Author: admin

An epidemiological cross-sectional study design was used, and data were collected from autumn 2021 until summer 2022 through an online questionnaire (Additional file 1).

Recruitment process

The recruitment process for the data collection started in spring 2021. Contact was made with Swedish companies (n = 15) in the private sector and with various trade unions (n = 15), primarily representing employees working in the private sector, to reach currently working individuals. Information about the study was provided at follow-up meetings and through emails. Private employers who agreed to support the project provided the employees’ email addresses. Unionized employees were invited to the survey through their trade union representatives via newsletters and emails. Municipalities and regional authorities (n = 136) were contacted to recruit participants working in the public sector in the same manner. The number of individuals recruited was insufficient to address the research questions. Therefore, a web panel (the Norstatpanel) was utilized to expand the sample size. The Norstatpanel consists of individuals who have been randomly contacted via telephone and subsequently agreed to participate in the overall panel. The panel is broadly representative of the population and has a nationwide scope [26]. Participants were recruited based on their match to the specified target population, defined as individuals aged 18 years or older who were currently working.

Data collection

The data were collected from three different sources at three time points. The initial data collection commenced in November 2021, and a second data collection phase was initiated in April 2022. The third data collection based on the Norstatpanel commenced in May 2022. Detailed information about the study, including ethical considerations and unique links to the questionnaire, was sent directly to employees in private companies and public organizations via email. Open-ended links were sent to union members via trade unions through newsletters and emails. The survey was concluded in August 2022. Two reminders were sent during each data collection period. Respondents were required to identify themselves using an e-ID to participate in the survey. The number of respondents from the first data collection was 397; there were 3764 and 6119 respondents from the second and third data collections, respectively, resulting in a total of 10 280 respondents.

Study population

The target population consisted of individuals aged 18–75 who reported being currently working. The inclusion procedure is presented in Fig. 1. Respondents not currently in active labour were excluded (n = 46). The data used in the descriptive statistics and statistical analyses were based on excluding cases with missing data for gender (n = 7) and the non-binary group (n = 37). For the Capacity to Work instrument (C2WI), we excluded response option 5 in any of the statements, as the combination “don’t know/not relevant” made it unclear (n = 1416). Those with items missing at random (n = 191) and those with internal data missing (n = 121) were also excluded. The proportion of women (58%) and men (42%) in the final study sample (n = 8462) was compared with that of the general working population and found to be similar (54% women and 46% men) [27].

Survey and instruments

The online survey included questions regarding sociodemographic characteristics and utilized instruments relevant for assessing the association between self-perceived mental well-being and work capacity (Additional file 1).

Dependent variable

The C2WI was developed to capture the different aspects of CMD-related work capacity [25]. In this study, it was applied as an indicator of strained work capacity. Capacity to work was measured through 14 statements (Additional file 2), such as “Thinking has been tough and slow”, “I have had to choose to not do free-time activities to have energy to work”, and “I have felt wound up”. Each statement had four response options: “not at all” (1), “to a low degree” (2), “to a moderate degree” (3), “to a high degree” (4). The minimum score for the C2WI was 14 (score 1 for 14 items) and the maximum score was 56 (score 4 for 14 items). For the descriptive statistics, scores were dichotomized at the 75th percentile (≥ 32) (range 14–56). The higher the scores, the more strained the work capacity. A continuous variable was used for the regression analyses. Cronbach’s alpha was 0.92.

Independent variable

The World Health Organization’s 5-item Well-Being Index (WHO-5) is a generic tool designed to measure subjective mental well-being [28], and the Swedish version of the WHO-5 has been deemed psychometrically sound [29]. The WHO-5 uses positively framed statements: ”I have felt cheerful and in good spirits”, “I have felt calm and relaxed”, “I have felt active and vigorous”, “I woke up feeling fresh and rested”, and “My daily life has been filled with things that interest me”, with response options ranging from “at no time” (0) to “all of the time” (5) on a 6-point Likert scale. Scores were summed and multiplied by four to form a scale from 0 (lowest) to 100 (highest). For the descriptive statistics, scores were dichotomized at the 25th percentile (≤ 44). Lower scores indicate reduced mental well-being. A continuous variable was used in the regression analysis. Cronbach’s alpha was 0.89.

