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BackgroundThe literature has described several challenges related to the quality of diabetes management clinics in public primary health care centres in Oman. These clinics continue to face challenges due to the continuous growth of individuals diagnosed with type 2 diabetes. We sought to explore the challenges faced in these clinics and discuss opportunities for improvement in Oman.MethodsThis qualitative study was designed to include non-participant observations of diabetic patients and care providers during service provision at diabetes management clinics, as well as semi-structured interviews with care providers, at five purposively selected public primary health care centres. Care providers included physicians, nurses, dieticians, health educators, pharmacists, an assistant pharmacist, a psychologist, and a medical orderly. The data were analysed using qualitative content analysis.ResultsThe study disclosed three different models of service delivery at diabetes management clinics, which, to varying degrees, face challenges related to health centre infrastructure, technical and pharmaceutical support, and care providers' interests, knowledge, and skills. Challenges related to the community were also found in terms of cultural beliefs, traditions, health awareness, and public transportation.ConclusionThe challenges encountered in diabetes management clinics fall within two contexts: health care centres and community. Although many challenges exist, opportunities for improvement are available. However, improvements in the quality of diabetic clinics in primary health care centres might take time and require extensive involvement, shared responsibilities, and implications from the government, health care centres, and community.

Background: Globally, many models of care through which the way health services are delivered have been adopted withinteam-based primary health care. Although these models have aimed to solve some of the health care challenges related tophysician’s shortages in clinics and further acceptance of non-physician-led clinics, their application is usually determined by arange of factors, such as preparedness of the health care providers, preparedness of patients and support from higher authorities.

Objective: The study was designed to explore health care providers’ perceptions for changes in models of care in diabetes clinicsat primary health care in Muscat, Oman.

Methods: A total of 27 semi-structured interviews were conducted with health care providers involved in diabetes clinics atfive purposively selected primary health care centres in Muscat. The interviewees included the core members of the diabetesmanagement team and other supportive members available at the centres, and were of mixed genders, nationalities and professions.Qualitative thematic analysis was applied.

Results: The analysis resulted in one main theme, which captured positive responses towards task-sharing model, but revealedworries and requirements for complete implementation. Nurses’ competences and diabetic patients’ acceptance were among themain concerns. Health care providers revealed that for complete implementation of the model, nurses’ involvement in the teamcould be improved through updating their knowledge and through the provision of support from higher authorities, while diabeticpatients’ acceptance could be improved through understanding of their perceived knowledge towards the model which couldpromote nurse-led clinics.

Conclusion: Task-sharing within the discussed possibilities could provide many positive outcomes and a rewarding future fordiabetes clinics at primary health care centres. Omani culture could play a role in its implementation; therefore, if successfulimplementation is desired, carefully considered steps must be applied by the government and the community

AIM: The aim of this study is to explore the perceptions among primary health center staff concerning competencies, values, skills and resources related to team-based diabetes management and to describe the availability of needed resources for team-based approaches.

BACKGROUND: The diabetes epidemic challenges services available at primary health care centers in the Middle East. Therefore, there is a demand for evaluation of the available resources and team-based diabetes management in relation to the National Diabetes Management Guidelines.

METHOD: A cross-sectional study was conducted with 26 public primary health care centers in Muscat, the capital of Oman. Data were collected from manual and electronic resources as well as a questionnaire that was distributed to the physician-in-charge and diabetes management team members.

FINDINGS: The study revealed significant differences between professional groups regarding how they perceived their own competencies, values and skills as well as available resources related to team-based diabetes management. The perceived competencies were high among all professions. The perceived team-related values and skills were also generally high but with overall lower recordings among the nurses. This pattern, along with the fact that very few nurses have specialized qualifications, is a barrier to providing team-based diabetes management. Participants indicated that there were sufficient laboratory resources; however, reported that pharmacological, technical and human resources were lacking. Further work should be done at public primary diabetes management clinics in order to fully implement team-based diabetes management.

Objectives, setting and subjects: Atherosclerosis screening with ultrasound is non-invasive and can be used as part of risk communication. The potential of personalised and pictorial-based risk communication is assessed in VIPVIZA, a population-based randomised controlled trial that aims at optimising cardiovascular disease (CVD) prevention by investigating the impact of visualisation of subclinical atherosclerosis. The present aim was to explore cognitive and emotional reactions evoked by the intervention as well as attitudes to any implemented life style changes in VIPVIZA participants in the intervention group with improved health status and furthermore to study possible interactions between these factors. Understanding mechanisms of action was central since non-adherence to preventive guidelines are often faced in clinical practice. Design: In-depth interviews with 14 individuals were analysed with qualitative content analysis. Results: Cognitive and emotional processes were highly interlinked and described by the main theme Cognitive and emotional reactions in strong interplay for orchestration of health oriented behavioural change. The informants’ descriptions revealed two distinctly different psychological processes which constituted the two subthemes, Problem-focused coping and Encouragement-driven process. Conclusions: The results highlight that an interaction between emotional reactions and efficacy beliefs is important in facilitating behavioural change. Furthermore, the results underscore the importance of the risk message being perceived as clear, accurate, reliable and also emotionally engaging and thereby show why atherosclerosis screening and pictorial-based risk communication have the potential to contribute to effective CVD prevention strategies and shared decision making in primary care.

