Karin Guldbrandsson

Association between childhood community safety interventions and hospital injury records: a multilevel study

Study objective: To study municipal variations in children’s injury risk and to assess the impact of safety promotion measures in general municipal, preschool, school, and leisure activity settings, on injury outcome. Design: A cohort study based on individual data on children’s consumption of hospital care as a result of injury, the age and sex of each child, and socioeconomic data on each child’s mother. Municipal characteristics—that is, population density and municipal safety measures—were also used. Connections between individual and community level determinants were analysed with multilevel logistic regression. Setting: Twenty five municipalities in Stockholm County in Sweden were studied. Participants: Children between 1 and 15 years old in 25 municipalities in Stockholm County, identified in the Total Population Register in Sweden. The study base included 1 055 179 person years. Main results: Municipality injury rates varied between 3.84–7.69 per 1000 person years among 1–6 year olds and, between 0.86–6.18 among 7–15 year olds. Implementation of multiple safety measures in a municipality had a significant effect on the risk of injury for preschool children. In municipalities that implemented few safety measures, the risk of injury was 33% higher than in municipalities that implemented many. A similar effect, though insignificant, was observed in the school aged children. Conclusions: This study shows that how municipalities organise their safety activities affect injury rates. Sweden has a comparatively low injury rate and thus, in a European perspective, there is an obvious potential for municipal safety efforts.

Impact of Direct Mail as a Method to Recruit Smoking Mothers into a "Quit and Win" Contest

In the early 1980s the concept of a Quit and Win (Q&W) contest was developed in the Minnesota Heart Health Program (MHHP) as a population-based smoking cessation strategy. The Q&W model has since spread and been applied in many countries around the world. Different communication strategies have been applied for recruiting participants for Q&W. In the Q&W contest in 1995 in Stockholm County, Sweden, direct mail was used as the main recruitment strategy among daily smoking mothers with children aged 0-6 years. Two additional strategies were employed to recruit participants, that is, ads in a local newspaper and personal communication. The target group was estimated to be approximately 4,300 women. In total 5.5% of the target group was recruited, and of those, 4.3% were recruited by direct mail. After 12 months, 14.3% of the women were sustained smoke-free, and the corresponding percentage for those women who were recruited by direct mail was 15.5%. In comparison with several other Q&W contests employing other strategies, the direct-mail technique seems not only to have been successful in recruiting participants, but also in aiding remained sustained smoke-free women after 12 months. To optimize recruitment for Q&W contests, a combination of recruiting strategies should be applied.In the early 1980s the concept of a Quit and Win (Q&W) contest was developed in the Minnesota Heart Health Program (MHHP) as a population-based smoking cessation strategy. The Q&W model has since spread and been applied in many countries around the world. Different communication strategies have been applied for recruiting participants for Q&W. In the Q&W contest in 1995 in Stockholm County, Sweden, direct mail was used as the main recruitment strategy among daily smoking mothers with children aged 0-6 years. Two additional strategies were employed to recruit participants, that is, ads in a local newspaper and personal communication. The target group was estimated to be approximately 4,300 women. In total 5.5% of the target group was recruited, and of those, 4.3% were recruited by direct mail. After 12 months, 14.3% of the women were sustained smoke-free, and the corresponding percentage for those women who were recruited by direct mail was 15.5%. In comparison with several other Q&W contests employing other strategies, the direct-mail technique seems not only to have been successful in recruiting participants, but also in aiding remained sustained smoke-free women after 12 months. To optimize recruitment for Q&W contests, a combination of recruiting strategies should be applied.

