Abstract
Abstract
Objective
To partner with healthcare professionals and other stakeholders to identify top 10 research priorities within universal child and adolescent health promotion and disease preventive services.
Design
The study used an adapted James Lind Alliance (JLA) approach. This included a priority setting partnership within the field of municipal health promotion and preventive services for children and adolescents, the gathering of research needs as reported by a national sample of healthcare professionals and other stakeholders and the sorting, evidence checking and final prioritisation of two top 10 lists corresponding with the two municipal service areas: (1) pregnancy care and child health centres 0–5 years and (2) school health service and youth health centres. The research needs were collected using an online survey asking: ‘In your opinion, what should scientific communities in Norway conduct research on to enhance child and adolescent health promotion and preventive services?’. Suggested needs framed as topics were sorted and categorised in Microsoft Excel. The digital survey Nettskjema was applied for final prioritisation by voting.
Setting
Municipal child and adolescent health promotion and disease prevention services in Norway.
Participants
Altogether, 1141 healthcare professionals and other stakeholders (government administrators and university staff).
Result
The participants submitted a total of 1780 research needs. Following the steps of the JLA priority setting process, the two final top 10 lists were generated. The lists include research priorities relating to, for example, health literacy, mental health promotion, counselling and teaching, follow-up of children and families in vulnerable positions and interdisciplinary collaboration.
Conclusion
Research priorities for child and adolescent health promotion and preventive services were identified through structured user involvement of healthcare professionals and other stakeholders using the JLA framework. The two lists address key knowledge gaps and reflect current societal and professional challenges. The findings can enhance research relevance, foster collaboration and guide research and research funding.
Keywords: Primary Health Care, PUBLIC HEALTH, Community child health, Adolescents, Health Services, Child
STRENGTHS AND LIMITATIONS OF THIS STUDY.
We engaged a large group of interdisciplinary healthcare professionals and other stakeholders (government administrators and university staff) from all over the country to systematically identify and prioritise research needs within health promotion and disease preventive health services for children and young people.
Such strong user involvement contributes to ensuring that academic communities align with the most urgent needs of the services.
Two service-based top 10 lists of research priorities were developed, deviating somewhat from the original James Lind Alliance approach, which typically produces a single list of specific research questions.
This study identifies research priorities among Norwegian healthcare professionals and stakeholders, which may limit the results’ transferability to other countries.
Background
Like other Scandinavian countries, Norwegian health promotion and disease preventive efforts are delivered through various settings, including pregnancy care in primary care health centres, child health centres (ages 0–5), school health services (years 1–13, ages 6–19) and youth health centres (ages 13–20).1 These services are public and free of charge and employ both individual and population-oriented approaches designed to support the physical, emotional and developmental well-being of individuals from the antenatal period through adolescence.1 The overall purpose of the services is regulated by Norwegian law.2 The aim is to provide comprehensive and universal health-promoting and disease-preventive care, to reduce social health disparities and to prevent and detect domestic violence and abuse.2 The services use a salutogenic approach to health and include, for example, maternity visits, well-child check-ups, health education, administration of the childhood immunisation programme, monitoring healthy growth and development, prevention of unwanted pregnancies among adolescents and addressing health issues that arise during critical developmental stages.1 2 Furthermore, the services aim to early identify children and adolescents at risk and refer to other municipal or specialised services when necessary.1
The Norwegian child and youth health promotion and disease prevention services are used by 98% of Norwegian families.1 3 Despite their significant position in primary healthcare, there is a paucity of research conducted on the services. As a result, the services provided and the guidelines that govern them are grounded in a relatively limited evidence base. In response to this scarcity, the Norwegian Institute of Public Health recently established a national centre for child and adolescent health promoting services (NAsjonalt kompetansemiljø for helsestasjons- og SKOlehelsetjenesten, NASKO), commissioned by the Norwegian Ministry of Health and Welfare, with a mandate to produce and communicate research that expands the child and youth health promotion and disease preventive services’ empirical foundation.4
To ensure that the research conducted by academic communities aligns with the most urgent needs of the services, it is essential to involve both those who provide the service and those who use them, such as children, adolescents and parents. Involving both service users and professionals is not only ethically important but is also believed to enhance the quality, relevance and implementation of research.5 To contribute to determining future research priorities within Norwegian child and adolescent health promotion and disease prevention services, the present study targeted those with direct experience and expertise in service delivery and implementation. A prioritised research agenda can enhance the quality and relevance of research to improve services for children, youth and their families. Furthermore, it may encourage collaboration among healthcare providers, researchers, community organisations, municipalities and other stakeholders and provide information for research funders.5
The purpose of this study was to partner with healthcare professionals and other stakeholders to identify top 10 research priorities within universal child and adolescent health promotion and disease preventive services.
