Encouraging greater empowerment for adolescents in consent procedures in social science research and policy projects.

The United Nations Convention on the Rights of the Child emphasizes the importance of allowing children and adolescents to influence decisions that are important to them following their age and maturity. This paper explores the principles, practices, and implications around using parental versus child/adolescent consent when participating in social science research and policy development. Experiences from two studies are presented: The Confronting Obesity: Co-creating policy with youth (CO-CREATE) and the Health Behaviour in School-aged Children (HBSC) study, a World Health Organization (WHO) Collaborative Cross-National study. Although parental consent may be an important gatekeeper for protecting children and adolescents from potentially harmful research participation, it may also be considered an obstacle to the empowerment of children and adolescents in case they want to share their views and experiences directly. This paper argues that evaluation of possible harm should be left to ethics committees and that, if no harm related to the research participation processes is identified and the project has a clear perspective on collaborating with the target group, adolescents from the age of 12 years should be granted the legal capacity to give consent to participate in the research project. Collaboration with adolescents in the development of the research project is encouraged.

Secular trends in mental health profiles among 15-year-olds in Sweden between 2002 and 2018.

Background: Studies of secular trends in mental unhealth indicate that adolescents in the Nordic countries, especially girls, have an increased reported prevalence of mental health problems the last decades. This increase needs to be seen in the light of the adolescents' assessments of their perceived overall health. Objective: To investigate whether a person-centered approach to research can enhance understanding of changes over time in the distribution of mental health problems among Swedish adolescents. Method: A dual-factor approach was used to study changes over time in mental health profiles among nationally representative 15-year-old adolescent samples from Sweden. Cluster analyses of subjective health symptoms (psychological and somatic) and perceived overall health from the Swedish Health Behavior in School-aged Children (HBSC) surveys of 2002, 2006, 2010, 2014, and 2018 were used to identify these mental health profiles (n = 9,007). Results: Four mental health profiles were identified by a cluster analysis which combined all five data collections-Perceived good health, Perceived poor health, High psychosomatic symptoms, and Poor mental health. There were no significant differences in the distributions of these four mental health profiles between the survey years 2002 and 2010, but substantial changes took place between 2010 and 2018. Here, particularly the High psychosomatic symptoms profile increased among both boys and girls. The Perceived good health profile decreased among both boys and girls, and the Perceived poor health profile decreased among girls. The profile involving the most pronounced mental health problems, the Poor mental health profile (perceived poor health, high psychosomatic problems), was stable from 2002 to 2018 among both boys and girls. Conclusion: The study shows the added value of using person-centered analyses to describe differences in mental health indicators between cohorts of adolescents over longer periods of time. In contrast to the long-term increase in mental health problems seen in many countries, this Swedish study did not find an increase among young persons, both boys and girls, with the poorest mental health, the Poor mental health profile. Rather, the most substantial increase over the survey years, predominantly between 2010 and 2018, was found among the 15-year-olds with High psychosomatic symptoms only.

Mental-health profiling with person-centred analysis: A study of adolescents in Sweden.

BACKGROUND: Studies that have examined time trends in adolescents' mental health have frequently been based on analyses of adolescents' psychosomatic symptoms. Adolescents' reports of psychosomatic complaints need to be seen in the light of their overall evaluations of their health. The objectives of this study were to apply a person-centred approach to identifying adolescents' mental-health profiles based on evaluations of their overall health and psychosomatic complaints. The relationships between these mental-health profiles and indicators of positive mental health and psychological and social-adjustment problems are examined. METHODS: A dual-factor approach was used for nationally representative adolescent samples and examined adolescents' self-rated psychosomatic complaints and perceived overall health simultaneously. Cluster analyses of data from the Swedish Health Behaviour in School-aged Children (HBSC) 2017/18 survey, including 3222 children aged 11, 13 and 15, were used to identify mental-health profiles. RESULTS: Four mental-health profiles were identified by cluster analyses in all age groups. The profiles showed good construct validity in relation to mental well-being, life satisfaction and self-esteem. The poorest psychological adjustment was found among the adolescents with high levels of psychosomatic symptoms together with low levels of perceived overall health. Adolescents with high levels of psychosomatic symptoms only or with low levels of overall health only showed considerably better psychological adjustment. CONCLUSIONS: Cluster analyses identified distinct, valid and consistent mental-health profiles based on differing levels of perceived health and psychosomatic complaints. The dual-factor model in population health research may increase our potential to understand the mental health of adolescents better.

