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Key features: 

• The Northern Sweden Health and Disease Study (NSHDS) was initiated in the mid-1980s. The NSHDS is a population-based prospective longitudinal cohort comprising >140 000 participants in the two northernmost regions in Sweden, Norrbotten and Västerbotten, with >240 000 blood samples and 1.5 million person-years of follow-up.
• The NSHDS includes three sub-cohorts: the Västerbotten Intervention Programme (VIP), the expanded Northern Sweden Monitoring of Trends and Determinants of Cardiovascular Disease (MONICA) Study, and the Mammography Screening Project (MSP). The VIP is both a community-based cardiometabolic intervention programme encouraging healthy lifestyle (targeting individuals 40, 50, and 60 years of age), and a corresponding research cohort. The MONICA is an observational study focusing on cardiovascular disease and its associated risk factors, recruiting individuals aged 25–74 years. The MSP recruited women attending mammography during 1995–2006. The NSHDS median participation age is 50 years (53% women).
• Most participants contribute data on health, lifestyle, anthropometric measures, blood pressure, blood lipids, and glucose tolerance, along with research blood samples that are fractionated, frozen within an hour of collection, and stored at –80°C. Linkage to registries, clinical cohorts, and biological tissue archives facilitates studies of well-characterized participants (often combined with intervention studies).
• Collaborations are encouraged. Additional information can be found at: info.brs@umu.se; https://www.umu.se/en/biobank

PURPOSE: Education and feedback on hypertension management has been associated with improved hypertension control. This study aimed to assess the effectiveness of such interventions to reduce the risk of stroke and cardiovascular events. MATERIALS AND METHODS: Individuals ≥18 years with a blood pressure (BP) recording in Västerbotten or Södermanland County during the study period 2001 to 2009 were included in 108 serial cohort studies, each with 24 months follow-up. The primary outcome was risk of first-ever stroke in Västerbotten County (intervention) compared with Södermanland County (control). Secondary outcomes were first-ever major adverse cardiovascular event (MACE), myocardial infarction, and heart failure, as well as all-cause and cardiovascular mortality. All outcomes were analysed using time-to-event data included in a Cox proportional hazards model adjusted for age, sex, hypertension, diabetes, coronary artery disease, atrial fibrillation, systolic BP at inclusion, marital status, and disposable income. RESULTS: A total of 121 365 individuals (mean [SD] age at inclusion 61.7 [16.3] years; 59.9% female; mean inclusion BP 142.3/82.6 mmHg) in the intervention county were compared to 131 924 individuals (63.6 [16.2] years; 61.2% female; 144.1/81.1 mmHg) in the control county. A first-ever stroke occurred in 2 823 (2.3%) individuals in the intervention county, and 3 584 (2.7%) individuals in the control county (adjusted hazard ratio 0.96, 95% CI 0.90 to 1.03). No differences were observed for MACE, myocardial infarction or heart failure, whereas all-cause mortality (HR 0.91, 95% CI 0.87 to 0.95) and cardiovascular mortality (HR 0.91, 95% CI 0.85 to 0.98) were lower in the intervention county. CONCLUSIONS: This study does not support an association between education and feedback on hypertension management to primary care physicians and the risk for stroke or cardiovascular outcomes. The observed differences for mortality outcomes should be interpreted with caution.

Introduction: The Västerbotten Intervention Programme (VIP) in the Region Västerbotten Sweden is one of the very few cardiovascular disease (CVD) prevention programmes globally that is integrated into routine primary health care. The VIP has been shown as a cost-effective intervention to significantly reduce CVD mortality. However, little is known about the effectiveness of a digital solution to tailor risk communication strategies for supporting behavioral change. STAR-C aims to develop and evaluate a technical platform for personalized digital coaching that will support behavioral change aimed at preventing CVD.

