| 1. |
- Alexandrou, Christina, 1981-
(författare)
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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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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)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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| 2. |
- Bendtsen, Marcus, 1982-, et al.
(författare)
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A Mobile Health Intervention for Mental Health Promotion Among University Students : Randomized Controlled Trial
- 2020
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Ingår i: JMIR mhealth and uhealth. - Toronto, ON, Canada : J M I R Publications, Inc.. - 2291-5222. ; 8:3
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Tidskriftsartikel (refereegranskat)abstract
- Background: High positive mental health, including the ability to cope with the normal stresses of life, work productively, and be able to contribute to one’s community, has been associated with various health outcomes. The role of positive mental health is therefore increasingly recognized in national mental health promotion programs and policies. Mobile health (mHealth) interventions could be a cost-effective way to disseminate positive psychological interventions to the general population.Objective: The aim of this study was to estimate the effect of a fully automated mHealth intervention on positive mental health, and anxiety and depression symptomology among Swedish university students using a randomized controlled trial design.Methods: A 2-arm, single-blind (researchers), parallel-groups randomized controlled trial with an mHealth positive psychology program intervention group and a relevant online mental health information control group was employed to estimate the effect of the novel intervention. Participants were recruited using digital advertising through student health care centers in Sweden. Inclusion criteria were (1) university students, (2) able to read and understand Swedish, (3) and have access to a mobile phone. Exclusion criteria were high positive mental health, as assessed by the Mental Health Continuum Short Form (MHC-SF), or high depression and anxiety symptomology, as assessed by the Hospital Anxiety Depression Scale (HADS). The primary outcome was positive mental health (MHC-SF), and the secondary outcomes were depression and anxiety symptomatology (HADS). The subscales of MHC-SF were also analyzed as exploratory outcomes. Outcomes were measured 3 months after randomization through questionnaires completed on the participants’ mobile phones.Results: A total of 654 participants (median age 25 years), including 510 (78.0%) identifying as female, were randomized to either the intervention (n=348) or control group (n=306). At follow-up, positive mental health was significantly higher in the intervention group compared with the control group (incidence rate ratio [IRR]=1.067, 95% CI 1.024-1.112, P=.002). For both depression and anxiety symptomatology, the intervention group showed significantly lower scores at follow-up compared with the control group (depression: IRR=0.820, 95% CI 0.714-0.942, P=.005; anxiety: IRR=0.899, 95% CI 0.840-0.962, P=.002). Follow-up rates were lower than expected (58.3% for primary outcomes and 52.3% for secondary outcomes); however, attrition analyses did not identify any systematic attrition with respect to baseline variables.Conclusions: The mHealth intervention was estimated to be superior to usual care in increasing positive mental health among university students. A protective effect of the intervention was also found on depressive and anxiety symptoms. These findings demonstrate the feasibility of using an automated mobile phone format to enhance positive mental health, which offers promise for the use of mHealth solutions in public mental health promotion.Trial Registration: International Standard Randomized Controlled Trial Registry ISRCTN54748632; http://www.isrctn.com/ISRCTN54748632
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| 3. |
- Bendtsen, Marcus, 1982-, et al.
(författare)
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mHealth intervention for multiple lifestyle behaviour change among high school students in Sweden (LIFE4YOUth) : Protocol for a randomised controlled trial
- 2021
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Ingår i: Public Health Nursing. - : BMC. - 0737-1209 .- 1525-1446 .- 1471-2458. ; 21:1
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundNational surveys in Sweden demonstrate that the majority of young people do not engage in health promoting behaviours at levels recommended by the Public Health Agency of Sweden. The objective of this study is to estimate the effectiveness of a novel mHealth intervention named LIFE4YOUth, which targets multiple lifestyle behaviours (alcohol, diet, physical activity, and smoking) among high school students in Sweden.MethodsA 2-arm parallel groups single blind randomised controlled trial (1:1) will be employed to estimate the effectiveness of the novel mHealth intervention. Students will be recruited at high schools throughout Sweden, and will be included if they fulfil one of six criteria relating to unhealthy behaviours with respect to alcohol, diet, physical activity and smoking. Eligible participants will be randomised to either receive the novel intervention immediately, or to be placed on a waiting list for 4 months. The intervention consists of a combination of recurring screening, text messages, and an interactive platform which is adaptable to individual preferences. Outcome measures with respect to alcohol, diet, physical activity and smoking will be assessed through questionnaires at 2 and 4 months post randomisation.DiscussionThe findings of this trial could be generalised to a diverse high-school student population as our recruitment encompass a large proportion of schools throughout Sweden with various educational profiles. Furthermore, if effective, the mHealth intervention has good potential to be able to be scaled up and disseminated at high schools nationally.Trial registrationRegistered prospectively on 2020-05-20 in ISRCTN (ISRCTN34468623).
