Home visiting for a better start in life : studies of an intervention to promote health equity in a socioeconomically disadvantaged area of Sweden

Abstract

Background: Early childhood is considered to be a crucial period for ensuring health over the life course of an individual. It is also a prioritized period for policies to reduce socially determined health inequities. Extended home visiting in early childhood is a recommended intervention to promote responsive parenting practices, and good health and development from the start of life. To reduce health inequities, international reports on the social determinants of health, have recommended the adoption of Proportionate Universalism, which implies guaranteeing the population’s universal access to welfare services, while offering targeted support to those groups with higher needs. An extended home visiting programme in early childhood was initiated in 2013, in a socioeconomically disadvantaged community of Stockholm, Sweden. As a collaboration between the child health care, and preventive social services, it aimed to act on the higher needs observed among the families, and to reduce the health gaps between children living in different socioeconomic circumstances in the county of Stockholm. The home visits were delivered by pairs of child health care nurses and parental advisors (social workers), and it was the first such initiative in the Swedish context. The intervention was embedded in the national child health care programme, and thus considered to represent targeted support within a universal framework, as proposed in Proportionate Universalism. Little research exists on interventions aimed to reduce health inequities from early childhood, and there is also an acknowledged need to deepen the understanding of pathways from socioeconomic disadvantage to health inequities from early life. When investigating interventions, it is important to identify their different components, as well as the theories of how and why they are supposed to create the desired effects.

Aim: The aim of this doctoral research project was to increase knowledge on the design and implementation of a multisectoral, early childhood home visiting intervention, developed to promote health equity in a socioeconomically disadvantaged setting in Sweden.

Methods: Qualitative research methods were applied in the studies of this research project. Investigations into the content and work methods of the intervention, were made through analysis of documentation of home visits, semi-structured interviews with professionals working in the programme, and observations of home visits. Semi-structured interviews with the professionals also generated data to explore how challenges in daily life of the families might lead to health inequities for children. Analysis of published documents produced an initial mapping of the intervention and semi-structured interviews with managers and other key actors rendered a final version of core components and programme theory of the intervention. The analyses were carried out using Data-driven Conventional Content Analysis, Constructivist Grounded theory, Reflexive Thematic analysis, and Framework method.

Results: The studies showed that the home visits contained contents regarding the health, care and development of the child; parenting and parenting practices; and the aspects in the families’ surroundings that influenced and supported them. The visits covered health promotion, prevention, early detection of adversities, psychosocial support and helping the families access additional resources. The studies also indicated that the content and work methods were flexible and families who have extra needs received additional adjusted support. The intervention was found to consist of five core components related to the additional support in the home environment; the qualified team of professionals; the flexibility of content; the child focus and parent-strengthening approach; and the scope of the work methods. From these core components, the intervention was supposed to generate positive effects on children’s health and development; parents’ health and responsive parenting practices; and families trust in and use of welfare services. Integration and families’ active participation in society were longer term expected effects, and the reduction of health inequities was the perceived overarching aim in the interventions programme theory. The study findings also included the identification of five pathways from different situations of low control in the families’ lives, that could negatively affect the health and wellbeing of parents and children, and cause health inequities. They regarded instability and insecurity, such as financial and housing; crowded and poor housing conditions; social isolation; restricted access to services; and experiences of segregation. The event of the Covid-19 pandemic was observed to have added negative influence over the families in multiple ways. The interviewed key persons considered that the intervention had the capacity to create better conditions towards health equity, but also recognizing the influence of structural determinants. The intervention was understood to be one part of a larger systemic effort needed to reduce the health gap.

Conclusions: The contents and work methods that have been developed and are implemented in the programme, are in line with the international recommendations for early childhood interventions. They also correspond well to recognized components of effective early childhood home visiting. The intervention reflects the principles of Proportionate Universalism, and it can be considered to have capacity to reduce the influence of some of the mechanisms that drive health inequities in early childhood. However, the findings are also in agreement with current research, when recognizing the complexity of the workings of the social determinants, and the large influence of structural determinants on health inequities. The findings support recommendations of favourable macro policies, general access to universal welfare, as well as multisectoral resources that can provide comprehensive additional support to families when needs arise at any point during childhood.