Methods
Inspired by the James Lind Alliance (JLA)’s priority setting partnership framework, we have worked systematically to gather, sort and prioritise research needs reported by healthcare professionals and stakeholders (government administrators and university staff).5 The process included (1) setting up a priority setting partnership, (2) gathering uncertainties (research needs), (3) data processing and verifying uncertainties, (4) interim priority setting and (5) final priority setting.5 The methods section is organised based on this process, and the entire manuscript is structured according to the REPorting guideline for PRIority SEtting of health research.6 While the JLA framework originally relies on gathering research questions related to the effect of treatment, we have chosen, in accordance with previous research,7 8 to identify suggestions for topics that should be prioritised in research to strengthen the evidence base for child and adolescent health promotion and preventive services. These topics are termed ‘research needs’ before they are prioritised and ‘research priorities’ after. The Norwegian child and adolescent health promotion and preventive services are organised within one department in the municipalities. However, the services cover two main areas: (1) municipal pregnancy care and child health centres and (2) school health service and youth health centres, with substantial differences in target populations, content and requirements. Thus, we found it appropriate to develop two top 10 lists corresponding with each of the two main service areas. The entire process from initial data collection to the two final top 10 research priorities is illustrated in figure 1.
Figure 1. Flow chart of the process from gathering uncertainties to final Top 10 lists.
The priority setting partnership
The initial phase of a priority setting process is designed to define the project’s scope, invite members and collaboratively develop a project protocol with the members of the partnership.5 NASKO initiated the current project in March 2024. A PSP was established consisting of advisors and researchers of NASKO (n=6) representing healthcare professionals in pregnancy care, child and youth health centres, and school health services (midwife, public health nurses and paediatric physiotherapists) and two external health science researchers experienced with the JLA framework. The partnership was responsible for idea development and project planning, data collection, coding and organisation of data and preparation and implementation of the process for prioritising research needs in two rounds.
Gathering uncertainties
As part of the establishment of NASKO, we issued an extensive national survey during spring 2024 to identify knowledge needs and expectations for NASKO among healthcare professionals in pregnancy care, child and youth health centres and school health services and other stakeholders (ie, government administration and staff at universities offering programmes for healthcare personnel). The survey tool ‘Nettskjema’9 was used to gather research needs. The survey, which included altogether 27 questions, was issued via e-mail directly to all Norwegian municipalities to relevant trade unions and organisations. It was also shared on various social media platforms. The survey was available from 11 March to 21 April 2024. For the aim of the current study, a question about research needs was included in the survey and outlined as follows: ‘In your opinion, what should scientific communities in Norway conduct research on to enhance child and adolescent health promotion and preventive services?’. The respondents were asked to suggest one or more needs, worded as topics or research questions, either as keywords or coherent text. We also collected information about the participants’ professional background.
Data processing and verifying uncertainties
All responses were extracted from Nettskjema to Microsoft Excel. We first removed all blank responses and those with unsubstantial text (eg, ‘x’, ‘?’, ‘no’ or ‘I don’t know’). Responses that included several research needs were split into individual needs. To align with the mandate of NASKO, we chose to exclude all responses on research needs relating to staff resources, recruitment and work environment. We also omitted suggestions for research that was not exclusive to or about the services (eg, risk factors for developing autism and consequences of screen time). To manage the large amount of data, we categorised the research needs according to the areas of the services: ‘pregnancy care’, ‘child health centre’, ‘school health service’ or ‘youth health centre’. The remaining responses that did not fit into either of the four categories were termed ‘general’. These were typically overarching topics that were not linked to one specific service area like ‘interdisciplinary efforts’ or ‘increased user participation’. The first author then coded the research needs within each category. Examples of the coding process are shown in table 1.