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| 4. |
- Bendtsen, Marcus, 1982-, et al.
(författare)
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The Mobile Health Multiple Lifestyle Behavior Interventions Across the Lifespan (MoBILE) Research Program : Protocol for Development, Evaluation, and Implementation
- 2020
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Ingår i: JMIR Research Protocols. - Toronto, Canada : JMIR Publications Inc. - 1929-0748. ; 9:4
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Tidskriftsartikel (refereegranskat)abstract
- Background: Clustering of multiple lifestyle risk behaviors has been associated with a greater risk of noncommunicable diseases and mortality than one lifestyle risk behavior or no lifestyle risk behaviors. The National Board of Health and Welfare in Sweden reported in 2018 that it is important to provide additional support to individuals with multiple lifestyle risk behaviors, as risks from these behaviors are multiplicative rather than additive. However, the same report emphasized that there is a lack of knowledge regarding interventions that support changes to unhealthy lifestyle behaviors.Objective: The MoBILE (Mobile health Multiple lifestyle Behavior Interventions across the LifEspan) research program has brought together two Swedish research groups supported by international collaborators. Through this collaboration, we aim to design and evaluate a number of novel and tailored mobile health (mHealth) multiple lifestyle behavior interventions across the life span of different health care populations. In addition, the MoBILE research program will extend ongoing research to include mHealth interventions for migrant pregnant women and children.Methods: Each project within the MoBILE program will focus on a specific group: pregnant women, preschool children, high school and university students, and adults in primary and clinical care. All the projects will follow the same 4 phases: requirements, development, evaluation, and implementation. During the requirements phase, implementers and end users will aid the design of content and functionality of the interventions. In the development phase, findings from the first phase will be synthesized with expert domain knowledge and theoretical constructs to create interventions tailored to the target groups. The third phase, evaluation, will comprise randomized controlled trials conducted to estimate the effects of the interventions on multiple lifestyle risk behaviors (eg, alcohol, nutrition, physical activity, and smoking). The final phase will investigate how the interventions, if found effective, can be disseminated into different health care contexts.Results: The research program commenced in 2019, and the first results will be available in 2020. Projects involving pregnant women, preschool children, and high school and university students will be completed in the first 3 years, with the remaining projects being planned for the program’s final 3 years.Conclusions:The development of evidence-based digital tools is complex, as they should be guided by theoretical frameworks, and requires large interdisciplinary teams with competence in technology, behavioral science, and lifestyle-specific areas. Individual researchers or smaller research groups developing their own tools is not the way forward, as it means reinventing the wheel over and over again. The MoBILE research program therefore aims to join forces and learn from the past 10 years of mHealth research to maximize scientific outcomes, as well as the use of financial resources to expand the growing body of evidence for mHealth lifestyle behavior interventions.
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| 5. |
- Leijon, Matti E., 1970-, et al.
(författare)
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Generation Pep – study protocol for an intersectoral community-wide physical activity and healthy eating habits initiative for children and young people in Sweden
- 2024
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Ingår i: Frontiers In Public Health. - Lausanne : Frontiers Media S.A.. - 2296-2565. ; 12
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Forskningsöversikt (refereegranskat)abstract
- Background: There is overwhelming evidence for the preventive effects of regular physical activity and healthy eating habits on the risk for developing a non-communicable disease (NCD). Increasing attention has been paid to community-wide approaches in the battle against NCDs. Communities can create supportive policies, modify physical environments, and foster local stakeholder engagement through intersectoral collaboration to encourage communities to support healthy lifestyles. The Pep initiative is based on intersectoral community-wide collaboration among Sweden’s municipalities. Primary targets are municipality professionals who work with children and young people as well as parents of children <18 years. The goal is to spread knowledge and create commitment to children’s and young people’s health with a special focus on physical activity and healthy eating habits to facilitate and support a healthy lifestyle. The overarching aim of the research project described in this study protocol is to investigate factors that influence the implementation of the Pep initiative in Sweden, to inform tailored implementation strategies addressing the needs and local prerequisites of the different municipalities.Methods: The project includes a qualitative and a quantitative study and is framed by a theoretical model involving four complementary forms of knowledge, explicitly recognized in the Pep initiative: knowledge about the issue; knowledge about interventions; knowledge about the context; and knowledge about implementation. Study 1 is a focus group study exploring barriers and facilitators for implementing the Pep initiative. The study will be carried out in six municipalities, selected purposively to provide wide variation in municipality characteristics, including population size and geographical location. Data will be analyzed using thematic analysis. Study 2 is a cross-sectional web-based survey investigating the implementability of the Pep initiative in Sweden’s 290 municipalities. Conditions for implementing different areas of the Pep initiative will be examined in terms of the acceptability, appropriateness, and feasibility, three predictors of implementation success. Data will be analyzed using non-parametric statistics.Discussion: The findings of the two studies will increase understanding of the prerequisites for implementing the Pep initiative in Swedish municipalities, which will provide valuable input into how implementation of the Pep initiative can best be facilitated in the different municipality settings.
