Public Health, Environmental and Occupational Health, Pediatrics, Perinatology and Child Health, Epidemiology
18
Scopus Publications
Scopus Publications
Study protocol for a cluster-randomized controlled trial of a universal home-based, multi-component intervention to promote healthy weight development in children during infancy and toddlerhood in denmark: the bloom study Camilla Thørring Bonnesen, Mette Rasmussen, Lene Kierkegaard, Rikke Rothkegel Carlsson, Marie Pil Jensen, Thilde Risager Ubbesen, Katrine Rich Madsen, Lau Caspar Thygesen, Rikke Fredenslund Krølner, Louise Ayoe Sparvath Brautsch, Johanne Aviaja Rosing, Line Planck Kongstad, Mette Skovgaard Væver, Ida Egmose, Trine Pagh Pedersen BMC Public Health, 2025 BACKGROUND: Child overweight and obesity are major public health challenges associated with poor physical, psychological, and social health through life. This protocol describes the study design for the Bloom Study, an evaluation of a theory- and evidence-based intervention addressing infancy and toddlerhood (age 0-3 years) to promote healthy weight development among children in Denmark. METHODS: The Bloom intervention is evaluated through an open-label, two-arm, cluster-randomized wait-list control trial, with 22 municipalities randomly allocated to 11 intervention and 11 control municipalities. All first-time families within one year are invited (approximately 3200 families). The intervention was developed using the Intervention Mapping protocol and a thorough co-creation process. It is delivered through the Danish community health nursing system and includes four main components: (1) Home visits, (2) Proactive telephone consultations, (3) Parent groups for both parents, and (4) A video library. The intervention begins during pregnancy (between weeks 22-24) and continues until the child is 30 months. The primary outcome measure is the BMI z-score at 36 months of age. Secondary outcomes relate to the key determinants of child weight development targeted by the Bloom intervention, including food and meals, sleep, movement and motor skills, screen use, and family sense of security. A comprehensive mixed methods process evaluation and a health economic evaluation will also be conducted. DISCUSSION: The protocol outlines the evaluation of a theory- and evidence-based intervention aimed at promoting healthy weight development in infants and toddlers in Denmark. Overall, the study has the potential to inform future health promotion initiatives at the municipal level, supporting healthy weight development during early childhood. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT06705400. Registered November 21, 2024.
Trends in social inequality in breastfeeding duration in Denmark 2002–2019 Rikke R. Carlsson, Lis Marie Pommerencke, Sofie W. Pant, Sanne E. Jørgensen, Katrine R. Madsen, Camilla T. Bonnesen, Lene Kierkegaard, Trine P. Pedersen Scandinavian Journal of Public Health, 2025 Aims: The aim of the present study was to analyse trends in full breastfeeding for at least 4 months across socioeconomic position in Denmark over a 17-year-long period from 2002 to 2019 using parental education as the indicator of socioeconomic position. Methods: The study used data on full breastfeeding collected between 2002 and 2019 by community health nurses in the collaboration Child Health Database, n=143,075. Data were linked with five categories of parental education from population registers. Social inequality was calculated as both the relative (odds ratio) and absolute social inequality (slope index of inequality). A trend test was conducted to assess changes in social inequality over time. Results: A social gradient in full breastfeeding was found for the entire study period. The odds ratio for not being fully breastfed for at least 4 months ranged from 3.30 (95% confidence interval 2.83–3.84) to 5.09 (95% confidence interval 4.28–6.06) during the study period for infants of parents with the lowest level of education (primary school) compared with infants of parents with the highest level of education (5+ years of university education). The slope index of inequality was between −38.86 and −48.81 during the entire study period, P=0.80. This indicated that both the relative and absolute social inequality in full breastfeeding to at least 4 months of age was unchanged in the study period from 2002 to 2019. Conclusions: This study showed a persistent relative and absolute social inequality in full breastfeeding for at least 4 months from 2002 to 2019 in Denmark.
