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Andersson, Agneta
Publications (10 of 25) Show all publications
Nilsson, S., Andersson, A., Janzon, M., Karlsson, J.-E. & Levin, L.-Å. (2014). Cost consequences of point-of-care troponin T testing in a Swedish primary health care setting. Scandinavian Journal of Primary Health Care, 32(4), 241-247
Open this publication in new window or tab >>Cost consequences of point-of-care troponin T testing in a Swedish primary health care setting
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2014 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 32, no 4, p. 241-247Article in journal (Refereed) Published
Abstract [en]

Objective. To evaluate the safety and cost-effectiveness of point-of-care troponin T testing (POCT-TnT) for the management of patients with chest pain in primary care. Design. Prospective observational study with follow-up. Setting. Three primary health care (PHC) centres using POCT-TnT and four PHC centres not using POCT-TnT in south-east Sweden. Patients. All patients greater than= 35 years of age, contacting one of the PHC centres for chest pain, dyspnoea on exertion, unexplained weakness and/or fatigue, with no other probable cause than cardiac, were included. Symptoms must have commenced or worsened during the previous seven days. Main outcome measures. Emergency referral rates, diagnoses of acute myocardial infarction (AMI) or unstable angina (UA), and costs were collected for 30 days after the patient sought care at the PHC centre. Results. A total of 196 patients with chest pain were included: 128 in PHC centres with POCT-TnT and 68 in PHC centres without POCT-TnT. Fewer patients from the PHC centres with POCT-TnT (n = 32, 25%) were emergently referred to hospital than from centres without POCT-TnT (n = 29, 43%; p = 0.011). Eight patients (6.2%) from PHC centres with POCT-TnT were diagnosed with AMI or UA compared with six patients (8.8%) from centres without POCT-TnT (p = 0.565). Two patients with AMI or UA were classified as missed cases from PHC centres with POCT-TnT and there were no missed cases from PHC centres without POCT-TnT. SKr290 000 was saved per missed case of AMI or UA. Conclusion. The use of POCT-TnT in primary care may be cost saving but at the expense of missed cases.

Place, publisher, year, edition, pages
Informa Healthcare, 2014
Keywords
Acute myocardial infarction; general practice; point-of-care testing; primary care; Sweden; troponin T; cost
National Category
Basic Medicine Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-113177 (URN)10.3109/02813432.2014.984901 (DOI)000346108700014 ()25434410 (PubMedID)
Note

Funding Agencies|County Council of Ostergotland

Available from: 2015-01-13 Created: 2015-01-12 Last updated: 2018-01-11
Carlfjord, S., Lindberg, M. & Andersson, A. (2013). Sustained use of a tool for lifestyle intervention implemented in primary health care: a 2-year follow-up. Journal of Evaluation In Clinical Practice, 19(2), 327-334
Open this publication in new window or tab >>Sustained use of a tool for lifestyle intervention implemented in primary health care: a 2-year follow-up
2013 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 19, no 2, p. 327-334Article in journal (Refereed) Published
Abstract [en]

Rational, aims and objectives: Sustainability of new methods implemented in health care is one of the most central issues in addressing the gap between research and practice, but is seldom assessed in implementation studies. The aim of this study was to evaluate the implementation of a new tool for lifestyle intervention in primary health care (PHC) 2 years after the introduction, and assess if the implementation strategy used influenced sustainability.

Method: A computer-based lifestyle intervention tool (CLT) was introduced at six PHC units in Sweden in 2008, using two implementation strategies: explicit and implicit. The main difference between the strategies was a 4-week test period followed by a decision session, included in the explicit strategy. Evaluations were performed after 6, 9 and 24 months. After 24 months, the RE-AIM framework was applied to assess and compare outcome according to strategy.

Results: A more positive outcome regarding Reach, Effectiveness, Adoption and Implementation in the explicit group could be almost completely attributed to one of the units. Maintenance was low and after 24 months, differences according to strategy were negligible.

