Golsäter et al. BMC Pediatrics(2024) 24:581
https://doi.org/10.1186/s12887-024-05064-8

BMC Pediatrics

RESEARCH

Open Access

Parents’ perceptions of the safe environment
for every kid (SEEK) model in the Swedish
child health services
Marie Golsäter1, Eva Randell2*, Maria Engström3 and Steven Lucas3
Abstract
Background The Safe Environment for Every Kid (SEEK) model was developed to address psychosocial risk factors(financial worries, depressive symptoms, major parental stress, alcohol misuse and intimate partner violence) in thepediatric primary care setting but has not been evaluated from the parents’ perspective. To further investigate theusefulness of SEEK, it is important to explore how parents perceive the model.
Objective The aim of the present study was to explore parents’ perceptions of the SEEK model as a part of regular
health visits in the Child Health Services in Sweden.
Participants and setting Eighteen parents (13 women and five men) in two Swedish counties participated in the
study.
Methods Semi-structured telephone interviews were conducted, and the resulting data were analyzed usingreflective thematic analysis.
Results Three themes were identified: Acceptance and understanding of the SEEK model in the child health services, Thequestionnaire as a bridge to a dialogue, and Feeling trust in the system and the child health nurse’s professional competence.
Further, an overarching theme was created that encompassed a core meaning of all three themes; SEEK provides aprocess-oriented framework to receive support in parenting with a focus on child health.
Conclusions The study showed that parents express both acceptance and understanding of the SEEK model andthey perceive that the model provides an avenue for repeated dialogues about the family’s situation during the child’s
upbringing and an opportunity to access support if needed.
Keywords Child Health Services, Health promotion, Parent, Psychosocial risk factors, The SEEK model*Correspondence:
Eva Randell
eva.randell@uu.se
1Child Research Group, School of Health and Welfare, Jönköping
University, Child Health Service and Futurum - Academy for Health andCare, Region Jönköping County, Jönköping, Jönköping, Sweden
2
Department of Social work, Uppsala University, Uppsala, Sweden
3
Department of Women’s and Children’s Health, Uppsala University,
Uppsala, Sweden© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in thisarticle are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not includedin the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you willneed to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Golsäter et al. BMC Pediatrics(2024) 24:581

Introduction
Child and parent wellbeing are central to the optimal
growth and development of each child according to his or
her own potential [1]. Multiple and integrated systems in
the child’s environment affect how families function, andin this context, psychosocial factors are key determinantsof the child’s potential to thrive [2]. Common psychosocial factors in the home that may negatively affect childhealth and development outcomes and increase the riskof child maltreatment include financial strain, parental
mental health problems, significant parental stress, substance abuse, and intimate partner violence (IPV) [3].
Pediatric primary care professionals see a number of
hurdles to universally asking parents about psychosocial problems. These include time constraints, lack ofknowledge about the available screening tools, insufficient training on how to address a positive screen, lackof knowledge on the resources available to refer to, andfear that the parent will find the questions uncomfortable or intrusive [4–7]. Survey studies of how parents
perceive being asked about psychosocial problems duringchild health visits show that parents are mostly positive
to discussing such issues with the child’s primary careprovider [8, 9]. Most of these studies have focused on single issues such as screening for post-partum depression
or substance use or abuse [10]. One study that evaluatedparents’ experiences of multifaceted methods for identification of several psychosocial risk factors also shows ahigh degree of acceptability among most parents [11].
The Safe Environment for Every Kid (SEEK) model
was developed to address psychosocial risk factors in thepediatric primary care setting [12]. The aim of the SEEK
model is to help improve child health and development,
strengthen families, and support parents by identifying common problems that parents may have, discussing what services parents may be willing to accept, andputting them in contact with the relevant resources.
Randomized trials of the SEEK model have shown reductions in the use of harsh parenting, fewer reports to childprotective services, and increased discussions about psychosocial issues with parents during child health visits inpediatric practices that employed SEEK [13, 14].
The Child Health Services (CHS) in Sweden is a partof primary care and aims to support children’s healthand development. The CHS is offered free of charge to all
children 0–5.
years of age and their parents. Uptake is nearly complete, with over 99% of children enrolled [15]. The CHS
follows a national program with at least 16 age-specificvisits, including two home visits; four of the 16 visits areteam-based visits with a physician (GP or pediatrician)and a CHS nurse. The CHS focuses on health promotion, primary prevention, and early detection of healthor developmental problems or risk factors in the child’s

