Changes in Comprehensive Health Literacy Among First-Time Parents Attending Extended Home Visiting in Swedish Multicultural Settings: A Case-Comparison Study.

INTRODUCTION: This study aimed to gain knowledge about the impact of an extended postnatal home visiting program on parents' comprehensive health literacy (CHL) in multicultural, socioeconomically disadvantaged Swedish settings. METHOD: This quasi-experimental study adopted a case-control sampling method recruiting first-time parents through two Child Health Care Centers in Stockholm. Participants were interviewed twice through structured questionnaires when their child was aged between less than two months (n = 193) and 15-18 months (n = 151) from October 2017 to August 2020. Analyses used linear regression models and nonparametric tests. RESULTS: A subgroup of parents that needed language interpreters demonstrated statistically significantly improved CHL from premeasures to postmeasures within the intervention group that received an extended home visiting intervention (F = 11.429; p <.001), and when compared with a corresponding subgroup that received merely the ordinary Swedish Child Health Care Centers program (F = 5.025; p = .027). DISCUSSION: Postnatal home visiting interventions may reduce inequity in CHL for parents living in multicultural, socioeconomically disadvantaged settings.

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 ).

Experiences of involuntary job loss and health during the economic crisis in Portugal.

BACKGROUND: The economic recession that started in 2008 left many unemployed across several European countries. Many studies have analyzed the relationship between job loss, health, and well-being in other contexts. This study aimed to explore experiences of involuntary unemployment during the economic recession and their relationship with health, conceptualized as a state of physical, mental, and social well-being among unemployed individuals. METHODS: Semistructured qualitative interviews were carried out among a convenience sample of participants who became unemployed during the economic recession. The analysis was conducted to identify patterns and themes. RESULTS: Participants (n = 22; 8 men and 14 women; 23-51 years) experienced feelings of loss of identity, stress, and a sense of powerlessness due to unemployment, as well as a lack of purpose and structure in their daily lives. Six themes were identified: work as the basis for life structure and personal fulfillment; response to unemployment and the importance of its duration; unemployment leading to isolation and loss of a role in society; impact of a change in financial situation on social life and consumption patterns; the physical and psychological health consequences of unemployment; and searching for ways to cope with unemployment and to feel well. CONCLUSIONS: Losing a job is an adverse experience that impairs an individual's perception of overall health and well-being. From a public health perspective, the results of this study highlight the need for policymakers' awareness to help mitigate the potential consequences of involuntary job loss in the short- and long-term.

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.

What value for whom? - provider perspectives on health examinations for asylum seekers in Stockholm, Sweden.

BACKGROUND: In Sweden asylum seekers are offered a voluntary health examination, free-of-charge (HE). The HE coverage is low. The organization and implementation of the HE involves collaboration between different agencies with different roles within the provision of health information and service. This study aimed to assess their perspectives on the barriers and facilitators regarding implementation of the HE, as well as on the purpose, content and value of the HE. METHOD: Thematic analysis of focus groups, individual and group interviews conducted between 2016 and 17 with 41 participants from various authorities and healthcare professionals involved in the delivery of HE in Stockholm. RESULTS: Suggestions were taken from interviewees of how to facilitate the uptake and delivery of HE through improved outreach to the target group with better collaboration, coordination and continuity between authorities. Apart from control of specific communicable diseases, the perceived ultimate goal of HE varied and was often vaguely formulated. Respondents desired better monitoring to assess the effects of HE and predict needs among asylum seekers. This included standardized procedures to promote equitable health care access and more explicit inclusion of mental health and other health dimensions in the HE. CONCLUSION: There are several possible avenues for improving HE coverage and uptake. However, ambiguity exists concerning the benefits of such efforts given the uncertainty of the value of HE. Lack of available data on health status, determinants of health and impact of HE among asylum seekers emerged as barriers preventing optimal approaches for the assessment of health needs. Implementation of standardized guidelines, procedures and documentation would aid the understanding. A more holistic approach beyond infectious diseases is necessary. This would only be useful if there is value in screening for such conditions. More research is required to assess the effectiveness and cost-effectiveness of HE and related screening policies in Sweden.

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.

Practising proportionate universalism - a study protocol of an extended postnatal home visiting programme in a disadvantaged area in Stockholm, Sweden.

