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- Seiterö, Anna, 1982-
(author)
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mHealth Targeting Physical Activity, Diet, Alcohol, and Smoking among Swedish High School Students : Processes and Outcomes of a Multiple Health Behavior Change Intervention (LIFE4YOUth)
- 2024
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Doctoral thesis (other academic/artistic)abstract
- Background: Effective health promotion and disease prevention strategies are required to achieve societies where preventable diseases are effectively prevented. Physical activity, diet, alcohol consumption, and tobacco use are all determinants for high-prevalent diseases such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. The cumulative risk of multiple health risk behaviors exceeds the combined risk of each individual behavior. Because health behaviors are formed during childhood and adolescence and occur in clusters that overall affect health, interventions targeting multiple health behaviors in these populations may have a lasting impact on public health. Schools are important for health promotion and disease prevention in children and adolescents. Nevertheless, the literature indicates that school-based interventions that involve school staff to address health-risk behaviors tend to be short-term projects due to barriers that impede long-term implementation. Mobile phones can provide resources for adolescents to promote their health, such as health applications and short text messages that do not rely on school personnel. However, more research is required to better understand whether stand-alone mobile phone-delivered interventions that target multiple health behaviors are a viable way to encourage health-promoting behaviors in adolescents.Aim: This thesis aims to gain knowledge about health behavior change among Swedish high school students, including the use and effects of an mHealth intervention (LIFE4YOUth) targeting four health behaviors (physical activity, diet, alcohol consumption, and cigarette smoking). The overall aim was addressed through four sub-studies, which specifically aimed to: identify and describe how high school students perceive health behavior change and how mobile phones are used in the process of change (Paper I), explore how high school students understand, interpret, and apply the content of LIFE4YOUth and describe consequences on psychological resources relevant to behavior change (Paper II), investigate explanations for engagement among high school students with access to LIFE4YOUth (Paper III), and estimate the two- and four-month effectiveness of LIFE4YOUth on individual health behaviors (physical activity, diet, alcohol consumption, and cigarette smoking) compared to a waiting list control condition (Paper IV).Intervention: The LIFE4YOUth intervention gave participants four-month access to weekly prompts for recording health behaviors and receiving feedback based on national guidelines, a four-module interactive dashboard with content structured around two main questions: why change and how to change health behaviors, and text message services for each targeted behavior.Methods: All studies were conducted between 2019 and 2023 and included approximately 800 students from high schools all over Sweden. Two studies had a qualitative approach, with data collected through focus groups (Paper I) and individual interviews with "think aloud" techniques (Paper II). Data were analyzed using thematic analysis (Paper I) and qualitative content analysis (Paper II). One study (paper III) had a mixed-methods design with data collected from participants in the intervention arm of the LIFE4YOUth trial. The analysis included statistical analyses, qualitative content analysis, and qualitative comparative analysis. Finally, a two-armed randomized controlled trial (1:1) with an intervention group and a waiting list control group was enrolled (Paper IV). Data was collected through web-based questionnaires at baseline and after two and four months. All primary outcomes were analyzed using regression models with inferences drawn from Bayesian analysis and null hypothesis testing.Results: The process of health behavior change was understood as a learning process facilitated by independence, an open approach, and self-acceptance while striving for social ideals such as togetherness with friends. Participants engaged with LIFE4YOUth to varied extent, which can be explained by varied interest in behavior change, experiences with the intervention, and circumstances in their social environment. Most participants responded to the weekly prompts in ≤ 2 out of 16 weeks, with 58% engaging with the intervention at least once. The dashboard content had the potential to provide participants with insights that facilitate health behavior change, but participants understood, interpreted, and applied the content in varied ways depending on whether they deliberately acknowledged their interpretation of concepts, took their prior knowledge into consideration to comprehend what was not explicitly outlined, and placed themselves in the center by accounting for their personal needs when interacting with the content.After two months, the intervention group participants had on average 50 minutes more of moderate to vigorous physical activity per week compared with the control group participants (95% CI = -0.19; 99.73, probability of effect = 97.4%, P=.05), and on average 0.32 more daily portions of fruits and vegetables (95% CI = 0.13; 0.53, probability of effect = 99.9%, P=.001). Furthermore, the probability of effect on weekly consumption of sugary drinks was 86% (IRR = 0.89, 95% CI = 0.73; 1.1, P=.29) and 94% on monthly frequency of heavy episodic drinking (IRR = 0.77, 95% CI = 0.55; 1.07, P=.14). The evidence for effect was weaker after four months. There was no marked evidence for an effect on weekly alcohol consumption or smoking cessation.Conclusion: The findings of this thesis indicate that the LIFE4YOUth intervention can raise Swedish high school students’ awareness of their health behaviors, encourage them to change their health-risk behaviors, and facilitate their process of adopting new behaviors. Nonetheless, the intervention’s potential may vary depending on high school students' interest in and cognitive processing of the intervention content. The strongest evidence for effect was on the weekly time spent in moderate to vigorous physical activity and the daily number of portions consumed of fruit and vegetables. These findings should encourage further research to gain more robust evidence on whether and how stand-alone mHealth multiple behavior change interventions are effective in promoting healthy behaviors among adolescents.