Table 1. Examples of coding of research needs within each category (area of the service).
| Suggested research needs | Category | Code |
|---|---|---|
| How to achieve better distribution of tasks between physicians and midwives? | Pregnancy care | Interdisciplinary collaboration in pregnancy care |
| The importance of sleep and the role of the public health nurse in promoting infant sleep | Child health centre | Sleep counselling |
| Standardised evidence-based teaching material on typical problem areas for young people (eg, loneliness, exercise and nutrition) | School health service | Evidence-based teaching material |
| How can we increase male participation in the youth health centre? | Youth health centre | Boys in the youth health centre |
| User participation | General | User participation in pregnancy care User participation in the child health centre User participation in the school health service User participation in the youth health centre |
The PSP verified the codes and drew random samples from all research needs within each category to check if they were covered by the codes. Duplicate codes were removed. The coded needs were then organised corresponding to (1) municipal pregnancy care and child health centre and (2) school health and youth health centre. Codes from the ‘general’ category were added to both long lists. The two lists were reviewed and discussed by the members of the PSP, and minor changes to the wording were made before finalising the lists for the interim priority setting. According to JLA methodology, every suggested research need should be verified as a true uncertainty before prioritisation to assure that the proposed need has not already been sufficiently addressed.5 The framework suggests that systematic searches for relevant up-to-date and reliable systematic reviews are undertaken and that any identified reviews are no more than 5 years old.5 The needs in the present study were mostly reported by the respondents as topics and not phrased as research questions, which challenged verification against systematic reviews. We adopted a pragmatic strategy and performed searches in Epistemonikos, a database of systematic reviews with extensive coverage from several major healthcare databases.10 We combined context (municipal pregnancy care and child health centre or school health service and youth health centre) and concept (eg, breastfeeding counselling or children’s health literacy) and limited the search to systematic reviews from 2019 to present. We found no relevant reviews matching the inclusion criteria; thus, no further research needs were excluded. The long lists ended up containing an equal number of 53 research needs.
Interim priority setting
The JLA encourages alternative means of consultation for interim prioritisation.5 We chose to invite participants who attended a free 2 day national conference for healthcare professionals affiliated with child and adolescent health promotion and disease preventive services to contribute to the priority setting. The majority were public health nurses, but midwives, physiotherapists, doctors, psychologists and occupational therapists participated. All were physically present. The interim prioritisation was carried out on the first day of the conference. No reimbursement for participation was provided. All conference participants were given access to a survey on ‘Nettskjema’ containing the two long lists. The participants were asked to individually vote, without ranking, up to 10 research needs from the list corresponding with their service engagement. Each participant received a randomised list that differed from all others. Based on the number of votes, two short lists each containing 25 research needs were prepared for the final priority setting. The cutoff of 25 needs was chosen based on previous research.11
Final priority setting
According to JLA, a standard final priority setting is organised as workshop discussions with rounds of group ranking and a final whole group review to decide on the final top 10.5 The final priority setting was based on one session of roundtable discussions. On the second day of the conference, all participants were seated in interdisciplinary groups depending on their main area of service engagement. Totally, 25 groups were presented with the two short lists of the 25 research needs in a non-ranked order and encouraged to discuss the interim results. After a 30-min discussion, the participants individually voted on ‘Nettskjema’. The participants were instructed to choose their top five research needs from each list to ensure the number of votes would allow a ranked order. All participants could decide whether they wanted to give votes to one or both short lists of research needs. The final top 10 lists were formed from the 10 most voted research needs, ranked in descending order of votes. The lists were presented to the conference participants immediately after prioritisation and will be made publicly available on the NASKO website and in a newsletter when the scientific paper describing the process has been published.
Ethics statement
No identifiable personal data were collected in the survey, and Nettskjema does not store IP addresses; thus, the survey was completely anonymous. Participation was entirely voluntary, with informed consent implied through the submission of responses. No data were collected about the participants during the interim and final priority setting. Therefore, ethical approval was not required for any part of the project. However, to ensure compliance with privacy regulations, the local data protection officer at the Norwegian Institute of Public Health was consulted prior to data collection.
Patient and public involvement
No patients or members of the public were involved in the design, conduct, reporting or dissemination of this study. However, because the JLA approach relies on stakeholder engagement to elicit and prioritise research needs, the study lays an important foundation for subsequent research that can be argued to be truly user-identified.
Results
Altogether, n=1141 people responded to the initial survey (figure 1), of which there were n=1077 healthcare personnel (n=676 public health nurses or acting public health nurses, n=77 physiotherapists, n=60 midwives, n=19 physicians, n=4 administrative staff, n=2 psychologists, n=45 other healthcare personnel, mainly registered nurses and occupational therapists) and n=64 other stakeholders (government administration and university staff). Most healthcare personnel reported having engagements within more than one service area (pregnancy care, child health centres 0–5 years, school health service and youth health centres). All 15 Norwegian counties were represented in the survey. The total number of research needs after sorting, before exclusion and duplicate removal was 1780.