Page 2 of 10

environment and referral to appropriate services [16].
Together, the focus on child and family health, ubiquitouscoverage in the population, high level of trust among parents, many recurring visits, and a high level of continuity
make the CHS an ideal environment to address psychosocial issues in order to promote children’s health [16].
The SEEK model has recently been introduced into the
CHS context in several Swedish counties. The implementation of SEEK in a county has consisted of several steps.
In the initial pilot phase, 3–5 CHCs in one or two municipalities used the model. Experiences from the pilot werethen used in the subsequent expansion phases. Usually,
two to three expansion phases took place before all units
in a county had implemented SEEK. Today, the SEEK
model is used in 11 (of 21) counties in Sweden. During
the period of 2020–2023, a total of six counties had fully
introduced the model, and an additional five counties
were in the pilot or expansion phase.
The primary focus of the SEEK model is to prevent ill
health and reduce the risk of child maltreatment, and themodel provides a method for identifying children livingin families with psychosocial risk factors [13, 14].
At five of the regular health visits when the child is
6–8 weeks, 10 months, 18 months, two and a half years,
and four years of age, the parents are offered to fill in the
Swedish version of the SEEK Parent Screening Questionnaire (PSQ), comprised of 17 questions including childsafety, economic worries, parental depression, extreme
parenting stress, alcohol misuse, and IPV. The parents’answers are then used as a starting point for a dialogue
concerning how any existing problems may affect thefamily and the child. Based on each family’s individual
needs, further support by the CHS nurse or other services, e.g. a social worker, is offered according to thewishes of the parent [17].
Two studies have thus far examined the CHS nurses’
experiences of addressing psychosocial risk factors in thefamilies they meet and found that the SEEK model provided a previously lacking structure that facilitated theidentification of psychosocial risk factors. Further, themodel made the issues approachable and supported theprofessionals in their sense of competence and security inaddressing complex psychosocial issues [17, 18]. To further investigate the usefulness of the model, it was of vital
importance to explore how parents’ perceived answering
the PSQ and discussing psychosocial issues, which has
not been previously studied. The aim of the present study
was to explore parents’ perceptions of the SEEK model asa part of regular health visits in the CHS in Sweden.

Methods
DesignA qualitative explorative design [19] employing semistructured interviews was used to obtain a detailed

Golsäter et al. BMC Pediatrics(2024) 24:581

understanding of parents’ perceptions of the SEEK model
as a part of regular health visits in two counties in Sweden. According to statistics Sweden (SCB), one of thecounties has about 370,00 inhabitants divided into 13
municipalities with a variation from 6,900 to 147,000
inhabitants, and the second county has about 288,000
inhabitants divided into 15 municipalities varying fromaround 6,800 to 60,000 inhabitants. Both counties have a
combination of urban and rural areas.
Participants

A convenience sampling method was used to recruit parents to the study. At regular child health visits, parents
at seven different CHS units were informed by their CHS
nurse about the study, and parents who were interested
in taking part received an information letter and were
contacted by one of the researchers by telephone.
Eighteen parents (thirteen women and five men) whosechildren were enrolled in the national CHS program took
part in telephone-based individual interviews. The lastconducted interviews established aspects already existingin the data without adding new information, suggesting
we had approached saturation.
The parents’ age ranged from 25 to 41 years (mean age33), and all were born in Sweden. Altogether, the parents
had 33 children aged two months to 11 years. In one family, both parents were interviewed, and in all other families, one of the parents participated. Most of the parents
had been exposed to the SEEK model at more than one
health visit.
Data collection