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| 6. |
- Müssener, Ulrika, 1974-, et al.
(författare)
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A Text Message-Based Intervention Targeting Alcohol Consumption Among University Students : User Satisfaction and Acceptability Study.
- 2018
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Ingår i: JMIR Human Factors. - Toronto, Canada : J M I R Publications, Inc.. - 2292-9495. ; 5:3
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Heavy consumption of alcohol among university students is a global problem, with excessive drinking being the social norm. Students can be a difficult target group to reach, and only a minority seek alcohol-related support. It is important to develop interventions that can reach university students in a way that does not further stretch the resources of the health services. Text messaging (short message service, SMS)-based interventions can enable continuous, real-time, cost-effective, brief support in a real-world setting, but there is a limited amount of evidence for effective interventions on alcohol consumption among young people based on text messaging. To address this, a text messaging-based alcohol consumption intervention, the Amadeus 3 intervention, was developed.OBJECTIVE: This study explored self-reported changes in drinking habits in an intervention group and a control group. Additionally, user satisfaction among the intervention group and the experience of being allocated to a control group were explored.METHODS: Students allocated to the intervention group (n=460) were asked about their drinking habits and offered the opportunity to give their opinion on the structure and content of the intervention. Students in the control group (n=436) were asked about their drinking habits and their experience in being allocated to the control group. Participants received an email containing an electronic link to a short questionnaire. Descriptive analyses of the distribution of the responses to the 12 questions for the intervention group and 5 questions for the control group were performed.RESULTS: The response rate for the user feedback questionnaire of the intervention group was 38% (176/460) and of the control group was 30% (129/436). The variation in the content of the text messages from facts to motivational and practical advice was appreciated by 77% (135/176) participants, and 55% (97/176) found the number of messages per week to be adequate. Overall, 81% (142/176) participants stated that they had read all or nearly all the messages, and 52% (91/176) participants stated that they were drinking less, and increased awareness regarding negative consequences was expressed as the main reason for reduced alcohol consumption. Among the participants in the control group, 40% (52/129) stated that it did not matter that they had to wait for access to the intervention. Regarding actions taken while waiting for access, 48% (62/129) participants claimed that they continued to drink as before, whereas 35% (45/129) tried to reduce their consumption without any support.CONCLUSIONS: Although the main randomized controlled trial was not able to detect a statistically significant effect of the intervention, most participants in this qualitative follow-up study stated that participation in the study helped them reflect upon their consumption, leading to altered drinking habits and reduced alcohol consumption.TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number ISRCTN95054707; http://www.isrctn.com/ISRCTN95054707 (Archived by WebCite at http://www.webcitation.org/705putNZT).
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| 7. |
- Müssener, Ulrika, 1974-
(författare)
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Det goda mötet - en viktig del i sjukskrivnings- och rehabiliteringsprocessen
- 2012
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Ingår i: Socialmedicinsk Tidskrift. - 0037-833X. ; 89:2, s. 169-177
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Tidskriftsartikel (refereegranskat)abstract
- Ansvaret för att stötta individer vid återgång i arbete delas mellan flera offentliga aktörer såsom Försäkringskassan, hälso- och sjukvården, Arbetsförmedlingen, arbetsgivaren och den sjukskrivne själv. Studien visar att bemötandet från dessa aktörer påverkar hur personer som varit sjukskrivna hanterar sin situation relaterat till de förändringar som genomförts i sjukförsäkringen samt deras möjlighet att återgå till arbete. Möten där individens styrkor och förmågor på olika sätt lyfts fram tycks påverka självförtroendet och synen på den egna arbetsförmågan. Kritik riktas mot sjukförsäkringssystemet, t.ex. regler och bestämmelser, snarare än mot aktörerna som arbetar i det. I intervjuerna framkommer att systemets utformning i sig bidrar till att de professionella har svårt att se och beakta individuella behov vilket bidrar till orättvisa bedömningar och beslut.
