer adolescents support for minor mental health problems. IMPACT: The findings have implications for nurses and other professionals who encounter adolescents in their profession, for example specialist nurses, school nurses and public health professionals. The findings add knowledge that could be useful for communication with adolescents about their mental health and methods to assess their mental health status. PATIENT OR PUBLIC CONTRIBUTION: The preliminary results were presented to three classes, in year nine in lower secondary school, for validation.

Rainbows over the world's public health: determinants of health models in the past, present, and future.

The need to visualise the complexity of the determinants of population health and their interactions inspired the development of the rainbow model. In this commentary we chronicle how variations of this model have emerged, including the initial models of Haglund and Svanström (1982), Dahlgren and Whitehead (1991), and the Östgöta model (2014), and we illustrate how these models have been influential in both public health and beyond. All these models have strong Nordic connections and are thus an important Nordic contribution to public health. Further, these models have underpinned and facilitated other examples of Nordic leadership in public health, including practical efforts to address health inequalities and design new health policy approaches.Apart from documenting the emergence of rainbow models and their wide range of contemporary uses, we examine a range of criticisms levelled at these models - including limitations in methodological development and in scope. We propose the time is ripe for an updated generic determinants of health model, one that elucidates and preserves the core value in older models, while recognising the developments that have occurred over the past decades in our understanding of the determinants of health. We conclude with an example of a generic model that fulfills the general purposes of a determinants of health model while maintaining the necessary scope for further adjustments to be made in the future, as well as adjustments to location or context-specific purposes, in education, research, health promotion and beyond.

Ameliorating Child poverty through Connecting Economic Services with child health Services (ACCESS): study protocol for a randomised controlled trial of the healthier wealthier families model in Sweden.

BACKGROUND: Sweden is often held up as an example of a country with low child deprivation; yet, rates of relative deprivation are rising. Every municipality in Sweden is required to provide free, timely and accessible budget and debt counselling under the Social Services Act. The services have been encouraged to perform preventative practice with families; however, this has not been realised. The Healthier Wealthier Families (HWF) model embeds universal screening for economic hardship into child health services and creates a referral pathway to economic support services. Given the universal child health system in Sweden, which is freely available and has excellent coverage of the child population, implementation of the HWF model has potential to support families to access the freely available municipal budget and debt counselling and ultimately improve rates of child deprivation in Sweden. METHODS/DESIGN: We will conduct a two-arm randomised waitlist-control superiority trial to examine the effectiveness and cost-effectiveness of the HWF model in the Sweden. A longitudinal follow-up with the cohort will explore whether any effects are maintained in the longer-term. DISCUSSION: HWF is a collaborative and sustainable model that could maximise the effectiveness of current services to address child deprivation in Sweden. The study outlined in this protocol is the first effectiveness evaluation of the HWF model in Sweden and is a crucial step before HWF can be recommended for national implementation within the child health services. TRIAL REGISTRATION: Clinicaltrials.gov; NCT05511961. Prospectively registered on 23 August 2022. https://clinicaltrials.gov/ct2/show/NCT05511961.

Mental Health of Refugee and Non-refugee Migrant Young People in European Secondary Education: The Role of Family Separation, Daily Material Stress and Perceived Discrimination in Resettlement.

While scholarly literature indicates that both refugee and non-refugee migrant young people display increased levels of psychosocial vulnerability, studies comparing the mental health of the two groups remain scarce. This study aims to further the existing evidence by examining refugee and non-refugee migrants' mental health, in relation to their migration history and resettlement conditions. The mental health of 883 refugee and 483 non-refugee migrants (mean age 15.41, range 11-24, 45.9% girls, average length of stay in the host country 3.75 years) in five European countries was studied in their relation to family separation, daily material stress and perceived discrimination in resettlement. All participants reported high levels of post-traumatic stress symptoms. Family separation predicted post-trauma and internalizing behavioral difficulties only in refugees. Daily material stress related to lower levels of overall well-being in all participants, and higher levels of internalizing and externalizing behavioral difficulties in refugees. Perceived discrimination was associated with increased levels of mental health problems for refugees and non-refugee migrants. The relationship between perceived discrimination and post-traumatic stress symptoms in non-refugee migrants, together with the high levels of post-traumatic stress symptoms in this subsample, raises important questions on the nature of trauma exposure in non-refugee migrants, as well as the ways in which experiences of discrimination may interact with other traumatic stressors in predicting mental health.

Children's Expressions of Worry During the COVID-19 Pandemic in Sweden.

