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Abstract Background Child health and development can be promoted by strengthening and supporting parents. Research on parental support programs based on positive psychology and a health-promoting approach aimed at all parents, and in particular parents of infants is limited. All Children in Focus (ACF) is a parental support program that has been evaluated in a randomized trial in parents of children 3–12 years. The ACF is based on health promotion aiming to increase parents’ confidence and child’s well-being. In the current study, we will study the effects of a revised version of the ACF called Little ACF adapted to parents with children aged 1–2 years. Methods The study includes a randomized controlled trial (RCT) taking place at several Child Health Centers (CHCs) in Sweden. The RCT will evaluate the efficacy of Little ACF (intervention) in comparison with four digital lectures about child development and parenting (active control). Parents are recruited at the 10-, 12-, or 18-month visits to CHC by CHC-nurses. Data to assess changes in parental competencies and child socio-emotional development are collected through online questionnaires completed by parents at five time points: baseline, post-intervention, after 6 and 12 months, and when the child is 3 years old. Discussion The paper describes a study protocol of a randomized controlled trial evaluating the effects of a parental support program during infancy. Several issues related to the methodology and implementation are discussed. Trial registration ClinicalTrials.gov NCT05445141. Registered on 6 July 2022.

Abstract Background To study the association of maternal age upon arrival and length of residence in Sweden with the 4-year caries increment in their children between ages 3 and 7 years in relation to the human development index (HDI) of the maternal country of origin. Method This registry-based cohort study included all children born in 2000–2003 who resided in Stockholm County, Sweden, at age 3 years and who were followed up at age 7 (n = 63,931). Negative binomial regressions were used to analyze different models adjusted for sociodemographic factors. Results Children of foreign-born mothers, regardless of the HDI of the maternal country of origin, had a higher risk of caries increment between ages 3 and 7 years than children of Swedish-born mothers. Furthermore, children of mothers who had arrived from a low or medium HDI country had a lower caries increment if their mothers arrived before age 7 compared with after age 7. Nearly half (44%) of the children whose mothers arrived in Sweden at age ≥ 20 years from a low HDI country had a caries increment compared to 22% of the children whose mothers had arrived in Sweden before 7 years of age. Furthermore, children whose mothers were born in a low HDI country and had resided in Sweden ≤ 19 years had approximately 1.5 times higher risk of caries increment compared to children of mothers who had resided in Sweden for more than 20 years. Conclusions Caries increment in the children of foreign-born mothers was associated with the age of their mother when she arrived in Sweden and was lower when the mother had arrived before age 7 years. This indicates an intergenerational effect that carries over to the children and is greater the longer the mother has participated in Swedish dental healthcare.

Aim: The aim of this study was to describe parental concerns about child health and behaviour and their sociodemographic predictors in 3‐year‐olds, in relation to the national guidelines of well‐baby clinics. Methods: The study included parents of 33 526 children in Stockholm who had completed a questionnaire prior to a routine visit to a well‐baby clinic at age 3 years. Multivariate regression was used to analyse predictors for concerns. Results: Child behaviour problems, defined as defiance and problem with adherence to daily routines, were the most common parental concerns (36.4%), with poor social skills and relations being second (21.8%). Regarding development, 9.6% had concerns about speech and 4.7% about motor development. Screen use (9.5%) and being underweight (6.3%) were other common parental concerns, while lifestyle concerns regarding physical activity and overweight were rare. Parents raised about twice as many concerns for first‐born children compared with younger siblings. Child behaviour and developmental concerns were more frequent in families where the mother had primary education only and attended a well‐baby clinic with a high Care Need Index. Conclusion: Parents' concerns reflected the national guidelines about child development and behaviour, but not its emphasis on a healthy lifestyle. [ABSTRACT FROM AUTHOR]