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| 8. |
- Müssener, Ulrika, 1974-
(författare)
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Encouraging Encounters : Experiences of People on Sick Leave in Their Meetings with Professionals
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The recent increase in long-term sickness absence both in Sweden and many other countries has been met with various attempts to intensify the use of rehabilitation measures in order to prevent people from remaining long-term sickness absent. Several actors, among them professionals in healthcare, occupational health services, and social insurance are involved in handling issues related to the sick leave of an individual, and in providing measures to promote return to work (RTW). Identification of the factors that are related to RTW of the individual is a multifaceted task; therefore to meet the individual in this process is an essential challenge for many actors involved. Knowledge is needed about factors that might promote RTW in order to facilitate future research aimed at designing effective rehabilitation programs. Such information is of great importance to improve the work situations of the professionals, to decrease the cost for society, and to improve the situations for people on sick leave by facilitating RTW.Objectives: The overall aim of the work underlying this thesis was to ascertain whether contacts between professionals and sickness absentees might a factor that can promote RTW, and also to identify different aspects of how such positive encounters are experienced by those who are sick listed.Material and methods: Five investigations were conducted using different study designs, data, and methods of data analyses. The first two (papers I and II) concerned interviews with people on sick leave about positive experiences of their encounters with professionals. The third study (paper III) was based on four questions about encounters, which were included in a questionnaire that was administrated to people who were on sick leave. The fourth study (paper IV) used a broad questionnaire to examine experiences of positive encounters, and the final study (paper V) proposed a model of possible effects of the encounters on RTW.Results: In paper I and II different aspects of sick-listed person’s experiences of positive encounters were identified. For example, it seemed that important qualities included being treated with respect, feeling supported, establishing a personal relationship, and participating in decisions regarding RTW measures. Several of the interviewees stated that RTW might be promoted by positive encounters. Paper III showed that perceptions of interactions varied with the type of professionals, as well as with demographics. The respondents perceived their encounters with professionals within healthcare as most positive, followed by social insurance, and lastly occupational health services. In general, females, people born in Sweden, and those who were older, or had a higher education rated their encounters with professionals as more positive. The main finding reported in paper IV was that the majority of the participants had experienced being positive encountered by professionals. Three aspects of such encounters were stressed, namely being treated with ”competence”, ”personal attention”, and ”competence and trust”. The results related in paper V indicated that theories about empowerment and on social emotions could be successfully applied in this area, after they were specifically adapted to some unique features of the contacts between sickness absentees and rehabilitation professionals.Conclusions: This thesis emphasizes that being positively encountered by professionals can have a beneficial impact on RTW after a period of sickness absence. More research is required to elucidate the interaction between sick-listed persons and professionals who are involved in their cases. Further studies should focus on how methods for professionals can be provided to increase sick-listed persons’ own ability to mobilize and develop their resources. Moreover, additional knowledge is needed to extend professional treatment strategies that enhance self-confidence and empowerment of individuals during sickness absence.
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| 9. |
- Müssener, Ulrika, 1974-, et al.
(författare)
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Exploring the Experiences of Individuals Allocated to a Control Setting : Findings From a Mobile Health Smoking Cessation Trial
- 2019
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Ingår i: JMIR Human Factors. - Toronto, Canada : J M I R Publications, Inc.. - 2292-9495. ; 6:2
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Tidskriftsartikel (refereegranskat)abstract
- Background: Tobacco smoking is the primary cause of preventable premature disease and death worldwide. Evidence of the efficacy of text messaging interventions to reduce smoking behavior is well established, but there is still a need for studies targeting young people, especially because young adult smokers are less likely to seek treatment than older adults. A mobile health intervention, Nicotine Exit (NEXit), targeting smoking among university students was developed to support university students to quit smoking. Short-term effectiveness was measured through a randomized controlled trial, which found that immediately after the 12-week intervention, 26% of smokers in the intervention group had prolonged abstinence compared with 15% in the control group.Objective: The objective of this study was to explore the experience of being allocated to the control group in the NEXit smoking cessation intervention.Methods: We asked students who were allocated to the control group in the main NEXit randomized controlled trial to report their experiences. An email was sent to the participants with an electronic link to a short questionnaire. We assessed the distribution of the responses to the questionnaire by descriptive analysis. We analyzed free-text comments to 4 questions.Results: The response rate for the questionnaire was 33.8% (258/763), and we collected 143 free-text comments. Of the responders, 60.9% (157/258) experienced frustration, disappointment, and irritation about being allocated to the control group; they felt they were being denied support by having to wait for the intervention. Monthly text messages during the waiting period thanking them for taking part in the trial were perceived as negative by 72.3% (189/258), but for some the messages served as a reminder about the decision to quit smoking. Of the responders, 61.2% (158/258) chose to wait to quit smoking until they had access to the intervention, and 29.8% (77/258) decided to try to quit smoking without support. Of the respondents, 77.5% (200/258) claimed they were still smoking and had signed up or were thinking about signing up for the smoking cessation program at the time of the questionnaire.Conclusions: Most of the respondents reported negative feelings about having to wait for the support of the intervention and that they had decided to continue smoking. A similar number decided to wait to quit smoking until they had access to the intervention, and these respondents reported a high interest in the intervention. Free-text comments indicated that some control group participants believed that they had been excluded from the trial, while others were confused when asked to sign up for the intervention again.