Pathways of Adolescent Life Satisfaction Association with Family Support, Structure and Affluence: A Cross-National Comparative Analysis.

Background and Objectives: Despite the importance of life satisfaction for health and well-being, there is a paucity of cross-national comparative studies in life satisfaction related to the family environment. The present research examined the pathways of life satisfaction association with perceived family support and other family environment variables among adolescents aged from 11 to 15 years in 45 countries. Materials and Methods: Samples from the Health Behaviour in School-aged Children (HBSC) survey in 2017/2018 were analysed (n = 188,619). Path analysis was applied to evaluate the associations among the study variables. Results: A positive association between the life satisfaction score and high family support was identified in all 45 countries (standardized regression weight ranged from 0.067 to 0.420, p < 0.05). In majority of countries, living with both parents and higher levels of family affluence had a positive effect on adolescent life satisfaction both directly and indirectly through family support. In the described path model, the proportion of life satisfaction score variance that was accounted for by family support, family structure, family affluence, gender and age was up to 25.3%. The path models made it possible to group the participating countries into two clusters. In the first cluster (10 countries) the Eastern and Southern European countries dominated, while the second cluster (35 countries) united the countries of Western and Central Europe. Conclusions: There is evidence that countries with high level of adolescent life satisfaction differ in the high rate of intact family structure and the strong relation between family support and perceived life satisfaction.

Nordic adolescents responding to demanding survey scales in boring contexts: Examining straightlining.

INTRODUCTION: Straightlining, or identical responses across all items within a multi-item scale, is often taken as an indication that responses to all items in a questionnaire are of poor quality. The purpose of this study was to examine straightlining on two scales: The Sense of Unity Scale (SUS) and the short version of the Warwick-Edinburgh Mental Well-being Scale (SWEMWBS). METHODS: Data stem from the 2017-2018 data collections in four Nordic countries of the Health Behaviour in School-children study (HBSC) (15-year-old students only; 50.9% girls; n = 5928). Data were weighted to adjust for oversampling of Swedish-speaking Finnish students and to equalize sample size across countries. The main analyses were done with general linear modeling with adjustments for cluster effects (school classes). RESULTS: The proportion with straightlining on SUS was 22.8%, varying from 5.8% among Swedish girls to 46.4% among Finnish boys. The proportion with straightlining on SWEMWBS was 18.4%, varying from 5.2% among Norwegian girls to 46.0% among Finnish boys. Straightlining on one of the scales correlated with straightlining on the other one. Straightlining tended to inflate Cronbach's α values and reduce number of factors in factor analyses. Associations between the two scales and external variables tended to be lower among straightlining students. Associations between external variables (other than SUS/SWEMWBS) are on average slightly weaker among straightliners. Straightlining students obtained more favorable scores on several resource-related variables. CONCLUSION: Although some problems have been identified, straightlining does not serve well as a general indicator of poor data quality.

Typologies of Joint Family Activities and Associations With Mental Health and Wellbeing Among Adolescents From Four Countries.