Abstract Background Undocumented migrants face many hardships in their everyday life such as poor living conditions, discrimination, and lack of access to healthcare. Previous studies have demonstrated considerable health care needs for psychiatric disorders as well as physical diseases. The aim of this paper was to find out the main barriers that undocumented migrants experience in accessing the Swedish healthcare system and to explore their relation with socioeconomic factors. Methods A cross-sectional study with adult undocumented migrants was performed in the three largest cities of Sweden in 2014–2016. Sampling was done via informal networks. A socioeconomic questionnaire was constructed including 22 barriers to health care. Trained field workers conducted the interviews. A principal component analysis was conducted of all barriers to reveal central components. Then, Pearson’s chi-squared test was used to explore the characteristics of undocumented migrants experiencing barriers to care. Results Two main components/barriers were extracted: “Fear of being taken by police/authorities”, which was related to fear of disclosure by or in relation to seeking health care, and “Structural and psychosocial factors” which was related to practical obstacles or shame of being ill. Lower age (74.1 % vs 56.0 %), lower level of education (75.0 % vs. 45.1 %), and having no children (70.3 % vs. 48.1 %) were significantly related to a higher likelihood of experiencing a barrier. Conclusion Fear of deportation and practical and psychosocial factors constitute hinderance of access to healthcare for undocumented migrants in Sweden. This highlights the importance of clear instructions, both to undocumented migrants and health professionals about the right to health care according to the international law on human rights as well as the law of confidentiality.

Abstract Background To analyse the impact of austerity measures taken by European governments as a response to the 2008 economic and financial crisis on social determinants on child health (SDCH), and child health outcomes (CHO). Methods A systematic literature review was carried out in Medline (Ovid), Embase, Web of Science, PsycInfo, and Sociological abstracts in the last 5 years from European countries. Studies aimed at analysing the Great Recession, governments’ responses to the crisis, and its impact on SDCH were included. A narrative synthesis of the results was carried out. The risk of bias was assessed using the STROBE and EPICURE tools. Results Fourteen studies were included, most of them with a low to intermediate risk of bias (average score 72.1%). Government responses to the crisis varied, although there was general agreement that Greece, Spain, Ireland and the United Kingdom applied higher levels of austerity. High austerity periods, compared to pre-austerity periods were associated with increased material deprivation, child poverty rates, and low birth weight. Increasing child poverty subsequent to austerity measures was associated with deterioration of child health. High austerity was also related to poorer access and quality of services provided to disabled children. An annual reduction of 1% on public health expenditure was associated to 0.5% reduction on Measles-Mumps-Rubella vaccination coverage in Italy. Conclusions Countries that applied high level of austerity showed worse trends on SDCH and CHO, demonstrating the importance that economic policy may have for equity in child health and development. European governments must act urgently and reverse these austerity policy measures that are detrimental to family benefits and child protection.

Abstract Background Fathers may affect expectant mothers’ daily living situations, which in turn might influence pregnancy outcomes. We investigated the association between paternal violent criminality and risk of preterm birth (≤36 weeks). Methods We conducted a register-based study with all live singleton births in the Swedish Medical Birth Register from 1992 to 2012, linked with records of paternal violent crime convictions from the National Crime Register from 1973 to 2012. Results Paternal violent criminality was associated with increased risk of preterm birth and lower gestational age. The association was especially pronounced among infants of reoffenders: men convicted of three or more violent crimes (adjusted odds ratio [aOR] 1.23 [95% CI 1.17, 1.29]). Maternal half sibling-comparisons, an analytic approach controlling for maternal factors stable across pregnancies, also suggested increased risk of preterm birth and lower gestational age when exposed to a violently reoffending father compared to a father without violent criminal convictions (aOR 1.30 [0.99, 1.72], adjusted mean difference − 1.07 [− 1.78, − 0.36]). Conclusions Persistent paternal violent criminality was associated with increased risk of preterm birth, even after controlling for maternal characteristics that did not change between pregnancies.