Covariates

Sociodemographic characteristics such as age, education, and occupational class influence working conditions and access to health-supporting resources, which are associated with risks of work disability [14,15,16]. Mental well-being, general health status, and the presence of long-term health conditions are closely linked to perceived work capacity [18,19,20]. Finally, working positions such as work sector, managerial position and working time were added [21, 22].

The respondent’s birth year was recalculated into age, ranging from 18 to 74 years, and recoded into the categories: 18–34, 35–54, and 55–74 years. In Sweden, the official retirement age is 67 years. Thereafter, an employee may continue working until 69 years of age, and beyond that age, upon mutual agreement between the employee and the employer. Level of education was recoded into four categories: compulsory or lower secondary school, upper secondary school, post-secondary school, and university or higher education. Occupational class was determined using the Swedish Standard for Swedish Occupational Classification (SSYK2012) [30]. SSYK is based on a four-level hierarchy and was recoded into four categories: non-manual high-skilled; non-manual low-skilled; manual high-skilled, and manual low-skilled as an indicator of occupational class.

General health status was assessed with one question from the from the 36-Item Short Form Survey (SF-36) [31]: “In general, how would you describe your health?” with response options ranging from “very good” (1) “ good” (2), “fair” (3), “poor” (4) and “very poor” (5). The categories were recoded into three levels: low (“poor, very poor” (1), moderate (“fair”) (2), and high (“good, very good”) (3).

A question on long-term health conditions encompassed 12 different disease groups. Respondents could select multiple disease groups. We created four groups: (i) none of the listed disease groups, (ii) mental health conditions only, (iii) mental health conditions combined with other long-term health conditions, and (iv) other long-term health conditions only [32].

Work sector was categorized as public, private, or other. The category “other” was deemed too small (n = 117) and was therefore excluded.

A managerial position provides occupational prestige and increased job autonomy, both of which positively affect job satisfaction [33]. At the same time, gender inequality regarding the benefits associated with managerial roles has been identified and was therefore included. Managerial position was measured as a binary variable (“yes” or “no”). Female employees are more likely to work part-time than men [34]. This phenomenon is more prevalent in female-dominated occupations and is partly driven by occupational segregation [35]. Working part-time or full-time was measured as a binary variable (“yes” or “no”).

Statistical analysis

Data analyses were performed using IBM SPSS Statistics 29.0.2.0 [36]. The baseline characteristics are presented as proportions with 95% confidence intervals (95% CI).

Descriptive and inferential methods were employed to assess mental well-being and work capacity. Building on previous research on mental well-being in a population sample, this study adopted the same approach, using a cutoff score at the first quartile [37, 38]. As the C2WI is a newly developed instrument, we applied the same method. With a high score reflecting a negative outcome, the scale was dichotomized at the third quartile (Additional files 3 and 4).

Univariable linear regression was conducted to examine the individual associations between mental well-being, each covariate, and work capacity. This approach allows for an initial assessment of the strength and direction of the relationship before adjusting for potential confounders in the multivariable models. The assumption of linearity between the continuous independent variable and the dependent variable was assessed using residual plots and found to be acceptable. The regression analyses were performed with the C2WI as the dependent variable and mental well-being (WHO–5) as the independent variable. Both entered as continuous variables. Age, level of education, general health, long-term health conditions, occupational class, work sector, managerial position and working time were entered as categorical variables. Long-term health conditions were grouped into two groups: No (none of the listed disease groups) and Yes (mental health conditions only and mental health conditions combined with other conditions). Long-term health conditions only were excluded.

In Model I, adjustments were made for sociodemographic characteristics. In Model II, adjustment was made for general health, long-term health conditions, and the variables in Model I. Based on regression analysis, we present the unstandardized regression coefficient (B), and the corresponding 95% CIs.