PURPOSE: This study aims to identify distinct typologies of joint family activities and the associations with mental health and wellbeing among adolescents across four countries from the World Health Organization European region. METHODS: The 2017/2018 data from adolescents from Armenia (n = 3,977, Mage = 13.5 ± 1.6 years, 53.4% female), Czechia (n = 10,656, Mage = 13.4 ± 1.7, 50.1% female), Russia (n = 4,096, Mage = 13.8 ± 1.7, 52.4% female), and Slovakia (n = 3,282, Mage = 13.4 ± 1.5, 51.0% female) were collected in schools. The respondents self-reported their participation in joint family leisure-time activities, life satisfaction, psychological and somatic complaints, as well as a range of demographic and family situational factors. Stratified by countries, latent class analysis identified typologies of joint family activities, and logistic regression models explored cross-sectional associations with life satisfaction, and psychological and somatic complaints. RESULTS: Three typologies were identified across each of the four countries, distinguished by low, moderate, and high levels of family engagement. Adolescents with higher family engagement generally reported greater life satisfaction and fewer psychological complaints compared to those with lower family engagement. Russian adolescents in the high family engagement typology reported fewer somatic complaints compared to those with low family engagement. In addition, adolescents from Czechia and Russia showing moderate family engagement also reported fewer psychological complaints compared to those in the low family engagement typology. DISCUSSION: Our findings from four countries suggest that adolescents with high family engagement have greater life satisfaction and fewer psychological complaints, pointing toward a need for interventions to support family engagement among adolescents. Further research is needed to fully explore underlying mechanisms.

Family Support as Smoking Prevention during Transition from Early to Late Adolescence: A Study in 42 Countries.

Family support has a beneficial impact on protecting health-risk behaviour in adolescents. This study aimed to explore whether family support is associated with risk of smoking during transition from early (11 years) to late (15 years) adolescence across 42 countries. The data from the cross-national Health Behaviour in School-aged Children (HBSC) study in 2017/2018 were employed (N = 195,966). Family support was measured using the four-item Family dimension of the Multidimensional Scale of Perceived Social Support (sum score 20 or more was categorised as high family support). Smoking was defined as a reported cigarette smoking at least 1-2 days in the last 30 days. The association between smoking and family support was assessed using a prevalence ratio (PR) obtained from the multivariate Poisson regression. Over two thirds of adolescents reported high levels of support from their family. Family support was found to significantly decrease with age in most of the countries, with the boys reported high level of family support more often than girls. The adolescents who reported having low family support also were more likely to smoke compared to their peers who reported having high family support (PR = 1.81; 95% CI: 1.71-1.91 in boys, and PR = 2.19; 95% CI: 2.08-2.31 in girls). The countries with a stronger effect of family support in reducing smoking risk indicated lower rates of adolescent smoking as well as lower increases in the cigarette smoking prevalence during the age period from 11 to 15 years. This study reinforces the need for family support, which is an important asset helping adolescents to overcome the risk of smoking during their transition from early to late adolescence.

The Association between Loneliness, Mental Well-Being, and Self-Esteem among Adolescents in Four Nordic Countries.

Positive mental health is central to adolescent well-being. The present study examines the prevalence of loneliness and positive mental health indicators (mental well-being and self-esteem) in four Nordic countries and associations between loneliness, mental well-being, and high self-esteem. This study is based on data from the Health Behaviour in School-aged Children (HBSC) study which was conducted in 2018 in Denmark, Finland, Iceland, and Sweden. Participants were 5883 15-year-old boys and girls. To examine the associations between loneliness, mental well-being, and self-esteem, structural equation modeling (SEM) was applied. In the comparison of Nordic countries, the prevalence of loneliness was highest among Finnish and Icelandic adolescents. High mental well-being and high self-esteem were most prevalent in Denmark and Sweden. In general, boys scored higher on positive mental health indicators and girls on loneliness. Loneliness was also a strong indicator of low mental well-being and low self-esteem in all Nordic countries. Loneliness is not only associated with mental health problems such as anxiety and depression, but it is also a risk factor for adolescents' positive mental health. Positive mental health is important for healthy maturation and there is a need to develop initiatives to reduce adolescent loneliness and so support positive development.