Abstract Background Birth order has been shown to affect the health of the child; less is known, however, about how birth order affects caries development in children. Thus, the present study investigated the association between birth order and dental caries development in young children. Methods This retrospective registry-based cohort study included all children born in 2000–2003 who were residing in Stockholm County, Sweden, at age 3 years (n = 83,147). The study followed the cohort until subjects reached 7 years of age. Children with registry data on dental examinations and sociodemographic characteristics at ages 3- and 7 years constituted the final study cohort (n = 65,259). The outcome variable was “caries increment from age 3- to 7 years” (Δdeft > 0) and the key exposure, “birth order”, was divided into five groups. A forward stepwise logistic binary regression was done for the multivariate analysis with adjustments for sociodemographic factors. Results At age 3 years, 94% had no fillings or manifest caries lesions. During the study period, 22.5% (n = 14,711) developed dental caries. The final logistic regression analysis found a statistically significant positive association between birth order and caries increment. Further, excess risk increased with higher birth order; with the mother’s first-born child as reference, risk for the second-born child was OR 1.17, 95% CI = 1.12–1.23; for the third-born child, OR 1.47, 95% CI = 1.38–1.56; for the fourth-born child, OR 1.69, 95% CI = 1.52–1.88; and for the fifth-born or higher birth-order child, OR 1.84, 95% CI = 1.58–2.14. Conclusions These findings show that birth order influences caries development in siblings, suggesting that birth order can be regarded as a predictor for caries development in young children. This factor may be helpful in assessing caries risk in preschool children and should be considered in caries prevention work in young children with older siblings.

BackgroundDue to the circumstances of their early lives, young refugees are at risk of experiencing adverse labour market and health outcomes. The post-settlement environment is thought to play a decisive role in determining how this vulnerability plays out. This study compared trends in labour market marginalisation in young refugees and their majority peers during early adulthood in two national contexts, Denmark and Sweden, and explored the mediating role of common mental disorders and secondary school completions.MethodsUsing registry data, 13,390/45,687 refugees were included in Denmark/Sweden and 1:5 matched to majority peers. Inequalities in labour market marginalisation were investigated during 2012-2015 in each country using linear probability models and mediation analysis. Country trends were standardised to account for differences in observed population characteristics.ResultsThe risk of marginalisation was 2.1-2.3 times higher among young refugees compared with their majority peers, but the risk decreased with age in Sweden and increased in Denmark for refugees. Birth-cohort differences drove the increase in Denmark, while trends were consistent across birth-cohorts in Sweden. Differences in population characteristics did not contribute to country differences. Common mental disorders did not mediate the inequality in either country, but secondary school completions did (77-85% of associations eliminated).ConclusionsThe findings document both the vulnerability of young refugees to labour market marginalisation and the variability in this vulnerability across post-settlement contexts. While the contrast in policy climates in Denmark and Sweden sharpened over time, the risk of marginalisation appeared more similar in younger cohorts, pointing to the importance of factors other than national immigration and integration policies. Institutional efforts to assist young refugees through secondary education are likely to have long-lasting consequences for their socio-economic trajectories.

Background In the context of containment measures against the COVID-19 pandemic, the aims were to examine the impact of lockdown and school closures on childs’ and adolescents’ health and well-being and social inequalities in health.Methods Literature review by searching five databases until November 2020. We included quantitative peer-reviewed studies reporting health and well-being outcomes in children (0–18 years) related to closure measures' impact due to COVID-19. A pair of authors assessed the risk of bias of included studies. A descriptive and narrative synthesis was carried out.Findings Twenty-two studies, including high-income, middle-income and low-income countries, fulfilled our search criteria and were judged not to have an increased risk of bias. Studies from Australia, Spain and China showed an increase in depressive symptoms and decrease in life satisfaction. A decrease in physical activity and increase in unhealthy food consumption were shown in studies from two countries. There was a decrease in the number of visits to the emergency department in four countries, an increase in child mortality in Cameroon and a decrease by over 50% of immunisations administered in Pakistan. A significant drop of 39% in child protection medical examination referrals during 2020 compared with the previous years was found in the UK, a decrease in allegations of child abuse and neglect by almost one-third due to school closures in Florida, and an increase in the number of children with physical child abuse trauma was found in one centre in the USA.Interpretation From available reports, pandemic school closure and lockdown have adverse effects on child health and well-being in the short and probably long term. We urge governments to take the negative public health consequences into account before adopting restrictive measures in childhood.