Trends in Social Inequality in Overweight and Obesity Among Danish Infants, 2002-2022 Lis Marie Pommerencke, Sanne Ellegård Jørgensen, Sofie Weber Pant, Rikke Rothkegel Carlsson, Camilla Thørring Bonnesen, Lene Kierkegaard, Mette Rasmussen, Michael Davidsen, Trine Pagh Pedersen International Journal of Public Health, 2025 ObjectivesThis study aimed to examine trends in relative and absolute social inequality in overweight/obesity among Danish infants born between 2002 and 2022.MethodsThe study applied yearly cross-sectional data on infants’ weight and length at age 6–10 months, n = 63,100. Data was linked with parental education from population registers. Social inequality was measured by OR, relative index of inequality (RII), and slope index of inequality (SII). Trend tests measured changes over time.ResultsNo difference in odds for overweight/obesity by parental education was observed between 2002 and 2004, but from 2005 social inequality in overweight/obesity was revealed. The OR for overweight/obesity ranged from 1.20 (95% CI: 0.76–1.89) to 2.31 (95% CI: 1.64–3.25) for infants of parents with lowest educational attainment. RII ranged from 0.78 to 0.41 (test for trend, p = 0.179) and SII ranged from −0.92 to −4.54 (test for trend, p = 0.026) indicating a persistent relative social inequality and an increase in absolute social inequality in overweight/obesity from 2002 to 2022, respectively.ConclusionThe study revealed persistent relative social inequality and increased absolute social inequality in overweight/obesity among Danish infants from 2002 to 2022.
Preventing Stress among High School Students in Denmark through the Multicomponent Healthy High School Intervention—The Effectiveness at First Follow-Up Camilla Thørring Bonnesen, Lau Caspar Thygesen, Naja Hulvej Rod, Mette Toftager, Katrine Rich Madsen, Marie Pil Jensen, Johanne Aviaja Rosing, Stine Kjær Wehner, Pernille Due, Rikke Fredenslund Krølner International Journal of Environmental Research and Public Health, 2023 Stress is a widespread phenomenon and young people especially are experiencing high levels of stress. School-related factors are the most frequently self-reported stressors among adolescents, but few interventions have targeted the school environment. This study evaluated the effectiveness of the Healthy High School (HHS) intervention on stress at a 9-month follow-up. The study included 5201 first-year high school students (~16 years) in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (N = 15). Baseline measurements were conducted in August 2016 and the follow-up was conducted in May 2017. The intervention was designed to promote well-being (primary outcome) by focusing on physical activity, meals, sleep, sense of security, and stress (secondary outcomes). The intervention comprised: structural initiatives at the school level; a teaching material; peer-led innovation workshops; and a smartphone app. The 10-item Perceived Stress Scale was used to measure stress. Intervention effects on perceived stress were estimated using an intention-to-treat approach with multiple imputations of missing data and multilevel general linear regression modelling. A total of 4577 students answered the baseline questionnaire. No statistically significant difference was found in stress between students at intervention and control schools at the follow-up (mean score: 16.7 versus 16.7, adjusted b = 0.42, 95% CI: −0.16;1.00). The HHS Study is one of the first large randomized controlled trials targeting school environmental stressors. Potential implementation failures and the failures of the program theory are discussed.