OBJECTIVE: Sweden is an international exception in its public health response to the COVID-19 pandemic, with a higher number of deaths, albeit not pediatric, compared with other Nordic countries. The objective of this study was to investigate what worries children and adolescents living in Sweden expressed in relation to the pandemic. METHODS: Using an anonymous web-survey, 1,047 children (4-12 years; N = 717) and adolescents (13-18 years; N = 330) responded to five background and four open-ended questions, one of which was: Is there anything that you are worried about when it comes to 'Corona'? The responses were coded using manifest content analysis. Interrater reliability was .95, assessed on the code level. RESULTS: Worry was common (77%); mostly (60%) related to disease or death of elderly relatives, parents, the child him/herself or general worry for the elderly/risk groups. Existential worry (15%) comprised worries about the future, including economy and worries about the world perishing or the contagion becoming uncontrollable. A developmental trajectory was evident in the nature of responses. Adolescents' worries about the future included missing out on their youth and employment. They also worried about society (6%), for example, the future of democracy and the world economy. There was no indication of socioeconomic status or geographic area (urban vs. rural) affecting the presence of worrisome thoughts. CONCLUSIONS: Worry about "Corona" was common. Universal preventative mental health intervention is warranted and could be conducted in the school setting. Intervention could be tailored by age, covering discussion on financial aspects with adolescents.

'I felt like a human being'-An exploratory, multi-method study of refugee involvement in the development of mental health intervention research.

BACKGROUND: Great advancements have been made in patient and public involvement (PPI), including the development of guidance on how to conduct, report and evaluate PPI. Despite these efforts, the evidence base remains relatively weak. A substantive methodological development is required. This is particularly important for vulnerable groups within society, for whom PPI can be challenging but has the potential to play a transformative role in shaping research. OBJECTIVES: To describe the group dynamic characteristics and immediate impact of PPI from the user representatives' perspective in a case study of refugee involvement in the development of mental health intervention research. To pilot and methodologically appraise the Active Involvement of Users in Research Observation Schedule and Questionnaire. DESIGN: The Active Involvement of Users in Research Observation Schedule and Questionnaire were administered together with a focus group discussion. SETTING: 'Refugee Advisors' were involved in the development of a randomized controlled trial protocol evaluating a brief group intervention for refugee children experiencing symptoms of post-traumatic stress in Sweden. RESULTS: The multi-method approach demonstrated good feasibility. There were clear examples of how the advisors influenced research development. The advisors described a perceived impact on the research, equality and acceptance, and knowledge gain. A sense of appreciation and empowerment was also interpreted. However, potential issues relating to the relevance of contributions and use of an interpreter were identified. DISCUSSION AND CONCLUSION: The methodological approach piloted in this study offers a promising, rigorous way to evaluate PPI. The research tools require further refinement and validation.

Outside the norm: Mental health, school adjustment and community engagement in non-binary youth.

Aims: The aim of this study was to explore the role of self-reported non-binary gender identity in mental health problems, school adjustment, and wish to exert influence on municipal issues in a community sample of adolescents. Methods: In a cross-sectional design, data were collected through an anonymous survey in Uppsala County, Sweden, among 8385 students (response rate 58.2%) in grades 7, 9, and 11, aged 13-17 years. The Strengths and Difficulties Questionnaire (SDQ) self-report was used to assess mental health problems. Gender identity was measured with one item and youth were categorized into those who identified as male or female (i.e. binary youth), and those who did or could not identify with either gender (i.e. non-binary youth). Logistic regressions and qualitative content analysis were used to analyse data. Results: Youth with non-binary gender identity (n = 137; 1.6%) had higher odds of having mental problems according to the SDQ total score (OR=3.05; 1.77-5.25). The association between non-binary gender identity and mental health problems remained significant after adjusting for confounders. Additionally, compared to their binary peers, the non-binary youth reported more truancy (36.5% vs 49.6%), more often failed a subject (21.5% vs 36.5%), and were more interested in exerting influence on municipal issues such as sociopolitical development, education, municipal services, and drug and alcohol policies (25.3% vs 38.0%). Conclusions: Youth with non-binary gender identity constitute a vulnerable population regarding mental health problems and school adjustment. The willingness to exert influence on municipal issues suggests a possible pathway to engagement.

Identifying language disorder in bilingual children aged 2.5 years requires screening in both languages.

AIM: Bilingual children are at risk of being overlooked for early identification of language difficulties. We investigated the accuracy of four screening models for children aged 2.5. The first model screened the child using their mother tongue, the second screened in Swedish, and the third screened in both languages used by the child. The fourth model consisted of direct screening in Swedish and using parental information about the child's language development in their mother tongue. METHODS: Overall, 111 bilingual children (51% girls), 29-33 months, were recruited from three child health centres in Gävle, Sweden, from November 2015 to June 2017. All children were consecutively assessed by a speech and language pathologist, blinded to the screening outcomes. RESULTS: Developmental language disorder was confirmed in 32 children (29%). Only the third model, based on direct assessment using the two languages used by the child, attained adequate accuracy; 88% sensitivity, 82% specificity, 67% positive and 94% negative predictive values. CONCLUSION: Bilingual children should be screened directly in both their languages in order to achieve adequate accuracy. Such screening procedure is particularly important for children from families with low socio-economic status living in complex linguistic environments.