When tested with Chi2 analysis, we found a statistically significant difference in the distribution of work capacity scores between genders. In addition, it is well-documented that industrial countries reflect a traditional divide through occupational segregation, which warrants analytical consideration [35, 39]. The normality of the residuals was confirmed by examining the variation inflation factors and tolerances. No problems with multicollinearity were noted between the variables.

ALSO READ: Should you floss before or after brushing? Dentist shares what your ideal oral care routine should be

The study, published in the Journal of the American Heart Association on August 6, 2025, identified mouth bacteria as one of the causes. Shocking? Yes, as per the researchers, the bacteria can trigger a chain reaction that impacts the arteries and subsequently causes a heart attack. This addition to the list of risk factors demonstrates how intricately complicated, interconnected and multifaceted the cardiovascular system is. So you cannot let your guard down just because you are eating healthy and exercising daily.

Which bacteria?

The bacteria the team of researchers identified were viridans streptococci. Normally, they are present in the mouth, and during brushing or chewing, they can enter the bloodstream. From here, the simple bacteria turn into a major health hazard as they settle in atherosclerotic plaques and form biofilms. Biofilms are bacterial communities with shields that antibiotics can’t reach and sometimes even immune cells (macrophages) can’t detect.

For the uninformed, plaque is a buildup on the artery walls, causing them to narrow and block blood flow. So, in other words, bacterial community (biofilms) form inside the arterial plaques, and the immune system can’t catch them because they are inactive.

What’s even more concerning is that these biofilms were present in over 40 per cent of coronary plaques from sudden death victims and patients undergoing surgery.

Next, the researchers explained that these bacteria stay dormant and then ‘wake up,’ making them visible to the immune system and, in turn, causing inflammation. This inflammation then causes a rupture of these plaques and can trigger a heart attack.

What does it mean?

The implications of this finding is clear that oral hygeine matters more than ever. They cannot be neglected as heart attacks are not only restructed to triggers like stress or cholestrol. Oral bacterial infections are also a silent trigger. So even a healthy person who may be neglectful with their oral care may be at the risk of heart failure. So no, you can’t skip out on oral hygiene essentials like brushing, as it would also safeguard your heart health.

Note to readers: This article is for informational purposes only and not a substitute for professional medical advice. Always seek the advice of your doctor with any questions about a medical condition.

The findings of this study highlight that preschool teachers perceived themselves and the preschool environment as important facilitators for promoting physical activity in the early years. Teacher involvement emerged as a key factor in motivating children to engage in physical activity, particularly in children who do not naturally enjoy it. Dialogue and collaboration between parents and preschool teachers was also important for fostering healthy lifestyle behaviour among children. Moreover, face-to-face support such as inspirational lectures or education days, which also could be complemented by a digital support tool, were seen as valuable for increasing awareness and motivation among educators to promote healthy lifestyle behaviours. Furthermore, such a combined approach was highlighted as particularly beneficial for supporting educators with lower engagement or interest in physical activity. Finally, participants perceived the sections on physical activity in the preschool curriculum as vague and difficult to interpret and expressed a need for a revision to better support the promotion of physical activity.

The results of this study are in line with a systematic review of qualitative literature by Hesketh et al., exploring barriers and facilitators for physical activity in children aged 0–6 years [23]. Similar to the current study, Hesketh et al. [23] found that childcare providers in preschool settings are essential for promoting physical activity in children. Not only the providers’ skills in engaging the children were highlighted as important, but also the providers’ own physical activity behaviours [23]. Interestingly, the role of teachers for preschool-aged children’s physical activity levels was also confirmed in a systematic review including objectively measured physical activity [24]. Tonge et al. found correlations between children’s physical activity and the presence and skills of educators, suggesting that active involvement and engagement may be important aspects, but found no studies investigating this [24].

Additionally, in a qualitative study by Ek et al. [25], Swedish preschool teachers underscored the impact of their own attitudes, interest and engagement in physical activity on children’s level and intensity of physical activity. Furthermore, the impact of the outdoor and indoor preschool environment on children’s physical activity has been addressed by previous research [23, 24, 26], emphasizing the importance of space as well as portable and fixed equipment for promoting physical activity, which is in line with the current study.