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| 10. |
- Müssener, Ulrika, 1974-, et al.
(författare)
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High School Students’ Preferences and Design Recommendations for a Mobile Phone–Based Intervention to Improve Psychological Well-Being: Mixed Methods Study
- 2020
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Ingår i: JMIR Pediatrics and Parenting. - Toronto, ON, Canada : J M I R Publications, Inc.. - 2561-6722. ; 3:2
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Tidskriftsartikel (refereegranskat)abstract
- Background:Young adults’ mental health is characterized by relatively high rates of stress and anxiety and low levels of help-seeking behavior. Mobile health (mHealth) interventions could offer a cost-effective and readily available avenue to provide personalized support to young adults. More research needs to be directed at the development of mHealth interventions targeting youths specifically, as well as at determining how to reach young people and how to effectively intervene to improve psychological well-being.Objective:The objective was to gather perceptions from high school students to inform the development of a prototype mHealth intervention aiming to promote psychological well-being.Methods:A mixed methods design was used to (1) investigate high school students’ perceptions about stress and its consequences in daily life, as well as their ability to cope with stress, and (2) explore their preferences and design recommendations for an mHealth intervention to improve psychological well-being. Students from two high schools in the southeast of Sweden were invited to take part in the study. Recruitment of high school students was completed over a 6-week period, between October 25 and December 7, 2018. Recruitment entailed inviting students to complete a stress test (ie, screening and feedback) on their mobile phones. After completing the stress test, all participants were invited to complete a follow-up questionnaire and take part in telephone interviews.Results:A total of 149 high school students completed the stress test, of which 68 completed the questionnaire. There were 67 free-text comments distributed across the items. The majority of participants (55/68, 81%) stated that they coped with stress better or in the same way after engaging in the stress test, due to time management, dialogue with others, and self-refection. A total of 4 out of 68 participants (6%)—3 female students (75%) and 1 male student (25%)—took part in telephone interviews. Three main themes were identified from the interview data: perceptions about stress, design features, and intervention features.Conclusions:Stress was described by the students as a condition caused by high demands set by oneself and the social environment that impacted their physical health, personal relationships, school performance, and emotional well-being. Participants claimed that mHealth interventions need to be clearly tailored to a young age group, be evidence based, and offer varied types of support, such as information about stress, exercises to help organize tasks, self-assessment, coping tools, and recommendations of other useful websites, literature, blogs, self-help books, or role models. Mobile phones seemed to be a feasible and acceptable platform for the delivery of an intervention.
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| 11. |
- Müssener, Ulrika, 1974-, et al.
(författare)
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Kan jag få ett läkarintyg? : - Erfarenheter av telefonrådgivning i primärvården
- 2009. - 86
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Ingår i: Socialmedicinsk Tidskrift. - Stockholm : Socialmedicinsk tidskrift. - 0037-833X. ; 86:6, s. 539-547
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Tidskriftsartikel (refereegranskat)abstract
- En stor andel av telefonsamtalen till primärvårdens telefonrådgivning avser andra problem än sjukdom, skada eller medicinska frågor. Sammanlagt deltog 35 sjuksköterskor som arbetar med telefonrådgivning i fokusgruppintervjuer. De hade tidigare deltagit i en två dagars utbildning i försäkringsmedicin. Resultaten visar att sjuksköterskorna ansåg att de efter utbildningen ökat sin kunskap om sjukförsäkringen, att de lättare kunde ställa frågor om alternativ till att besöka läkaren och stödja patienten i att fatta beslut om t.ex. egenvård.
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| 12. |
- Müssener, Ulrika, 1974-, et al.