Effect of the multicomponent healthy high school intervention on meal frequency and eating habits among high school students in Denmark: a cluster randomized controlled trial Katrine Sidenius Duus, Camilla Thørring Bonnesen, Johanne Aviaja Rosing, Katrine Rich Madsen, Trine Pagh Pedersen, Mette Toftager, Lau Caspar Thygesen, Rikke Fredenslund Krølner International Journal of Behavioral Nutrition and Physical Activity, 2022 Background Previous studies have shown that multicomponent interventions may improve meal frequency and eating habits in children, but evidence among young people is limited. This study evaluated the effect of the Healthy High School (HHS) intervention on daily intake of breakfast, lunch, water, fruit, and vegetables at 9-month follow-up. Methods The study included first-year students (≈16 years) attending high school in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (operating as usual) (N = 15). The intervention was designed to promote well-being (primary outcome) by focusing on healthy habits including meals, stress prevention, and strong peer relations. It included a curriculum, structural and organisational initiatives, a workshop, and a smartphone application. Students completed self-administered online questionnaires at the beginning of the school year and nine months later. To account for clustering of data, we used multilevel logistic regression analyses to estimate odds ratios (OR). We applied an intention-to-treat approach with multiple imputations of missing data. Results At baseline 4577 of 5201 students answered the questionnaire and 4512 at follow-up. In both groups the proportion of students eating breakfast decreased from approximately 50% to 40% from baseline to follow-up, and lunch frequency decreased from approximately 50% to 47%. Daily water intake, intake of fresh fruit and intake of vegetables remained unchanged from baseline to follow-up. There were no significant between group differences on any of the outcomes at first follow-up: breakfast: OR = 0.85 (95% CI: 0.65;1.10), lunch: OR = 0.96 (95% CI: 0.75;1.22), water intake: OR = 1.14 (95% CI: 0.92;1.40), intake of fresh fruit: (OR = 1.07, 95% CI: 0.84;1.37), vegetables: (OR = 1.01, 95% CI: 0.77;1.33). Conclusion No evidence of an effect of the HHS intervention was found for any of the outcomes. Future studies are warranted to explore how health promoting interventions can be integrated in further education to support educational goals. Moreover, how to fit interventions to the lives and wishes of young people, by also including systems outside of the school setting. Trial registration ISRCTN, ISRCTN43284296. Registered 28 April 2017 - retrospectively registered.
Peer mentors' role in school-based health promotion: qualitative findings from the Young & Active study Stine Kjær Wehner, Tine Tjørnhøj-Thomsen, Camilla Thørring Bonnesen, Katrine Rich Madsen, Marie Pil Jensen, Rikke Fredenslund Krølner Health Promotion International, 2022 SummaryPeer-led interventions are highlighted as promising strategies to promote health among adolescents, but little is known about the mechanisms underlying this approach. To better understand the role of peer mentors (PMs) as implementers in school-based health promotion, we combined participant observations, focus group interviews and video recordings to explore high school students’ reception of a peer-led intervention component (Young & Active). Young & Active aimed to increase well-being among first-year high school students (∼16 years of age) through the promotion of movement and sense of community and was implemented during the school year 2016–2017 in a larger school-based intervention study, the Healthy High School study in Denmark. The Healthy High School study was designed as a cluster-randomized controlled trial with 15 intervention schools and 15 control schools. At each intervention school, university students in Sports Science and Health (members of the research group) facilitated an innovation workshop aiming at inspiring all first-year students to initiate movement activities at schools. The findings illustrate potentials and challenges implied in the PM role. The peer mentors’ profound commitment, as well as their response and sensibility to situational contingencies, were found to be significant for the students’ reception and experience of the intervention. In conclusion, the specific job of PMs as implementers seems to consist of simultaneously following a manual and situationally adjusting in an emerging context balancing commitment and identification to the target group and the intervention project.
Adaptation, student participation and gradual withdrawal by researchers as sustainability strategies in the high school-based young and active intervention: School coordinators’ perspectives Stine Kjær Wehner, Tine Tjørnhøj-Thomsen, Katrine Sidenius Duus, Louise Ayoe Sparvath Brautsch, Andreas Jørgensen, Camilla Thørring Bonnesen, Rikke Fredenslund Krølner International Journal of Environmental Research and Public Health, 2021 Ensuring the sustainability of school-based public health intervention activities remains a challenge. The Young and Active (Y&A) intervention used peer-led workshops to promote movement and strengthen students’ sense of community in 16 Danish high schools. Peer mentors inspired first-year students to implement movement activities. To support sustainability, we applied a three-year stepwise implementation strategy using university students as peer mentors in year 1 and senior high school students in the following two years. This study explores the sustainability potential of Y&A, focusing on school coordinators’ reflections on the intervention’s fit to their schools and the student-driven approach, and we assess the three-step implementation strategy. The study is based on telephone interviews with coordinators (n = 7) from schools that participated in all three years and participant observations of four workshops (a total of approximately 250 participating students). Results were generated through an abductive analysis. Seven schools continued the intervention throughout the three years and adapted it to fit their priorities. The student-driven approach was perceived to be valuable, but few student-driven activities were initiated. Teacher support seemed crucial to support students in starting up activities and acting as peer mentors in workshops. The three-step implementation strategy proved valuable due to the peer-approach and the possibility of gradual adaptation. In future similar initiatives, it is important to address how the adequate staff support of students can be facilitated.