Conclusion: After 24 months the most positive outcomes regarding all RE-AIM dimensions were found in one of the units where the explicit strategy was used. The explicit strategy per se had some effect on the dimension Effectiveness, but was not associated with sustainability overall. Staff at the most successful unit earlier had positive expectations regarding the CLT and found it compatible with existing routines.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2013
Keywords
implementation, lifestyle, primary health care, sustainability
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-74877 (URN)10.1111/j.1365-2753.2012.01827.x (DOI)000315964800017 ()
Note

Funding Agencies|Medical Research Council of Southeast Sweden (FORSS)||Swedish Council for Working Life and Social Research (FAS)||

Available from: 2012-02-10 Created: 2012-02-10 Last updated: 2017-12-07Bibliographically approved
Carlfjord, S., Andersson, A., Bendtsen, P., Nilsen, P. & Lindberg, M. (2012). Applying the RE-AIM framework to evaluate two implementation strategies used to introduce a tool for lifestyle intervention in Swedish primary health care. Health Promotion International, 27(2), 167-176
Open this publication in new window or tab >>Applying the RE-AIM framework to evaluate two implementation strategies used to introduce a tool for lifestyle intervention in Swedish primary health care
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2012 (English)In: Health Promotion International, ISSN 0957-4824, E-ISSN 1460-2245, Vol. 27, no 2, p. 167-176Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to evaluate two implementation strategies for the introduction of a lifestyle intervention tool in primary health care (PHC), applying the RE-AIM framework to assess outcome. A computer-based tool for lifestyle intervention was introduced in PHC. A theory-based, explicit, implementation strategy was used at three centers, and an implicit strategy with a minimum of implementation efforts at three others. After 9 months a questionnaire was sent to staff members (n= 159) and data from a test database and county council registers were collected. The RE-AIM framework was applied to evaluate outcome in terms of reach, effectiveness, adoption and implementation. The response rate for the questionnaire was 73%. Significant differences in outcome were found between the strategies regarding reach, effectiveness and adoption, in favor of the explicit implementation strategy. Regarding the dimension implementation, no differences were found according to the implementation strategy. A theory-based implementation strategy including a testing period before using a new tool in daily practice seemed to be more successful than a strategy in which the tool was introduced and immediately used for patients.                 

Place, publisher, year, edition, pages
Oxford University Press, 2012
Keywords
Implementation; Primary health care; RE-AIM
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-73379 (URN)10.1093/heapro/dar016 (DOI)000304016100004 ()
Available from: 2012-01-13 Created: 2012-01-02 Last updated: 2017-12-08Bibliographically approved
Carlfjord, S., Lindberg, M. & Andersson, A. (2012). Staff perceptions of addressing lifestyle in primary health care: a qualitative evaluation 2 years after the introduction of a lifestyle intervention tool. BMC Family Practice, 13(99)
Open this publication in new window or tab >>Staff perceptions of addressing lifestyle in primary health care: a qualitative evaluation 2 years after the introduction of a lifestyle intervention tool
2012 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, no 99Article in journal (Refereed) Published
Abstract [en]