(författare)
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mHealth smoking cessation intervention among high school students : 3-month primary outcome findings from a randomized controlled trial
- 2020
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Ingår i: PLOS ONE. - San Francisco, CA, United States : Public Library of Science. - 1932-6203. ; 15:3
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundSmoking among adolescents remains a global public health issue as youth continue to maintain high prevalence rates. The evidence for the efficacy of text messaging interventions to reduce smoking behavior is well established, yet there is still a need for studies targeting high school students. The aim of the study was to determine the effectiveness of a text-based smoking cessation intervention among high school students in Sweden.MethodsThe study was a two-arm randomized trial conducted from January 10 2018 to January 11 2019, data were analysed from April 12 2019 to May 21 2019. Inclusion criteria were high school students who were daily or weekly smokers willing to attempt to quit smoking and owned a mobile phone. The study invited all students at 630 high schools units throughout Sweden. The intervention group received text messages based on components of effective smoking cessation interventions for 12 weeks. The control group were offered treatment as usual. The primary outcomes were self-reported prolonged abstinence (not having smoked more than 5 cigarettes over the last 8 weeks) and 4-week point prevalence of smoking abstinence.FindingsA total of 535 participants, with a median age of 17 (IQR 16–18), were randomized into the study; 276 (164 [59.4%] women) were allocated to the intervention and 259 (162 [62.5%] women) to the control group. The outcomes of the trial were analyzed on a total of 212 (76.8%) participants in the intervention group and 201 (77.6%) participants in the control group. Prolonged abstinence at the 3-month follow-up was reported by 49 (23.1%) individuals in the intervention group and 39 (19.4%) individuals in the control group (adjusted OR, 1.21; 95% CI, 0.73–2.01; P value, .46). Four-week point prevalence of complete smoking cessation was reported by 53 (25.0%) individuals in the intervention group and 31 (15.4%) individuals in the control group (adjusted OR, 1.87; 95% CI, 1.12–3.17; P value, .018).ConclusionsEstimates of 4-week point prevalence of complete cessation was 10 percentage points higher in the group that were given access to the intervention compared to the control. Findings provide confirmation that text messaging-based smoking cessation programs can affect quit rates among adolescents.Trial registrationISRCTN15396225; registration date October 13, 2017, https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3028-2.
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| 13. |
- Müssener, Ulrika, 1974-, et al.
(författare)
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Using Mobile Devices to Deliver Lifestyle Interventions Targeting At-Risk High School Students : Protocol for a Participatory Design Study
- 2020
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Ingår i: JMIR Research Protocols. - Toronto, Canada : J M I R Publications, Inc.. - 1929-0748. ; 1:9
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Tidskriftsartikel (refereegranskat)abstract
- Background: Unhealthy lifestyle behaviors such as insufficient physical activity, unhealthy diet, smoking, and harmful use of alcohol tend to cluster (ie, individuals may be at risk from more than one lifestyle behavior that can be established in early childhood and adolescence and track into adulthood). Previous research has underlined the potential of lifestyle interventions delivered via mobile phones. However, there is a need for deepened knowledge on how to design mobile health (mHealth) interventions taking end user views into consideration in order to optimize the overall usability of such interventions. Adolescents are early adopters of technology and frequent users of mobile phones, yet research on interventions that use mobile devices to deliver multiple lifestyle behavior changes targeting at-risk high school students is lacking.Objective: This protocol describes a participatory design study with the aim of developing an mHealth lifestyle behavior intervention to promote healthy lifestyles among high school students.Methods: Through an iterative process using participatory design, user requirements are investigated in terms of technical features and content. The procedures around the design and development of the intervention, including heuristic evaluations, focus group interviews, and usability tests, are described.Results: Recruitment started in May 2019. Data collection, analysis, and scientific reporting from heuristic evaluations and usability tests are expected to be completed in November 2019. Focus group interviews were being undertaken with high school students from October through December, and full results are expected to be published in Spring 2020. A planned clinical trial will commence in Summer 2020. The study was funded by a grant from the Swedish Research Council for Health, Working Life, and Welfare.Conclusions: The study is expected to add knowledge on how to design an mHealth intervention taking end users’ views into consideration in order to develop a novel, evidence-based, low-cost, and scalable intervention that high school students want to use in order to achieve a healthier lifestyle.
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| 14. |
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| 15. |
- Norvell Gustavsson, Isa, 1988-
(författare)
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The roots grow deep: Strong yet changeable : Social norms and working life
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)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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| 16. |
- Seiterö, Anna, 1982-
(författare)
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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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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)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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| 17. |
- Ståhl, Christian, 1980-, et al.
