Parents’ experiences of an antenatal visit being part of a home visiting program in deprived areas

Background

There are considerable health divides between residential areas in many Swedish cities. In more disadvantaged areas children grow up with poorer health outcomes than the country average. To meet the greater needs of children growing up in these areas through proportionate universalism, an extended home visiting program has been delivered. A novel part of this program has been the social worker and nurse later conducting home visits meeting the parents at the maternity care clinic before childbirth. The aim of this study was to explore parents’ experiences of that antenatal visit.

Methods

Semi-structured interviews were carried out with nine mothers and three fathers around 3 months postpartum. Nine of the participants were foreign-born and a translator was used for four of the interviews. The interviews were recorded and transcribed verbatim and the data was analyzed with thematic analysis with an inductive approach.

Results

The parents’ overall experiences are comprised in the main theme: ‘A feeling of security and care for the whole family'. This main theme is derived from the three following themes: 1) ‘Staff - a trustworthy source of information'. Parents perceived the staff as experienced and knowledgeable and appreciated obtaining information about practical things and about the Swedish system; 2) ‘Access to emotional support'. Several parents expressed the need for emotional support and valued that by meeting the staff they knew they had someone to turn to; 3) ‘Becoming familiar with the staff'. It was appreciated to know who will come to your home as this gave parents an increased sense of security.

Conclusions

Initiating the program through introducing home visiting staff at a scheduled antenatal visit benefited parents, by giving them useful information and social support. The visit also seems to be indirectly beneficial as it contributes to building trust for the staff and the rest of the program.

Key messages

• Initiating an extended home visiting program at a scheduled antenatal visit benefited parents, by giving them useful information and social support.

• Initiating an extended home visiting program at a scheduled antenatal visit contributed to building parents’ sense of trust for the staff and the rest of the program.

Sustainable Behavior Change for Health Supported by Person-Tailored, Adaptive, Risk-Aware Digital Coaching in a Social Context: Study Protocol for the STAR-C Research Programme

Introduction: The Västerbotten Intervention Programme (VIP) in the Region Västerbotten Sweden is one of the very few cardiovascular disease (CVD) prevention programmes globally that is integrated into routine primary health care. The VIP has been shown as a cost-effective intervention to significantly reduce CVD mortality. However, little is known about the effectiveness of a digital solution to tailor risk communication strategies for supporting behavioral change. STAR-C aims to develop and evaluate a technical platform for personalized digital coaching that will support behavioral change aimed at preventing CVD.

Methods: STAR-C employs a mixed-methods design in seven multidisciplinary projects, which runs in two phases during 2019–2024: (i) a formative intervention design and development phase, and (ii) an intervention implementation and evaluation phase. In the 1st phase, STAR-C will model the trajectories of health behaviors and their impact on CVDs (Project 1), evaluate the role of the social environment and social networks on behavioral change (Project 2) and assess whether and how social media facilitates the spread of health information beyond targeted individuals and stimulates public engagement in health promotion (Project 3). The findings will be utilized in carrying out the iterative, user-centered design, and development of a person-tailored digital coaching platform (Project 4). In the 2nd phase, STAR-C will evaluate the implementation of the coaching programme and its effectiveness for promoting behavioral change and the spreading of health information across social networks and via social media (Project 5). The cost-effectiveness (Project 6) and ethical issues (Project 7) related to the coaching programme intervention will be evaluated.

Discussion: The STAR-C research programme will address the knowledge and practice research gaps in the use of information technologies in health promotion and non-communicable disease (NCD) prevention programmes in order to narrow the health inequality gaps.

Ethics: STAR-C has received approval from the Swedish Ethical Review Authority (Dnr. 2019-02924;2020-02985).

Dissemination: The collaboration between Umeå University and Region Västerbotten will ensure the feasibility of STAR-C in the service delivery context. Results will be communicated with decision-makers at different levels of society, stakeholders from other regions and healthcare professional organizations, and through NGOs, local and social media platforms.

Association of Physician Education and Feedback on Hypertension Management With Patient Blood Pressure and Hypertension Control

IMPORTANCE

Elevated systolic blood pressure (SBP) is the most important risk factor for premature death worldwide. However, hypertension detection and control rates continue to be suboptimal.

OBJECTIVE

To assess the association of education and feedback to primary care physicians with population-level SBP and hypertension control rates.

DESIGN, SETTING, AND PARTICIPANTS

This pooled series of 108 population-based cohort studies involving 283 079 patients used data from primary care centers in 2 counties (Västerbotten and Södermanland) in Sweden from 2001 to 2009. Participants were individuals aged 18 years or older who had their blood pressure (BP) measured and recorded in either county during the intervention period. All analyses were performed in February 2019.

