Towards health equity: core components of an extended home visiting intervention in disadvantaged areas of Sweden.

BACKGROUND: Understanding the mechanisms of implementation of public health interventions in community settings is a key aspect of programme assessments. To determine core components and establish a programme theory are important tools to improve functioning and support dissemination of programme models to new locations. An extended early childhood home visiting intervention has been developed on-site in a socioeconomically disadvantaged area of Sweden since 2013 with the aim of reducing persisting health inequities in the population. This study aimed at investigating the core programme components and how the intervention was perceived to contribute towards health equity from early childhood. METHODS: Qualitative framework method was applied in a document analysis and subsequent semi-structured interviews with 15 key actors involved in the programme. RESULTS: The intervention was found to be constituted of five core components centred around the situation-based, parental strengthening work method delivered by a qualified team of child health care nurse and social worker. The programme theory foresaw positive effects on child and parental health, responsive parenting practices, families' use of welfare services according to need and increased integration and participation in society. The principles of Proportionate Universalism were recognised in the programme theory and the intervention was perceived as an important contribution to creating conditions for improved health equity for the families. Still, barriers to health equity were identified on the structural level which limit the potential impact of the programme. CONCLUSIONS: The core components of the Extended home visiting programme in Rinkeby correspond well to those of similar evidence-based home visiting interventions. Combining focus on early childhood development and responsive parenting with promoting access to the universal welfare services and integration into society are considered important steppingstones towards health equity. However, a favourable macro-political environment is required in the endeavour to balance the structural determinants' influence on health inequities. Improved availability and accessibility to welfare services that respond to the needs of the families regarding housing, education and employment are priorities. TRIAL REGISTRATION: The study was retrospectively registered on 11/08/2016 in the ISRCTN registry ( ISRCTN11832097 ).

Covid-19 and pathways to health inequities for families in a socioeconomically disadvantaged area of Sweden - qualitative analysis of home visitors' observations.

BACKGROUND: Lack of control over life situations is an important social determinant that may negatively affect parental and child health. This study took place in an area of Stockholm, Sweden with high indications of socioeconomic disadvantage, a large part of the population with foreign background, as well as higher levels of poor health than the county average. It investigated staff perceptions of pathways from situations of low control, potentially leading to health inequities, affecting families enrolled in an early childhood home visiting programme during the Covid-19 pandemic. METHODS: Semi-structured interviews were carried out with 23 child health care nurses and parental advisors working in a home visiting programme. The data was analysed using Reflexive Thematic Analysis. RESULTS: The analysis resulted in five pathways on two explanatory levels, affecting parents' health and parenting capacity and children's health and well-being, potentially damaging health and leading to health inequities. The first four pathways related to control at the personal explanatory level: Families facing instability and insecurity; Caring for children in crowded and poor housing conditions; Experiencing restricted access to resources; and Parenting with limited social support. The fifth pathway, Living in a segregated society, covered the collective experience of lack of control on community level. The Covid-19 pandemic was observed to negatively affect all pathways and thus potentially aggravate health inequities for this population. The pandemic has also limited the delivery of home visits to the families which creates further barriers in families' access to resources and increases isolation for parents with already limited social support. CONCLUSIONS: The diversity of pathways connected to health inequities presented in this study highlights the importance of considering this variety of influences when designing interventions for socioeconomically disadvantaged areas. The additional negative consequences of Covid-19 indicate the need for sustainable preventive early childhood interventions for families in such areas. The study also emphasizes the need for further research as well as policy action on possible long-term effects of changing behaviours during the Covid-19 period on child health and health equity. TRIAL REGISTRATION: The study was retrospectively registered (11 August 2016) in the ISRCTN registry ( ISRCTN11832097 ).

Contributions of Preventive Social Services in Early Childhood Home Visiting in a Disadvantaged Area of Sweden: The Practice of the Parental Advisor.

Early childhood home visiting to improve health and development is commonly delivered by child health care (CHC) whereas home visitors from the social services are rare. We applied a constructivist grounded theory approach to explore the practice and contributions of parental advisors from the preventive social services in a home visiting collaboration with CHC in a socioeconomically disadvantaged area of Sweden. The analysis rendered a conceptual model of a situation-based practice, built on interactive encounters between parents and professionals. It includes strengthening of positive parenting, connecting parents to additional services, early detection of needs and provision of psychosocial support in accordance with each family's specific situation. Rooted in the training and experience in social work, the practice can be seen as contributory to the delivery of complex support to families through home visiting and could provide input to efforts of improving training of home visitors in different contexts.

A better start for health equity? Qualitative content analysis of implementation of extended postnatal home visiting in a disadvantaged area in Sweden.

BACKGROUND: Health inequities among children in Sweden persist despite the country's well-developed welfare system and near universal access to the national child health care programme. A multisectoral extended home visiting intervention, based on the principles of proportionate universalism, has been carried out in a disadvantaged area since 2013. The present study investigates the content of the meetings between families and professionals during the home visits to gain a deeper understanding of how it relates to a health equity perspective on early childhood development. METHODS: Three child health care nurses documented 501 visits to the families of 98 children between 2013 and 2016. A qualitative data-driven conventional content analysis was performed on all data from the cycle of six visits per child, and a general content model was developed. Additional content analysis was carried out on the data from visits to families who experienced adverse situations or greater needs. RESULTS: The analysis revealed that the home visits covered three main categories of content related to the health, care and development of the child; the strengthening of roles and relations within the new family unit; and the influence and support located in the broader external context around the family. The model of categories and sub-categories proved stable over all six visits. Families with extra needs received continuous attention to their additional issues during the visits, as well as the standard content described in the content model. CONCLUSIONS: This study on home visiting implementation indicates that the participating families received programme content which covered all the domains of nurturing care as recommended by the WHO Commission on Social Determinants of Health and recent research. The content of the home visits can be understood to create enabling conditions for health equity effects. The intervention can be seen to represent a practical example of proportionate universalism.