Johan Åhlén

Research problem and questionsThe first five years of life are crucial for child health and provide a foundation for health over the life course. Prevention of mental health problems is today one of the most important public health challenges. Parenting support is essential to promote young children’s development and already during the first years of life there is a social gradient in how parents’ social and economic position influences parenting and child health. The overarching aim of this programme is to support child wellbeing and mental health through developing, evaluating and implementing feasible and effective interventions within and between the existing health care and municipality services for pregnant couples and families with 0-5 year-old children.Data and methodsWe propose ten interventions on the universal, selective and indicated levels. The basis for these interventions is research on early child development and parenting strategies, from our group and the international literature. We develop new interventions and adapt evidence-based methods in dialogue with practitioners in health care and municipality services to ensure feasibility and early implementation of results.A prerequisite for application of the concept of proportionate universalism is an infrastructure for systematic identification of needs and risk factors and for evaluation of results in relation to social determinants. Here we expand an existing cohort of parent reported data, including validated instruments on wellbeing and mental health, that allows such identification and evaluation from mid pregnancy to child age 4 years. We apply a mixed methods research design including pilot and feasibility studies as well as randomised controlled trials. We apply qualitative and quantitative statistical methods to evaluate feasibility and effects of the interventions in relation to social determinants. In addition, we conduct methodological studies on measurements of parenting strategies as well as child wellbeing and mental health.Relevance and utilisationDespite the broad agreement on the importance of the concept of proportionate universalism, the literature states that improved cross-sectoral collaboration and monitoring of parental support is needed and that research on how interventions on different levels could be combined is lacking. In this programme we intend to fill these knowledge gaps.Programme realisationThis research programme is based on collaboration between several research groups, combining several disciplines and expertise from various fields. We have close links to clinical practice. We aim at introducing junior researchers to research on promotion and prevention during the first years of life, to ensure regrowth and a continued focus on this particularly important phase of life.

Eating disorders (EDs) are common conditions that cause significant suffering, reduction in functioning and deterioration in quality of life. The need for efficient preventive interventions against EDs are huge, as the majority of the patients do not seek treatment, and only half of those who receive treatment recover fully. Consequently, EDs tend to have an enduring course. The target of efficient prevention programs has been to reduce risk specific factors for EDs (e.g., internalization of the thin ideal), but they have been difficult to implement on a broad basis to make a notable impact on public health. It has proven difficult to scale up these interventions due to the resources needed for adequate implementation. Recent research has shown that optimization of protective factors (e.g., intuitive eating, appreciation of what we can do with our bodies, or self-compassion) might be a viable option and easier to implement on a large scale. The aim of the current project is to evaluate the efficacy and cost-effectiveness of such an interactive prevention program in a randomized controlled trial, and to investigate the mechanisms of change in the intervention.The innovative aspects of this project are 1) notable focus on optimizing protective factors, instead of only reducing risk factors (e.g., body dissatisfaction), 2) targeting at-risk-groups instead of universal prevention, 3) interactive program instead of standard psychoeducation, 4) possibility of including individuals of all genders and the minority groups, 5) recruitment of participants through social media, and 6) delivery of the intervention through Internet to make it flexible, and to make later large-scale implementation possible.Focus on protective factors has also the benefit of lower potential stigma for participation in prevention, despite recruiting an at-risk-group.In a randomized controlled trial, we recruit 644 participant aged 15-20 years who will receive either the prevention program (one hour per week across four weeks), or a placebo condition (Expressive Writing). In addition to the outcome after the intervention, and at follow-ups (six-, and 12-months post intervention) and cost-effectiveness will be investigated. Mediators and moderators of outcome as well as the reach of the program, risk for stigma, and possibility of spreading the program on a large-scale though collaborative projects in social media channels will also be investigated.

Research area and aims Eating disorders (EDs) are common and cause significant morbidity and mortality. Due to stigma, only 25% seek help and only 50% fully recover after receiving treatments. Large-scale prevention is urgently needed to reduce the emergence and burden of EDs at a population level. However, current prevention programs do not meet requirements for efficient and economically attractive large-scale implementation. The main aim of this project is to investigate the efficacy and cost-effectiveness of a scalable, brief, and interactive prevention program based on reinforcement of protective factors against EDs using a randomized controlled design. A focus on protective factors disrupts the processes by which risk factors increase the probability for EDs to emerge and minimizes the risks for stigmatization. Research questions: How effective is an internet-based prevention program, that reinforces protective factors against EDs, in reducing the onset of EDs 6, 12, and 24 months post-intervention?Does the intervention reduce the incidence of EDs through enhancement of specifically targeted protective factors (mediators)?Is prevention of EDs based on reinforcement of protective factors cost-effective?How sustainable are virtual communities for maintenance of future recruitment and prevention on a large scale? Secondary questions concern gender differences in enrollment and compliance, potential moderators of outcome, participation in booster sessions, and potential risk for stigma. Data and MethodParticipants (15-20 years old, n=644, based on power analysis) will be recruited online and randomized to prevention or a credible placebo. The intervention will be selective (target those with significant body dissatisfaction), delivered in a scalable format (Internet-based), brief (45 minutes/week for four weeks), and with interactive components of the program moderated by artificial intelligence for future scalability. Assessments will be done using the gold standard within the field of EDs.  Plan for project realisationThe proposed project is an extension of our previous work, including the largest controlled trial of prevention of EDs in Sweden. Recruitment, intervention, and assessments will be done using established methods. The costs are necessary for running a large randomized controlled trial. RelevanceA brief, scalable and efficacious prevention program is the pre-requisite for reducing the emergence and burden of EDs on public health level.

The discussion on how to support the possibly increasing group of adolescents with mental health problems sometimes becomes polarized due to our fragmentary knowledge of the actual needs and numbers. This project will, for the first time, systematically assess:the proportions of adolescents in Sweden with different levels of mental health problems, ranging from emotional distress (which does not fulfill diagnostic criteria) to mental disorders (fulfilling criteria, for, e.g., depression or anxiety), andtheir need and utilization of support and care, taking a broad view of potential support structures beyond, but including, the health care system.The study is based on computer assisted assessments of 6,000 eligible 14- and 17-year-olds in schools and their parents online. Emotional distress will be measured with validated symptom scales (GAD-7 and PHQ-A) and mental disorders using a well-established diagnostic instrument (DAWBA). Information on the frequency, severity, and duration of symptoms and their impact on function will be integrated into Children’s Global Assessment Scale (CGAS) ratings. All together these measures form a solid ground for experienced psychiatrists to appraise  levels of emotional distress and diagnosed mental disorders as well as need of support. Information on self-reported need of a wide range of support functions will be compared with professionals’ assessments of need. Health care data from registers in combination with self-reported utilization of support and care will be compared with professionals’ judgement of need, to estimate hidden proportions of those who are not in contact with care despite an existing need or identify potential “overutilization”. Key demographic and socioeconomic information will be linked from registers to understand how the prevalence of emotional distress and mental disorders varies among different populations, as well as the degree to which needs for support are met in different groups.  The main applicant is responsible for the project, supported by a senior researcher as academic coordinator and a fulltime project leader for practical tasks. Questions on self-reported needs and utilization will be developed in collaboration with e.g. adolescents, NGOs, school health care. The budget is estimated to total 6.9 million over four years.Not until we have the facts can we appropriately act and lay the ground for a broader perspective on support for mental health for adolescents in Sweden.