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| 2. |
- Alexandrou, Christina, 1981-
(author)
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MINISTOP 2.0 : a smartphone app integrated in primary child health care to promote healthy diet and physical activity behaviors and prevent obesity in preschool-aged children
- 2023
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Doctoral thesis (other academic/artistic)abstract
- BackgroundChildhood overweight and obesity is currently estimated to affect 39 million children under the age of five worldwide. After the COVID-19 pandemic, further increases have been observed in several countries including Sweden, where an increased incidence was observed in 3- and 4-year-old children, especially in disadvantaged areas. This development emphasizes the urgent need for population-based childhood obesity prevention interventions, and Swedish primary child health care provides an ideal setting for primary preventive efforts during the preschool years. However, thus far, previous child health care-based obesity prevention interventions have demonstrated limited effectiveness. As previous interventions also have been face-to-face delivered and thus resource-demanding; new, and scalable ways of delivering interventions also need to be evaluated. Mobile health or mHealth refers to the use of mobile devices for medical and public health practice and provides opportunity for development and dissemination of digital interventions for various purposes and populations at scale. This thesis reports the results of the MINISTOP 2.0 project, which covers the development and evaluation of the MINISTOP 2.0 digital intervention, from adaptation and translation of the intervention to Somali, Arabic and English (Paper I), to evaluation of real-world effectiveness within the Swedish primary child health care setting (Paper II) followed by exploration of user experiences and implementation aspects (Paper III) and a cost-consequence analysis of the intervention costs (Paper IV). AimThe overall aim of this thesis was to evaluate whether a 6-month parent-oriented mHealth intervention (MINISTOP 2.0 app), embedded in the routine services of Swedish primary child health care, can be used to improve diet and physical activity behaviors, and decrease the prevalence of over-weight and obesity in 2.5-to-3-year-old children. MethodsThe MINISTOP 2.0 project utilized a hybrid type 1 effectiveness-implementation study design to enable simultaneous evaluation and exploration of intervention effectiveness, user experiences and implementation aspects. Paper I: A qualitative exploration of user requirements in an app-based parental support intervention was conducted through three focus group interviews with Somali- (n = 5), Arabic- (n = 4), and Swedish-speaking parents (n = 6), and individual interviews with child health care nurses (n = 15). Data was analyzed using thematic analysis. Paper II: A two-arm parallel randomized controlled trial was conducted at 19 child health care centers located in six Swedish regions. Participating parents (n = 552) were invited during their routine visit at 2.5/3-years at their primary child health care center. All baseline and follow-up procedures were conducted by the nurses. Parents that were randomized to the control group received standard care, while the intervention group received access to the MINISTOP 2.0 app for six months, alongside standard care. Prior to randomization, nurses measured the child’s height and weight for assessment of BMI, and parents answered a questionnaire about their child’s intake of fruit and vegetables, sweet and savory treats, and sweet drinks; time spent in moderate-to-vigorous physical activity (MVPA) and screen time; and parental self-efficacy (PSE) for promoting healthy diet, physical activity, and screen time behaviors. These baseline procedures were then repeated at a 6-month follow-up visit to the child health care center. Paper III: A qualitative exploration of user experiences, acceptability, and feasibility of the MINISTOP 2.0 intervention was conducted through individual interviews with parents (n = 24) with diverse backgrounds, and with child health care nurses (n = 15). Data was analyzed using content analysis. Paper IV: Data on all costs related to the MINISTOP 2.0 intervention, including costs for app and interface upkeep as well as salary costs for introduction and dissemination of the app by nurses, was collected retrospectively. A cost-consequence analysis was then performed to estimate the costs of the intervention. ResultsPaper I: Parents expressed several challenges related to promoting healthy eating behaviors, such as worrying about their child not eating enough, and difficulties balancing different food cultures. There were also requests for the app content to be accessible through alternative modes of delivery (e.g., audio/video) for parents with low literacy. Nurses underlined the importance of supporting parents early with health behavior interventions, and the value of a shared digital platform, available in several languages, to facilitate communication with parents. Paper II: Seventy-nine percent of the participating parents (n = 552) were mothers and 62% had a university degree. Among the children, 24% had two foreign-born parents. Children in the intervention group had lower in-takes of sweet and savory treats (-6.97 g/day; p = 0.001), sweet drinks (-31.52 g/day; p < 0.001), and screen time (-7.00 min/day; p = 0.012) com-pared to the control group at follow-up. Parents in the intervention group also reported higher total PSE (0.91; p = 0.006), PSE for promoting healthy diet behaviors (0.34; p = 0.008) and PSE for promoting healthy physical activity behaviors (0.31; p = 0.009) compared to the control group. For children’s MVPA or BMI z-score, no statistically significant effect was observed between groups. Finally, parents also reported high satisfaction with the app, and 54% reported using the app once a week or more. Paper III: Findings indicated that the app was well accepted and appreciated, as it increased knowledge and awareness around current health behaviors. Furthermore, evidence-based information available in one place and from a trusted source, was highly valued, especially when living in a country with a different culture