Perceived Social Support from Different Sources and Adolescent Life Satisfaction Across 42 Countries/Regions: The Moderating Role of National-Level Generalized Trust.

Although previous research established a positive association between perceived social support and adolescent life satisfaction, little is known about the relative importance of different sources of support for adolescent life satisfaction and cross-country variations in this respect. Using large-scale representative samples from the 2017/18 Health Behaviour in School-aged Children (HBSC) study, this study examined to what extent the association between social support and life satisfaction in early adolescence varied across different social sources and countries. Also, it examined whether cross-country variations are explained by national-level generalized trust, a sociocultural factor that shapes adolescent socialization. National-level data were linked to data from 183,918 early adolescents (Mage = 13.56, SD = 1.63, 52% girls) from 42 European and North American countries/regions obtained from HBSC. Multilevel regression analyses yielded a positive association between support from different sources and life satisfaction. The strongest associations were found for support from families, followed by teachers and classmates, and weakest for support from friends. Associations varied across different countries/regions. National-level trust amplified the association between perceived classmate support and adolescent life satisfaction. The revealed cross-country differences open avenues for future cross-cultural research on explanations for cross-cultural differences in the association between social support from different sources and life satisfaction in early adolescence.

Does the Delivery System Matter? The Scaling-Out of a School-Based Resilience Curriculum to the Social Services Sector.

Background: The context is highly relevant to the implementation of new health-related programs and is an implicit or explicit part of the major implementation models in the literature. The Resilience Curriculum (RESCUR) program was developed to foster the psychosocial development of children in early and primary education. RESCUR seeks specifically to decrease children's vulnerability. It aims to promote the emotional and social learning of children who may be at risk of leaving school pre-maturely, social exclusion and mental-health problems. The program is taught using a teachers' manual to support consistency of delivery, a parents' guide, and a resource package. This study aimed to examine the scaling-out of RESCUR to social services, and specifically to test if implementation differs between the school and social services sectors. Methods: RESCUR was implemented in schools and social services in Sweden 2017-2019. Data were collected via group leaders' self-reports and observation protocols for 3 months after implementation started. There were 34 self-reports from schools, and 12 from the social services sector; 30 observation protocols were collected from schools, and 10 from social services. We examined whether there were differences in implementation outcomes (in, for example, dosage, duration, fidelity, adaptation, quality of delivery) between the two delivery systems. Descriptive statistics were prepared and non-parametric tests of significance conducted to compare implementation-related factors across the two settings. Results: Analyses of both the observation protocols and group leaders' self-reports revealed that RESCUR was well-implemented in both schools and social services. The results showed a few significant differences in the outcomes of implementation between the sectors. First, regarding observations, school staff more often adapted the pace of RESCUR lessons to ensure that the children could understand than did social services staff (p < 0.01). Second, social services staff demonstrated greater interest in students and sensitivity to the needs of individual students than did school staff (p = 0.02). Regarding self-reports, social services staff reported having delivered more (p = 0.4) and longer (p < 0.01) lessons than did school staff. Second, school staff reported greater fidelity to (p = 0.02) and less adaptation of (p < 0.01) the intervention than did social services staff. Both observations and self-reports, however, indicated a high fidelity of implementation. Conclusions: Overall, the findings suggest that the resilience program, designed for delivery in schools, can be scaled-out to social services with its implementation outcomes retained. Further research is needed to test the effectiveness of the program regarding child health-related outcomes. Clinical Trial Registration: National Institute of Health, ClinicalTrials.gov, identifier: NCT03655418. Registered August 31, 2018.

Perceptions of Non-Communicable Disease and War Injury Management in the Palestinian Health System: A Qualitative Study of Healthcare Providers Perspectives.