Asthma and allergies correlate with mental health problems in preschool children.

AIM: To explore the relations between asthma, allergies and mental health problems in preschool children, aged 3-5 years. METHODS: In this cross-sectional Swedish study, we used data on 4649 children in Uppsala municipality whose parents and preschool teachers had responded to questions measuring asthma and allergies, and the Strengths and Difficulties Questionnaire (SDQ) for assessment of mental health problems. Logistic regression models were used to explore the relations between asthma and allergies and mental health problems. RESULTS: Children with asthma (8.5%) had elevated odds of having emotional symptoms as rated by parents (OR: 1.34; 1.02-1.76) and teachers (OR: 1.44; 1.09-1.91). According to parents' ratings, these children also had elevated odds of showing mental health problems in general according to the SDQ total score (OR: 1.42; 1.05-1.94). Children with food allergies or intolerance (4.4%) only had elevated odds of having emotional symptoms (OR: 1.64; 1.16-2.33), as reported by parents. These results remained significant after adjustment for parental background factors. CONCLUSION: Preschool children with asthma and food allergies or intolerance are at risk of having concurrent mental health problems. Mental health problems should be assessed in children with these disorders. Adequate support and/or referral to specialised services should be offered when needed.

Narrative review of interventions suitable for well-baby clinics to promote infant attachment security and parents' sensitivity.

AIM: The aim of this narrative review was to evaluate the evidence for interventions for children's secure attachment relationships and parents' caregiving sensitivity that could potentially be implemented in the context of a well-baby clinic. METHODS: Literature search on programmes for parental caregiving sensitivity and secure attachment for infants aged 0-24 months. Randomised controlled trials (RCTs) published 1995-2018 with interventions starting from one week postpartum, and with a maximum of 12 sessions (plus potential booster session) were included. RESULTS: We identified 25 studies, of which 22 studied effects of home-based programmes using video feedback techniques. Positive effects of these interventions in families at risk were found on parental caregiving sensitivity and to a lesser extent also on children's secure or disorganised attachment. The effects of two of these programmes were supported by several RCTs. Three intervention studies based on group and individual psychotherapy showed no significant positive effects. Most of the interventions targeted mothers only. CONCLUSION: The review found some evidence for positive effects of selective interventions with video feedback techniques for children's secure attachment and strong evidence for positive effects on parental caregiving sensitivity. Important knowledge gaps were identified for universal interventions and interventions for fathers and parents with a non-Western background.

Swedish norms for the Strengths and Difficulties Questionnaire for children 3-5 years rated by parents and preschool teachers.

The Strengths and Difficulties Questionnaire (SDQ) is a widespread tool for assessing behavior problems in children and adolescents. Despite being investigated thoroughly concerning both validity and reliability, peer reviewed studies that provide norms, especially for preschool children, are lacking. This paper provides Swedish norms using data from a large community sample of children aged 3-5, based on mothers', fathers', and preschool teacher's ratings. Preschool teachers' ratings were generally lower than parents' ratings, which contradicts some previous studies. Differences between girls and boys were found, suggesting that boys display higher levels of behavior problems. Lower parental education and country of origin outside of Sweden were also associated with more difficulties. Cut-offs are presented for each age group, gender and rater category. Population-specific norms and percentile cut-offs provided in this study facilitate identifying children in need of interventions in paediatric care and enable cross-country comparisons of children's mental health problems.

Indicated preventive interventions for depression in children and adolescents: A meta-analysis and meta-regression.

Depression contributes about 2% to the global burden of disease. A first onset of depressive disorder or subsyndromal depressive symptoms is common in adolescence, indicating that early prevention is a priority. However, trials of preventive interventions for depression in youths show conflicting results. This systematic review and meta-analysis investigated the effectiveness of group-based cognitive behavioral therapy (GB-CBT) as a preventive intervention targeting subsyndromal depression in children and adolescents. In addition, the impact of different covariates (type of comparator and use of booster sessions) was assessed. Relevant articles were identified from previous systematic reviews, and supplemented with an electronic search spanning from 01/09/2014 to 28/02/2018. The retrieved articles were assessed for eligibility and risk of bias. Relevant data were extracted. Intervention effectiveness was pooled using a random-effects model and the impact of covariates assessed using meta-regression. 38 eligible articles (34 trials) were obtained. The analysis showed GB-CBT to significantly reduce the incidence (relative risk 0.43, 95% CI 0.21-0.87) and symptoms (Cohen's d -0.22, 95% CI -0.32 to -0.11) of depression at post-test compared to all controls. Comparisons with passive comparators suggested that the effect decayed over time. However, compared to active controls, a significant intervention effect was evident only after 12 month or more. Our results suggest that the preventive effect of GB-CBT wears off, but still lasts longer than the effect of active comparators. Only a few studies included booster sessions, precluding firm conclusions. Future studies should clarify to what extent maintenance strategies can prolong the preventive effect of GB-CBT.