The telephone interviews were conducted by three of theauthors; ME conducted three interviews, MG conducted
six, and ER conducted the remaining nine interviews.
The interviewers had not previously met the parents
and had not worked clinically with the SEEK model
Table 1 Overarching theme, themes and sub-themes
developed from interviews with parents exposed to the SEEK
model
SEEK provides a process-oriented framework to receive support inparenting with a focus on child health
1. Acceptance and understanding of the SEEK model in the CHS
1.1 Relevant issues for the sake of all children
1.2 Paying attention to the family’s life situation as a whole
1.3 The CHS as a neutral arena for parenting support and health promotion
2. The questionnaire as a bridge to dialogue
2.1 Structured questions provide specific answers
2.2 The questionnaire as a starting point for discussion and reflection
2.3 Recurrent questions provide repeated opportunities
3. Feeling trust in the system and the nurse’s professional
competence
3.1 Safe and confident in receiving support from the CHS
3.2 Trusting the nurse in the encounter
3.3 Trust is created through several visits

Page 3 of 10

themselves. The 18 interviews were conducted between
December 2021 and January 2022. The interviews lasted
15–42 min (median 23 min) and were audio-recorded
and transcribed verbatim.
An interview guide was used to ensure that the central
topics of interest were discussed. Each interview started
with the question, “What are your thoughts about CHS
nurses using a questionnaire to ask about various factorsthat can affect young children’s family environment?”
Subsequent questions related to the following aspects
found in the SEEK questionnaire: Child safety; smoking;economic worries; parental depression; stress; IPV andalcohol misuse. Questions were then posed about how
the parent perceived the questions in the PSQ and thesubsequent dialogue with the CHS nurse. Finally, questions were posed about how the parent’s responses andexpressed needs were handled by the nurse.
Data analysis

Reflexive thematic analysis (TA), according to Braun and
Clarke [20], was used to analyze the interviews. In theinitial phase, all transcripts were read through several
times by MG and ER to become initially acquainted withthe data. In the next step, data segments that were relevant for the aim of the study were highlighted in the coding process, and preliminary codes were developed andfurther discussed. The preliminary codes from the initial
reading were compared between MG and ER to create afirst common understanding. Through continuing revision of codes and reflection, the core understanding of
the data was generated, and the codes were clustered togenerate potential themes. A theme in reflexive TA is apattern of shared meaning around an organizing concept [20]. Themes were further reviewed against codesand data. The analysis was developed from a semantic
understanding to a more latent one in an ongoing reflexive discussion by MG and ER striving for a more refinedinterpretation of the parents’ perceptions of the SEEK
model. In the later phases of the analysis process, allauthors were involved in discussing the findings.

Results
Based on the analysis of the parents’ experiences andthoughts, three themes were developed; Acceptance andunderstanding of the SEEK model in the CHS, The questionnaire as a bridge to a dialogue, and Feeling trust in
the system and the child health nurse’s professional competence. Each theme consisted of several sub-themes. In
addition, an overarching theme was created that encompassed a core meaning of all three themes: SEEK provides
a process-oriented framework to receive support in parenting with a focus on child health. An overview of theoverarching theme, themes, and sub-themes is presented
in Table 1.

Golsäter et al. BMC Pediatrics(2024) 24:581

SEEK provides a process-oriented framework to receive
support in parenting with a focus on child healthParents showed both acceptance and understanding of
the SEEK model and were willing to answer questions
about their psychosocial situation. The dialogue, basedon the structured SEEK PSQ combined with the parents’
confidence in the CHS, enabled parents to get early support. According to the parents, confidence in the CHS
and the professionals’ knowledge provided a basis forparents to take advantage of the support offered. Several
processes were involved: the process of gaining confidence in the CHS, the process of child development in
the early years, and the process of the family’s changing
needs for support. Therefore, the SEEK model provided
a process-oriented framework for parents to receive parenting support with a focus on the child’s health.
Acceptance and understanding of the SEEK model in the
CHS

The parents expressed that the questions dealt with relevant issues in the child’s best interest and that they
focused attention on the family’s life situation as a whole.
The CHS was perceived as a neutral arena for all parents
and especially for those parents in need of support byfollowing children and families through the crucial earlyyears of the child’s life. Offering the SEEK model to allfamilies normalized the method for the parents.
Relevant issues for the sake of all children