One perceived barrier for increasing children’s physical activity was the preschool curriculum and daily scheduling, which were described by the participants as more focused on school preparatory subjects rather than on physical activity. This aligns with Mak et al. [27] who reviewed strategies for promoting physical activity in the preschool setting and suggested that such prioritization may be explained by limited knowledge among decision makers about the importance of physical activity in young children. Indeed, the Swedish government recently called for the need to strengthen and clarify the guidance on physical activity in the preschool curriculum in order to emphasize the importance of integrating movement into daily routines [28, 29] and a new curriculum is planned to be published in 2025 [29]. Participants in the current study voiced that revising the sections on physical activity in the curriculum could be a way to motivate teachers to engage children in more physical activity, especially teachers with low interest in this area. Also, some respondents believed that moderate-to-vigorous physical activity is obtained when children play spontaneously, while others thought structured, teacher-led exercise is required. This highlights the importance of providing training and guidance for educators on what moderate-to-vigorous physical activity is and how it can be effectively integrated into everyday preschool routines. Furthermore, there was a lack of clear policies for physical activity among the participating preschools. This is noteworthy, as formal physical activity policies in Swedish preschools have been found to be associated with more active children, compared to preschools without policies [30]. Hence, a clear preschool curriculum as well as having local physical activity policies in place are essential to ensure an effective approach to promote healthy movement behaviours in young children. It is important to note that preschool systems across countries may differ and that the generalizability of the results regarding the Swedish curriculum and policies may be limited to countries with similar preschool systems as Sweden. However, having clear policies or guidelines for the preschool staff may contribute to healthier lifestyle behaviours in preschoolers, regardless of country, and we can also learn from each other’s systems.

With regards to screen time in the preschool setting, Ek et al. [25] found that teachers expressed concerns about the requirement to integrate screens into the daily routine, even before the publication of the WHO movement guidelines for young children [2]. Thus, although integrating screens into preschool routines was in accordance with the preschool curriculum at that time, teachers questioned the use of screens as they saw no educational benefit or believed it would be challenging for young children to learn how to use them [25]. Notably, this requirement has now been removed from the preschool curriculum, suggesting that these concerns were well-founded. Furthermore, participants in the present study emphasized that teaching children how to use screens is not the responsibility of preschools. It is also relevant to note that the planned update to the preschool curriculum will emphasize that preschools should be free from screen time [29].

In terms of sleep, participants highlighted that it is common for parents to stop allowing their child to nap at preschool, which was reported a barrier for supporting and promoting healthy sleep routines. This parental preference aligns with findings from a questionnaire-based study in Australian parents, which found that parents favoured putting their child to bed early over ensuring that their child naps at preschool [31]. Interestingly, teachers and principals in the current study believed that downtime is crucial for children’s recovery and described it as a natural part of the preschool schedule. Similarly, Hesketh et al. [23] found that childcare providers repeatedly stressed the importance of children having downtime. While other sedentary activities during downtime, such as reading, are known as being important for children’s development, both studies highlighted the significance of downtime itself. Currently, the WHO guidelines [2] include napping as part of the 10–13 h of daily sleep recommended; however, the benefits of downtime in the preschool setting are not clearly supported by current evidence. Therefore, more research is needed on possible advantages of downtime for recovery in the preschool setting.

Although it was emphasized that selective eating occurs to a small extent and that it is important to encourage all children to try new vegetables and foods, eating behaviours in the preschool setting were not considered challenging. Similar to our findings, qualitative data from early childhood teachers in Portugal, where preschool meals are also provided, highlighted that teachers are important role models for healthy eating behaviours in children [32]. They also expressed that the healthy meals provided at preschools may compensate for poor eating habits at home [32]. Together, this suggests that when healthy meals are provided within the preschool setting, teachers are not concerned about children’s eating behaviours in the preschool environment.