Implementation of a computerized alcohol advice concept in routine emergency care

BACKGROUND There is a growing body of evidence for computer-generated advice for many health behaviours. This study evaluated the implementation of a computerized concept to provide tailored advice on alcohol in a Swedish emergency department (ED). AIM The aim was to evaluate the usage of the concept over 12 months: participation rate among the ED population; representativeness of the participants; and participation development over time. METHODS The target population was defined as all patients aged 18-69 years given a card from ED triage staff with a request to conduct a computerized test about their alcohol use. After completing the 5-10-min programme, the patient received a printout, containing personalised alcohol habit feedback, as calculated by the computer from the patients answers. Data for this study were primarily obtained from the computer programme and ED logs. RESULTS Forty-one percent of the target population completed the computerized test and received tailored alcohol advice. The number of patients who used the concept showed a slight decreasing trend during the first half of the year, leveling off for the second half of the year. CONCLUSION A computerized concept for provision of alcohol advice can be implemented in an ED without unrealistic demands on staff and with limited external support to attain sustainability.

The significance of policy documents in municipal child health promotion

Aims: To investigate municipal utilization of policy documents in child health-promoting activities with reference to document types, substance in the documents and timing in the policy process. Methods: Fifty semi-structured interviews were performed using the snowball method, and content analyses of written documentation were made. Data were categorized by means of a policy process matrix, and nine case studies were written. Triangulation was used as a validating method, and the coding reliability was assessed. Statements related to various policy documents were categorized according to document types, substance in the documents, and timing in the policy process. Results: Various policy documents were spontaneously mentioned by 33 of 50 interviewees, in eight of nine case studies, and in all stages of the policy process. Well-defined statements concerning which content in the policy documents that actually impacted on the policy process development were uncommon. Conclusions: This study shows that policy documents are present in policy processes related to child health-promoting activities in Swedish municipalities. As Swedish municipalities are autonomous and not forced to pursue governmental recommendations, this probably demonstrates that policy documents are significant in the development of such processes.

Identification of potential opinion leaders in child health promotion in Sweden using network analysis

BackgroundOpinion leaders are often local individuals with high credibility who can influence other people. Robust effects using opinion leaders in diffusing innovations have been shown in several randomized controlled trials, for example regarding sexually transmitted infections (STI), human immunodeficiency virus (HIV) prevention, mammography rates and caesarean birth delivery rates. In a Cochrane review 2010 it was concluded that the use of opinion leaders can successfully promote evidence-based practice. Thus, using opinion leaders within the public health sector might be one means to speed up the dissemination of health promoting and disease preventing innovations. Social network analysis has been used to trace and map networks, with focus on relationships and positions, in widely spread arenas and topics. The purpose of this study was to use social network analysis in order to identify potential opinion leaders at the arena of child health promotion in Sweden.ResultsBy using snowball technique a short e-mail question was spread in up to five links, starting from seven initially invited persons. This inquiry resulted in a network consisting of 153 individuals. The most often mentioned actors were researchers, public health officials and paediatricians, or a combination of these professions. Four single individuals were mentioned by five to seven other persons in the network. These individuals obviously possess qualities that make other professionals within the public health sector listen to and trust them.ConclusionsSocial network analysis seemed to be a useful method to identify influential persons with high credibility, i.e. potential opinion leaders, at the arena of child health promotion in Sweden. If genuine opinion leaders could be identified directed measures can be carried out in order to spread new and relevant knowledge. This may facilitate for public health actors at the local, regional and national level to more rapidly progress innovations into everyday practice. However, effectiveness studies of opinion leaders in the public health sector still have to be performed.

Municipal policies and plans of action aiming to promote physical activity and healthy eating habits among schoolchildren in Stockholm, Sweden: a cross-sectional study