Background: Non-adherence in the general population to preventive guidelines on cardiovascular disease calls for an interdisciplinary approach acknowledging psychological factors of relevance for risk communication and lifestyle modification. Evidence is building up regarding the advantage of sharing arterial imaging evidence of subclinical atherosclerosis with asymptomatic individuals, but there is limited understanding of how this relates to mechanisms of importance for behavioural change. Longitudinal studies on associations between patients’ reactions and lifestyle modification are missing. The population-based randomized controlled trial VIPVIZA investigates the impact of pictorial information about subclinical atherosclerosis, added to traditional risk factor-based communication. The intervention includes a personalized, colour-coded and age-related risk communication strategy and a motivational conversation, and has been shown to reduce cardiovascular disease risk. 

Methods: In the present study we assessed cognitive and emotional reactions to the intervention, and how these reactions are associated to lifestyle modification. The participants’ evaluation of the risk communication was assessed in the intervention group (n=1749). Lifestyle modification was assessed with a lifestyle index based on physical activity, diet, smoking and alcohol consumption at baseline and after 3 years. Associations between cognitive and emotional response and lifestyle modification were tested with analyses of covariance in a subset of participants (n=714-857).

Results: The intervention increased understanding of personal CVD risk, the possibility to influence the risk, and how to influence the risk. Severity of atherosclerosis was associated with emotional reactions, but emotions of strong negative valence were uncommon. Cognitive response and emotional arousal evoked by the intervention were positively associated with lifestyle modification, whereas negative emotions in isolation were not. High level of cognitive response in combination with high level of emotional arousal was found to be most beneficial for lifestyle modification.

Conclusions: The results demonstrate the potential of communicating asymptomatic atherosclerosis with a pictorial, colour-coded and age-related strategy, also including a motivational conversation. Furthermore, the results show the importance of CVD risk communication evoking engagement, and that an interaction between cognitive and emotional reactions might be central for sustained lifestyle modification. Our results also indicate that, in an asymptomatic population, atherosclerosis screening may strengthen disease prevention and health promotion.

Childhood obesity is increasing in Sweden. All children are offered regularly spread health visits to a school nurse. As health visits include a measure of height and weight and a health dialogue, school nurses can discover, disclose, and treat a child's weight gain. The aim of this study was to describe school nurses’ experiences and challenges in working with childhood obesity. This qualitative study collected data through focus-group discussion and semi-structured interviews with ten female school nurses from six municipalities. Data were analysed inductively using manifest qualitative content analysis. The study was reported using the COREQ guidelines. Stigmatization and lack of resources are major challenges for school nurses working with childhood obesity, and they experience frustration, powerlessness and feel that they provide unequal treatment. The present study concludes that obesity stigmatization is a widespread challenge for school nurses. They cannot alone generate all the resources needed or conquer all challenges. Evidence-based guidelines, increased knowledge, time for reflections and peer support could potentially empower school nurses, reduce frustration, and improve the quality of and equality in childhood obesity treatment.

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. 

BACKGROUND: Despite various guidelines, shortcomings in lifestyle counseling in primary care have been demonstrated. Comparisons between countries may provide insight on how to improve such counseling. To the best of our knowledge, studies comparing patients' views of lifestyle counseling beween the United States (US) and European countries have not been reported.

OBJECTIVES: To quantify and compare patients' perspectives in the US and Sweden on primary care providers' counseling on weight, eating habits, physical activity, smoking, and alcohol consumption.

METHODS: In a cross-sectional study, 629 patients from Sweden and the US completed a telephone interview about their experiences after a visit to a physician in primary care. The survey focused on patients' perception of the importance of healthy lifestyle habits, their need to change, their desire to receive support from primary care, and the support they had actually received. Data were analyzed using chi-square or Fisher's exact test.

RESULTS: For three of the four lifestyle habits, the proportion saying they needed to change was higher in the US. The exception was for alcohol, where Swedish subjects indicated a greater need to change. Among those stating a need to change, the proportion saying that they would like to have support from primary care was generally above 80% in both countries. The proportion of US patients reporting that their primary care provider had initiated a discussion of lifestyle modification was, with the exception of alcohol, roughly double the level reported by the Swedish patients.