What characterizes schools and students participating in health promoting school-based intervention studies? Findings from the healthy high school study Camilla Thørring Bonnesen, Johanne Aviaja Rosing, Marie Pil Jensen, Stine Kjær Wehner, Katrine Rich Madsen, Mette Toftager, Pernille Due, Rikke Fredenslund Krølner Preventive Medicine Reports, 2021 The Healthy High School (HHS) intervention was developed to promote well-being among first-year high school students (~16 years of age) in Denmark by targeting stress, physical activity, meal habits, sleep, and sense of community. Thirty-one schools were randomly allocated to intervention (16 schools) or control (15 schools) groups in a cluster-randomized controlled trial. The purpose of this short communication was to compare characteristics of students and schools between 1) schools accepting to participate in the HHS study and non-participating schools using national survey data and 2) intervention and control schools using HHS baseline data. We included cross-sectional data from the Danish National Youth Study 2014 on 119 schools and 22,935 first-year students to characterize participating schools and students. At baseline (August 2016), students (n = 4577; 88.0%) and principals (n = 29; 96.7%) completed online questionnaires. Compared to non-participating schools, fewer HHS schools perceived their school as being popular and offered weekly sport activities outside school hours. More HHS schools had teachers engaged in health promotion activities and focused on stress prevention. The characteristics of HHS students did not differ markedly from non-participating high school students. There were no socio-demographic, outcome or contextual differences between the study arms. To ensure successful recruitment of schools it is important that the intervention meets the need of the schools and that the advantages of participation are explicit. This underlines the need for a thorough needs assessment prior to intervention development, co-creation of intervention activities with school staff, and a well-planned recruitment strategy.
School Coordinators’ Perceptions of Organizational Readiness Is Associated with Implementation Fidelity in a Smoking Prevention Program: Findings from the X:IT II Study Lotus Sofie Bast, Henriette Bondo Andersen, Anette Andersen, Stine Glenstrup Lauemøller, Camilla Thørring Bonnesen, Rikke Fredenslund Krølner Prevention Science, 2021 School organizational readiness to implement interventions may play an important role for the actual obtained implementation level, and knowledge about organizational readiness prior to intervention start can help pinpoint how to optimize support to the schools. In this study, we applied a novel heuristic, R = MC2 to assess school organizational readiness prior to implementation of a multicomponent smoking prevention program. Furthermore, we examined the association to actual implementation after the first year of study. We used questionnaire data from school coordinators at 40 schools in Denmark who had accepted to implement the multi-component smoking prevention intervention—X:IT II—in the school year 2017–2018 including three main components: (1) Rules on smoke-free school time, (2) A smoke-free curriculum, and (3) Parental involvement. On behalf of the school, a school coordinator answered a baseline questionnaire about the organizational readiness and a follow-up questionnaire about implementation of the three components after first year of study. Readiness was measured by summing aspects of motivation (relative advantage, compatibility, complexity, and priority), general capacity (culture, climate, and staff capacity), and innovation-specific capacity (knowledge, skills, and abilities). Based on school coordinators’ perceptions, almost all schools had good general capacity while the other two areas of readiness varied across schools; overall, 56.8% of schools (N = 25) had good motivation for implementing the X:IT II intervention and 61.3% (N = 27) had high innovation-specific capacity. Half of the schools had high overall readiness defined as high motivation and high innovation-specific capacity. Schools with high overall readiness implemented the rules on smoke-free school time, smoke-free curriculum, and parental involvement to a higher degree than schools with low overall readiness. All participating schools possessed sufficient levels of general capacity, e.g., a well-functioning organizational culture and sufficient staff capacity. High levels of motivation and innovation-specific capacity were positively associated with the schools’ actual implementation of the main intervention components. This way of conceptualizing and measuring organizational readiness may be useful in future studies, i.e., in studies where enhancing readiness is a main objective.
