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

Addressing health equity during design and implementation of health system reform initiatives: a scoping review and framework

BACKGROUND

Health equity is a commonly asserted goal of health systems. However, there is a limited understanding on how best to promote equity as a part of health system reform initiatives. We conducted a scoping review to (1) identify and characterise strategies that promote health equity during the design and implementation of health system reform initiatives; and (2) determine opportunities to strengthen health equity informed policy design and implementation processes and outcomes.

METHOD

We systematically searched peer-reviewed literature from 2013 to 2022 focussing on four search domains: (1) health equity; (2) implementation; (3) health system; and (4) reform, policy, or theories, and only included papers that represented a population health or system-wide intention. Health equity promoting strategies were categorised into those occurring at national, regional, state, or local levels. Themes common across system levels were mapped, which alongside theory, informed the development of a health equity promoting framework for reform initiatives.

RESULTS

The search returned 10,999 articles after duplicates were removed. 384 articles underwent full text review and 68 met the inclusion criteria. Thematic analysis of results identified health equity promoting themes derived from numerous strategies, with a median of 10 strategies (interquartile range 7,15) per article. Accountability, commitment, shared power, and adaptability emerged as some of the most prominent equity promoting themes applicable at all system levels. Across strategies, two cardinal conditions were identified: (1) the need for health equity implementation strategies to be made explicit, and (2) the need for alignment and complementarity of strategies. The framework developed demonstrates equity-oriented reform implementation, which embeds broader equity change throughout the system through inclusive and reflexive governance.

CONCLUSION

This review synthesises diverse literature about how health equity has been considered across levels of the health system during reform design and implementation, providing to our knowledge, the first comprehensive multi-level approach to this issue. Our resulting framework presents policymakers, implementers, and researchers a novel cross-scholarship perspective and process to support the implementation of health equity within system reform initiatives. Throughout design and implementation, consistent vision and a coordinated approach for equity across system levels, underpinned by reflexive governance, will be vital to ensuring that those most in need of healthcare benefit equitably.

Parents' comprehensive health literacy and child health after attending extended home visiting in Swedish multicultural settings-A case-comparison study

BACKGROUND

Parents' low health literacy (HL) has negative impacts on child health. Parental interventions may improve parents' HL and thus impact child health positively.

OBJECTIVES

This study aimed to gain knowledge about associations between parents' comprehensive HL (CHL) and child health after an extended postnatal home visiting program in Swedish multicultural, disadvantaged settings compared to parents receiving regular child healthcare (CHC).

MATERIALS AND METHODS

This quasi-experimental study used a case-control sampling method to recruit first-time parents through two CHC centres in Stockholm (2017-2020). Participants (N = 151) were interviewed twice through structured questionnaires when their child was <2 months and 15-18 months old. HLS-EU-Q16 assessed parents' CHL. Children's medical records (0-18 months) were reviewed regarding breastfeeding, children's exposure to smoking, language development and healthcare utilisation. Data were analysed with regression models and non-parametric tests.

RESULTS

No significant association was found between parents' CHL and child health. However, significantly fewer unplanned visits to the CHC centre were observed among children (0-18 months) in the intervention group irrespective of CHL, compared with children to parents with improved CHL in the comparison group (F = 3.856, p = 0.011).

CONCLUSIONS

Postnatal home visiting interventions practicing proportional universalism and family-centred care may reduce unplanned visits within CHC in disadvantaged settings despite parents' CHL. Further studies with long-term follow-up are suggested to explore associations between parents' CHL and child health.

TRIAL REGISTRATION

As a clinical study (not a clinical trial) with appropriate ethical permission with participants' consents, this study was retrospectively registered (18 February 2020) in the ISRCTN registry (ISRCTN10336603).

Identifying children at risk in Swedish Child Health Services

BACKGROUND

Child Health Services plays an important role in identifying at-risk children and intervening early to break negative trends in child health. Sociodemographic risk factors can impact the workload of Child Health Services and affect the possibilities of providing the national child healthcare programme.

AIMS

This study aims to present the sociodemographic characteristics of families who are registered within the Child Health Services, as defined by the Child adjusted Care Need Index.

METHODS

By collecting personal identification numbers from children six years or younger registered at a child healthcare centre, and combining this with their caregiver's sociodemographic background, this study was able to create a sociodemographic index for each child healthcare centre in Sweden.

RESULTS

The study included 687,543 children and 1,335,540 caregivers from 981 child healthcare centres in Sweden. Approximately 21% of all children in the study population had a caregiver born in Southern or Eastern Europe outside the European Union, or in Africa, Asia, or South America, 7% had single parents, 17% had at least one unemployed caregiver, and 9% had at least one caregiver who had not completed high school. The average input values and the average index values varied widely both between and within the regions.

CONCLUSIONS

This study displays a large variation in sociodemographics for child healthcare centres both within and between regions. Since several regions and national agencies in Sweden use the Child adjusted Care Need Index, it is necessary to keep the dispersion in mind.