The parents expressed an understanding that universal
application of the SEEK model in the CHS could support
the entire parenting community. They described thinking that, by inviting every parent on several occasions
to answer the questionnaire and discuss their situation,
the parents’ sense of security would be strengthened
and they would dare to express their needs. The parents
commented that this was especially true for parents withseveral psychosocial risk factors, such as depression, violence, or alcohol abuse.
“The questions I think are quite relevant. Yes, I guess I
don’t take it personally in any way, but I see it as the big
picture that the CHS nurse needs to be informed about
and can quickly see if there are gaps in parents’ knowledge and perhaps new parents in particular” (father,interview person 10).
The parents’ thoughts regarding the SEEK model
included an overall sense of the importance of trying to
make it easier for families with difficult life situations to
get help. The parents expressed a sense of responsibility
for all parents and children and especially, thanks to the
support provided by the SEEK model, that the CHS wereable to find parents and children in need of support. A
mother explained why it was beneficial to ask questions:Page 4 of 10“I think the CHS should ask questions. Because otherwise children might live in a home where things
are not as they should be and the parents need help
and support. So that things will be good for the child.
And yes, it’s good if you can draw attention to suchthings so the parents can get that support” (mother,interview person 14).

Paying attention to the family’s life situation as a whole

Parents expressed that all questions in the questionnaire
were relevant for parents with children aged 0–5 years as
they concerned factors that may affect the wellbeing andsafety of a family. According to the parents, the different
issues that the questions covered helped to shed light on
the family’s life situation as a whole, including the wellbeing of the child. The parents described that the questions were about many things in addition to the child’s
health and development, including how the parents felt.
The parents described many thoughts they had about
how important it was that parents feel and function well.
As one mother put it, “I realized after these questions
that there is so much more, it is absolutely mostly about
how we as parents feel and our ability to take care of thechild. So, I thought about how important it is that we alsofeel well, that we function” (mother, interview person 5).
Several parents highlighted that the questions regarding the family’s financial situation brought up an issue
that may affect the entire family and that they had notthought about previously. They considered it important
to be asked about possible financial worries. One mothercommented, “I thought the questions were very good
actually, I remember mainly reacting to that question
about financial security, like, “They talk about things likethis too, that’s great!” (mother, interview person 11).
Paying attention to the family’s life situation involved
including fathers or partners as well as mothers: “I wasoffered an individual parent visit, and it was something I
wanted to do because I felt being a parent was very hardin the beginning. I had very good support from home,
but I felt that it was important to talk, and maybe not justfor my sake, but to make it clear that men can also feelthat it’s difficult” (father, interview person 10).
The CHS as a neutral arena for parenting support and healthpromotion

The CHS was considered to be a neutral place where parents felt confident that the services focused on promoting the child’s well-being. Even if the role of the CHS was
not clear for the parents, they appreciated the CHS as anarena. One father said. “I don’t know exactly what kind offunction the CHS has, but I suppose they have some ideaof how the parents are, in case the children might be atrisk, and can help. That’s what I think. No one has ever

Golsäter et al. BMC Pediatrics(2024) 24:581

said that, but I have understood through the questions
that they want to know if the parents are good parents,
and I think that is very positive” (father, interview person
16).
The important role of prevention and support provided by the CHS was highlighted; “There is no one elseat that early age, there is no school, so only the CHS has
the opportunity to get a picture themselves, and it is also
important to work preventively, to get parents to reflect,
and that interaction is based on gentle pedagogy… whichsimply enables the parents’ own reflections on parenting”(mother, interview person 9).
Because the SEEK-questionnaire was offered to all parents they thought that it would make it easier for parents not to feel singled out or questioned. One motherexplained how she experienced receiving the questionnaire: “She just showed me the questionnaire and said
that this is something we always do, everybody gets thisform, it’s not just you. It’s standard” (mother, interview
person 12).
The questionnaire as a bridge to a dialogue

The questionnaire was a starting point for discussion
and reflections. The structured questions provided specific response alternatives, and the parents felt that being
asked the same questions on several occasions provided
opportunities for further reflection and consideration.
Structured questions provide specific answers