(författare)
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Implementation of standardized time limits in sickness insurance and return-to-work : Experiences of four actors
- 2012
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Ingår i: Disability and Rehabilitation. - : Informa Healthcare. - 0963-8288 .- 1464-5165. ; 34:16, s. 1404-1411
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: In 2008, time limits were introduced in Swedish sickness insurance, comprising a pre-defined schedule for return-to-work. The purpose of this study was to explore experienced consequences of these time limits. Sick-listed persons, physicians, insurance officials and employers were interviewed regarding the process of sick-listing, rehabilitation and return-to-work in relation to the reform.Method: The study comprises qualitative interviews with 11 sick-listed persons, 4 insurance officials, 5 employers and 4 physicians (n = 24). Results: Physicians, employers, and sick-listed persons described insurance officials as increasingly passive, and that responsibility for the process was placed on the sick-listed. Several ethical dilemmas were identified, where officials were forced to act against their ethical principles. Insurance officials' principle of care often clashed with the standardization of the process, that is based on principles of egalitarianism and equal treatment.Conclusions: The cases reported in this study suggest that a policy for activation and early return-to-work in some cases has had the opposite effect: central actors remain passive and the responsibility is placed on the sick-listed, who lacks the strength and knowledge to understand and navigate through the system. The standardized insurance system here promoted experiences of procedural injustice, for both officials and sick-listed persons.
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| 18. |
- Ståhl, Christian, 1980-, et al.
(författare)
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Sjukskrivningssystemet och dess aktörer : Efter införandet av rehabiliteringskedjan
- 2011
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Rapport (övrigt vetenskapligt/konstnärligt)abstract
- Sedan 2008 har ett antal större förändringar gjorts i sjukförsäkringen. Främst har rehabiliteringskedjan, dvs. införandet av fasta tidsgränser för bedömning av arbetsförmåga och rätt till ersättning, stått i fokus för debatten. Med tidsgränserna sattes en slutgräns för hur länge sjukpenning betalas ut, vilket tidigare inte fanns i försäkringen. I denna studie undersöks hur sjukskrivna, arbetsgivare, försäkringskassehandläggare och läkare resonerar kring dessa tidsgränser, arbetsförmågebedömningar, rehabilitering och återgång i arbete. Studien omfattar kvalitativa intervjuer med sjukskrivna, arbetsgivare, handläggare på Försäkringskassan samt primärvårds- och företagsläkare. Totalt intervjuades 24 personer. Sjukskrivna, arbetsgivare och läkare upplever att Försäkringskassans handläggare blivit mindre tillgängliga, och generellt uppfattas handläggarna som alltmer passiva i rehabiliteringsprocessen. Handläggare på Försäkringskassan menar att de senaste årens regeländringar har medfört en mer administrativ handläggarroll, där mer tid läggs på att hålla tidsgränser än att arbeta med faktisk rehabilitering. Handläggare upplever också att etiska dilemman uppstår när individuella bedömningar kommer i konflikt med tidsgränserna, vilket upplevs som stressande. De sjukskrivna upplever att Försäkringskassan borde ta ett större ansvar för att driva sjukskrivnings- och rehabiliteringsprocessen framåt, eftersom de själva har svårt att överblicka och navigera i sjukförsäkringssystemet. Även arbetsgivarna i studien förväntar sig att Försäkringskassan ska ta större ansvar för sjukskrivningsprocessen. Handläggarna på Försäkringskassan har å sin sida blivit alltmer benägna att lägga detta ansvar på de sjukskrivna. Studien identifierar också flera brister i samverkan mellan arbetsgivare, sjukvård och Försäkringskassan kring bedömningen av sjukskrivnas arbetsförmåga. Försäkringskassans handläggare lägger stor vikt vid de medicinska underlagen i bedömningarna, och ger uttryck för en tveksamhet inför att använda andra informationskällor (såsom SASSAMkartläggningar), då det upplevs som avsteg från rådande riktlinjer. Ett av syftena med rehabiliteringskedjan var att skapa en mer enhetlig och standardiserad sjukskrivningsprocess. Dock upplever såväl handläggare som sjukskrivna att systemet är oflexibelt och inte tar hänsyn till individers olikheter och skilda behov, och att de fasta tidsgränserna därmed medfört en ökad orättvisa för de sjukskrivna. Även om bemötandet från handläggare på Försäkringskassan i många fall upplevs som bra, uppfattas sjukförsäkringssystemet som orättvist; studien ger därmed i första hand exempel på upplevd proceduriell orättvisa, snarare än upplevelser av orättvist bemötande. Studien visar på ett ytterligare behov av att studera etik, rättvisa och kvalitet i sjukskrivningsprocessen.
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| 19. |
- Svensson, Tommy, et al.