Perceptions of facilitators, barriers and solutions when preparing to implement a home visiting program in Sweden: a mixed-methods study

Background

Although there is growing awareness that early childhood development programs are important for a sustainable society, there is a knowledge gap about how to implement such programs. Successful implementation requires attention to implementation drivers (competency, organization, and leadership) during all phases of the implementation. The purpose of this study was to describe cross-sectoral operational workgroups' perceptions of facilitators, barriers and solutions related to implementation drivers in the preparationphase of implementing an evidence-based early childhood home visiting program.

Methods

Quantitative and qualitative data were collected from twenty-four participants, divided into 5 groups, during implementation planning workshops. The workshops were guided by a structured method informed by the principles of Motivational Interviewing and within a framework of implementation drivers. Groups sorted cards with statements representing implementation drivers according to perceptions of facilitators and barriers, and percentages were calculated for each type of implementation determinant, for each type of driver. The groups discussed their card sorting and wrote action plans to address barriers, yielding documentation that was analyzed using deductive qualitative content analysis.

Results

A mixed-methods analysis resulted identification of facilitators, barriers, unknowns and solutions in two to three subcategories under each main category of implementation driver. A competent and confident workforce, and enthusiasm and commitment were key facilitators. Key barriers were unclear roles and responsibilities, and insufficient articulation of local vision and goals. Many factors were described as yet unknown. Specific solutions were generated to support the implementation.

Conclusions

Our study furthers the scientific understanding of how to take evidence-based early childhood programs from research to practice within an implementation drivers framework. Facilitators, barriers and solutions in key areas during the preparation phase were identified with the help of a novel tool. The results provide useful knowledge for decision makers and organizations preparing similar initiatives in communities striving to attain sustainable development goals.

Implementing a social innovation for community-based peer support for immigrant mothers in Sweden: a mixed-methods process evaluation

Introduction

A South African social innovation based on peer support for mothers was contextualized in southern Sweden. The objective of the project was to support expectant women and mothers of young children in immigrant communities to access public services that would benefit maternal and child health. This study aimed to assess how the intervention was implemented, what the contextual barriers and facilitators were, and how the implementation was perceived by those who delivered and received it.

Methods

The study used mixed methods with a convergent parallel design and followed the Medical Research Council guidance on process evaluations of complex interventions. Semi-structured interviews (n = 19) were conducted with peer supporters, client mothers, and key stakeholders involved in the intervention. The qualitative data were analyzed using content analysis. Quantitative data on peer supporters' activities were collected during contacts with client mothers and were presented descriptively.

Results

The five peer supporters had 1,294 contacts with client mothers, of which 507 were first-time contacts. The reach was perceived as wide, and the dose of the intervention was tailored to individual needs. Barriers to implementation included community mistrust of social services, norms on gender roles and parenting, and funding challenges. The implementation was facilitated by the organization's reputation, network, experience, and third-sector affiliation. Peer supporters tended to prioritize linking clients to other services over the educational components of the intervention, sometimes doing more than what was originally planned. Implementation strategies used included building trust, using multiple outreach venues, using internal support structures, and providing practical assistance as an entry point to comprehensive psychosocial support. The personal connection between peer supporters and clients was highly valued, and the building of relationships enabled them to address sensitive topics. Peer supporters sometimes experienced a blurred line between professional and personal roles.

Conclusions

Peer supporters used a variety of strategies to navigate identified barriers and facilitators. Trust was central both as a contextual factor and a strategy for implementation. It is valuable to maintain a balance between flexibility and adherence to the function of peer supporters. Further research is needed to evaluate the effects of the intervention.

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.

Swedish Child Health Services Register: a quality register for child health services and children's well-being

BACKGROUND

Swedish child health services (CHS) is a free-of-charge healthcare system that reaches almost all children under the age of 6. The aim for the CHS is to improve children's physical, psychological and social health by promoting health and development, preventing illness and detecting emerging problems early in the child's life. The services are defined in a national programme divided into three parts: universal interventions, targeted interventions and indicated interventions.The Swedish Child Health Services Register (BHVQ) is a national Quality Register developed in 2013. The register extracts data from the child's health record and automatically presents current data in real time. At present, the register includes 21 variables.

AIM

We aim to describe data available in the BHVQ and the completeness of data in BHVQ across variables.

METHODS

Child-specific data were exported from the register, and data for children born in the regions were retrieved from Statistics Sweden to calculate coverage.

RESULTS

The register includes over 110 000 children born between 2011 and 2022 from 221 child healthcare centres in eight of Sweden's 21 regions. In seven of the eight regions, 100% of centres report data.The completeness of data differs between participating regions and birth cohorts. The average coverage for children born in 2021 is 71%.

CONCLUSIONS

The BHVQ is a valuable resource for evaluating Child Health Services nationally, with high coverage for the youngest children. As a result of continuous improvement of the services, the possibility to follow the development of children's health in Sweden is possible through the register. When fully expanded, the register will be a natural and essential part of developing preventive services, improving healthcare for children below 6 years of age and a tool for developing evidence-based child health interventions.