Background Parental separation has been associated with adverse child mental health outcomes in the literature. For school-aged children, joint physical custody (JPC), that is, spending equal time in both parents’ homes after a divorce, has been associated with better health and well-being than single care arrangements. Preschool children’s well-being in JPC is less studied. The aim of this study was to investigate the association of living arrangements and coparenting quality with mental health in preschool children after parental separation.Methods This cross-sectional population-based study includes 12 845 three-year-old children in Sweden. Mental health was measured by parental reports of the Strength and Difficulties Questionnaire and coparenting quality with a four-item scale. The living arrangements of the 642 children in non-intact families were categorised into JPC, living mostly with one parent and living only with one parent.Results Linear regression models, adjusted for sociodemographic confounders, showed an association between increased mental health problems and living mostly and only with one parent (B=1.18; 95% CI 0.37 to 2.00, and B=1.20; 95% CI 0.40 to 2.00, respectively), while children in intact families vs JPC did not differ significantly (B=−0.11; 95% CI −0.58 to 0.36). After adjusting the analyses for coparenting quality, differences in child mental health between the post divorce living arrangements were, however, minimal while children in intact families had more mental health problems compared with JPC (B=0.70; 95% CI 0.24 to 1.15). Factorial analysis of covariance revealed that low coparenting quality was more strongly related to mental health problems for children in intact families and JPC compared with children living mostly or only with one parent.Conclusions This study suggests that coparenting quality is a key determinant of mental health in preschool children and thus should be targeted in preventive interventions.

Introduction Sweden has long been praised for a generous parental leave policy oriented towards facilitating a gender-equitable approach to work and parenting. Yet certain aspects of Swedish parental leave could also be responsible for the maintenance of (or even the increase in) health inequalities. Using a ‘Health in All Policies’ lens, this research project aims to assess the unintended health consequences of various components of Sweden’s parental leave policy, including eligibility for and uptake of earnings based benefits.Methods and analysis We will use individual-level data from multiple Swedish registers. Sociodemographic information, including parental leave use, will be retrieved from the total population register, Longitudinal Integration Database for Health Insurance and Labour Market Studies and Social Insurance Agency registers. Health information for parents and children will be retrieved from the patient, prescribed drug, cause of death, medical birth and children’s health registers. We will evaluate parents’ mental, mothers’ reproductive and children’s general health outcomes in relation to several policy reforms aiming to protect parental leave benefits in short birth spacing (the speed premium) and to promote father’s uptake (the father’s quota) and sharing of parental leave days (the double days reform). We will also examine effects of increases in basic parental leave benefit levels. Using quasi-experimental designs, we will compare health outcomes across these reforms and eligibility thresholds with interrupted time series, difference-in-difference and regression discontinuity approaches to reduce the risk of health selection and assess causality in the link between parental leave use and health.Ethics and dissemination This project has been granted all necessary ethical permissions from the Stockholm Regional Ethical Review Board (Dnr 2019-04913) for accessing and analysing deidentified data. The final outputs will primarily be disseminated as scientific articles published in open-access, high-impact peer-reviewed international journals, as well as press releases and policy briefs.

It is well-known that experiences of out-of-home care (OHC; foster-family care and residential care) are linked to criminal behavior. Less is known how criminal activity in the OHC population develops over the life course and to what extent such development is characterized by desistance or persistence. Using population-based longitudinal register data for more than 740,000 Swedish men and women, of which around 2.5% have experience of OHC, followed until age 40, results from group-based trajectory modelling and multinomial regression suggest that OHC-experienced individuals with various timing and duration of placement, especially men first placed as teenagers, have substantially elevated likelihood for persistent offending compared to peers without OHC experience. However, most OHC-experienced followed pathways characterized by desistance. Our findings have implications for understanding the dynamics of offending in OHC populations and underscores the necessity for interventions that can prevent the onset of criminal careers, as well as disrupt or modify the ongoing paths of offending within this disadvantaged group of individuals. [ABSTRACT FROM AUTHOR]