Background: Preventive services and health promotion in terms of lifestyle counselling provided through primary health care (PHC) has the potential to reduce morbidity and mortality in the population. Health professionals in general are positive about and willing to develop a health-promoting and/or preventive role. A number of obstacles hindering PHC staff from addressing lifestyle issues have been identified, and one facilitator is the use of modern technology. When a computer-based tool for lifestyle intervention (CLT) was introduced at a number of PHC units in Sweden, this provided an opportunity to study staff perspectives on the subject. The aim of this study was to explore PHC staffs perceptions of handling lifestyle issues, including the consultation situation as well as the perceived usefulness of the CLT. less thanbrgreater than less thanbrgreater thanMethods: A qualitative study was conducted after the CLT had been in operation for 2 years. Six focus group interviews, one at each participating unit, including a total of 30 staff members with different professions participated. The interviews were designed to capture perceptions of addressing lifestyle issues, and of using the CLT. Interview data were analysed using manifest content analysis. less thanbrgreater than less thanbrgreater thanResults: Two main themes emerged from the interviews: a challenging task and confidence in handling lifestyle issues. The first theme covered the categories responsibilities and emotions, and the second theme covered the categories first contact, existing tools, and role of the CLT. Staff at the units showed commitment to health promotion/prevention, and saw that patients, caregivers, managers and politicians all have responsibilities regarding the issue. They expressed confidence in handling lifestyle-related conditions, but to a lesser extent had routines for general screening of lifestyle habits, and found addressing alcohol the most problematic issue. The CLT, intended to facilitate screening, was viewed as a complement, but was not considered an important tool for health promotion/prevention. less thanbrgreater than less thanbrgreater thanConclusion: Additional resources, for example in terms of manpower, may help to build the structures necessary for the health promotion/prevention task. Committed leaders could enhance the engagement among staff. Cooperation in multi-professional teams seems to be important, and methods or tools perceived by staff as compatible have a potential to be successfully implemented. Economic incentives rewarding quantity rather than quality appear to be frustrating to PHC staff.

Place, publisher, year, edition, pages
BioMed Central, 2012
Keywords
Staff perception, Lifestyle counselling, Primary health care, Computerized tool
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-87253 (URN)10.1186/1471-2296-13-99 (DOI)000312275300001 ()
Note

Funding Agencies|Medical Research Council of Southeast Sweden (FORSS)||Swedish Council for Working Life and Social Research (FAS)||

Available from: 2013-01-14 Created: 2013-01-14 Last updated: 2017-12-06
Kärner, A., Nilsson, S., Jaarsma, T., Andersson, A., Wiréhn, A.-B., Wodlin, P., . . . Tingström, P. (2012). The effect of problem-based learning in patient education after an event of CORONARY heart disease - a randomised study in PRIMARY health care: design and methodology of the COR-PRIM study. BMC Family Practice, 13(110)
Open this publication in new window or tab >>The effect of problem-based learning in patient education after an event of CORONARY heart disease - a randomised study in PRIMARY health care: design and methodology of the COR-PRIM study
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2012 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, no 110Article in journal (Refereed) Published
Abstract [en]

Background

Even though there is convincing evidence that self-care, such as regular exercise         and/or stopping smoking, alters the outcomes after an event of coronary heart disease         (CHD), risk factors remain. Outcomes can improve if core components of secondary prevention         programmes are structurally and pedagogically applied using adult learning principles         e.g. problem-based learning (PBL). Until now, most education programs for patients         with CHD have not been based on such principles. The basic aim is to discover whether         PBL provided in primary health care (PHC) has long-term effects on empowerment and         self-care after an event of CHD.     

Methods/Design

A randomised controlled study is planned for patients with CHD. The primary outcome         is empowerment to reach self-care goals. Data collection will be performed at baseline         at hospital and after one, three and five years in PHC using quantitative and qualitative         methodologies involving questionnaires, medical assessments, interviews, diaries and         observations. Randomisation of 165 patients will take place when they are stable in         their cardiac condition and have optimised cardiac medication that has not substantially         changed during the last month. All patients will receive conventional care from their         general practitioner and other care providers. The intervention consists of a patient         education program in PHC by trained district nurses (tutors) who will apply PBL to         groups of 6–9 patients meeting on 13 occasions for two hours over one year. Patients         in the control group will not attend a PBL group but will receive home-sent patient         information on 11 occasions during the year.     

Discussion

We expect that the 1-year PBL-patient education will improve patients’ beliefs, self-efficacy         and empowerment to achieve self-care goals significantly more than one year of standardised         home-sent patient information. The assumption is that PBL will reduce cardiovascular         events in the long-term and will also be cost-effective compared to controls. Further,         the knowledge obtained from this study may contribute to improving patients’ ability         to handle self-care, and furthermore, may reduce the number of patients having subsequent         CHD events in Sweden.