The parents described how the structured questionnaire
opened the door to more in-depth reflections in contrast to more generally framed oral questions about thefamily’s well-being. One mother highlighted the universal approach: “She introduced it [the questionnaire] assomething universal, something voluntary, and something important” (mother, interview person 7).
Parents described that broad questions about wellbeing, such as “how are things at home?”, encouraged
responses that were general and less reflecting. The
structured questions in the SEEK model facilitated forthe parents to both reflect over and describe their situation in a dialogue with the nurse:“If our nurse hadn’t asked these questions, I don’t
think my partner would have talked to her about
these things that she felt” (father, interview person
9).
Being asked as part of a universal routine also made iteasier to talk about problems: “It’s probably too deeply
hidden for many to tell. So, it’s easier when it happens
on a routine basis, like you need to give an answer, thenyou might let it out. I think so, it’s always easier if someone actively asks. So, that’s great. If you ask, you get anPage 5 of 10

answer. If you get a question, it makes it easier to tell”(mother, interview person 1).
The questionnaire as a starting point for discussion andreflection

The main task of the questionnaire, according to the parents, was as a starting point for dialogues, not just to get
answers without further follow-up. “It is a way to get control of the conversation. So, it’s great that the questionnaire exists, because I think about this conversation that
we had the last time, the form itself served as a starting
point for a broader conversation, where you kind of pickup different parts and feel what need there is” (father,interview person 4). The parents described how the questions opened up to reflection about factors that affected
the family in ways they previously had not reflected on orwhen they needed help: “I think it was a good conversation because that’s when this depression issue came up.
So that was sort of what we discussed. And I did get help”(mother, interview person 14).
Parents also described that the questionnaire clarified
their situation both in the dialogue with the CHS nurse
and in a longer perspective after the visit when the parents continued to reflect on their situation both individually and in further conversations with their partner. The
parents described that in some cases it might be difficult to answer the questions honestly, for example whena parent hasn’t thought about the connection between
their problems and consequences for the child’s wellbeing or when a parent was afraid of being questioned or
criticized by the nurse.
Recurrent questions provide repeated opportunities

The parents highlighted how circumstances that may
affect a family during the child’s early years of life mayvary over time and therefore appreciated that the SEEK
model repeatedly follows the families during the crucial
years of early childhood. The changing needs of the parents and their children during the early years were alsoemphasized. Answering the SEEK questionnaire at several CHC visits during the child’s upbringing made it easier for parents to express their needs and receive support
in the long run. As one father explained:“The questions come up again, and so do thethemes… exactly. It’s great, I thought that the nurses
get feedback all the time. And also… some kind ofreminder that a lot can happen during these years
as time goes by. New sides of reality and new sidesof yourself and your family” (father, interview person
4).
The parents described that it was important to explore
their needs on several occasions during their child’s firstGolsäter et al. BMC Pediatrics(2024) 24:581

years of life. The parents conveyed that they saw thechild’s first five years as a process of development for
both the child and the family and that the need for support could vary depending on the child’s developmental
phase and the family’s situation.
Feeling trust in the system and the nurse’s professional
competence

Feeling safe and confident with the CHS was a prerequisite for getting help, and many parents expected toreceive adequate support and assistance. The nurse’s professional and relational competence was important in theencounter, and trust was often created through several
encounters.
Safe and confident in receiving support from the CHS

The parents expressed a feeling of trust in the CHS as apart of the social welfare system in Sweden and in thecompetence of the nurses. They described that the SEEK
model was perceived as an accepted and well-functioning
part of the CHS. Based on their confidence in the CHS,
the parents described an expectation of being provided
with help and support when they expressed their worries through the SEEK questionnaire and the following
discussion with the nurse. One parent described having difficulties with their child: “Our daughter has a lotof emotions, and that was something that my partnerbrought up with our nurse. She helped us get in touchwith someone to talk to about the whole situation. Whenthe nurse felt that she didn’t have the skills herself, shereferred us on to someone who did. Fantastic.” (father,interview person 16). The parents described that the CHS
nurse’s caring relationship facilitated for them to express
needs and problems that arose in the family at later
health visits. A parent highlighted a feeling of security
because the nurse showed that she was available: “WhenI talked to her [the nurse] about how I was having a hardtime, she kept offering contact with family therapists andso on. So, I always felt that she was there if I needed help”(mother, interview person 11).
Trusting the nurse in the encounter

Parents described that they felt safe and confident andwere able to bring up difficult problems when they felt
trust in the nurse’s competence and ability to care, andthat this increased over time.
A father described how the mother of their child felt
during a visit: “It was a neutral person who asked thequestions, someone she felt she trusted (father, interview
person 9).
Trusting the nurse was also a path to gathering thecourage to talk about more difficult problems: “If I feelsafe to tell my nurse how I’m feeling, it’s easier, it’s a doorway to talk about other things if I feel bad… So, stress andPage 6 of 10

depression feel like the entrance, if I dare to talk about
that, then I might dare to talk about threats and violence”(mother, interview person 7).
Trust is created through several visits