CONCLUSIONS: This study demonstrates high and quite similar patient expectations concerning lifestyle counseling in both countries, but more frequent initiation of discussions of most lifestyle issues in US primary care. Further studies, e.g. qualitative interviews with physicians, and medical record reviews, are required to better understand what can explain the differences between countries indicated by the study.

Introduktion: Under de senaste decennierna har det förts en diskussion om behovet av att omorientera hälso- och sjukvårdens verksamhet för att på ett effektivare sätt bidra till befolkningens hälsa. Detta togs också upp som ett av målen i 2003 års svenska nationella folkhälsopolitik som sedan uppdaterades 2008. Målet ”en mer hälso- främjande hälso- och sjukvård anger att ett hälsofrämjande och sjukdomsförebyggande perspektiv ska genomsyra hela hälso- och sjukvården och vara en självklar del i all vård och behandling. Vårdpersonalen förväntas spela en nyckelroll i genomförandet. Deras inställning till och kunskap om hälsofrämjande kommer sannolikt att ha en stor inverkan på hur målet kommer att tillämpas i framtiden.

Det övergripande syftet med denna avhandling är, att utifrån professionernas perspektiv, analysera möjligheterna till att omorientera hälso- och sjukvården mot en mer hälsofrämjande inriktning. De specifika frågeställningar som avhandlingen avser att besvara är hur vårdpersonalen uppfattar begreppen hälsa och hälsofrämjande, hur de uppfattar den hälsofrämjande rollen samt hur de uppfattar hinder och möjligheter för att ha en hälsofrämjande roll i det dagliga kliniska arbetet.

Metoder: Avhandlingen baseras på fyra delarbeten utgående från två dataset, ett kvalitativt och ett kvantitativt. Sju fokusgrupper genomfördes med totalt 34 informanter från primärvård och olika sjukhuskliniker. Informanterna representerade sju av vårdens stora yrkesgrupper. Data analyserades med kvalitativ innehållsanalys. Uppfattningar och frågor som genererades av den kvalitativa datainsamlingen låg till grund för utformningen av en enkät, som pilottestades och användes i en undersökning. Av totalt 3.751 anställda som arbetade dagtid med kliniskt arbete i Västerbottens läns landsting inbjöds 1.810 att delta. Dessa representerade arbets- terapeuter, barnmorskor, dietister, kuratorer, läkare, sjukgymnaster, sjuksköterskor och psykologer.

Huvudsakliga resultat och konklusion: Majoriteten av vårdpersonalen hade en holistisk syn på hälsa, samtidigt ansåg 40% att hälso- och sjukvården genomsyras av en biomedicinsk syn på hälsa. Begreppet hälsofrämjande framstod som diffust, svårgripbart och därmed svårt att tillämpa i praktiken. Detta var delvis kopplat till en brist på samsyn beträffande förhållandet mellan hälsofrämjande och sjukdoms- förebyggande.

Avhandlingen visar att det finns ett starkt stöd för omorientering av hälso- och sjukvården mot en mer hälsofrämjande inriktning. Majoriteten av de tillfrågade ansåg att hälso- och sjukvården har stor betydelse när det gäller den långsiktiga hälso- utvecklingen i befolkningen och såg ett behov av att utveckla den hälsofrämjande och sjukdomsförebyggande rollen för att på sikt få en effektivare hälso- och sjukvård. Önskan att fokusera mer på hälsofrämjande och sjukdomsförebyggande rapporterades signifikant oftare av kvinnor än män och av primärvårdspersonal jämfört med sjukhus- personal. Speciellt viktigt att beakta är att män och läkare, dvs grupper som ofta har en hög maktposition, rapporterade mindre positiva attityder till en mer hälsofrämjande hälso- och sjukvård, samtidigt som psykologer, arbetsterapeuter och sjukgymnaster oftast rapporterade det motsatta. En medvetenhet om maktrelationerna spelar därför en strategisk roll i förändringsprocessen. De vanligaste hindren för att ha en hälso- främjande roll i det dagliga kliniska arbetet var en pressad arbetssituation, brist på riktlinjer och otydliga mål. Ledningens stöd är avgörande för tillgången till tid och andra resurser som krävs för vårdpersonal att bedriva hälsofrämjande och sjukdomsförebyggande arbete.