BackgroundPromoting physical activity and healthy eating habits by structural measures that reach most children in a society is presumably the most sustainable way of preventing development of overweight and obesity in childhood. The main purpose of the present study was to analyse whether policies and plans of action at the central level in municipalities increased the number of measures that aim to promote physical activity and healthy eating habits among schoolchildren aged six to 16. Another purpose was to analyse whether demographic and socio-economic characteristics were associated with the level of such measures.MethodsQuestionnaires were used to collect data from 25 municipalities and 18 town districts in Stockholm County, Sweden. The questions were developed to capture municipal structural work and factors facilitating physical activity and the development of healthy eating habits for children. Local policy documents and plans of action were gathered. Information regarding municipal demographic and socio-economic characteristics was collected from public statistics.ResultsPolicy documents and plans of action in municipalities and town districts did not seem to influence the number of measures aiming to promote physical activity and healthy eating habits among schoolchildren in Stockholm County. Municipal demographic and socio-economic characteristics were, however, shown to influence the number of measures. In town districts with a high total population size, and in municipalities and town districts with a high proportion of adults with more than 12 years of education, a higher level of health-promoting measures was found. In municipalities with a high annual population growth, the number of measures was lower than in municipalities with a lower annual population growth. Another key finding was the lack of agreement between what was reported in the questionnaires regarding existence and contents of local policies and plans of action and what was actually found when these documents were scrutinized.ConclusionPolicy documents and plans of action aiming to promote physical activity and healthy eating habits among schoolchildren aged six to 16 in municipalities and town districts in Stockholm County did not seem to have an impact on the local level of measures. Demographic and socio-economic characteristics of the municipalities and town districts were on the other hand associated with local health-promoting measures.

Factors associated with implementation of a multicomponent responsible beverage service program – results from two surveys in 290 Swedish municipalities

BackgroundThe purpose of this study was to investigate which factors affected the implementation of a multicomponent Responsible Beverage Service (RBS) program in 290 Swedish municipalities and whether the amount of such factors influenced the level of implementation of the program.MethodsThis study used variation in the presence of implementation-promoting factors to predict the level of implementation of the RBS program in municipalities throughout Sweden. The presence of such factors and the level of implementation of the program were studied by means of two surveys in all Swedish municipalities (N=290). Logistic regression and Spearman’s correlation analyses were used to analyze the relationship between implementation-promoting factors and the level of implementation of the RBS program.ResultsThe response rates of the two surveys were 96% and 98%, respectively. One main finding was that program fidelity was low. Only 13% of the municipalities surveyed had implemented the RBS program as a whole, as stated in the specification of requirements. In municipalities reporting a higher amount of implementation-promoting factors, a significantly higher level of implementation of the program was shown. Evaluation and feedback was the only factor that correlated significantly with the level of implementation of the RBS program as a whole.ConclusionEvaluation and feedback constitutes an important implementation-promoting factor also in complex programs like the RBS program. Program fidelity is significant for the outcome of an intervention and must be a major focus of the implementation processes.

Effects of mental health interventions for students in higher education are sustainable over time: a systematic review and meta-analysis of randomized controlled trials

Background Symptoms of depression, anxiety, and distress are more common in undergraduates compared to age-matched peers. Mental ill health among students is associated with impaired academic achievement, worse occupational preparedness, and lower future occupational performance. Research on mental health promoting and mental ill health preventing interventions has shown promising short-term effects, though the sustainability of intervention benefits deserve closer attention. We aimed to identify, appraise and summarize existing data from randomized control trials (RCTs) reporting on whether the effects of mental health promoting and mental ill health preventing interventions were sustained at least three months post-intervention, and to analyze how the effects vary for different outcomes in relation to follow-up length. Further, we aimed to assess whether the effect sustainability varied by intervention type, study-level determinants and of participant characteristics. Material and Methods A systematic search in MEDLINE, PsycInfo, ERIC, and Scopus was performed for RCTs published in 1995–2015 reporting an assessment of mental ill health and positive mental health outcomes for, at least, three months of post-intervention follow-up. Random-effect modeling was utilized for quantitative synthesis of the existing evidence with standardized mean difference (Hedges’ g) used to estimate an aggregated effect size. Sustainability of the effects of interventions was analyzed separately for 3–6 months, 7–12 months, and 13–18 months of post-intervention follow-up. Results About 26 studies were eligible after reviewing 6,571 citations. The pooled effects were mainly small, but significant for several categories of outcomes. Thus, for the combined mental ill health outcomes, symptom-reduction sustained up to 7–12 months post-intervention (standardized mean difference (Hedges’ g) effect size (ES) = −0.28 (95% CI [−0.49, −0.08])). Further, sustainability of symptom-reductions were evident for depression with intervention effect lasting up to 13–18 months (ES = −0.30 (95% CI [−0.51, −0.08])), for anxiety up to 7–12 months (ES = −0.27 (95% CI [−0.54, −0.01])), and for stress up to 3–6 months (ES = −0.30 (95% CI [−0.58, −0.03])). The effects of interventions to enhance positive mental health were sustained up to 3–6 months for the combined positive mental health outcomes (ES = 0.32 (95% CI [0.05, 0.59])). For enhanced active coping, sustainability up to 3–6 months was observed with a medium and significant effect (ES = 0.75 (95% CI [0.19, 1.30])). Discussion The evidence suggests long-term effect sustainability for mental ill health preventive interventions, especially for interventions to reduce the symptoms of depression and symptoms of anxiety. Interventions to promote positive mental health offer promising, but shorter-lasting effects. Future research should focus on mental health organizational interventions to examine their potential for students in tertiary education.

