Survey of the pre-school child health surveillance programme in Sweden

National survey of physicians in Swedish child health centres finds insecurity and unawareness regarding management of undescended testicles

AIM

To investigate underlying factors for previously reported shortcomings in child health centres' (CHC) referral process of boys with undescended testicles.

METHODS

A total of 386 physicians working at Swedish CHCs were surveyed regarding their knowledge about undescended testicles and their clinical management. Multivariate regression analyses were performed to identify risk factors of non-adherence to guidelines and self-reported lack of clinical skills.

RESULTS

The overall knowledge of the health benefits of undescended testicle surgery was high (89%), while two-thirds were unaware of surgery being recommended <1 year of age. One-fifth of respondents had never received guidance on examination techniques. Male gender (adjusted odds ratio [aOR] 0.51, 95% confidence interval [95% CI] 0.31-0.86), education in paediatrics (aOR 0.37, 95% CI 0.18-0.76) and more experience (aOR 0.02, 95% CI 0.01-0.09) significantly decreased the risk of unfamiliarity with examinations. More experience decreased the risk of stating the incorrect indications for undescended testicle surgery (aOR 0.17, 95% CI 0.03-0.95) and finding examinations difficult (aOR 0.22, 95% CI 0.07-0.72). Medical education outside Nordic countries was a risk factor for unawareness of guidelines (aOR 2.06, 95% CI 1.21-3.51).

CONCLUSION

The knowledge and confidence level of the study population varied widely. The results indicate a need for further theoretical and practical education among Swedish CHC physicians.

The ESSENCE-Questionnaire in Medical Records Screening for Neurodevelopmental Symptoms/Problems: Utility and Clinical Validity

PURPOSE

Determine the prevalence of symptoms of neurodevelopmental problems (NDPs) with a semi-structured review of fourth grade students' medical records, its interrater agreement and validity as compared with clinical assessment.

METHODS

A school-based sample of 11-year-old children provided child health care (CHC) records and school health care (SHC) records. A pediatric neurologist, child psychiatrist and an adult psychiatrist scored the records, with the "Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations-Questionnaire" (ESSENCE-Q, 12 items scored 0-2, summary score range 0-24). Agreement was measured with model-based kappa and intraclass correlation coefficient (ICC). Ratings were validated against a multidisciplinary assessment involving a physician, psychologist, teacher- and parental behavioral rating scales rendering a clinical global impression severity rating (CGI-S, range 1-7) of NDPs.

RESULTS

Out of 223 participants, medical charts were available from 201, of whom 169 were rated by all three raters. Kappa agreement was moderate/strong (~0.8) for 7 of the 12 questionnaire items. Measured with the ICC, concordance in the summary score was good for agreement (~0.8) and excellent (~0.9) for consistency. Test-retest reliability was excellent (ICC = ~0.9). Area under the curve for the ESSENCE-Q in predicting clinical-level problems (CGI ≥4) was ~80% for all three raters, albeit with differing optimal cutoffs.

CONCLUSION

Using the ESSENCE-Q as a template, NDPs appear to be common in medical records, are identified reliably, and predict clinical-level concern. Medical records screening may facilitate a structured review of medical records in work-ups or be applied in conjunction with other screening measures for neurodevelopmental disorders. However, differences in calibration currently preclude defining a universal cutoff for using the ESSENCE-Q for medical records screening.

Economic Evaluation of PRIMROSE-A Trial-Based Analysis of an Early Childhood Intervention to Prevent Obesity

BACKGROUND

Childhood obesity is a major clinical and economic health concern. Alongside the clinical understanding of obesity, there is a growing interest in designing and implementing interventions that are worth their money given the scarce resources in the health care sector. This study is one of the first efforts to provide evidence by assessing the effects and costs of a population-based primary prevention intervention targeting pre-school children attending child health centers in Sweden.

METHODS

The economic evaluation is based on the PRIMROSE cluster-randomized controlled trial aiming to establish healthy eating and physical activity among pre-school children (9-48 months of age) through motivational interviewing applied by trained nurses at child health centers. The cost-effectiveness is assessed over the trial period from a societal perspective. The primary outcome was BMI at age 4. Cost data was prospectively collected alongside the trial. Scenario analyses were carried out to identify uncertainty.

RESULTS

The estimated additional mean total costs of the PRIMROSE intervention were 342 Euro (95% CI: 334; 348) per child. During pre-school years direct costs mainly consist of training costs and costs for the additional time used by nurses to implement the intervention compared to usual care. Early indirect costs mainly consist of parents' absence from work due to their participation in the intervention. The incremental cost-effectiveness ratio in the base case analysis was 3,109 Euro per 1 BMI unit prevented.

CONCLUSION

We cannot provide evidence that the PRIMROSE intervention is cost-effective, given the uncertainty in the effect measure. Until further evidence is provided, we recommend resources to be spent elsewhere within the field of obesity prevention. Furthermore, to achieve valid and reliable cost-effectiveness results, the economic evaluation of obesity prevention programs in early childhood should incorporate the life time impact to capture all relevant costs and benefits.