Methods: STAR-C employs a mixed-methods design in seven multidisciplinary projects, which runs in two phases during 2019–2024: (i) a formative intervention design and development phase, and (ii) an intervention implementation and evaluation phase. In the 1st phase, STAR-C will model the trajectories of health behaviors and their impact on CVDs (Project 1), evaluate the role of the social environment and social networks on behavioral change (Project 2) and assess whether and how social media facilitates the spread of health information beyond targeted individuals and stimulates public engagement in health promotion (Project 3). The findings will be utilized in carrying out the iterative, user-centered design, and development of a person-tailored digital coaching platform (Project 4). In the 2nd phase, STAR-C will evaluate the implementation of the coaching programme and its effectiveness for promoting behavioral change and the spreading of health information across social networks and via social media (Project 5). The cost-effectiveness (Project 6) and ethical issues (Project 7) related to the coaching programme intervention will be evaluated.

Discussion: The STAR-C research programme will address the knowledge and practice research gaps in the use of information technologies in health promotion and non-communicable disease (NCD) prevention programmes in order to narrow the health inequality gaps.

Ethics: STAR-C has received approval from the Swedish Ethical Review Authority (Dnr. 2019-02924;2020-02985).

Dissemination: The collaboration between Umeå University and Region Västerbotten will ensure the feasibility of STAR-C in the service delivery context. Results will be communicated with decision-makers at different levels of society, stakeholders from other regions and healthcare professional organizations, and through NGOs, local and social media platforms.

Aim: The aim was to investigate assistant nurses’ perceptions of how working with national quality registries affected their work situation in care of older people.

Design: Qualitative interview study.

Methods: Sixteen semi‐structured interviews were conducted at four special housing units in Sweden, and a conventional content analysis, with elements of thematic analysis, was applied.

Results: The introduction of national quality registries contributed to role clarifications and the development of new formal work procedures in terms of documentation and arenas and routines for communication. The increased systematics and effectiveness gained from these changes had a perceived positive effect on the work situation, workload, work satisfaction, staff interactions and learning and reflection.

Uppdrag: I denna rapport sammanfattas det regeringsuppdrag som Länsstyrelsen Västerbotten haft under åren 2019–2021. Syftet med uppdraget var att utveckla metoder och arbetssätt för samordning av ett regionalt arbete för en god och jämlik hälsa utifrån bestämningsfaktorerna i de åtta målområdena, med målet att skapa bättre förutsättningar för det lokala främjande och förebyggande folkhälsoarbetet i länet. 

Genomförande: Uppdraget har genomförts i nära samarbete mellan Länsstyrelsen Västerbotten, Region Västerbotten och Umeå Universitet. Tillsammans har dessa tre aktörer genomfört en omfattande och noggrann inventering av förutsättningarna för lokalt och regionalt folkhälsoarbetet i länet, vilken har legat till grund för aktiviteter som genomförts och processer som startats under pilotprojektets tid. Detta innefattar i huvudsak kommunbesök, dialoger, samverkanskonferenser, utbildning i folkhälsa och folkhälsoarbete, studiebesök till Bodö samt förankring och framtagande av en avsiktsförklaring för en god, jämlik och jämställd hälsa.

Resultat: Pilotprojektet har bidragit till goda förutsättning för att etablera en samordningsstruktur som stimulerar och förtydligar det gemensamma regionala folkhälsoarbetet, vilket i sin tur stärker det lokala folkhälsoarbetet. Arbetet med pilotprojektet har lett till ökad kunskap hos beslutsfattare och andra aktörer om betydelsen av och förutsättningarna för att bedriva ett folkhälsoarbete med fokus på jämlikhet. Pilotprojektet har även bidragit till att utveckla relationer, kunskaper, drivkrafter, engagemang och motivation hos länets folkhälsoaktörer. Med utgångspunkt i de lokala behoven har pilotprojektet utvecklat arbetssätt för samordning av lokalt och regionalt folkhälsoarbete. Detta arbetssätt kan sammanfattas i en modell som möjliggör för aktörer att bidra till, få hjälp med och samarbeta efter de egna förutsättningarna i syfte att stärka både det lokala och regionala folkhälsoarbetet. Västerbottensmodellen består av följande komponenter:

Lyssna – ett behovsorienterat förhållningssätt: Lokala perspektiv och behov styr hur samverkan fungerar och utvecklas för att olika aktörer tillsammans ska kunna bidra till ett gott folkhälsoarbete utifrån sina förutsättningar.