EXPOSURES

An intervention comprising education and feedback for primary care physicians in Västerbotten County (intervention group) compared with usual care in Södermanland County (control group).

MAIN OUTCOMES AND MEASURES

Difference in mean SBP levels between counties and likelihood of hypertension control in the intervention county compared with the control county during 24 months of follow-up.

RESULTS

A total of 136 541 unique individuals (mean [SD] age at inclusion, 64.6 [16.1] years; 57.0% female; mean inclusion BP, 142/82 mm Hg) in the intervention county were compared with 146 538 individuals (mean [SD] age at inclusion, 65.7 [15.9] years; 58.3% female; mean inclusion BP, 144/80 mm Hg) in the control county. Mean SBP difference between counties during follow-up, adjusted for inclusion BP and other covariates, was 1.1 mm Hg (95% CI, 1.0-1.1 mm Hg). Hypertension control improved by 8.4 percentage points, and control was achieved in 37.8% of participants in the intervention county compared with 29.4% in the control county (adjusted odds ratio, 1.30; 95% CI, 1.29-1.31). Differences between counties increased during the intervention period and were more pronounced in participants with higher SBP at inclusion. Results were consistent across all subgroups.

CONCLUSIONS AND RELEVANCE

This study suggests that SBP levels and hypertension control rates in a county population may be improved by educational approaches directed at physicians and other health care workers. Similar strategies may be adopted to reinforce the implementation of clinical practice guidelines for hypertension management.

From efficacy in trials to effectiveness in clinical practice: The Swedish Stroke Prevention Study

Blood pressure treatment has shown great efficacy in reducing cardiovascular events in randomized controlled trials. If this is effective in reducing cardiovascular disease in the general population, is less studied. Between 2001 and 2009 we performed an intervention to improve blood pressure control in the county of Västerbotten, using Södermanland County as a control. The intervention was directed towards primary care physicians and included lectures on blood pressure treatment, a computerized decision support system with treatment recommendations, and yearly feed back on hypertension control. Each county had approximately 255 000 inhabitants. Differences in age and incidence of cardiovascular disease were small. During follow-up, more than 400 000 patients had their blood pressure recorded. The mean number of measurements was eight per patient, yielding a total of 3.4 million blood pressure recordings. The effect of the intervention will be estimated combining the blood pressure data collected from the electronic medical records, with data on stroke, myocardial infarction and mortality from Swedish health registers. Additional variables, from health registers and Statistics Sweden, will be collected to address for confounders. The blood pressure data collected within this study will be an important asset for future epidemiological studies within the field of hypertension.

Impact of a combined community and primary care prevention strategy on all-cause and cardiovascular mortality: a cohort analysis based on 1 million person-years of follow-up in Västerbotten County, Sweden, during 1990-2006

OBJECTIVE

To evaluate the impact of the Västerbotten Intervention Programme (VIP) by comparing all eligible individuals (target group impact) according to the intention-to-treat principle and VIP participants with the general Swedish population.

DESIGN

Dynamic cohort study.

SETTING/PARTICIPANTS

All individuals aged 40, 50 or 60 years, residing in Västerbotten County, Sweden, between 1990 and 2006 (N=101,918) were followed from their first opportunity to participate in the VIP until age 75, study end point or prior death.

INTERVENTION

The VIP is a systematic, long-term, county-wide cardiovascular disease (CVD) intervention that is performed within the primary healthcare setting and combines individual and population approaches. The core component is a health dialogue based on a physical examination and a comprehensive questionnaire at the ages of 40, 50 and 60 years.

PRIMARY OUTCOMES

All-cause and CVD mortality.

RESULTS

For the target group, there were 5646 deaths observed over 1,054,607 person-years. Compared to Sweden at large, the standardised all-cause mortality ratio was 90.6% (95% CI 88.2% to 93.0%): for women 87.9% (95% CI 84.1% to 91.7%) and for men 92.2% (95% CI 89.2% to 95.3%). For CVD, the ratio was 95.0% (95% CI 90.7% to 99.4%): for women 90.4% (95% CI 82.6% to 98.7%) and for men 96.8% (95% CI 91.7 to 102.0). For participants, subject to further impact as well as selection, when compared to Sweden at large, the standardised all-cause mortality ratio was 66.3% (95% CI 63.7% to 69.0%), whereas the CVD ratio was 68.9% (95% CI 64.2% to 73.9%). For the target group as well as for the participants, standardised mortality ratios for all-cause mortality were reduced within all educational strata.

CONCLUSIONS

The study suggests that the VIP model of CVD prevention is able to impact on all-cause and cardiovascular mortality when evaluated according to the intention-to-treat principle.