Abstract Background Herd immunity levels of vaccine uptake are still not reached in some high-income countries, usually in countries with persisting social inequities in uptake. Previous studies have focused on factors within one health care system. This study takes a broader health care systems approach by reviewing the socioeconomic distribution of vaccination coverage on the national level in light of structural and organizational differences of primary care for children. Methods A systematic literature review of socio-economic patterns of uptake of Measles-Mumps-Rubella (MMR) and/or Diphteria-Tetanus-Pertusis (DTP) in population based studies of children 0–5 years of age living in the 30 European Economic Area (EEA) or European Free Trade Association (EFTA) countries and Australia, was carried out using the PRISMA guidelines. The health care system in the countries in the study were categorized by degree of freedom of the primary care provider (hierarchical or non-hierarchical) and whether preventive services were provided in a separate organization (well-baby clinics). Results The review identified 15 studies from 10 European countries and Australia that fulfilled the criteria. Although the heterogeneity of the socio-economic indicators did not allow for a conclusive meta-analysis, the study pointed towards lower levels of inequities in primary care models with well-baby clinics. In non-hierarchical primary care organizations that also lacked well-baby clinics, socioeconomic gaps in uptake were often found to be large. Conclusion This review indicates that structural and organizational aspects of health care systems for young children are important for equity in vaccine uptake.

Abstract Background Undocumented migrants (UMs) in Europe constitute a heterogeneous group. They are typically in a vulnerable and marginalised situation, since most of them have exhausted their options for gaining asylum and protection from war and persecution, many are traumatised and fear disclosure and deportation, and they typically lack basic social security. The present study investigates living conditions, access to human rights and mental health of UMs living in Sweden. Methods A cross-sectional study with adult UMs was performed in the three largest cities in Sweden in 2014–2016. Sampling was done via informal networks. A socioeconomic questionnaire was constructed, and psychiatric symptoms were screened for using Beck’s Depression Inventory II, Beck’s Anxiety Inventory and the PTSD Checklist (PCL) for civilians. Trained field workers conducted the interviews. Descriptive statistics, chi-square tests and logistic regression models were used. Results A total number of 104 individuals participated. Preliminary findings show that 68% of respondents were suffering from either moderate or severe anxiety, 71% from either moderate or severe depression and 58% from PTSD. No statistically significant gender differences occurred, but age was statistically significant in relation to anxiety and depression. The majority feared returning to their country of origin, for political reasons, due to war in progress there and/or because they belonged to a minority and feared harassment. Almost all had an unstable housing situation and were often forced to move. Fifty-seven percent experienced food insecurity. Conclusion The psychosocial situation among UMs in Sweden, in addition to insecure living conditions without a guarantee of basic needs being met is stressful, and many UMs live in constant fear of disclosure and deportation, all of which has a detrimental effect of the mental health. It is important to understand both associated risk factors for ill-health and coping strategies in this vulnerable population in order try to reduce ongoing stress.

This study aims to examine whether disparities in gestational age outcomes between foreign and Swedish-born mothers are contingent on the measure used to estimate gestational age and, if so, to identify which maternal factors are associated with the discrepancy. Using population register data, we studied all singleton live births in Sweden from 1992-2012 (n = 1,317,265). Multinomial logistic regression was performed to compare gestational age outcomes classified into very (