The parents described that the frequent continuous
encounters with the nurse during the child’s first year
provided the conditions for developing and deepening acaring relationship if the nurse treated the parent withtrust.
“The relationship is very important. If I had a problem, I wouldn’t open up if I met a temporary nurse.
I would have waited until my regular nurse was inplace, because you have a relationship, I think therelationship is very important, so you have the courage to say that things are not going well. (mother,interview person 2)
The parents described that, in the context of this caring
relationship with the nurse, they expected to be met withmutual understanding, based on their own thoughts andexperiences and knowledge of their own situation. Trustand confidence grew over the course of years:“We have confidence in our nurse because there
are so many different areas where she shows greatcompetence, and we have gained more and more
confidence over several years… Her experience andher personality fit well with ours, and the way she
offers information is more like asking, “Can I give
you information about… what the latest studies say
about… different things” (father, interview person
16).
The relational trust created a feeling of “knowing eachother”, as a father explained:“Confidence building. You’ve been able to talk… Yes,I think she’s been good from the start, and it’s workedout great. It has felt very secure. You feel that you
almost know each other, even if you only meet oncea year or every six months” (father, interview person
10).

Discussion
This study aimed to explore parents’ perceptions of the
SEEK model at health visits in the CHS. The overarching theme SEEK provides a process-oriented framework toreceive support in parenting with a focus on child healthillustrates the parents’ favorable opinions of the SEEK
model as a way to get support through the families’ yearsof contact with the CHS.

Golsäter et al. BMC Pediatrics(2024) 24:581

The results showed that parents accept the model aspart of the CHS’s approach to health promotion. Parents showed both acceptance and understanding of the
SEEK model and showed a collective responsibility for
all children. Through a normalizing, health-promoting
approach addressed to all parents, psychosocial risk factors could be expressed by the parents and identified by
the CHS nurse. The parents highlighted the importanceof regularly asking questions to identify families in need,even if they themselves did not require support. The CHS
was felt to be a neutral arena that made it easier for parents to get early support based on their needs. Further,
the parents described that the model enabled the nurse
to capture the family’s changing situation and needs overtime.
Acceptance and understanding of the SEEK model in the
CHS

The parents in the present study described good general acceptance and understanding of the SEEK model
as a natural part of the CHS’s overall health-promoting
work focusing on relevant aspects of the child’s andthe parents’ life situation. The model reinforced andenhanced the CHS nurses’ parental supportive work andcould strengthen a child’s health and development. This
description is in accordance with the overall aim of thenational CHS program in Sweden [16].
The parents thought that the SEEK model facilitateddiscussions about sensitive topics concerning the childand the parents’ situation by using the same questions for
all parents. In another study [21], mothers also expressedthe value of using the same questions with all parents
regarding questions about intimate partner violence in
the CHS context. The mothers highlighted the importance of offering the same questions to everyone to avoid
the feeling of being singled out [21], which was also evident in the present study. The parents’ thoughts were also
in line with results from a study among Swedish CHS
nurses, who found that the SEEK model fit well into the
CHS program and that it was valuable in identifying families in need of extra support [17]. In the United States,
the SEEK model was also described as useful in helping
health professionals reach families with psychosocial risk
factors [22]. In a recent study, parents expressed a highdegree of acceptability for universal screening for psychosocial risk factors among all parents in the context ofwell-child visits, findings that are in line with those of ourstudy [11].
Selvaraj et al. [23] highlighted the need for regular
screening for risk factors to enable parents to talk about
their situation and needs, as readiness to disclose problems may come after several encounters. Parents also
described the SEEK model as a way to open up valuable
conversations about topics that are not usually discussed

Page 7 of 10with parents [22]. As the family’s situation and needs
often change over the course of the child’s first years oflife, the parents in the present study and the parents inthe study by Selvaraj et al. [23] described the advantage ofreiterating screening instruments at different time points.
This indicates the need for repeated universal screening
during childhood. As the national CHS program in Sweden is based on many age-related health visits, the SEEK
model can be used several times within the framework of
the program [16].
The questionnaire as a bridge to a dialogue