BACKGROUND: Palestine, like other low-income countries, is confronting an increasing epidemic of non-communicable disease (NCD) and trend of war injury. The management of health problems often presents a critical challenge to the Palestinian health system (PHS). Understanding the perceptions of healthcare providers is essential in exploring the gaps in the health system to develop an effective healthcare intervention. Unfortunately, health research on management of NCD and war injury has largely been neglected and received little attention. Therefore, the study aimed to explore the perspectives of healthcare providers regarding NCD and war injury management in the PHS in the Gaza Strip. METHODS: A qualitative study approach was used, based on four focus group discussions (FGDs) involving a purposive sampling strategy of 30 healthcare providers from three main public hospitals in Gaza Strip. A semi-structured topic guide was used, and the focus group interviews data were analyzed using manifest content analysis. The study was approved by the Palestinian Health Research Council (PHRC) for ethics approval. RESULTS: From the healthcare providers perspective, four main themes and several sub-themes have emerged from the descriptive manifest content analysis: functioning of healthcare system; system-related challenges; patients-related challenges; strategies and actions to navigating the challenges and improving care. Informants frequently discussed that despite some positive aspects in the system, fundamental changes and significant improvements are needed. Some expressed serious concerns that the healthcare system needs complete rebuilding to facilitate the management of NCD and war-related injury. They perceived important barriers to effective management of NCD and war injury such as poor hospital infrastructure and logistics, shortage of micro and sub-specialities and essential resources. Participants also expressed a dilemma and troubles in communication and interactions, especially during emergencies or crises. The informants stressed the unused of updated clinical management guidelines. There was a consensus regarding poor shared-care/task sharing, partnership, and cooperation among healthcare facilities. CONCLUSION: Our findings suggest that fundamental changes and significant reforms are needed in the health system to make healthcare services more effective, timely, and efficient. The study disclosed the non-use of clinical guidelines as well as suboptimal sectorial task-sharing among different stakeholders and healthcare providers. A clear and comprehensive healthcare policy considering the gaps in the system must be adopted for the improvement and development of care in the PHS.

Barriers to managing and delivery of care to war-injured survivors or patients with non-communicable disease: a qualitative study of Palestinian patients' and policy-makers' perspectives.

BACKGROUND: Improving access to optimal quality of care is a core priority and ambitious health policy goal in spite of impediments, threats and challenges in Palestine. Understanding the factors that may impede quality of care is essential in developing an effective healthcare intervention for patient with non-communicable disease (NCD) or war-injured survivors. METHODS: Qualitative interviews were performed using a purposive sampling strategy of 18 political-key informants, 10 patients with NCD and 7 war-injured survivors from different health facilities in Gaza Strip. A semi-structured interview guide was developed for data collection. The interviews were audio recorded and transcribed verbatim. Important field notes of the individual interviews were also reported. Thematic-driven analytic approach was used to identify key themes and patterns. RESULTS: From the policy maker's perspective, the following important barriers to accessing optimal healthcare for patients with NCD or war-injured survivors' treatment were identified; 1) organizational/structural 2) availability 3) communication 4) personnel/lack of staff 5) financial and political barriers. Patient with NCD or war-injury had similar experiences of barriers as the policy makers. In addition, they also identified socioeconomic, physical and psychological barriers for accessing optimal healthcare and treatment. CONCLUSIONS: The main perceived barriers explored through this study will be very interesting and useful if they are considered seriously and handled carefully, in order to ensure efficient, productive, cost-effective intervention and delivery of a high-standard quality of care and better disease management.

Design and implementation of RESCUR in Sweden for promoting resilience in children: a study protocol.