The top 10 lists
The priority setting process, carried out by the interdisciplinary group of healthcare personnel at the national 2 day conference (n=188), resulted in two top 10 lists of research priorities within (1) pregnancy care and child health centres and (2) school health service and youth health centres. In the interim priority setting, n=105 participants gave votes to list number 1, and n=107 participants gave votes to list number 2. In the final priority setting, n=105 participants gave votes to list number 1, and n=116 participants gave votes to list number 2. The lists are presented in table 2. Six of the top 10 research priorities in pregnancy care and child health centres were already among the top 10 in the initial short list of 25 priorities: parental health literacy, parenting counselling programmes, group consultations versus individual consultations, parenting preparation classes and enhanced services for vulnerable families. Four topics gained higher priority in the second prioritisation round: collaboration with kindergartens, tailored services for families with ethnic minority backgrounds, measures to support parents’ mental health and breastfeeding counselling. A similar result was seen for the top 10 research priorities in school health service and youth health centres. Seven of the priorities were among the 10 highest ranked in the short list: health literacy among children and adolescents, system collaboration between schools and school health services, prevention and follow-up of school absenteeism, collaboration on ‘public health and life skills’ theme in schools, prevention of social exclusion and loneliness, evidence-based teaching materials and parent counselling programmes. The three topics that were assigned higher priority in the second round were interdisciplinary collaboration in the school health service, follow-up of children living in parental conflict and mental health promotion initiatives (see online supplemental additional file 2).
Table 2. Top 10 research priorities in ranked order.
| Top 10 research priorities in pregnancy care and child health centres | Top 10 research priorities in school health service and youth health centres |
|---|---|
|
|
Discussion
This study presents the most critical research priorities within child and adolescent health promotion and preventive services, as identified by healthcare professionals and other stakeholders. The research priorities reflect current societal challenges, strategic initiatives and professional debates and cover efforts at individual, group and system levels within the scope of the national guideline for child and youth health centres and school health service.1 The substantial participation in the survey and the high number of proposed research needs indicate that the practitioners have a significant demand for research on the services they provide. The multidisciplinary participation corresponds with the distribution of professionals working in these services. Public health nurses are the primary profession in these services1 and, as expected, represented the largest group of respondents in the survey as well as in the priority setting. The findings show consistency between the two rounds of priority setting, with six and seven of the top 10 priorities in the lists overlapping with the highest ranked topics from the interim priority setting. In the final round, participants had only five votes to allocate, which required stricter prioritisation and a more focused selection of topics, potentially reinforcing agreement on the highest priority topics. However, four topics in the final list gained higher priority compared with the interim list, which may have been influenced by the interdisciplinary discussions that took place before the final voting round.
Health literacy came out on top of both top 10 lists. This is a likely consequence of health literacy being placed high on the health policy agenda in Norway in the past couple of years.12 Health literacy involves the personal and social resources needed to access, understand, appraise and use health information and services, as well as how health services address public health literacy needs and ensure accessibility of services, programmes and information.13 14 So far, there is very little research to inform how health services best accommodate children, adolescents and parents’ various health literacy needs and contribute to increasing their health literacy, as reflected by the results in this study. Health literacy may influence the relationship between poor socioeconomic conditions and subsequent negative health outcomes,15 which makes an argument for increasing health literacy across populations and making health services more accessible to those with low health literacy. The need for research on parents’ health literacy partially overlaps with the identified need for more research on tailored services for families with ethnic minority backgrounds who are at risk of having lower health literacy due to language and cultural barriers.
The lists also reflect the increasing prevalence of mental health issues among young people. Studies show that mental health problems are reported by a substantial proportion of the population, particularly girls.16 Moreover, associations are found between Norwegian parents’ mental disorders and child mental health.17 Public health nurses working in the school health service report dedicating more than 50% of their time to pupils with emotional or psychological problems.18 They also report that mental health issues are being significantly more discussed by children, adolescents and parents over the last years.19 Therefore, it is noteworthy to observe that mental health promotion and measures to support parents’ mental health received more votes than measures for individual follow-up of mental health problems, which is not represented in either of the top 10 lists. This could arise from public health nurses’ experience of prioritising individual consultations and urgent issues over promotional and preventive efforts,19 which contrasts with the national guidelines directing services towards promotion and prevention rather than treatment.1 It also acknowledges that initiatives promoting mental health can help prevent mental problems.20
Both lists of research priorities reflect a demand for evidence-based measures to provide effective and tailored support for those in vulnerable positions, for example, follow-up of children living in family conflict and enhanced services for vulnerable families. Furthermore, healthcare professionals in health clinics and school health services are at the front line in meeting with families, children and adolescents who are experiencing various distress such as social exclusion and loneliness. There has also been an increased attention to school absenteeism. The causes for chronic school absenteeism are multifaceted, but mental, social or physical health issues are important contributors.21 Healthcare professionals working in school can play a critical role in preventing and reducing chronic school absence, yet limited research exists on how the school health service can contribute to this issue.
