Feasibility of a randomised controlled trial of Healthier Wealthier Families in Sweden: results from the Ameliorating Child poverty through Connecting Economic Services with child health Services (ACCESS) pilot study

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