Lita på varandra – en tillitsbaserad arbetsprocess: Det behovsorienterade förhållningssättet karakteriserar såväl de externa som det interna arbetsprocesserna med en kontinuerlig dialog mellan lokala och regionala aktörer.

Göra – strukturerade metoder: Gemensamt utformade och väl förankrade metoder ger goda förutsättningar för att kunna etablera en samordningsstruktur för lokalt och regionalt folkhälsoarbete.

När pilotprojektet tar slut behövs en samordnade funktion som tar vid helheten av det pilotprojektet stått för, varför pilotprojektet tog initiativ till att bilda Forum för folkhälsa i Västerbotten. Intentionen är att Forum för folkhälsa i Västerbotten ska förvalta och utveckla de metoder och arbetssätt för regional samordning som pilotprojektet arbetat fram, vilka inkluderar: kunskapshöjande insatser, dialoger, överenskommelser, samverkanskonferenser och informationsspridning. Förhoppningen är att Forum för folkhälsa i Västerbotten kommer utgöra ett nav för samverkan som både främjar och stödjer dialog, informations- och erfarenhetsutbyte, utveckling och utbildning och bidrar till uppföljning av folkhälsoarbetet i länet. 

Importance: Elevated systolic blood pressure (SBP) is the most important risk factor for premature death worldwide. However, hypertension detection and control rates continue to be suboptimal.

Objective: To assess the association of education and feedback to primary care physicians with population-level SBP and hypertension control rates.

Design, Setting, and Participants: This pooled series of 108 population-based cohort studies involving 283 079 patients used data from primary care centers in 2 counties (Västerbotten and Södermanland) in Sweden from 2001 to 2009. Participants were individuals aged 18 years or older who had their blood pressure (BP) measured and recorded in either county during the intervention period. All analyses were performed in February 2019.

Exposures: An intervention comprising education and feedback for primary care physicians in Västerbotten County (intervention group) compared with usual care in Södermanland County (control group).

Main Outcomes and Measures: Difference in mean SBP levels between counties and likelihood of hypertension control in the intervention county compared with the control county during 24 months of follow-up.

Results: A total of 136 541 unique individuals (mean [SD] age at inclusion, 64.6 [16.1] years; 57.0% female; mean inclusion BP, 142/82 mm Hg) in the intervention county were compared with 146 538 individuals (mean [SD] age at inclusion, 65.7 [15.9] years; 58.3% female; mean inclusion BP, 144/80 mm Hg) in the control county. Mean SBP difference between counties during follow-up, adjusted for inclusion BP and other covariates, was 1.1 mm Hg (95% CI, 1.0-1.1 mm Hg). Hypertension control improved by 8.4 percentage points, and control was achieved in 37.8% of participants in the intervention county compared with 29.4% in the control county (adjusted odds ratio, 1.30; 95% CI, 1.29-1.31). Differences between counties increased during the intervention period and were more pronounced in participants with higher SBP at inclusion. Results were consistent across all subgroups.

Conclusions and Relevance: This study suggests that SBP levels and hypertension control rates in a county population may be improved by educational approaches directed at physicians and other health care workers. Similar strategies may be adopted to reinforce the implementation of clinical practice guidelines for hypertension management.

BACKGROUND: Failure to promote early detection and better management of hypertension will contribute to the increasing burden of cardiovascular diseases. This study aims to assess the gender differences in the prevalence, awareness, treatment and control of hypertension, together with its associated factors, in China and Sweden.

METHODS: We used data from two cross-sectional studies: the Västerbotten Intervention Program in northern Sweden (n = 25,511) and the Shanghai survey in eastern China (n = 25,356). We employed multivariable logistic regression to examine the socio-demographics, lifestyle behaviours, and biological factors associated with the prevalence, awareness, treatment and control of hypertension.