Denna rapport är ett resultat av en undersökning som genomfördes på uppdrag av Stockholms läns landsting. Undersökningen fokuserade på Vårdval Stockholm, husläkarverksamheten och det hälsofrämjande arbetet. Det övergripande syftet var - att utifrån ett organisationsperspektiv - studera förutsättningar för hälsofrämjande/sjukdomsförebyggande arbete. Målgruppen för undersökningen var vårdpersonal. Med vårdpersonal avses: leg läkare, ST-läkare, specialistläkare, leg sjuksköterskor, distriktssköterskor, undersköterskor, kuratorer, psykologer och terapeuter. Ansvariga för undersökningen var forskare Helene Johansson samt professorerna Urban Janlert och Lars Weinehall, vid enheten för Epidemiologi och Global Hälsa, Umeå universitet. För innehållet i rapporten ansvarar Helene Johansson (helene.johansson@epiph.umu.se).

I en första fas genomfördes ett antal intervjuer med vårdpersonal på slumpmässigt utvalda husläkar- mottagningar. Syftet med intervjuerna var att få en inblick i personalens synsätt, erfarenheter och frågeställningar kring hälsofrämjande/sjukdomsförebyggande arbete. Specifikt var avsikten att undersöka vilken roll de anser att husläkarverksamheten generellt, och de själva har i ett hälsofrämjande perspektiv, samt vilka möjligheter och hinder de upplever i vårdens sätt att fungera som organisation och struktur. I en andra fas genomfördes en enkätundersökning i samarbete med SCB. Intervjuerna, Stockholms Läns Landstings Regelbok för husläkarverksamhet med basal hemsjukvård, samt en tidigare genomförd forskningsstudie från Västerbotten, utgjorde underlag för enkätfrågorna. Förutom ett antal frågeområden med fasta svarsalternativ fanns möjligheter att bifoga egna kommentarer. Enkäten besvarades av 1448 anställda . Av dessa, uppgav 121 individer att de förutom att arbeta kliniskt också hade en chefsbefattning. Dessa individer ingår i totala undersökningsgruppen men har också analyserats separat.

Enkätundersökningen visade att det finns en positiv inställning till hälsofrämjande/sjukdoms- förebyggande arbete i husläkarverksamheten och att det på ett stort antal mottagningar förs samtal om hur arbetet kan utvecklas. De hälsofrämjande/sjukdomsförebyggande insatser som svarsgruppen ansåg viktigast att utveckla var ”Arbeta med stöd och behandling av ohälsa kopplat till riskbruk av alkohol” och ”Delta i befolkningsinriktat hälsofrämjande arbete som bedrivs lokalt av kommunen eller andra aktörer”. ”Hälsosamtal med 75-åringar” upplevdes av 68 % av respondenterna som ett meningsfullt uppdrag för husläkarverksamheten men 50 % skulle hellre lägga resurserna på någonting annat. I de bifogade kommentarerna efterfrågas från vårdpersonalens sida större möjligheter att själva få bestämma innehållet i de hälsofrämjande/sjukdomsförebyggande insatserna, liksom till vilken grupp/vilka grupper insatserna ska riktas.

Mellan 32 % (undersköterskor) och 81 % (kuratorer/psykologer/terapeuter) av de professionella grupperna rapporterade att hälsofrämjande/sjukdomsförebyggande i hög eller mycket hög utsträckning utgör en del av deras egna arbetsuppgifter. Sextiotvå procent av respondenterna uppgav att de vill arbeta mer hälsofrämjande/sjukdomsförebyggande. Som grupp var distriktssköterskorna (81 %) mest angelägna.

Det två största hindren för hälsofrämjande/sjukdomsförebyggande arbete som studien identifierar, är en pressad arbetssituation och en inadekvat ekonomisk ersättning, där i princip enbart produktion av ”sjukvård” ger lönsamhet. Den produktionsrelaterade besöksersättningen anges premiera många och korta besök samtidigt som hälsofrämjande och sjukdomsförebyggande insatser trängs undan. Av de professionella grupperna var det allmänläkarna som i störst utsträckning rapporterade dessa hinder (93 % resp. 63 %). Flertalet av kommentarerna i enkätformulären förtydligar ytterligare orsaker till den pressade arbetssituationen samt beskriver den målkonflikt som uppstår när tiden inte räcker till för både sjukvårdande och förebyggande arbete.

Aim: The objective of this study is to analyze the commitment to a more health-promoting health service and to illuminate important barriers for having a health-promoting role in daily practice, among Swedish health care professionals.

Material and method: Out of a total of 3751 health professionals who are working daytime in clinical practice in the province of Västerbotten, 1810 were invited to participate in a survey. The health professionals represented eight different occupational groups: counselors, dieticians, midwives, nurses, occupational therapists, physical therapists, psychologists, and physicians. A questionnaire that operationalized perceptions found in a previous qualitative study was mailed to residential addresses of the participants.