Participants in the current study expressed interest in being supported in promoting healthy movement and eating behaviours through inspirational lectures. Also, having a library of activities easily accessible, for instance in an app, was desired, especially to facilitate physical activity promotion for teachers with a low interest in physical activity. In the study by Ek et al. [25], teachers were also interested in an app to promote physical activity; however, they emphasized the particular need for it in situations where spontaneous activity is restricted, such as on days spent mostly indoors or when space is limited. Taken together, this highlights the need for a support that offers concrete, practical guidance tailored to the preschool setting.

Strengths and limitations

This study has several strengths. First, performing the interviews using video calls enabled participation from multiple regions in Sweden, increasing the geographic range of the sample. Additionally, conducting the interviews in a familiar setting may have encouraged participants to speak more openly about their experiences and perspectives [33]. The study was further strengthened by the inclusion of participants from a wide range of preschool contexts across Sweden, capturing experiences from different settings. Furthermore, participants’ levels of education and years of work experience varied, contributing to a broad range of perspectives. A potential limitation is related to sample characteristics, as it is possible that the teachers and principals agreeing to participate had a specific interest in healthy lifestyle behaviours. Hence, perspectives from teachers and principals that are less engaged in this topic may be underrepresented. However, as most of those invited chose to participate (15 out of 18), the risk of selection bias appears small. Nevertheless, this study provides valuable insights and perspectives of preschool teachers and principals on promoting healthy lifestyle behaviours, and findings contribute to the evidence on how to best support preschools in fostering healthy lifestyle behaviours.

To ensure the trustworthiness of this study, established criteria for qualitative research were followed, including credibility, dependability, and transferability [21]. Credibility was strengthened through data triangulation using purposive sampling, ensuring that participants represented diverse perspectives (e.g. various regions, urban and rural locations, and women and men). Additionally, a wide age range (31–64 years), and participant triangulation via including two levels of respondents (principals and teachers) provided nuanced experiences. The semi-structured interview guide ensured consistency across interviews while also leaving room for individualized questions. Additionally, credibility was strengthened by investigator triangulation, as researchers with different expertise (nutrition and physiotherapy) developed the interview guide and analysed the data. Dependability was accomplished by having the same researcher conduct all interviews, ensuring consistency. The interviews were audio-recorded to assure no details were lost. Transferability of the findings was supported through a detailed study description of participants and the preschool settings. Finally, to further increase trustworthiness, COREQ [20] was used to confirm that all necessary aspects of the study were reported.

Implications

The findings of this study indicate the need for a clearer curriculum and preschool policies to better support physical activity in the preschool setting. Notably, the Swedish government has announced that an updated preschool curriculum will be published in 2025, with a strengthened emphasis on increasing physical activity and reducing screen time. Our results support this direction, as participants expressed a need for more concrete and practical guidance to promote healthy movement behaviours. The results also indicate a need for evidence-based support tailored to the preschool setting as the level of encouragement is highly dependent on individual knowledge and interests among preschool teachers. Decision makers should include clear guidance on supporting healthy movement behaviours in the preschool curriculum and local policies to ensure consistency across preschools. In addition, we suggest that the curriculum highlight the importance of physical activity in early childhood for long-term health. Strengthening this may help boost teachers’ motivation and the prioritization of physical activity in the preschool setting.

Strategies for effectively integrating physical activity into daily routines are also warranted. Workshops, lectures, and providing teachers with concrete approaches to encourage physical activity should be prioritized in such strategies. Furthermore, a digital tool for promoting healthy lifestyle behaviours, combined with face-to-face support, align with needs and preferences of preschool teachers and principals, proposing a broad support to fit all preschool settings. Preferably, such a tool should be developed through a co-design process [34] together with teachers, principals and parents. In addition, encouraging collaboration between preschools and parents is essential in shaping healthy lifestyle behaviours and future initiatives should aim to strengthen the communication between them to ensure a unified approach towards healthy lifestyle behaviours. Taken together, addressing these gaps is crucial to ensure that all children, receive the best possible opportunities for healthy movement behaviours throughout childhood.