The SEEK model applies a holistic perspective, where thechild and family are seen in a common context. The parents understood that the questions were provided for thesake of all children in the municipality, especially thosechildren in need of support. The questionnaire, offered
to all parents, normalized the procedure and was perceived as a good starting point for an in-depth conversation. This is well in line with the contextual dimension ofhealth and wellbeing and a socioecological understanding that focuses on the child in different contexts linking
the individual and their surrounding environment [24,25].
The parents felt that the questionnaire opened up for
dialogue where it was possible to discuss family problems and concerns regarding the child. Parents explainedthat they answered because the questions were asked,
and some explained that they probably would not havebrought up the issue if they hadn’t been asked directly.
Therefore, this study suggests that asking direct questions
provides answers that likely would not have been offeredspontaneously. Continuous health dialogues are in accordance with the aims of the CHS [16], and such dialogues
provide guidance and understanding as well as space forchildren’s and parents’ involvement [26]. In one study[27], CHS nurses highlighted that using a questionnaire
can lead to more responses regarding sensitive issues
compared to asking verbal questions in a conversational
form. Simply asking such questions demonstrates to theparent that the conversation is essential and that it is permissible to talk about the issues [27].
The SEEK model was a way to include aspects suchas intimate partner violence, family finances, and alcohol use that the CHS nurses previously did not usually
discuss with parents. Modern health promotion work
includes the whole family, which places increasingly
complex demands on the nurse’s competence to communicate about and meet different needs. It is of vital importance to individualize the support and advice offeredaccording to the specific needs of each parent and child.
Fathers were offered individual “partner visits” with thenurse, which they found positive. Paternal mental healthis intimately associated with child mental health andGolsäter et al. BMC Pediatrics(2024) 24:581

developmental outcomes from birth and throughout thechild’s lifespan [28] underscoring the importance of identifying fathers in need of help.
Parents reported that the CHS nurse offered referrals toother professionals, such as a psychologist or other mental health professional, based on factors that emerged in
the SEEK- based dialogue. Thus, connecting parents withother resources that can support them was a result of the
SEEK model and all professionals were seen as a pool ofresources. Our findings showed that the positive attitudeand competence of the CHS nurse were crucial in creating a supportive climate and initiating dialogues with theparents, even about difficult and demanding issues.
Feeling trust in the system and the nurse’s professional
competence

The study showed that an important prerequisite for the
CHS to function as a supportive environment was thatparents felt trust in the CHS nurse and the CHS as anarena. According to the parents’ experiences, the CHS
was an important and neutral setting for health promotion and family support. Feeling trust in the nurse andthe system was an important cornerstone. Trust was built
through a process of dialogue over the course of several
visits during the child’s early years. Trust enabled the parents to express needs and receive support.
Several parents highlighted that there were many challenging changes and demands during their child’s earlyyears. Being able to meet and support families with complex needs placed demands on the nurse’s competence.
Studies have identified the importance of early life experiences for people’s health throughout the life course,and studies have established the link between adverse
childhood experiences (ACE) and ill-health in adulthood [29, 30]. ACEs include harms that affect children
directly, such as neglect, and indirectly through theirhome environments, such as household financial problems and parental substance abuse. Children with ACEs
suffer from more physical and mental health problems
as adults compared to those without ACEs [31]. Counteracting childhood stressors is thus crucial to finding
ways to counteract later ill-health. The parents in ourstudy felt that the CHS nurse could strengthen theirparenting skills by providing adequate knowledge andindividualized support to increase psychological wellbeing. One study supporting parents during the first two
years found that parents prefer support that is tailoredto their personal needs and practices based on a trusting relationship between healthcare professionals andparents [32]. The concept of trust is in accordance with
an empowerment approach, which is about promoting
individuals’ health and quality of life through support
that strengthens the individual’s control over factors that
affect their family life [33, 34]. How the parents perceived

Page 8 of 10

the competence and skills of the CHS nurse in this study
and the extent to which they trusted the nurse to act andsupport them, influenced what they brought up in theencounter. According to Bidmead et al. [35], nurses needto make the parent feel safe, highlighting kindness, reliability, empathy, openness, and honesty as essential qualities in the meeting to help the parent to open up and behonest. The present study showed that through trust andcontinuity, the CHS nurse was able to raise awareness of
issues that affect children, and many parents themselves
were able to reflect on the consequences and change theiractions for the benefit of the child.

