Making a difference with home visiting : studies of an intervention in multicultural, disadvantaged settings in Sweden

Abstract: Introduction: Inequalities in health, including child health, occur even in welfare countries like Sweden because of unequal distribution of the social determinants of health. Children’s health is poorer in multicultural and disadvantaged neighborhoods in Stockholm, compared with the Stockholm County average. Poorer child health can be related to parents’ lower social position in society, which is associated both with poorer health and lower health literacy (HL). Parents’ low HL relates to poorer knowledge and competencies in healthrelated issues and has negative consequences on children’s health. However, parents’ HL can be improved, and the well-established Swedish Child Health Care (CHC) program reaches all families with children from 0–5 years. Furthermore, an extended postnatal home visiting program for first-time parents, provided as a supplement to the CHC program was initiated in 2013 in Rinkeby, one of the multicultural and disadvantaged Stockholm neighborhoods to address obvious disparities in child health outcomes. The intervention consists of six joint extended home visits, conducted by CHC nurses and parental advisors from preventive social services during the child’s first 15 months of life. Postnatal home visiting is an evidencebased method in improving families and children’s psychosocial conditions among vulnerable families across the globe. This thesis includes four studies exploring the impacts of the extended postnatal home visiting program on parents and children. Aims: The overall aim of this thesis was to increase knowledge about the possible effects of an extended postnatal home visiting program within Swedish Child Health Care regarding parental experiences, parents’ health literacy, and child health, in multicultural, socioeconomically disadvantaged settings. Methods: This thesis used a multi-method approach consisting of one qualitative and three quantitative studies. All studies were conducted through CHC centers in multicultural, disadvantaged settings in northwest Stockholm from 2015 to 2020. The qualitative in-depth interview study with nine migrant fathers explored their perspectives on participating in the extended postnatal home visiting program and analyses used constructivist grounded theory. Data for the cross-sectional quantitative study (N=193) was collected through face-to face and phone interviews with first-time parents of newborn children, through structured questionnaires including the HLS-EU-Q16 tool (Swedish version), designed to measure comprehensive HL (CHL) in general populations. Psychometric properties of HLS-EU-Q16 that were evaluated through statistical methods, including exploratory factor analyses were: internal consistency, reliability, construct validity, floor and ceiling effects, reproducibility, ease of scoring, time to administer, and content validity. Face-to-face and phone interviews with first-time parents through structured questionnaires, including HLS-EU-Q16, were also used to collect data for the two quasi-experimental studies with pre-and post-measures. Pre-measures were conducted when first-time parents’ children were newborns and post-measures were conducted when children turned 15–18 months old (N=151). Additional data from the medical records of participants’ children and earlier published findings about measles, mumps, rubella (MMR) immunization coverage in the intervention area were used. Both quasi-experimental studies explored change in parents’ CHL from pre-to post-measures. One of the studies made comparisons of the change of parents’ CHL within and between the intervention group that attended the extended postnatal home visiting program vs. the comparison group that attended the ordinary Swedish CHC program. Data analyses used descriptive statistics, parametric/non-parametric tests, and general linear regression models. The other quasi-experimental study explored differences in children’s health outcomes (breastfeeding, MMR immunization, children’s exposure to smoke, language development and children’s healthcare utilization) and the associations between parents’ CHL and the children’s health outcomes (N=127) after participation in the intervention vs. the ordinary CHC program. Data analyses used descriptive statistics, nonparametric tests, and linear and logistic regression analyses. Results: Migrant fathers described their improved child-related knowledge and parental confidence during the in-depth interviews, as well as access to available societal resources that came about due to the extended postnatal home visiting program. One factor solution of exploratory factor analyses for HLS-EU-Q16 (Swedish version) explained 37.7% of the total variance of the tool when evaluating psychometric properties. Migrant background, educational level, and access to support from social networks had significant effects on CHL. Challenges related to comprehension of the HLS-EU-Q16 questions were found among participants with migrant backgrounds but were also expressed by Swedish-born participants. Significantly improved CHL after the extended home visiting program was only found in a sub-group of parents who needed an interpreter within the intervention group (F=11.429, p<0.001), and when compared with the corresponding sub-group of parents who attended the ordinary CHC program (F=5.025, p=0.027). A significantly reduced number of additional visits to the CHC center was observed in the intervention group (Kruskal-Wallis=10.063, p=0.002) but the rate of children’s normal language development at the age of 18 months was significantly lower in the intervention group, at 0.363 (95%CI [0.141,0.932]. MMR immunization coverage in the intervention site was higher after the program implementation in comparison with before (Chi2 =3.988, p=0.046). Changes in parents’ CHL after the home visits were not related to children’s health outcomes. Conclusions: This thesis indicates some positive impacts of the extended postnatal home visiting program on migrant fathers, parents’ CHL, and child health. The findings show the importance of including migrant fathers in home visiting programs, as it is beneficial to them in their parental role. When exploring parents’ CHL more specifically as an outcome of the extended postnatal home visiting program, despite HLS-EU-Q16 tools’ acceptable psychometric properties, the use of additional methods to measure parents’ HL is suggested in similar settings, as the questionnaire may not cover relevant aspects of HL. Even if parents’ comprehensive HL was measured to be improved in a sub-group of parents, HLSEU- Q16 is not measuring parents’ child-related HL, specifically. Further research is proposed to explore the extended home visiting program’s positive impacts on additional child health outcomes and their relationship to parental child-related HL in similar settings, as the research field remains relatively unexplored.