Community participation and sustainability--evidence over 25 years in the Västerbotten Intervention Programme

Background

Selection bias and declining participation rates are of concern in many long-term epidemiological studies. The Västerbotten Intervention Programme (VIP) was launched in 1985 as a response to alarming reports on elevated cardiovascular disease (CVD) mortality in Västerbotten County in Northern Sweden. The VIP invites women and men to a health examination and health counselling during the year of their 40th, 50th, and 60th birthdays.

Objective

To evaluate trends in participation rates and determinants of participation in the VIP from 1990 to 2006.

Design

Registry data on socio-economic status from Statistics Sweden, and mortality and hospitalisation data from the National Board of Health and Welfare, both covering the whole Swedish population, were linked to the VIP and analysed for participants and non-participants.

Results

During 1990–2006, 117,710 individuals were eligible to participate in the VIP, and 40,472 of them were eligible to participate twice. There were 96,560 observations for participants and 61,622 for non-participants. The overall participation rate increased from 56 to 65%. Participants and non-participants had minimal differences in education and age. Initial small differences by sex and degree of urban residence decreased over time. Despite an increasing participation rate in all groups, those with low income or who were single had an approximately 10% lower participation rate than those with high or medium-income or who were married or cohabitating.

Conclusion

Sustainability of the VIP is based on organisational integration into primary health care services and targeting of the entire middle-aged population. This enables the programme to meet population expectations of health promotion and to identify high-risk individuals who are then entered into routine preventive health care services. This has the potential to increase participation rates, to minimise social selection bias, and to reinforce other community-based interventions.

Self-rated health does not predict 10-year weight change among middle-aged adults in a longitudinal population study

BACKGROUND

There is a worldwide obesity epidemic, but lack of a simple method, applicable for research or clinical use, to identify individuals at high risk of weight gain. Therefore, the relationship of self-rated health and 10-year percent weight change was evaluated to determine if self-rated health would predict weight change.

METHODS

From 1990 to 2008, adults aged 30, 40, 50 and 60 years were invited to health surveys that included self-rated health and measured weight and height. ANOVA was used to evaluate the relationship of 10-year percent weight change and self-rated health.

RESULTS

The study population consisted of 29,207 participants (46.5% men). There was no relationship between baseline self-rated health and 10-year percent weight change for middle-aged men or women.

CONCLUSIONS

Self-rated health is not able to predict weight change over a 10-year period in this age group.

Difference in celiac disease risk between Swedish birth cohorts suggests an opportunity for primary prevention

OBJECTIVES

Sweden experienced a unique epidemic of celiac disease in children <2 years of age. The epidemic was partly explained by changes in infant feeding over time and indicated a multifactorial pathogenesis. The main aim of this study was to analyze celiac disease risk in epidemic and postepidemic birth cohorts up to preschool age, to explore further the opportunity for primary prevention.

METHODS

A population-based incidence register of celiac disease in children covering the entire nation from 1998 to 2003 and part of the country back to 1973 was analyzed. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition diagnostic criteria for celiac disease were used. The annual incidence rate for each age group and the cumulative incidence according to age for each birth cohort were calculated.

RESULTS

A considerable difference in cumulative incidences of celiac disease at comparable ages was demonstrated between birth cohorts from the epidemic and postepidemic periods. The difference persisted during the preschool years, although it decreased somewhat with age. During the last years of the follow-up period, there was again a successive increase in incidence rate among children <2 years of age.

CONCLUSIONS

The difference in celiac disease risk between birth cohorts at comparable ages suggests an opportunity for primary prevention. This highlights the importance of further exploring the role of infant feeding and exogenous factors besides dietary gluten that might initiate or prevent disease development. Moreover, on the basis of postepidemic incidence trends, we speculate that the Swedish epidemic might not have been as unique as thought previously, although its magnitude was striking.

Gender differences and temporal variation in the incidence of type 1 diabetes: results of 8012 cases in the nationwide Diabetes Incidence Study in Sweden 1983-2002

OBJECTIVES

To establish the gender difference amongst newly diagnosed type 1 diabetic patients aged 15-34 years, considering age at diagnosis, temporal trend and seasonal variation at time of diagnosis.

STUDY DESIGN

A population-based prospective study with a mean annual population at risk of 2.3 million.

SETTING

All departments of medicine, endocrinology and paediatrics and primary health care units in Sweden.

SUBJECTS

Incident cases of diabetes aged 15-34 years at diagnosis 1983-2002. MEASURE INSTRUMENT: Basic characteristics of patients at diagnosis were reported by the diagnosing doctor on a standardized form. Level of ascertainment was estimated at 80-90%.