Methodological considerations
This study’s results should be reflected in relation to its
limitations. Parents visiting the CHS during a time periodof approximately 6 weeks were informed about the study
by the CHS nurse. Those who were willing to participate in the study gave their consent to be contacted byresearchers.
We lack data on how many parents were asked andhow many refused, but all parents who were contacted
agreed to participate. The data collection was limited toparents living in two of Sweden’s 21 counties, and all parents were born in Sweden. The fact that we did not reach
immigrant families is a disadvantage. Earlier studies showthat immigrant parents to a lower degree feel trust in thehealth care system [36]. Thus, further studies including
immigrant parents are needed. However, both mothers
and fathers participated, and both well-functioning parents and parents in need of extra support from the CHS
took part in the interviews, which could be seen as astrength as we to some extent also gathered experiencesfrom parents in need of extra support.
Potential sources of bias include the recruitment process, which may have led to inclusion of the parents who
were mostly positive to the SEEK model and the CHS asa whole, while more critical parents may have declined
participation. We cannot assess the extent to which thismay have affected the results, but the possibility must be
acknowledged.
The three interviewers used a semi-structured interview guide to ensure that the interviews were conductedin a similar way. The data gathered were rich in describing the parents’ various experiences and thoughts about
taking part in the SEEK model during their regular visits to the CHS. To ensure the trustworthiness of the data
analyses, two of the authors (MG and ER) performed theanalysis in an ongoing reflexive discussion as describedby Braun & Clarke 2022. Quotes from the parents’descriptions were used to further describe the content
of the themes. The authors who conducted the analysis
had no personal experience of the SEEK-based conversations and thus no preconceptions, which may haveGolsäter et al. BMC Pediatrics(2024) 24:581

contributed to a more open approach in the data analysis.
The research team consisted of two registered specialist
nurses, one pediatrician and one social worker, contributing to interdisciplinary perspectives in the analysis. All
authors collaborated in the analysis and were involved innegotiating the findings.

Conclusions
The study showed that parents are both accepting andunderstanding of the SEEK model. They perceive that themodel provided a way to initiate recurring opportunities
for dialogue about the family’s situation and to receive
support if needed throughout the child’s first years of life.
Implications for clinical practice

As part of the CHS’s efforts to promote health, the parents demonstrated acceptance and comprehension of the
SEEK model and its aims. The parents’ comments madeit clear that use of the SEEK model in the CHS provides
an ideal opportunity to address psychosocial issues inorder to improve clinical practice and promote children’s
health.

Supplementary Information

The online version contains supplementary material available at https://doi.
org/10.1186/s12887-024-05064-8.
Supplementary Material 1
Acknowledgements
The authors would like to thank all participating parents.
Author contributions
ME, MG and ER conducted the data collection. MG and ER analyzed the data
and wrote the main manuscript, and all authors (MG, ER, ME and SL) reviewed
the manuscript. MG and ER contributed equally and are both considered firstauthors.
Funding
This work was supported by the World Childhood Foundation [grant numbers
15814], the Children’s Welfare Foundation, the Uppsala-Orebro Regional
Research Council [grant numbers RFR 930686], and Uppsala County Council
Grants for Healthcare Research.
Open access funding provided by Uppsala University.
Data availability
Availability of Data and materials. The dataset supporting the conclusionof this article is not publicly available due to ethical reasons. The data are
available from the corresponding author upon reasonable request.

Declarations
Ethics approval and consent to participate
Before each interview, the parents received both written and oral information
about the aim of the study and the study procedure. The information specified
that participation was voluntary and that their choice to participate or not
would not affect their forthcoming care at the CHS. Before the interview
started, the interviewer repeated the study information verbally. The study
is part of a larger study of the SEEK model and has been approved by the
Regional Ethical Review Board in Uppsala, Sweden, Dnr 2017/009.

Page 9 of 10

Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 5 December 2023 / Accepted: 6 September 2024

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