Background: Non-European international adoptees in Sweden were shown to have a three-to fourfold higher risk of suicidal behaviour in youth during 1986–1995 compared with the general population. The aim of this study was to investigate whether this high risk persists beyond youth and in later cohorts. Methods: A register study of Swedish national cohorts born 1972–86 including 20 625 non-European international adoptees, and comparison populations of 10 915 non-European immigrants and 1 435 167 Swedish born was performed. The study population was followed from age 18 between 1991 and 2016, with suicide and hospital admissions due to suicide attempt as outcomes. Poisson regression models of person time in the study, adjusted for gender and household income at age 17, were fitted to calculate relative risks (RR). Findings: Adjusted RR for suicide in non-European international adoptees was high at age 18–22, 2·74 (95% C.I. 1·95–3·86), but decreased gradually to age 33–43 when the risk was similar to Swedish-born. Adjusted RR for suicide attempts in international adoptees was 2·33 (2·15–2·52) at age 18–22, decreased slightly with older age, but remained higher than Swedish born in all age-classes. Risks for both outcomes were greatest, around three times higher compared with the Swedish-born in the oldest birth cohorts of non-European international adoptees, born 1972–76. Risks for both suicidal outcomes increased with higher age at adoption. Interpretation: The risk of suicidal behaviour in non-European international adoptees in Sweden decreases with age and is lower in later birth cohorts and in infant adoptions.

Abstract Background Child psychiatric treatment facilities vary greatly worldwide and are virtually non-existent in many low-income countries. One of the most common psychiatric disorders in childhood is ADHD, with an estimated prevalence of 3–5% in Sweden. Previous studies have shown a similar prevalence of ADHD in minority and majority children in Sweden and the UK. However, clinical studies demonstrated that children from immigrant families living in Sweden received less psychiatric care than those of native-born parents. We tested the hypothesis that the consumption of child psychiatric care in immigrant families would be determined by the availability of such treatment in the parents’ country of origin. Patterns of medication for attention-deficit hyperactivity disorder (ADHD) were studied as a proxy for child psychiatric care. Methods This was a register study of dispensed stimulant medication during 2013–2014 in Swedish national birth cohorts from 1995–2009. The study population, consisting of nearly 1.4 million children, was divided by national income of the parental country of origin and whether the parents were native Swedes, European immigrants, non-European immigrants or a mixture. Logistic regression was used to calculate the odds ratios of having been dispensed at least one ADHD drug during 2013, with adjustments for gender, family status indicating whether the child is living with both parents, household income and area of residence. Results Having parents born in low-income (OR [95% confidence interval] 0.27 [0.24–0.29]) or middle-income (European: OR 0.23 [0.20–0.26], non-European: OR 0.39 [0.34–0.41]) countries was associated with lower ADHD treatment levels than having parents born in high-income countries (European: OR 0.60 [0.54–0.66], non-European: OR 0.68 [0.59–0.79]), when compared to children of parents born in Sweden. In families with a background in low or middle income countries, there was no significant association between household income and ADHD medication, while in children with Swedish and mixed backgrounds high level of disposable income was associated with lower levels of ADHD medication. Conclusion The use of child psychiatric care by immigrant families in Sweden was largely associated with the income level of the country of origin.

Abstract Background Fetal alcohol spectrum disorders (FASD) is an umbrella term covering several conditions for which alcohol consumption during pregnancy is taken to play a causal role. The benefit of individuals being identified with a condition within FASD remains controversial. The objective of the present study was to identify ethical aspects and consequences of diagnostics, interventions, and family support in relation to FASD. Methods Ethical aspects relating to diagnostics, interventions, and family support regarding FASD were compiled and discussed, drawing on a series of discussions with experts in the field, published literature, and medical ethicists. Results Several advantages and disadvantages in regards of obtaining a diagnosis or description of the condition were identified. For instance, it provides an explanation and potential preparedness for not yet encountered difficulties, which may play an essential role in acquiring much needed help and support from health care, school, and the social services. There are no interventions specifically evaluated for FASD conditions, but training programs and family support for conditions with symptoms overlapping with FASD, e.g. ADHD, autism, and intellectual disability, are likely to be relevant. Stigmatization, blame, and guilt are potential downsides. There might also be unfortunate prioritization if individuals with equal needs are treated differently depending on whether or not they meet the criteria for a specific condition. Conclusions The value for the concerned individuals of obtaining a FASD-related description of their condition – for instance, in terms of wellbeing – is not established. Nor is it established that allocating resources based on whether individuals fulfil FASD-related criteria is justified, compared to allocations directed to the most prominent specific needs.