RESULTS: Men had a higher prevalence of hypertension (43% in Sweden, 39% in China) than their female counterparts (29 and 36%, respectively). In Sweden, men were less aware of, less treated for, and had less control over their hypertension than women. Chinese men were more aware of, had similar levels of treatment for, and had less control over their hypertension compared to women. Awareness and control of hypertension was lower in China compared to Sweden. Only 33 and 38% of hypertensive Chinese men and women who were treated reached the treatment goals, compared with a respective 48 and 59% in Sweden. Old age, impaired glucose tolerance or diabetes, a family history of hypertension or cardiovascular diseases, low physical activity and overweight or obesity were found to increase the odds of hypertension and its diagnosis.

CONCLUSIONS: This study shows the age and gender differences in the prevalence, awareness, treatment and control of hypertension among adults in China and Sweden. Multisectoral intervention should be developed to address the increasing burden of sedentary lifestyle, overweight and obesity and diabetes, all of which are linked to the prevention and control of hypertension. Development and implementation of the gender- and context-specific intervention for the prevention and control of hypertension facilitates understanding with regard to the implementation barriers and facilitators.

Objectives: On US farms, tractor overturns are the leading cause of death; however, these fatalities are preventable with the use of a rollover protection structure (ROPS). A ROPS rebate program was established in New York in 2006 to address these fatalities. Due to its success, the program expanded to six additional states before being implemented as the National ROPS Rebate Program (NRRP) in 2017. The aim of this study was to evaluate the success of the NRRP implementation using short- and long-term ROPS outcome measures and identify which components of the consolidated framework for implementation research (CFIR) correlate with these outcomes.

Methods: Stakeholders involved in the NRRP implementation were surveyed at four time points, beginning at the time of the NRRP launch and then every six months. These surveys measured 14 relevant CFIR constructs. Correlations between CFIR survey items (representing constructs) and three outcome measures (intakes, funding progress, and retrofits) were used to identify CFIR survey items that are predictive of the outcomes.

Results: Eight CFIR survey items were highly correlated (rho ≥0.50) with at least one of the three outcome measures. These eight CFIR survey items included four constructs: access to knowledge and information, leadership engagement, engaging (in fundraising and funding requests), and reflecting and evaluating.

Conclusions: The results of this study provide important guidance for continuing the implementation of the NRRP. Similarly, these findings can inform the evaluation of other similarly structured implementation efforts and the application of CFIR in a variety of settings.

BACKGROUND: Living alone is increasingly common and has been depicted as an important cause of mortality. We examined the association between living alone and mortality risks among older men and women in northern Sweden, by linking two unique longitudinal datasets.

METHODS: We used the Linnaeus database, which links several population registers on socioeconomic and health. This register-based study included 22,226 men and 23,390 women aged 50 and 60 years in Västerbotten County who had participated in the Västerbotten Intervention Program (VIP) during 1990-2006, with a total of 445,823 person-years of observation. We conducted Cox-proportional hazard regression to assess the risk of living alone on the mortality that was observed between 1990 and 2015, controlling for socio-demographic factors, chronic disease risk factors and access to social capital.

RESULTS: Older men and women who lived alone with no children at home were at a significantly higher risk of death compared to married/cohabiting couples with children at home (with an adjusted hazard ratio of 1.38, 95% CI of 1.26-1.50 in men and 1.27, 95% CI of 1.13-1.42 in women). Living alone was an even stronger factor than the well-established chronic disease risk factors and a lack of access to social capital.

CONCLUSIONS: A significant association between living alone and mortality among the older adult population in Sweden was observed. Providing good social support for older people is important in preventing the negative health impact of living alone.

A broad range of aspects are needed to be taken into consideration in the design and development of personalized coaching systems based on artificial intelligence methodologies. This research presents the initial phase of joining different professional and stakeholder perspectives on behavior change technologies into a flexible design proposal for a digital coaching system. The diversity and sometimes opposed views on content, behavior, purposes and context were managed using a structured argument-based design approach, which also feed into the behavior of the personalized system. Results include a set of personalization strategies that will be further elaborated with the target user group to manage sensitive issues such as ethics, social norms, privacy, motivation, autonomy and social relatedness.