The Norwegian well-child programme suggests content and structure (individual or group-based) for 14 recommended consultations during a child’s first 5 years.1 In addition to performing standardised check-ups, the public health nurse, a doctor and occasionally a physiotherapist provide advice and guidance on topics like breastfeeding, diet and motor development. The results of the present study show that healthcare professionals and stakeholders require more research on the requested guidance, whether in the form of specific counselling programmes, standardised teaching materials or different ways of organising communication or counselling (individually or in groups).
Research on interdisciplinary collaboration is among the most frequently reported priorities on the lists. Collaboration between child health centres and kindergartens and school health services and schools as well as extended services is emphasised and strongly recommended in the national guidelines.1 However, there is limited information on how to organise such collaborations, particularly at the system level. There are examples of studies that have explored interdisciplinary cooperation,22,24 but more research is needed to understand context-specific collaborations from different perspectives to inform new, effective practices, for example, in relation to health and life skills education in schools.25 Interestingly, our study shows that there is also a need for more research on interdisciplinary collaboration within the child health centre and the school health service. Norwegian municipalities employ various healthcare professionals to cover health promotion and preventive services for children and adolescents.1 Many regulated tasks like pregnancy checks, vaccination and motor assessments, performed by specialised healthcare professionals, do not typically necessitate interdisciplinary efforts. However, the guidelines also encourage formalised collaboration for more complex tasks. This study calls for research into how various professional groups in child health centres and school health services can improve their collaboration to meet the guidelines.
Strengths and limitations
The most important strength of this study is the engagement of healthcare professionals and other stakeholders in systematically identifying and prioritising research needs within health promotion and disease preventive health services for children and young people. Another strength is the interdisciplinary participation in both the initial data collection and the two rounds of prioritisation. An obvious limitation of this study is that we only included representatives of those responsible for providing the services and not the users of the services. Given that the child health clinic and school health services aim to reach a very large user group and encompass a wide range of tasks, it would not have been feasible to involve representatives of all users of the services (pregnant women, parents, children and adolescents) and all service providers in one single study. Follow-up studies involving service users are crucial to capture their experiences and ensure research priorities address their needs. Another important limitation of the study is the deviation from the rigorous process as outlined by the JLA, such as our application of only one database for the verification of uncertainties and the brief time allocated for participants to familiarise themselves with the research needs in the interim priority setting. The participants also had limited time for discussions in the interdisciplinary groups before the final priority setting. Yet another limitation is the inability to provide exact numbers for the exclusion of research needs during the initial sorting process. Since responses were often presented as continuous text rather than discrete topics or research questions, topics could be excluded not only as duplicates but also if they were deemed irrelevant within one or more themes or outside the scope of the study. This study aimed to identify research priorities among Norwegian healthcare professionals and stakeholders, which may limit the results’ transferability. However, common global public health challenges like increased mental distress among youth and rising immigration necessitating more culturally adapted health services make our study relevant for countries with similar universal health services. Importantly, this study can inspire a structured, transparent and user-engaged approach to identifying national-level research priorities for health service improvement.
Conclusion
In partnership with healthcare professionals and other stakeholders within the child and adolescent health promotion and disease preventive services, two service-based top 10 lists of research priorities within these services were successfully identified. The lists address key knowledge gaps and reflect current societal and professional challenges. They hold the potential to boost research quality and relevance and thereby enhance the evidence base for the services, promote collaboration among various stakeholders and inform research funders.
Supplementary material
Acknowledgements
We would like to express our appreciation to healthcare professionals and other stakeholders for their engaged participation in this study. We also thank Boye Welde and Marit Müller De Bortoli, both researchers at the Norwegian Institute of Public Health, for thoroughly reviewing the manuscript before submission, and Anna Macintyre for translating the top 10 lists from Norwegian to English.
Footnotes
Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The conference where interim and final prioritisation took place was funded by NASKO.
Prepub: Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2025-101966).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants, but the Data Protection Officer at the Norwegian Institute of Public Health assessed the project. Since we did not collect personally identifiable data and Nettskjema does not store IP addresses, the survey was evaluated as completely anonymous. Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
No data are available.
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