Place, publisher, year, edition, pages
BioMed Central, 2012
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-86741 (URN)10.1186/1471-2296-13-110 (DOI)000312733600001 ()
Projects
COR-PRIM study
Available from: 2013-01-14 Created: 2013-01-02 Last updated: 2017-12-06Bibliographically approved
Stark Ekman, D., Andersson, A., Nilsen, P., Ståhlbrandt, H., Johansson, A. L. & Bendtsen, P. (2011). Electronic screening and brief intervention for risky drinking in Swedish university students - A randomized controlled trial. Addictive Behaviours, 36(6), 654-659
Open this publication in new window or tab >>Electronic screening and brief intervention for risky drinking in Swedish university students - A randomized controlled trial
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2011 (English)In: Addictive Behaviours, ISSN 0306-4603, E-ISSN 1873-6327, Vol. 36, no 6, p. 654-659Article in journal (Refereed) Published
Abstract [en]

Background: The limited number of electronic screening and brief intervention (e-SBI) projects taking place in young adult student populations has left knowledge gaps about the specific methods needed to motivate reduced drinking. The aim of the present study was to compare differences in alcohol consumption over time after a series of e-SBIs was conducted with two groups of young adult students who were considered risky drinkers. The intervention group (IC) (n = 80) received extensive normative feedback; the control group (CG) (n = 78) received very brief feedback consisting of only three statements. Method: An e-SBI project was conducted in naturalistic settings among young adult students at a Swedish university. This study used a randomized controlled trial design, with respondents having an equal chance of being assigned to either the IC or the CG. The study assessed changes comparing the IC with the CG on four alcohol-related measurements: proportion with risky alcohol consumption, average weekly alcohol consumption, frequency of heavy episodic drinking (HED) and peak blood alcohol concentration (BAC). Follow-up was performed at 3 and 6 months after baseline. Results: The study documented a significant decrease in the average weekly consumption for the IC over time but not for the CG, although the differences between the groups were non-significant. The study also found that there were significant decreases in HED over time within both groups: the differences were about equal in both groups at the 6-month follow-up. The proportion of risky drinkers decreased by about a third in both the CG and IC at the 3- and 6-month follow-ups. Conclusions: As the differences between the groups at 6 months for all alcohol-related outcome variables were not significant, the shorter, generic brief intervention appears to be as effective as the longer one including normative feedback. However, further studies in similar naturalistic settings are warranted with delayed assessment groups as controls in order to increase our understanding of reactivity assessment in email-based interventions among students.

Place, publisher, year, edition, pages
Amsterdam: Elsevier, 2011
Keywords
College student, Alcohol, Electronic screening, Brief intervention, Computer, RCT
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-68696 (URN)10.1016/j.addbeh.2011.01.015 (DOI)000290193400016 ()
Available from: 2011-05-27 Created: 2011-05-27 Last updated: 2017-12-11
Carlfjord, S., Andersson, A. & Lindberg, M. (2011). Experiences of the implementation of a tool for lifestyle intervention in primary health care: a qualitative study among managers and professional groups. BMC Health Services Research, 11(195)
Open this publication in new window or tab >>Experiences of the implementation of a tool for lifestyle intervention in primary health care: a qualitative study among managers and professional groups
2011 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, no 195Article in journal (Refereed) Published
Abstract [en]

Background:In recent years there has been increasing interest in transferring new knowledge into health care practices, a process often referred to as implementation. The various subcultures that exist among health care workers may be an obstacle in this process. The aim of this study was to explore how professional groups and managers experienced the implementation of a new tool for lifestyle intervention in primary health care (PHC). The computer-based tool was introduced with the intention of facilitating the delivery of preventive services.