BACKGROUND: In spite of a well-developed welfare system in Sweden, there are important health divides between residential areas in Stockholm county, with shorter life expectancy in disadvantaged areas. These socioeconomic and health divides also affect children. Extra efforts and organized collaboration by different authorities are required to meet the greater needs of children growing up in these areas. METHODS/DESIGN: This article reports on the programme logic and evaluation design of an extended postnatal home visiting programme in collaboration between child health services and social services in the Rinkeby area, Stockholm, Sweden, where a large proportion are recent immigrants and more than 50% are at-risk of poverty. The intervention consists of five extra home visits when the child is aged between 2-15 months, jointly by a child health nurse and a social service parental advisor, offered to all parents of first-born children attending Rinkeby child health centre. Parents of first-born children attending child health centres in neighboring areas serve as controls. The evaluation will use a mixed methods approach, including participant observation, in-depth interviews, interviews using structured questionnaires, review and analysis of child health records and records of health care utilization. DISCUSSION: The intervention has so far been very positively received by the parents (95% participation rate), who seem to perceive that they actually benefit from participating, and also from staff in child health services and social services who find this approach to be in line with their professional intentions. The staff members interviewed also appreciate the inter-professional collaboration. The intervention has sparked activities also in other sectors (the local library, the open child day care centre) of the local area. The timing of the intervention, at the start of the child's life, may be well suited to support parents in reorienting themselves and finding a positive parenting role, to the benefit of the development of the child. The intervention may be seen as a concrete example of "proportionate universalism", as a strategy to reduce inequalities in health - applying a universal intervention with increased intensity in groups that have a greater need for it. TRIAL REGISTRATION: The study was retrospectively registered (11 August 2016) in the ISRCTN registry ( ISRCTN11832097 DOI: 10.1186/ISRCTN11832097 ).

Experiences of unemployment and well-being after job loss during economic recession: Results of a qualitative study in east central Sweden.

Introduction: Several studies have revealed an association between unemployment and ill health, and shown that unemployment can affect people differently. This study aimed to provide an understanding of the experiences of unemployment and perceptions of wellbeing among persons who involuntary lost their work during the recent economic recession in Gävle Municipality. Methods: Sixteen unemployed men and women aged 28-62 were interviewed face-to-face. A purposeful sampling strategy was used in order to suit the research question and to increase the variation among informants. The interview texts were analysed using thematic analysis. Results: Six different themes emerged from the accounts: The respondents perceived work as the basis for belonging, and loss of work affected their social life and consumption patterns due to changes in their financial situation. They also expressed feelings of isolation, loss of self-esteem, and feelings of hopelessness, which affected their physical well-being. Longer duration of unemployment increased the respondents' negative emotions. The respondents reported activities, structure, and affiliation in other contexts as part of their coping strategy against poor mental health. Conclusions: After job loss, the respondents experienced feelings of loss of dignity and belonging as a human being. They also felt worry, insecurity, and stress due to their changed financial situation, which in turn led to isolation and loss of self-esteem. Social support and having other activities gave the respondents structure and meaning.

Keep going in adversity - using a resilience perspective to understand the narratives of long-term social assistance recipients in Sweden.

INTRODUCTION: In Sweden, means-tested social assistance serves as a temporary, last resort safety net. However, increasing numbers of people are receiving it for longer periods and about a third has assistance for more than a year. The aim of this study was to explore the ways social assistance recipients manage long lasting adversity and their roles as active, rather than passive, agents in this process, using a resilience perspective. METHOD: The study is based on thirteen in-depth interviews with long-term social assistance recipients from diverse areas in Stockholm County. The interviews were guided by narrative inquiry to interpret and construct stories of experiences and are part of a larger qualitative study exploring experiences of living on social assistance in Sweden. RESULTS: Experiences of cumulative adversity during many years compounded recipients' difficulties in finding ways out of hardship. They had different strategies to deal with adversities, and many had underlying "core problems", including mental health problems, which had not been properly resolved. Recipients' showed resistance in adverse situations. Some made attempts to find ways out of hardship, whereas others struggled mainly to achieve a sense of mastering life. They received important support from individual professionals in different authorities, but mostly the help from the welfare system was fragmented. CONCLUSIONS: Social assistance recipients in this study demonstrated agency in ways of managing long lasting difficulties, sometimes caused by "core problems", which were often accumulated into complex difficulties. Resilience was about keeping going and resisting these difficulties. To find ways out of social assistance required help from different welfare agencies and professionals and was hindered by the fragmentation of services. This study shows that there is a need for more long-term personalised, comprehensive support, including interventions both to increase individual well-being and self-esteem and to open up opportunities for education and employment. Adequate benefit levels and overall quality of welfare services such as health and social care, day care and schools, are of major importance for those in greatest need.

Dilemmas in providing resilience-enhancing social services to long-term social assistance clients. A qualitative study of Swedish social workers.