RESULTS

Amongst all incident cases (n = 8012), 74% was diagnosed with type 1 diabetes. The mean annual incidence rate of type 1 diabetes was 12.7/100,000, in men 16.4/100,000 and in women 8.9/100,000. The incidence of type 1 diabetes decreased slowly by increasing age but was in all age groups higher in men, yielding an overall male/female ratio of 1.8. In both genders the incidence of type 1 diabetes decreased in average of 1.0% per year. A seasonal pattern with significantly higher incidence during January-March and lower during May-July was seen in both genders.

CONCLUSIONS

A clear male predominance of type 1 diabetes was seen in all ages. The temporal trend and the seasonal pattern was similar in men and women. Hence, internal factors related to the gender rather than differences in the exposure to environmental factors seem to explain the consistent male-female bias in the postpubertal risk of developing type 1 diabetes.

The Butajira project in Ethiopia: a nested case-referent study of under-five mortality and its public health determinants

During one year of follow-up, 306 deaths of children under the age of 5 years were included in a concurrent case-referent study that was based on a population estimated at 28,780 in 1987. A total of 612 live referents, matched for age, sex and study area, were also selected from the study population through density sampling. Data were collected by lay reporters by verbal autopsy. For the study period the estimated cumulative under-five mortality rate was 293 and the infant (0-11 months old) mortality rate was 136 per 1000. Major probable causes of death were diarrhoeal disease or acute respiratory infections (ARI). The relative importance of parental and environmental characteristics was assessed using conditional multiple logistic regression analysis. Under-five mortality was associated with paternal illiteracy, maternal ethnicity, and not being in the committee of people's organizations. Parental factors affected the infants relatively more than they did the children, especially with regard to ARI mortality. This was also noted with "absence of window", a proxy measure for evaluating the type of housing. In terms of etiological fractions a greater number of under-five deaths could be ascribed to parental than environmental conditions, with relatively more infants being affected than children.

The Swedish Childhood Diabetes Study--a multivariate analysis of risk determinants for diabetes in different age groups

In a nationwide incident case-referent study stepwise univariate analysis has revealed several risk determinants for childhood diabetes mellitus. In a multivariate analysis we have determined the set of risk determinants that would independently predict childhood Type 1 (insulin-dependent) diabetes. Possible interactions between the risk determinants and differences in risk profiles with different ages at onset were also examined. Reported familial insulin-treated and non-insulin-treated diabetes were significant risk factors in all age groups, as was also a low frequency of milk intake. The frequency of infections and a high intake of foods rich in nitrosamine tended to interact (OR 11.8, p = 0.053) indicating a synergistic effect. A Cox regression analysis revealed that stressful life events during the last year was the only variable that tended to affect the age at onset (p = 0.055). This indicated that psychological stress may rather precipitate than induce Type 1 diabetes. A short breast-feeding duration (OR = 3.81), and an increased body height (OR = 3.82) contributed significantly to the predictive model in only the youngest age group (0-4 years). An increased frequency of infections in the year preceding onset (OR = 2.15) and no vaccination against measles (OR = 3.33) contributed significantly to the model only in the age group 5-9 years. Various nutrients had different impacts on the risk of developing Type 1 diabetes in different age groups. It is concluded that in the genetically susceptible child, risk factors which are associated with eating habits, frequency of infections, vaccination status, growth pattern and severe psychological stress affect the risk of developing diabetes independently of each other.(ABSTRACT TRUNCATED AT 250 WORDS)

The Swedish childhood diabetes study: indications of severe psychological stress as a risk factor for type 1 (insulin-dependent) diabetes mellitus in childhood

This study is part of a nationwide case-referent study. All recent-onset Type 1 (insulin-dependent) diabetic children aged 0-14 years in Sweden were invited to participate. Referent subjects matched for age-, sex- and geographical distribution were selected. In all, 338 patients and 528 referent subjects took part. Life events during the last year prior to clinical onset of Type 1 diabetes were recorded on a questionnaire. The total frequency of life events did not differ between diabetic and referent children. However, qualitatively the life events reported by diabetic children revealed a tendency to increased severity. Events related specifically to actual or threatened losses within the family--events that may affect children differently in different age groups--were reported with a significantly higher frequency by diabetic patients than by referent subjects, aged 5-9 years. The relative risk that such events in fact comprise a risk factor for Type 1 diabetes was 1.82 (95% confidence limits 1.09, 3.03). The relative risk was significantly increased even when standardized for possible confounding factors such as age, sex and indices of social status of the family. We conclude that stressful life events, related to actual or threatened losses within the family, occurring in the vulnerable age group of 5-9 years, are associated with the onset of childhood Type 1 diabetes. Such stressful events may in fact be a risk factor for the disease.