Methods:Focus group interviews with staff and individual interviews with managers at six PHC units in the southeast of Sweden were performed 9 months after the introduction of the new working tool. Staff interviews were conducted in groups according to profession, and were analysed using manifest content analysis. Experiences and opinions from the different staff groups and from managers were analysed.

Results: Implementation preconditions, opinions about the lifestyle test, and opinions about usage were the main areas identified. In each of the groups, managers and professionals, factors related to the existing subcultures seemed to influence their experiences of the implementation. Managers were visionary, GPs were reluctant, nurses were open, and nurse assistants were indifferent.

Conclusion: This study indicates that the existing subcultures in PHC influence how the implementation of an innovation is perceived by managers and the different professionals. In PHC, an organization with several subcultures and an established hierarchical structure, an implementation strategy aimed at all groups did not seem to result in a successful uptake of the new method.

Place, publisher, year, edition, pages
BioMed Central, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-71112 (URN)10.1186/1472-6963-11-195 (DOI)000294735700002 ()
Available from: 2011-09-30 Created: 2011-09-30 Last updated: 2017-12-08
Leijon, M., Arvidsson, D., Nilsen, P., Stark Ekman, D., Carlfjord, S., Andersson, A., . . . Bendtsen, P. (2011). Improvement of Physical Activity by a Kiosk-based Electronic Screening and Brief Intervention in Routine Primary Health Care: Patient-Initiated Versus Staff-Referred. Journal of medical Internet research, 13(4), e99
Open this publication in new window or tab >>Improvement of Physical Activity by a Kiosk-based Electronic Screening and Brief Intervention in Routine Primary Health Care: Patient-Initiated Versus Staff-Referred
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2011 (English)In: Journal of medical Internet research, ISSN 1438-8871, Vol. 13, no 4, p. e99-Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Interactive behavior change technology (eg, computer programs, Internet websites, and mobile phones) may facilitate the implementation of lifestyle behavior interventions in routine primary health care. Effective, fully automated solutions not involving primary health care staff may offer low-cost support for behavior change.

OBJECTIVES: We explored the effectiveness of an electronic screening and brief intervention (e-SBI) deployed through a stand-alone information kiosk for promoting physical activity among sedentary patients in routine primary health care. We further tested whether its effectiveness differed between patients performing the e-SBI on their own initiative and those referred to it by primary health care staff.

METHODS: The e-SBI screens for the physical activity level, motivation to change, attitudes toward performing the test, and physical characteristics and provides tailored feedback supporting behavior change. A total of 7863 patients performed the e-SBI from 2007 through 2009 in routine primary health care in Östergötland County, Sweden. Of these, 2509 were considered not sufficiently physically active, and 311 of these 2509 patients agreed to participate in an optional 3-month follow-up. These 311 patients were included in the analysis and were further divided into two groups based on whether the e-SBI was performed on the patient´s own initiative (informed by posters in the waiting room) or if the patient was referred to it by staff. A physical activity score representing the number of days being physically active was compared between baseline e-SBI and the 3-month follow-up. Based on physical activity recommendations, a score of 5 was considered the cutoff for being sufficiently physically active.

RESULTS: In all, 137 of 311 patients (44%) were sufficiently physically active at the 3-month follow-up. The proportion becoming sufficiently physically active was 16/55 (29%), 40/101 (40%), and 81/155 (52%) for patients with a physical activity score at baseline of 0, 1 to 2, and 3 to 4, respectively. The patient-initiated group and staff-referred group had similar mean physical activity scores at baseline (2.1, 95% confidence interval [CI] 1.8-2.3, versus 2.3, 95% CI 2.1-2.5) and at follow-up, (4.1, 95% CI 3.4-4.7, vs 4.2, 95% CI 3.7-4.8).

CONCLUSIONS: Among the sedentary patients in primary health care who participated in the follow-up, the e-SBI appeared effective at promoting short-term improvement of physical activity for about half of them. The results were similar when the e-SBI was patient-initiated or staff-referred. The e-SBI may be a low-cost complement to lifestyle behavior interventions in routine primary health care and could work as a stand-alone technique not requiring the involvment of primary health care staff.