BACKGROUND: Long-term recipients of social assistance face barriers to social and economic inclusion, and have poorer health and more limited opportunities for improving their health than many other groups in the population. During recent decades there have been changes in Swedish social policy, with cutbacks in public benefits and a re-emphasis on means-tested policies. In this context, it is important to investigate the necessary conditions for social workers to offer social assistance and services, as well as the mediating role of social workers between public policies and their clients. Swedish social services aim to promote social inclusion by strengthening the individual's own resources. We investigated the issues that arise when providing social services to long-term social assistance clients within the framework of resilience, which focuses on the processes leading to positive functioning in adverse conditions. METHODS: Interviews were conducted with 23 social workers in Stockholm and analysed by qualitative content analysis. RESULTS: The main theme to emerge from the interviews concerned the constraints that the social workers faced in providing social services to social assistance clients. The first subtheme focused on dilemmas in the interaction between social workers and clients resulting from the dual role of exercising authority and supporting and building trust with clients. Working conditions of social workers also played a crucial role. The second subtheme addressed the impact of the societal context, such as labour market opportunities and coordination between authorities. CONCLUSIONS: Overall, we found that social workers to a great extent tried to find individual solutions to structural problems. To provide resilience-enhancing social services to long-term social assistance clients with varying obstacles and needs requires a constructive working environment, supportive societal structures and inter-sectoral cooperation between different authorities.

Living on social assistance with chronic illness: Buffering and undermining features to well-being.

BACKGROUND: In Sweden, the social security and sickness insurance systems are comprehensive and aim to provide people whose illness prevents them from earning their own living, with either sickness benefits or disability pension. Some, however, are not entitled to these benefits or receive social insurance benefits at a level too low for subsistence, and are referred to social assistance. The purpose of this study was to explore in depth how social assistance recipients with chronic illness perceive and respond to the experience of living on social assistance. METHODS: Seventeen in-depth interviews were carried out with chronically ill people who had received social assistance for several years. Grounded theory informed the design of the study. RESULTS: The study showed that different strategies (living one day at a time, taking steps forwards and backwards and making attempts to find ways out of the situation) were employed by social assistance recipients to maintain or improve their well-being. Contextual features like the prevailing welfare system, public services and the local neighbourhood could buffer or undermine these strategies and their overall well-being. These features together influenced how interviewees perceived their situation, the possible ways out of the situation and the consequences for their well-being. CONCLUSION: From this study it is evident that the way in which individuals on social assistance interact with services and how they are treated by professionals plays an important role in their well-being, in combination with what kind of help and support is available for recipients through the welfare system. In this respect, persons living on social assistance with chronic illness are particularly vulnerable. This study suggests that more effort should be made to find long term solutions concerning income support, rehabilitation and other services provided to this group.

Tales of the unexpected? Hidden resilience in poor households in Britain.

Society tends to have low expectations for the health, employment, and family stability of people living in poverty and disadvantage, reinforced by a body of research focused on risk factors and negative outcomes. This 'deficit model' has pervaded policy and interventions to tackle inequalities in health, in particular in relation to area-based initiatives to improve the health of socio-economically disadvantaged communities. In contrast, the study presented here adopts a positive approach, specifically that of resilience, which we conceptualise as: the process of achieving positive and unexpected outcomes in adverse conditions. Taking account of the critiques of resilience research, we aimed to discover what could be learnt from a health inequalities policy perspective about resilience in poor households in Britain if: a) the voices of people experiencing hardship were heard; b) resilience was conceptualised as a process, rather than as a an individual trait; and c) the social context and conditions that helped or hindered that process of resilience were identified. We interviewed 25 adults with experience of material adversity and 18 social welfare workers with experience of working with people in these circumstances, as well as recording observations at the 13 fieldwork sites in England and Wales. The study provided many "tales of the unexpected" from participants living in disadvantaged circumstances. The participants recounted how they coped with very difficult situations, their achievements in these circumstances, the transitions they had made in their lives and what had helped them along the way. These transitions often occurred contrary to participants' and others' expectations. Interactions that promoted these transitions included family and community support, respectful attitudes and behaviour of service providers, and the chances offered to them to engage in activities that bolstered self-esteem. Recognition of such resilience, however, should complement, rather than detract from, wider societal efforts to reduce the material deprivation in which too many people within the population live.

Studying social policy and resilience to adversity in different welfare states: Britain and Sweden.

Is poverty more damaging to health in Britain than in Sweden, and if so, why? Following previous research by the authors that suggested such an effect, a new comparative study is examining whether there are aspects of the social and policy context in Britain that add to and reinforce the health-damaging experience of being poor. Conversely, are there other aspects of living in Sweden that are supportive for people in poverty, which make the experience of poverty less stressful and health-damaging? Stemming from this ongoing study, the aim of this article is to present a framework for understanding the context in which social welfare policies are formed and operate in Britain and Sweden. It then uses the framework to consider the "upstream" influences of ideology, culture, and values on policy development in the two countries and what these developments might mean for the health and well-being of people facing financial adversity in the two societies.