Marie Löf

Research problem and specific questions: The promotion of healthy lifestyle behaviours needs to start early in life as once obesity is established it is difficult to treat. The overall aim of this project is to evaluate the effectiveness and implementation of a mobile health intervention (Health4Life) to support parents to create healthy lifestyle behaviours from the start of their infant’s life, in order to prevent overweight and obesity.Data and method: Health4Life will utilize a type I hybrid implementation-effectiveness study design. A cluster randomized controlled trial will be conducted in 44 child healthcare centers in Regions Halland and Jönköping (n = 620 parents with a 1-month-old infant). All parents/infants will receive standard care

however, the intervention group will receive the 17-month Health4Life app. Primary outcomes are: children´s dietary intake (mobile based), physical activity and sleep (accelerometry), and screen time (parental report). Secondary outcomes include children´s BMI z-scores (measured at child healthcare), as well as motor skills and parenting practices (questionnaires). The implementation outcomes that will be assessed (in the 22 child healthcare centers in the intervention group) are: acceptability, appropriateness, feasibility, costs, sustainability, and reach. These will be measured quantitatively (questionnaires) and quantitatively (semi-structured interviews). A cost-effectiveness analysis will determine if the implementation of Health4Life represents value for money when measured incrementally against usual practice.Societal relevance and utilization: Primary child healthcare’s mission is to promote healthy lifestyle habits to prevent poor health. The Health4Life app will support this mission through providing constant support for parents in their everyday lives. As it is well established that overweight and obesity are associated with numerous diseases and disorders, coupled with the fact that it is well established that overweight and obesity tracks from childhood to adulthood, it is a public health priority to intervene early on.Plan for project realization: Within this application we are applying for funding for a PhD student (100%), a post-doc (50%), salary for the applicants, and project costs. The highly competent research team, staff, and collaborators coupled with the carefully selected methodology make the proposed project highly feasible to conduct over the next 3 years.

The human papillomavirus (HPV) is responsible for most cervical and anogenital cancers. The HPV vaccine can effectively reduce invasive cervical cancer

however, HPV vaccine uptake is low in certain groups due to hesitancy and refusal, which undermines the success of the vaccine. In Sweden, HPV vaccine hesitancy has mainly been observed among parents and adolescents in socioeconomically disadvantaged communities with large immigrant populations.The purpose of this project is therefore to co-design and assess the feasibility and preliminary effects of digital health intervention tools to reduce HPV vaccine hesitancy and increase uptake of this vaccine in socioeconomically disadvantaged communities in Stockholm, Sweden. Several research questions shall assess whether a co-designed digital health intervention has the potential to improve HPV uptake, awareness and confidence.The project involves three sub-studies implemented by an interdisciplinary team.  Study 1 will involve a formative stage whereby adolescents, parents/guardians and school nurses situated in socially disadvantaged areas in Stockholm will be interviewed to understand their perspectives and concerns related to the HPV vaccine. Thereafter, study 2 will use knowledge gained from study 1 to inform the co-design phase where adolescent boys/girls and their parents/guardians are invited to develop and provide feedback on content and prototypes for digital health interventions. Finally, study 3 will involve pilot-testing of the intervention for feasibility, acceptability and preliminary effect, using a cluster-randomized design.This project is highly feasible as it builds on the study team’s previous research, which show that immigrant communities in Sweden experience poorer health outcomes as well as vaccine hesitancy. Because 1 in 5 Swedes have a migrant background this study is relevant to Swedish society. An appropriate and accessible digital health intervention has the potential to prevent cervical cancer, saving lives and reducing future burdens on an overstretched Swedish healthcare system. The results from this project will be generalizable to similar contexts in Sweden and possibily beyond.