than your own. The app was also acknowledged as a feasible support tool and a suitable complement to the standard care offered during visits. Finally, due to the accessibility in different languages and the possibility of disseminating the app at scale, both nurses and parents described the app as an appropriate tool for reaching larger populations of parents as well as parents in need of additional support. Paper IV: The total cost for the MINISTOP 2.0 intervention was 437 439 SEK based on the 277 families in the intervention group. The cost for child health care nurses introducing and registering families for the app represented only 9% of the total cost per family, which was considerably lower in comparison to other similar childhood obesity prevention interventions. Also, notably, for upscaling, sharing running costs for the user interface for larger populations of children, would result in much lower total costs per family. ConclusionsOverall, qualitative findings for adapting the intervention highlighted the need for early access to information, as well as the importance of adapting interventions to also be accessible for parents with migrant background and parents with lower literacy. When disseminated through primary child health care, the MINISTOP 2.0 intervention resulted in statistically significant reduced intakes of sweet and savory treats, sweet drinks, and screen time in children (primary outcomes) as well as increased PSE for promoting healthy diet and activity behaviors (secondary outcome). The app was well accepted and perceived as a feasible support tool for parents. Furthermore, accessibility in different languages was also appreciated. Finally, the relatively low salary costs in comparison to face-to-face interventions suggest that the MINISTOP 2.0 app and caregiver interface may be an affordable preventive effort for early promotion of healthy lifestyle behaviors in children when scaled up on a population level. Altogether, the results from the papers in this thesis support the large-scale implementation of the MINISTOP 2.0 app within the Swedish primary child health care setting for promotion of healthy lifestyle behaviours in 2.5-to-3-year-old children.
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| 3. |
- Norvell Gustavsson, Isa, 1988-
(author)
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The roots grow deep: Strong yet changeable : Social norms and working life
- 2022
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Doctoral thesis (other academic/artistic)abstract
- The overarching aim of this thesis was to explore social norms in relation to work and its influence on individuals’ actions and mindsets. This has been done through four empirical studies which investigated the work norm from three different perspectives: 1) the work norm in practice, through the actions of individuals on sick leave during their rehabilitation process and in relation to the system and the actors within the system, as well as managers actions within their organisations; 2) exploring perceptions of the work norm in terms of socialisation to working life and structural changes; 3) a comparative exploration of the work norm between different contexts. The specific research questions were:1. How do individuals’ various experiences influence their values and perceptions of themselves and their actions in relation to work? 2. How do individuals’ actions serve to reinforce or challenge the existing normative structures? 3. Are there differences, and if so, how are they expressed, in the work norm between different societal and cultural contexts? This thesis was exploratory in nature and aimed at gaining a rich, in-depth understanding of the participants’ experiences, values and actions by adopting an inductive, qualitative approach. The data collection consisted of a combination of semi-structured individual interviews and group interviews. The material was analysed through qualitative content analysis and thematic analysis. Study I focused on experiences of being on long-term sick leave, how the participants manage the societal norms and values, and how these influence their perspective on themselves throughout the rehabilitation process. Study II was concerned with first-line managers’ actions and attitudes towards employees with repeated short-term sickness absence. Of particular interest was how social and organisational factors in the workplace influenced and shaped the managers’ actions. Studies III and IV focused on young adults’ experiences of work, the role of work in their lives and their work values. The third study was mainly interested in the young adults’ expectations about work and their lived experiences of working. The fourth study’s main interest was how today’s young adults perceive the role of work in their lives and what they value in work. To capture how the social and cultural context may shape work centrality and work values data, from Sweden and the Netherlands were compared.The results of this thesis show that the work norm is strong, and that work plays a central part in the lives of the participants in these studies. The structure individuals find themselves in shape their views on work and the thesis displays a nuanced perspective of different expressions of the work norm. Its influence differs depending on one’s life situation, whether you are at the start of your working career, in the centre of it or currently outside of the labour market. The results highlight the importance of achieving balance and accommodating one’s concerns within the natural, practical and social orders of reality. Ignoring one of these orders might result in a lack of wellbeing in another.This thesis shows how the structural conditions which influence people’s possibilities to live up to the work norm differs depending on resources and social position. Even though the work norm is strong and people generally express a desire to work, it is not always practically reasonable to demand it, especially if it means too great of a sacrifice in other parts of the individual’s life. The results point to a difficulty in challenging the work norm as an individual, while organising with others around shared opposing values with others could be a start of bringing about a change.
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