Motivational Interviewing to Prevent Childhood Obesity: A Cluster RCT

OBJECTIVE

The objective was to evaluate a manualized theory-driven primary preventive intervention aimed at early childhood obesity. The intervention was embedded in Swedish child health services, starting when eligible children were 9 to 10 months of age and continuing until the children reached age 4.

METHODS

Child health care centers in 8 Swedish counties were randomized into intervention and control units and included 1355 families with 1369 infants. Over ∼39 months, families in the intervention group participated in 1 group session and 8 individual sessions with a nurse trained in motivational interviewing, focusing on healthy food habits and physical activity. Families in the control group received care as usual. Primary outcomes were children's BMI, overweight prevalence, and waist circumference at age 4. Secondary outcomes were children's and mothers' food and physical activity habits and mothers' anthropometrics. Effects were assessed in linear and log-binominal regression models using generalized estimating equations.

RESULTS

There were no statistically significant differences in children's BMI (β = -0.11, 95% confidence interval [CI]: -0.31 to 0.08), waist circumference (β = -0.48, 95% CI: -0.99 to 0.04), and prevalence of overweight (relative risk = 0.95, 95% CI: 0.69 to 1.32). No significant intervention effects were observed in mothers' anthropometric data or regarding mothers' and children's physical activity habits. There was a small intervention effect in terms of healthier food habits among children and mothers.

CONCLUSIONS

There were no significant group differences in children's and mothers' anthropometric data and physical activity habits. There was, however, some evidence suggesting healthier food habits, but this should be interpreted with caution.

Primary prevention of childhood obesity through counselling sessions at Swedish child health centres: design, methods and baseline sample characteristics of the PRIMROSE cluster-randomised trial

BACKGROUND

Childhood obesity is a growing concern in Sweden. Children with overweight and obesity run a high risk of becoming obese as adults, and are likely to develop comorbidities. Despite the immense demand, there is still a lack of evidence-based comprehensive prevention programmes targeting pre-school children and their families in primary health care settings. The aims are to describe the design and methodology of the PRIMROSE cluster-randomised controlled trial, assess the relative validity of a food frequency questionnaire, and describe the baseline characteristics of the eligible young children and their mothers.

METHODS/DESIGN

The PRIMROSE trial targets first-time parents and their children at Swedish child health centres (CHC) in eight counties in Sweden. Randomisation is conducted at the CHC unit level. CHC nurses employed at the participating CHC received training in carrying out the intervention alongside their provision of regular services. The intervention programme, starting when the child is 8-9 months of age and ending at age 4, is based on social cognitive theory and employs motivational interviewing. Primary outcomes are children's body mass index and waist circumference at four years. Secondary outcomes are children's and mothers' eating habits (assessed by a food frequency questionnaire), and children's and mothers' physical activity (measured by accelerometer and a validated questionnaire), and mothers' body mass index and waist circumference.

DISCUSSION

The on-going population-based PRIMROSE trial, which targets childhood obesity, is embedded in the regular national (routine) preventive child health services that are available free-of-charge to all young families in Sweden. Of the participants (n = 1369), 489 intervention and 550 control mothers (75.9%) responded to the validated physical activity and food frequency questionnaire at baseline (i.e., before the first intervention session, or, for children in the control group, before they reached 10 months of age). The food frequency questionnaire showed acceptable relative validity when compared with an 8-day food diary. We are not aware of any previous RCT, concerned with the primary prevention of childhood obesity through sessions at CHC that addresses healthy eating habits and physical activity in the context of a routine child health services programme.

TRIAL REGISTRATION

ISRCTN16991919.

Health and development in the first 4 years of life in offspring of women with schizophrenia and affective psychoses: Well-Baby Clinic information

The investigation of genetic high-risk (HR) groups provides the opportunity to study diathesis characteristics associated with schizophrenia (Sc) and affective psychoses. High-risk offspring of women with a history of schizophrenia, affective and other psychoses (n = 84), as well as normal-risk control (NC) offspring (n = 100), were studied from 0 to 4 years of age, using prospectively recorded information from Well-Baby Clinic (WBC) records. Blind assessment of an average of 25 contacts per subject yielded data concerning early life developmental, physical and behavioral characteristics associated with psychosis risk. As compared with controls, offspring of women with schizophrenia showed significantly increased rates of delayed walking, visual dysfunction, language skill disorders, enuresis, disturbed behavior (especially poor social competence), and multiple accumulated risk characteristics. Significant Sc-risk characteristics did not include impaired hearing, minor malformations, biological dysfunctions, or physical illness leading to treatment. Offspring of mothers with affective psychosis (Aff) showed only a significantly increased rate of delayed walking, with no significantly increased total aggregation of risk characteristics, compared with controls. The results suggest a limited overlap in the diathesis characteristics associated with risk for Sc vs. Aff psychosis. The importance of these early risk characteristics for the later development of psychopathology is being investigated in this sample.