BACKGROUND: This research program aims to investigate the implementation and effects of a theoretically promising prevention method. It is being developed in a European research collaboration within a Comenius project (2012-2015) between 6 European universities (in Malta, Italy, Greece, Croatia, Portugal and Sweden) with the purpose of enhancing European children's resilience. METHODS/DESIGN: RESCUR in Sweden consists in a RCT study of the Resilience Curriculum (RESCUR) that is taking place in Sweden 2017-2019. The study is being performed by Junis, IOGT-NTO's Junior Association, part of IOGT International, in conjunction with researchers at Göteborg, Umeå and Stockholm universities, and is being funded by the Public Health Agency of Sweden. Around 1000 children of the ages 7-12 will, through their schools and associations, or via groups in social services, be acquainted with the material. Children will learn and practice mindfulness, storytelling, group discussions and much more, all designed to strengthen protective factors and increase their resilience. The program also involves parents, who are taking part in the work to reinforce children's protective factors. Based on the work with groups of children, an effectiveness study including children aged 7-12 in school classes, with randomized and controlled pre- and post-measurements, self-rating questionnaires and group observations is being performed. The program will also be implemented in a non-governmental organization and in groups in social services. The study also investigates forms of implementation. DISCUSSION: The design of the study will enable the researchers to answer five research questions by using a mixed-methods approach. Implementation will be studied, which is a necessary prerequisite for an effect study. Moreover, the research procedure has been tailored to the target group, with age-appropriate measures as well as multiple informants, which will produce high-quality data for analysis. A special ethical challenge is the study of young children, and efforts to give children a voice have been included in the program. This project is regarded as having good potential to benefit children in general, and particularly children in vulnerable positions. TRIAL REGISTRATION: National Institute of Health, ClinicalTrials.gov identifier NCT03655418. Registered August 31, 2018.

Leisure-time youth centres as health-promoting settings: Experiences from multicultural neighbourhoods in Sweden.

AIMS: The aim of this paper is to advocate for the importance of meaningful leisure time for young people from a health-promotion perspective using experiences from two youth centres in multicultural neighbourhoods in Sweden. METHODS: In this practice-based study, data were collected between 2012 and 2014 at two youth centres in multicultural, socially deprived suburbs in Sweden using surveys with 12- to 16-year-old adolescents ( n = 207), seven individual interviews with staff and three cooperation partners in the neighbourhoods, and six group interviews with adolescents (50% girls). Quantitative, qualitative and mixed methods were used for analysis. RESULTS: As part of the youth centres' strategies, they are open and inclusive, foster supportive relationships, emphasise youth empowerment, and integrate family, school and community in their work. The youth centres are health-promoting settings with regard to four of the action areas in the Ottawa Charter: build healthy public policy, create supportive environments, strengthen community actions and develop personal skills. CONCLUSIONS: There is a need for a variety and a combination of various structured and unstructured leisure-time activities because young people's background and life situation plays a role for their participation in leisure-time activities. We conclude that youth centres are well placed to be or to become health-promoting settings if the activities takes place in a structured environment.

Exploring practices and perceptions of alcohol use during pregnancy in England and Sweden through a cross-cultural lens.

Background: Qualitative studies have aimed to understand why some women continue to drink during pregnancy; however, there is a lack of comparative cross-cultural research. We aimed to explore perceptions and practices of alcohol use during pregnancy in England and Sweden. Methods: Semi-structured interviews were conducted with 21 parents in Merseyside, England and 22 parents in Örebro County, Sweden. Interviews were audio recorded, transcribed verbatim and translated. Data were analyzed using thematic analysis. Results: The majority of women in both countries abstained from alcohol when they found out they were pregnant, despite alcohol being part of many social contexts before pregnancy. Nine of the seventeen English women drank at some point during pregnancy, typically on special occasions. Most parents felt women should modify their alcohol intake when they become mothers, though several English parents argued that responsible motherhood did not necessarily equate to abstinence. Swedish parents held strong opinions against drinking during pregnancy and argued that any amount of alcohol could harm the foetus. English parents' opinions were divided; some were skeptical of whether low to moderate drinking was associated with risks. Conclusions: Practices and attitudes towards alcohol use during pregnancy and views on foetal rights and responsibilities of pregnant women differed in England and Sweden. Shared social norms around drinking may be shaped within the policy context of pregnancy drinking guidelines, determining whether women consume alcohol or not.

