Logo: to the web site of Uppsala University

Aims: The Healthier Wealthier Families model uses the child healthcare services as an access point to screen and connect parents experiencing economic hardship to municipal Budget and Debt Counselling services. This study aimed to explore the perceptions and experiences of the Healthier Wealthier Families model in a Swedish context.

Methods: Semi-structured interviews were conducted with three stakeholder groups: eligible parents who declined (n=10) and received (n=9) financial counselling; nurses (n=7); and financial counsellors (n=5). The data were analysed using thematic analysis.

Results: The analysis resulted in three main themes conveying the stigma of talking about finance, the connection between economic situation and family wellbeing, and the nuts and bolts of providing preventive financial counselling.

Conclusions: A working model aiming to ameliorate child poverty in a societal service context needs to address the preconceptions and perceived mandate and role of the professionals, the prevalence of financial stigma in society, especially in relation to being a ‘good’ parent, and the current preoccupations and perceived financial needs and hopes of the families served.

Despite universal measures in Sweden, the proportion of children living in economic hardship is increasing. One strategy to mitigate hardship is integrating financial counselling within healthcare services. This paper describes a pilot randomised controlled trial (RCT) of the ‘Healthier Wealthier Families’ model in which child healthcare nurses screen parents of young children for economic hardship and refer those in need to free budget and debt counselling (BDC). The study was an internal pilot of a two-arm randomised waitlist-control trial with a one-to-one allocation. The intervention arm received BDC immediately after randomisation, while the waitlist-control arm was referred 3 months later. Both arms received a financial guidance book. Assessments were conducted at two points: pre-intervention (T1) and post-intervention (T2; 3 months post-randomisation). The main objective was to assess the feasibility of recruitment, randomisation, data collection, attendance, and adherence to the topic guide. Of 368 screened parents, 111 (30.2%) were eligible, most of whom were identified by two of the five screening questions focused on ‘worrying about running out of money’ and ‘meeting an unexpected cost’. The conversion rate from screening positive to consenting for trial was 18.0% (n=20). Reasons for declining were due to stigma, lack of capacity or already available knowledge and support. The randomisation was effective, with equal distribution between trial arms. No contamination was detected. Eight out of ten participants who were allocated to the intervention attended at least one session; the mean number of sessions was two. Topic guide implementation was inconsistent. There were high completion rates for most measures, except for income. The primary outcome measure of Child Material and Social Deprivation showed a floor effect, with many parents reporting zero ‘enforced lack’ items. Results from the pilot RCT indicate that the screening process identified the anticipated proportion of eligible parents (30.2%), but that three of the screening questions are redundant. The conversion rate was much lower than anticipated, questioning the feasibility of a full-scale RCT. BDC fidelity to protocol could be strengthened with implementation support. Finally, the primary outcome measure should be reconsidered, as well as the way in which participant income is captured. 

Economic hardship can have negative effects on public health and well-being, and is therefore a welfare concern. Budget and Debt Counselling forms part of the welfare services in Sweden. The service is legislated to provide free financial counselling and counsel citizens towards economic well-being. The responsible authority that guides and supports the services, has recommended preventive counselling. Our objective was to investigate if preventive counselling is being enacted, and the counsellors working condition to do so. The study used a survey design, with quantitative and qualitative data collection. A web-based survey was distributed to all Budget and Debt Counselling services. The quantitative findings were summarised using descriptive statistics. Answers to open-ended questions were analysed through deductive content analysis using Lipsky’s theory of Street Level Bureaucracy. The majority of the respondents met clients with acute support needs, in a later stage than preferred. A large part of the respondents emphasised the importance of preventive counselling but also identified barriers to why this was not performed in everyday work. Lipsky’s four categories of Street Level Bureaucracy’s working conditions were useful to understand these inherent tensions in the counsellors’ preventive work. It was a largely individual task for counsellors whether or not to prioritise preventive work, which was hindered by their working conditions, a lack of an adequate regulatory framework, and organisational support.

Prevention is a central but often ambiguously defined concept within public support services. In Swedish Budget and Debt Counselling (BDC), counsellors have been encouraged to adopt more preventive approaches, yet the meaning of preventive counselling remains unclear. This study explored how prevention is conceptualised within BDC, with a focus on how counsellor perceptions align with formal guidance documents. A convergent, qualitative multi-method study was adopted, in which content analysis was used to examine two sources: survey responses from counsellors and guidance documents from national and local authorities. The analysis explored how counsellors’ responses and guidance document content aligned with the tiered model of prevention, ranging from universal to selective, to indicated approaches. The results showed that there was an alignment in core understanding but a mismatch in emphasis across the levels of prevention. High value was placed on collaboration to enable preventive counselling, particularly by the counsellors. The findings highlight the need for clearer, more actionable guidance on universal and selective prevention within BDC services. More broadly, the study illustrates the value of articulating prevention concepts in practice settings and equipping professionals with the tools to translate policy into meaningful action.