In Sweden adolescent obesity is still a public health issue. The problem is reinforced by aggressive marketing of ultra-processed foods (UPF), like fast foods and sugary drinks, however real-world research is lacking. Our own research revealed that UPF advertising is more prominent in low socioeconomic (SES) areas. Digital food marketing (mobiles, TV, computers), especially for adolescents, also appears to be relevant to the challenge.This project will associate the geographic density of UPF advertisements with SES characteristics around 18 schools in 3 Swedish cities (Study 1). The project will also evaluate (Study 2) the effects of total UPF ad exposure (outdoor and digital) in the same student populations, in association with student BMI, gender and individual objective obesogenic student behaviours (i.e., school meal skipping, food selection habits and physical activity levels). The project will use tools from our ongoing EU project (BigO: Big Data against Childhood obesity) and will recruit a sample of 300 Swedish high-school students (15-18 yrs) from 6 schools in the same cities, monitoring them for two consecutive years. The project will coordinate with school administrations, through ongoing collaborations in the BigO project. In Study 3 (qualitative), the attitudes and the awareness of school students and educators on UPF and unhealthy behaviours will be evaluated. Also, the outcomes of Studies 1 and 2, will be communicated to them through focused school engagement workshops and we will evaluate their attitudes towards novel future interventions (e.g., data-driven awareness campaigns), aiming at limiting the obesogenic effects of increased UPF marketing.The project will provide new knowledge on the associations of food marketing, health behaviors and adolescent obesity, in various SES settings. It has a strong potential to support unique new strategies for public interventions and policies, promoting population health and limiting social inequalities.

Health behaviours in terms of “the big four” (tobacco use, alcohol intake, physical inactivity, and poor eating habits) account for more than 50% of preventable premature deaths globally. Given these serious health effects, promoting healthy lifestyles are major public health priorities. Limited resources makes preventative work in routine primary care challenging. Mobile health, “mHealth”, has been used effectively in preventative care to promote physical activity, smoking cessation and healthy diets. Still, our knowledge regarding how and for whom mHealth can be implemented is largely unknown.The MoBILE research program (funded by Forte 2018-01410, PI: M Löf) consists of seven mHealth randomized control trials in different health care settings. This proposed research grant aims to investigate the implementation of evidence-based mHealth tools in two of these settings: primary child health care (targeting families with a 2-3-year old children) and school health care (targeting 16-18-year-olds). Implementation will be studied from the perspectives of patients, professionals and policy makers. Particular attention will be paid to implementation among socioeconomically disadvantaged groups and immigrant families.In two studies, the (1) organizational readiness to implement mHealth and (2) the process of implementing mHealth in preventative services will be studied. Data will include interviews with policy makers, managers, primary care nurses and end-users. Register data will investigate to what extent mHealth is implemented in routine practice. Three county councils (Region Stockholm, Region Östergötland and Region Skåne) will take part including 15 child primary care centres and 15 high schools.This project will provide needed knowledge on the implementation of evidence-based mHealth in healthcare. Also, knowledge on the role of end-users in mHealth implementation will be provided as well as mHealth implemenation in socioeconomically disadvantaged groups.

Inadequate physical activity, unhealthy diets, smoking and harmful use of alcohol increases the risk of non-communicable disease and premature death. The responsibility of health care to provide support for patients in need of changing unhealthy lifestyle behaviors is difficult to meet with traditional methods such as individual and group counseling, since they are resource-intensive. Over the past ten years, there has been increased interest to provide lifestyle interventions and support for patients with non-communicable diseases such as diabetes type II via mobile phones (so-called mHealth, a special component of eHealth). In this mHealth multiple lifestyle behaviors program, two strong research groups in Sweden will collaborate (IMPACT, Prof Marie Löf and LiiR, Prof Preben Bendtsen) and two international groups, all of whom have been active in the mHealth area since the beginning. The program is an interdisciplinary collaboration with expertise in interventions for the four main lifestyle behaviors (diet, physical activity, smoking, and alcohol), behavioral science, medicine and IT. It also includes a critical mass of junior and senior researchers. This program aims  to develop, evaluate and implement seven lifestyle interventions that can be delivered by health care to different target groups (e.g., pregnant women, children and adults). One strength of the program is that the interventions will be grounded in the same theoretical and technical framework, but adapted to the different target groups and needs of the health care units. Another important aim is to adapt interventions for vulnerable groups. If the interventions are successful, they can be offered nationally and support different target groups at a low cost.Our program aligns well with the vision of the Swedish government: “In 2025, Sweden will be best in the world at using the opportunities offered by digitization and eHealth to make it easier for people to achieve good and equal health and welfare”.