Implementation of a Multicomponent Responsible Beverage Service Programme in Sweden - a Qualitative Study of Promoting and Hindering Factors

Aims The objective of this study was to identify factors that either promote or hinder implementation of a multicomponent Responsible Beverage Service programme in Swedish municipalities. Design Forty semi-structured interviews were conducted in six municipalities and directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), was performed. Results The CFIR framework was useful as an underlying theoretical model in this study. Importance of the following factors, described in the five domains of CFIR, was empirically supported in this study: local needs, evidence strength and advantages of the intervention, costs and available resources, clear goals, evaluation and feedback, access to knowledge and information, clear role definitions and cooperation, and enthusiastic key persons with high confidence in the effectiveness of the intervention. Hindering factors listed by the informants were lack of enthusiasm and opportunities to specialise, low degree of self-efficacy, unengaged decision-makers, complexities of the programme, and a top-down approach. Conclusions This study indicates that previously identified factors shown to promote and hinder implementation processes are also valid in the context of multicomponent community action programmes like RBS. Suggestions on how to elude some of the hindering factors are proposed, e.g. to develop long-time financial plans, to provide better information about the RBS program in full, and to stress the importance of collaboration between representatives from the municipalities, police authorities and owners of on-licenced premises.

Effects on Alcohol Consumption and Alcohol Related Harm of a Community-Based Prevention Intervention With National Support in Sweden

ABSTRACT Background: In order to strengthen local alcohol prevention work in Sweden the Swedish government has for the past almost 15 years commissioned the Public Health Agency of Sweden to initiate a series of community-based alcohol prevention projects. The latest of these, labeled local development with ambitions (LUMA), included 25 municipalities in Sweden. Objectives: Aim of this study is to examine if LUMA municipalities that received financial support, with requirements, increased local alcohol prevention and if alcohol consumption and harm declined. Methods: Twenty-five Swedish municipalities that received financial support aiming to strengthen local alcohol preventing activities (intervention group) were compared to municipalities that did not receive such support (control group, N = 224), before, during, and after the intervention period. Two composite measures of policy and activity were created and used. The composite activity measure includes seven activity indicators and the composite policy measure includes six policy indicators. Harm measures have been selected based on several recommended indicators for monitoring alcohol, tobacco, and other drugs in Sweden. A fixed effects model was used to analyze data. Results: The results reveal that prevention activities increased and several alcohol-related harm indicators were reduced in intervention municipalities (LUMA) compared with in control municipalities. Conclusions: It seems as if financial support, combined with specific requirements and support from the regional and national level, can stimulate local alcohol prevention activities and have a significant effect on alcohol consumption and alcohol-related harm. Similar evaluations in other countries would be of great value for assessing the generalizability of findings.