Results: The majority believed that health services play a major role in long-term health development in the population and saw a need for health orientation as a strategy to provide more effective health care. Willingness to work more in health promotion and disease prevention was reported significantly more often by women than men, and by primary health care personnel compared to hospital personnel. Among the professional groups, psychologists, occupational therapists, and physiotherapists most frequently reported willingness. The most common barriers to health promotion roles in daily practice were reported to be heavy workload, lack of guidelines, and unclear objectives.

Conclusions: This study found strong support for reorientation of health services in the incorporation of a greater health promotion. A number of professions that are not usually associated with health promotion practices are knowledgeable and wish to focus more on health promotion and disease prevention. Management has a major role in creating opportunities for these professionals to participate in health promotion practices. Men and physicians reported less positive attitudes to a more health-promoting health service and often possess high positions of power. Therefore, they may play an important role in the process of change toward more health promotion in health services.

Aim: With the overall objective to develop future strategies for a more health-promoting health service in Sweden, the aim of this paper was to describe how health personnel view barriers and possibilities for having a health-promoting role in practice.

Materials and methods: Seven focus group discussions were carried out with a total of 34 informants from both hospital and primary health care settings in Sweden. The informants represented seven professional groups; counselors, occupational therapists, assistant nurses, midwives, nurses, physicians, and physiotherapists. The data were analyzed using qualitative content analysis.

Results: The analysis resulted in one major theme "If we only got a chance". The theme captures the health professionals' positive view about, and their willingness to, develop a health-promoting and/or preventive role, while at the same time feeling limited by existing values, structures, and resources. The four categories, "organizational commitment to a paradigm shift", "recognition of staff as health-promoting instruments", "a balance between resources and tasks", and "freedom of action" capture what is needed for implementing and increasing health promotion and preventive efforts in the health services.

Conclusions: The study indicates that an organizational setting that support health promotion is still to be developed. There is a need for a more explicit leadership with a clear direction towards the goal of "a more health-promoting health service" and with enough resources for achieving this goal.

BACKGROUND: The role of health services must be re-oriented towards health promotion to more effectively contribute to population health. One of the objectives of the Swedish public health policy is that health promotion and disease prevention should be an integral part of the health care system and an important component of all care and treatment. However, the uncertainty about what the concepts of health and health promotion mean poses a challenge for implementation. Depending on how these concepts are interpreted, the attitudes of health professionals toward health promoting practices will differ. Thus, a more in-depth understanding of health professionals' views can be a starting point for a discussion about the values and attitudes that influence the current health care system and about the barriers and possibilities for future development of a health promoting health service.

METHODS: Seven focus group discussions (n = 34) were carried out with health professionals, from different health care settings, to understand how they communicate about health and health promotion. The data were analyzed using qualitative content analysis.

RESULTS: The analysis of health professional's general understanding of the concept of health resulted in the category; a multi-facetted concept, whilst the category; a subjective assessment describes what health means to themselves. A third category; health is about life, the whole life. describes their understanding of health as an outcome of a multiplicity of contextually dependent determinants. The health professional's multiple ways of associating health promotion to disease prevention suggest a concept that is diffuse, elusive and difficult to apply in practice. Despite a shared view of health, the health professionals described their health promotion role very differently depending partly on how the concept of health promotion was interpreted. The analysis resulted in the development of three ideal types, labelled the demarcater, the integrater and the promoter describing different strategies for handling a health promotion role in practice.

CONCLUSION: The study suggests that different interpretations of what constitutes health promotion can lead to unnecessary misunderstandings and pose barriers to further development of a health promoting practice.

Background: The role of primary care professionals in lifestyle counseling is receiving attention at the national level in many countries. The U.S. and Sweden are two countries currently establishing priorities in these areas. A study comparing the countries demonstrates large differences between the extents that family physicians report being engaged in counseling on lifestyle issues, and how important they perceive it to be (Weinehall et al. Counseling on lifestyle habits in the United States and Sweden. BMC Family Practice 2014;15:83).

With the overall aim of facilitating lifestyle counselling in primary care, the objective of the present qualitative study was to explore further the views of American and Swedish family physicians about lifestyle counseling, in order to clarify the differences in attitudes and practices in the two countries.

Methods: In total, twenty-nine semi-structured interviews were conducted with family physicians representing the county councils of Stockholm and Dalarna in Sweden, and the Bassett Healthcare Network, Upstate New York, U. S. Data were analyzed using qualitative content analysis.

Results/Conclusions: Preliminary results show that the majority of the informants in both countries believe that addressing lifestyle issues is important and a natural part of their work. However, the study indicates that the U.S. physicians to a higher extent work in a more systematic way with risk factor management and routinely ask about lifestyle habits as part of existing work processes. They also expressed to a higher extent that they themselves, despite lack of time, must engage in lifestyle counseling, due to limited access to collegial support and referral services. The Swedish doctors, on the other hand, are able to limit their own role and responsibility due to support from other professions in the health care center/access to referral services.