(författare)
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Sickness absence, social relations, and self-esteem: A qualitative study of the importance of relationships with family, workmates, and friends among persons initially long-term sickness absent due to back diagnoses
- 2010
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Ingår i: Work. - : IOS PRESS, NIEUWE HEMWEG 6B, 1013 BG AMSTERDAM, NETHERLANDS. - 1051-9815 .- 1875-9270. ; 37:2, s. 187-197
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Tidskriftsartikel (refereegranskat)abstract
- Objective: The aim of the present study was to explore and analyze accounts of social interactions and relationships with family, workmates, and friends supplied by persons with experience of sickness absence due to back, neck, or shoulder diagnoses. The focus was on experiences that seemed to involve positive and negative self-evaluative aspects, and therefore may be important to the self-conception and self-esteem of the absentee, and possibly to return to work. Participants: The interviewees were women and men between 25 to 34 years of age who had been sickness certified due to back, neck, or shoulder diagnosis. Methods: A descriptive and explorative method was used to analyze data from five focus-group interviews. Results: The importance of being supported and encouraged by family members, and the importance of feeling needed at work as well as being part of a social context were aspects stressed by the respondents. Conclusions: Our results indicate that these interactions and relations are important to the absentees self-esteem, and that this should be taken into account when discussing rehabilitation efforts.
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| 20. |
- Thomas, Kristin, 1978-, et al.
(författare)
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Effectiveness of a Text Messaging-Based Intervention Targeting Alcohol Consumption Among University Students: Randomized Controlled Trial
- 2018
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Ingår i: JMIR mhealth and uhealth. - : JMIR PUBLICATIONS, INC. - 2291-5222. ; 6:6
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Tidskriftsartikel (refereegranskat)abstract
- Background: Excessive drinking among university students is a global challenge, leading to significant health risks. However, heavy drinking among students is widely accepted and socially normalized. Mobile phone interventions have attempted to reach students who engage in excessive drinking. A growing number of studies suggest that text message-based interventions could potentially reach many students and, if effective, such an intervention might help reduce heavy drinking in the student community. Objective: The objective of this study was to test the effectiveness of a behavior change theory-based 6-week text message intervention among university students. Methods: This study was a two-arm, randomized controlled trial with an intervention group receiving a 6-week text message intervention and a control group that was referred to treatment as usual at the local student health care center. Outcome measures were collected at baseline and at 3 months after the initial invitation to participate in the intervention. The primary outcome was total weekly alcohol consumption. Secondary outcomes were frequency of heavy episodic drinking, highest estimated blood alcohol concentration, and number of negative consequences attributable to excessive drinking. Results: A total of 896 students were randomized to either the intervention or control group. The primary outcome analysis included 92.0% of the participants in the intervention group and 90.1% of the control group. At follow-up, total weekly alcohol consumption decreased in both groups, but no significant between-group difference was seen. Data on the secondary outcomes included 49.1% of the participants in the intervention group and 41.3% of the control group. No significant between-group difference was seen for any of the secondary outcomes. Conclusions: The present study was under-powered, which could partly explain the lack of significance. However, the intervention, although theory-based, needs to be re-assessed and refined to better support the target group. Apart from establishing which content forms an effective intervention, the optimal length of an alcohol intervention targeting students also needs to be addressed in future studies.
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| 21. |
- Thomas, Kristin, 1978-, et al.
(författare)
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Mobile phone-based lifestyle support for families with young children in primary health care (MINISTOP 2.0) : Exploring behavioral change determinants for implementation using the COM-B model.
- 2022
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Ingår i: Frontiers in health services. - : Frontiers Media S.A.. - 2813-0146. ; 2
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Obesity in childhood is a public health concern worldwide and mobile phone-based interventions (mHealth) has shown to facilitate obesity prevention. However, more research is needed on the implementation of digital tools in routine primary care. This study explored behavior change determinants for implementing a health promotion mHealth intervention (MINISTOP 2.0 app) targeting parents of 4-year-olds.METHODS: Secondary data from telephone interviews (n = 15) with child health care nurses working within primary child healthcare in Sweden was analyzed using directed content analysis and the COM-B model.RESULTS: Barriers for implementation included: limited knowledge about using technology and reservations about how and to what extent parents would use mHealth. Potential facilitators included nurses' openness to learn and try new tools, confidence in their role and engagement in reaching parents as well as beliefs that the app could improve practice by prompting dialogue and being a shared platform. Nurses expressed a strong professional identity and shared understanding of their practice, mechanisms that could potentially inhibit or facilitate implementation.CONCLUSIONS: Findings suggest cautious optimism regarding implementing mobile phone-based tools in child primary healthcare in terms of capability, opportunity and motivation among stakeholders. Implementation strategies such as educational outreach visits and making the intervention testable among stakeholders could further facilitate implementation in this clinical context. However, more research is needed on behavior change determinants in different stages of real-world implementation.
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