Effects on alcohol use of a Swedish school-based prevention program for early adolescents: a longitudinal study.

BACKGROUND: The aim of the study was to address the lack of evaluations of school-based substance use prevention programs and to conduct a quasi-experimental evaluation of the alcohol use part of the Triad intervention. METHODS: Eleven Swedish intervention schools (285 pupils) and three control schools (159 pupils) participated in the evaluation. Baseline measurements were conducted in 2011 before the alcohol part in the prevention program was implemented in the intervention schools (school year 6, ages 12-13). We estimated an Intention-To-Treat (ITT) Difference-in-Difference (DD) model to analyze the effectiveness of the intervention on subsequent alcohol use measured in grades 7, 8 and 9. RESULTS: The main results show no effect on the likelihood of drinking alcohol or drinking to intoxication. CONCLUSIONS: The lack of positive effects highlights the need for policy-makers and public health officials need to carefully consider and evaluate prevention programs in order to ensure that they are worthwhile from school, health, and societal perspectives.

Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance.

OBJECTIVES: Social Autopsy (SA) is an innovative strategy where a trained facilitator leads community groups through a structured, standardised analysis of the physical, environmental, cultural and social factors contributing to a serious, non-fatal health event or death. The discussion stimulated by the formal process of SA determines the causes and suggests preventative measures that are appropriate and achievable in the community. Here we explored individual experiences of SA, including acceptance and participant learning, and its effect on rural communities in Bangladesh. The present study had explored the experiences gained while undertaking SA of maternal and neonatal deaths and stillbirths in rural Bangladesh. DESIGN: Qualitative assessment of documents, observations, focus group discussions, group discussions and in-depth interviews by content and thematic analyses. RESULTS: Each community's maternal and neonatal death was a unique, sad story. SA undertaken by government field-level health workers were well accepted by rural communities. SA had the capability to explore the social reasons behind the medical cause of the death without apportioning blame to any individual or group. SA was a useful instrument to raise awareness and encourage community responses to errors within the society that contributed to the death. People participating in SA showed commitment to future preventative measures and devised their own solutions for the future prevention of maternal and neonatal deaths. CONCLUSIONS: SA highlights societal errors and promotes discussion around maternal or newborn death. SA is an effective means to deliver important preventative messages and to sensitise the community to death issues. Importantly, the community itself is enabled to devise future strategies to avert future maternal and neonatal deaths in Bangladesh.

Evaluating the effectiveness of the SMART contract-signing strategy in reducing the growth of Swedish Adolescents' substance use and problem behaviors.

BACKGROUND: In 2013, around 40 % of the schools in Sweden had structured programs to prevent tobacco and alcohol debut in compulsory school. There has unfortunately been a lack of scientific evidence to support most of the prevention methods focusing on primary prevention in schools in Sweden. The aim and purpose of the present study is to evaluate the effectiveness of the Non-Governmental Organization SMART contract-signing strategy in reducing the growth of youth substance use and other problem behaviors amongst Swedish adolescents. METHODS: Students from five schools in a medium-sized Swedish municipality were surveyed in three waves from 7(th) to 9(th) grade of compulsory school. We used General Linear Model (GLM) repeated-measures ANOVA to test if the outcome measures smoking, use of snus and alcohol, drunkenness, delinquency, and bullying significantly changed different amounts over time in groups that had participated in the SMART program for long time, a short time, sporadically- or not at all. Groups were compared on demographic background variables, and outcome measures were assessed on all measurement occasions by a one-way ANOVA. The magnitude of group differences at the end of the study was estimated according to Cohen's d. RESULTS: Number of years with a contract has an effect on the levels of self-reported youth problems in 9(th) grade. We found small to medium-sized differences in measured outcomes between students who participated in the program for the longest period of time, 5 years, and who participated for the shortest time, 0-2 years. CONCLUSION: Findings suggests that the SMART program has preventive effects on adolescent substance use.