Key messages:

• This study provide insight into how Swedish and U.S family physicians view the role of behavioral risk factor management in their clinical practice.
• Understanding professionals ‘take’ on lifestyle interventions, is invaluable, as they serve on the ‘front line’ in the battle to improve health outcomes in both countries.

Background: Implementation of interventions concerning prevention and health promotion in health care has faced particular challenges resulting in a low frequency and quality of these services. In November 2011, the Swedish National Board of Health and Welfare released national clinical practice guidelines to counteract patients’ unhealthy lifestyle habits. Drawing on the results of a previous study as a point of departure, the aim of this two-year follow up was to assess the progress of work with lifestyle interventions in primary healthcare as well as the uptake and usage of the new guidelines on lifestyle interventions in clinical practice.

Methods: Longitudinal study among health professionals with survey at baseline and 2 years later. Development over time and differences between professional groups were calculated with Pearson chi-square test.

Results: Eighteen percent of the physicians reported to use the clinical practice guidelines, compared to 58% of the nurses. Nurses were also more likely to consider them as a support in their work than physicians did. Over time, health professionals usage of methods to change patients’ tobacco habits and hazardous use of alcohol had increased, and the nurses worked to a higher extent than before with all four lifestyles. Knowledge on methods for lifestyle change was generally high; however, there was room for improvement concerning methods on alcohol, unhealthy eating and counselling. Forty-one percent reported to possess thorough knowledge of counselling skills.

Conclusions: Even if the uptake and usage of the CPGs on lifestyle interventions so far is low, the participants reported more frequent counselling on patients’ lifestyle changes concerning use of tobacco and hazardous use of alcohol. However, these findings should be evaluated acknowledging the possibility of selection bias in favour of health promotion and lifestyle guidance, and the loss of one study site in the follow up. Furthermore, this study indicates important differences in physicians and nurses’ attitudes to and use of the guidelines, where the nurses reported working to a higher extent with all four lifestyles compared to the first study. These findings suggest further investigations on the implementation process in clinical practice, and the physicians’ uptake and use of the CPGs.

BACKGROUND: Interventions that support patient efforts at lifestyle changes that reduce tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity represent important areas of development for health care. Current research shows that it is challenging to reorient health care toward health promotion. The aim of this study was to explore the extent of health care professional work with lifestyle interventions in Swedish primary health care, and to describe professional knowledge, attitudes and perceived organizational support for lifestyle interventions.

METHODS: The study is based on a cross-sectional Web-based survey directed at general practitioners, other physicians, residents, public health nurses and registered nurses (n = 315) in primary health care.

RESULTS: Fifty-nine percent of the participants indicated that lifestyle interventions were a substantial part of their duties. A majority (77%) would like to work more with patient lifestyles. Health professionals generally reported a thorough knowledge of lifestyle intervention methods for disease prevention. Significant differences between professional groups were found with regard to specific knowledge and extent of work with lifestyle interventions. Alcohol was the least addressed lifestyle habit. Management was supportive, but structures to sustain work with lifestyle interventions were scarce, and a need for national guidelines was identified.

CONCLUSIONS: Health professionals reported thorough knowledge and positive attitudes toward lifestyle interventions. When planning for further implementation of lifestyle interventions in primary health care, differences between professional groups in knowledge, extent of work with promotion of healthy lifestyles and lifestyle issues and provision of organizational support such as national guidelines should be considered.

Aims: Health literacy, the degree to which individuals understand and act upon health information, may have a pivotal role in the prevention of cardiovascular disease (CVD), with low health literacy potentially explaining poorer adherence to prevention guidelines. We investigated the associations between health literacy, ultrasound-detected carotid atherosclerosis and cardiovascular risk factors.

Methods: Baseline data (cross-sectional analysis) from a randomized controlled trial, integrated within the Västerbotten Intervention Program, Northern Sweden, was used. We included 3459 individuals, aged 40 or 50 years with ≥1 conventional risk factor or aged 60 years old. The participants underwent clinical examination, blood sampling, carotid ultrasound assessment of intima-media wall thickness (CIMT) and plaque formation, and answered a questionnaire on health literacy – the Brief Health Literacy Screen. The European Systematic Coronary Risk Evaluation and Framingham Risk Score were calculated.

Results: About 20% of the participants had low health literacy. Low health literacy was independently associated with the presence of ultrasound-detected carotid artery plaques after adjustment for age and education, odds ratio (95% confidence interval) 1.54 (1.28–1.85), demonstrating a similar level of risk as for smoking. Health literacy was associated with CIMT in men. Low health literacy was associated with higher CVD risk scores. Sensitivity analyses with low health literacy set to 9% or 30% of the study sample, respectively, yielded essentially the same results.

Conclusions: Low health literacy was independently associated with carotid artery plaques and a high level of CVD risk scores. Presenting health information in a fashion that is understood by all patients may improve preventive efforts.

Breast cancer is the most frequently diagnosed cancer among Vietnamese women. This qualitative study describes and discusses the mental health challenges of women with breast cancer in Vietnam. Two-rounds of semi-structured in-depth interviews were conducted among thirteen women with breast cancer and four caregivers from northern and southern Vietnam. Participants were recruited using purposive sampling technique. Data was collaboratively analyzed by qualitative content analysis using the Open Code Software version 4.02 and discussed among a team of local and international researchers. Women in the study experienced significant mental health challenges associated with their breast cancer diagnosis. Both psychological and emotional health were adversely affected. Women with breast cancer had profound concerns about how the diagnosis impacted their families. They experienced challenges in spousal relationships as well as facing social stigma and discrimination. Appropriate public health interventions should be implemented to raise society’s awareness and help improve the mental health of women with breast cancer.

Objective: To test the hypothesis of low emotional support being associated with lifestyle and biomedical cardiovascular disease (CVD) risk factors, estimated risk of CVD morbidity and mortality, and subclinical atherosclerosis in middle-aged healthy adults.

Methods and measures: Cross-sectional data were obtained from participants aged 40–60 years who had one or more conventional CVD risk factor. They underwent assessment based on questionnaires, clinical examination, blood sampling, and carotid ultrasound of plaque formation and carotid intima-media wall thickness (cIMT). Based on the Interview Schedule for Social Interaction, the participants were categorised as either low in emotional support (n = 884) or as a referent (n = 2570). Logistic regression analyses were conducted to study the associations.

Results: Logistic regression analyses showed that low emotional support was significantly associated with smoking, alcohol consumption and physical inactivity (OR = 1.53 − 1.94), estimated risk of CVD morbidity and mortality (OR = 1.56 − 1.68), and plaque formation (OR = 1.39). No significant associations were found regarding biomedical CVD risk factors or cIMT.

Conclusion: The findings suggest that low social support is associated with lifestyle CVD risk factors, estimated risk of CVD morbidity and mortality, and subclinical atherosclerosis in middle-aged healthy adults, encouraging causal evaluation with longitudinal data investigating an impact of emotional support on mechanisms underlying CVD.

BACKGROUND: Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasound-based pictorial information about subclinical carotid atherosclerosis, targeting both primary care physicians and individuals, improves prevention.

METHODS: Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) is a pragmatic, open-label, randomised controlled trial that was integrated within the Västerbotten Intervention Programme, an ongoing population-based cardiovascular disease prevention programme in northern Sweden. Individuals aged 40, 50, or 60 years with one or more conventional risk factors were eligible to participate. Participants underwent clinical examination, blood sampling, and ultrasound assessment of carotid intima media wall thickness and plaque formation. Participants were randomly assigned 1:1 with a computer-generated randomisation list to an intervention group (pictorial representation of carotid ultrasound plus a nurse phone call to confirm understanding) or a control group (not informed). The primary outcomes, Framingham risk score (FRS) and European systematic coronary risk evaluation (SCORE), were assessed after 1 year among participants who were followed up. This study is registered with ClinicalTrials.gov, number NCT01849575.

FINDINGS: 3532 individuals were enrolled between April 29, 2013, and June 7, 2016, of which 1783 were randomly assigned to the control group and 1749 were assigned to the intervention group. 3175 participants completed the 1-year follow-up. At the 1-year follow-up, FRS and SCORE differed significantly between groups (FRS 1·07 [95% CI 0·11 to 2·03, p=0·0017] and SCORE 0·16 [0·02 to 0·30, p=0·0010]). FRS decreased from baseline to the 1-year follow-up in the intervention group and increased in the control group (-0·58 [95% CI -0·86 to -0·30] vs 0·35 [0·08 to 0·63]). SCORE increased in both groups (0·13 [95% CI 0·09 to 0·18] vs 0·27 [0·23 to 0·30]).

INTERPRETATION: This study provides evidence of the contributory role of pictorial presentation of silent atherosclerosis for prevention of cardiovascular disease. It supports further development of methods to reduce the major problem of low adherence to medication and lifestyle modification.

BACKGROUND: The challenge of an aging population in the society makes it important to find strategies to promote health for all. The aim of this study is to evaluate if repeated health coaching in terms of motivational interviewing, and an offer of wide range of activities, will contribute to positive lifestyle modifications and health among persons aged 60-75 years, with moderately elevated risk for cardiovascular disease (CVD), diabetes, or mild depression.

METHODS/DESIGN: Men and women between 60 and 75 are recruited in four regions in Sweden if they fulfill one or more of the four inclusion criteria.•Current reading of blood pressure (140-159/90-99) without medication.•Current reading of blood sugar (Hba1c 42-52 mmol/mol) without medication.•A current waist-circumference of ≥94 cm for men and ≥80 for women.•A minor/mild depression (12-20 points) according to Montgomery-Åsberg Depression Rating Scale without medication.Individuals with a worse result than inclusion criteria are treated according to regular guidelines at the PHCs and therefore not included. Exclusion criteria for the study are dementia, mental illness or other condition deemed unsuitable for participation.All participants fill out a questionnaire at baseline, and at the 6-, 12- and 18-month follow-ups containing questions on demographic characteristics, social life, HRQoL, lifestyle habits, general health/medication, self-rated mental health, and sense of coherence. At the 12-month follow-up, the health coach will give each participant a second questionnaire to capture attitudes and perceptions related to health coaching and venues/activities offered.Qualitative data will be collected twice to obtain a deeper understanding of perceptions and attitudes related to health and lifestyle/lifestyle modifications. A health economic assessment will be performed. Individual costs for health care utilisation will be collected and QALY-scores will be estimated.

DISCUSSION: Several drawbacks can be identified when conducting research in real life. However, many of the identified problems can diminish the positive results of the intervention and if the intervention shows positive effects they might be underestimated.

Introduction: The incidence of chronic disease and treatment costs have been steadily increasing in the United States over the past few decades. Primary prevention and healthy lifestyle counseling have been identified as important strategies for reducing health-care costs and chronic disease prevalence. This article seeks to examine decision-makers’ experiences and self-perceived roles in guideline and lifestyle counseling implementation in a primary care setting in the United States. 

Methods: Qualitative interviews were conducted with administrators at a health-care network in Upstate New York and with state-level administrators, such as insurers. Decision-makers were asked to discuss prevention guidelines and healthy lifestyle counseling, as well as how they support implementation of these initiatives. Interviews were analyzed using a thematic analysis framework and relevant sections of text were sorted using a priori codes.

Results: Interviews identified numerous barriers to guideline implementation. These included the complexity and profusion of guidelines, the highly politicized nature of health-care provision, and resistance from providers who sometimes prefer to make decisions autonomously. Barriers to supporting prevention counseling included relatively time-limited patient encounters, the lack of reimbursement mechanisms for counseling, lack of patient resources, and regulatory complexities.

Conclusions: Our research indicates that administrators and administrative structures face barriers to supporting prevention activities such as guideline implementation and healthy lifestyle counseling in primary care settings. They also identified several solutions for addressing existing primary prevention barriers, such as relying on nurses to provide healthy lifestyle support to patients. This article provides an important assessment of institutional readiness to support primary prevention efforts.

BACKGROUND: The role of primary care professionals in lifestyle counseling for smoking, alcohol consumption, physical activity, and diet is receiving attention at the national level in many countries. The U. S. and Sweden are two countries currently establishing priorities in these areas. A previously existing international research collaboration provides a unique opportunity to study this issue.

METHODS: Data from a national survey in Sweden and a study in rural Upstate New York were compared to contrast the perspectives, attitudes, and practice of primary care professionals in the two countries. Answers to four key questions on counseling for tobacco use, alcohol consumption, physical activity, and eating habits were compared.

RESULTS: The response rates were 71% (n = 180) and 89% (n = 86) in the Sweden and the U.S. respectively. U.S. professionals rated counseling "very important" significantly more frequently than Swedish professionals for tobacco (99% versus 92%, p < .0001), physical activity (90% versus 79%, p = .04), and eating habits (86% versus 69%, p = .003). U.S. professionals also reported giving "very much" counseling more frequently for these same three endpoints than did the Swedish professionals (tobacco 81% versus 38%, p < .0001, physical activity 64% versus 31%, p < .0001, eating 59% versus 34%, p = .0001). Swedish professionals also rated their level of expertise in providing counseling significantly lower than did their U.S. counterparts for all four endpoints. A higher percentage of U.S. professionals expressed a desire to increase levels of counseling "very much", but only significantly so for eating habits (42% versus 28%, p = .037).

CONCLUSIONS: The study demonstrates large differences between the extent that Swedish and American primary care professionals report being engaged in counseling on lifestyle issues, how important they perceive counseling to be, and what expertise they possess in this regard. Explanations might be found in inter-professional attitudes, the organization of healthcare, including the method of reimbursement, traditions of preventive healthcare, and cultural differences between the two countries. Further studies are needed to explore these questions, with the aim of facilitating improved lifestyle counseling in primary care.