Keywords
Computer-tailored; eHealth; lifestyle behavior; exercise; automated
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-75304 (URN)10.2196/jmir.1745 (DOI)000299313300016 ()22107702 (PubMedID)
Note
funding agencies|Swedish National Institute for Public Health||Available from: 2012-02-24 Created: 2012-02-24 Last updated: 2013-09-30
Lorefelt, B., Andersson, A., Wiréhn, A.-B. & Wilhelmsson, S. (2011). Nutritional status and health care costs for the elderly living in municipal residential homes — An intervention study. The Journal of Nutrition, Health & Aging, 15(2), 92-97
Open this publication in new window or tab >>Nutritional status and health care costs for the elderly living in municipal residential homes — An intervention study
2011 (English)In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 15, no 2, p. 92-97Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

The aim was to study the effect of individualised meals on nutritional status among older people living in municipal residential homes and to compare the results with a control group. An additional aim was to estimate direct health care costs for both groups.

SETTING:

Six different municipal residential homes in the south-east of Sweden.

PARTICIPANTS:

Older people living in three residential homes constituted the intervention group n=42 and the rest constituted the control group n=67.

INTERVENTION:

A multifaceted intervention design was used. Based on an interview with staff a tailored education programme about nutritional care, including both theoretical and practical issues, was carried through to staff in the intervention group. Nutritional status among the elderly was measured by Mini Nutritional Assessment (MNA), individualised meals were offered to the residents based on the results of the MNA. Staff in the control group only received education on how to measure MNA and the residents followed the usual meal routines.

MEASUREMENTS:

Nutritional status was measured by MNA at baseline and after 3 months. Cost data on health care visits during 2007 were collected from the Cost Per Patient database.

RESULTS:

Nutritional status improved and body weight increased after 3 months in the intervention group. Thus, primary health care costs constituted about 80% of the total median cost in the intervention group and about 55% in the control group.

CONCLUSION:

With improved knowledge the staff could offer the elderly more individualised meals. One of their future challenges is to recognise and assess nutritional status among this group. If malnutrition could be prevented health care costs should be reduced.

Place, publisher, year, edition, pages
Springer, 2011
Keywords
Malnutrition; nutritional status; elderly people; intervention; health care costs
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-75769 (URN)10.1007/s12603-011-0019-3 (DOI)000287752900002 ()
Available from: 2012-03-09 Created: 2012-03-09 Last updated: 2017-12-07Bibliographically approved
Bendtsen, P., Stark Ekman, D., Johansson, A. L., Carlfjord, S., Andersson, A., Leijon, M., . . . Nilsen, P. (2011). Referral to an electronic screening and brief alcohol intervention in primary health care in Sweden: impact of staff referral to the computer. International Journal of Telemedicine and Applications, 2011, 1-11, Article ID 918763.
Open this publication in new window or tab >>Referral to an electronic screening and brief alcohol intervention in primary health care in Sweden: impact of staff referral to the computer
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2011 (English)In: International Journal of Telemedicine and Applications, ISSN 1687-6415, E-ISSN 1687-6423, Vol. 2011, p. 1-11, article id 918763Article in journal (Refereed) Published
Abstract [en]

The aim of this paper was to evaluate whether primary health care staff's referral of patients to perform an electronic screening and brief intervention (e-SBI) for alcohol use had a greater impact on change in alcohol consumption after 3 month, compared to patients who performed the test on their own initiative. Staff-referred responders reported reduced weekly alcohol consumption with an average decrease of 8.4 grams. In contrast, self-referred responders reported an average increase in weekly alcohol consumption of 2.4 grams. Staff-referred responders reported a 49% reduction of average number of heavy episodic drinking (HED) occasions per month. The corresponding reduction for self-referred responders was 62%. The differences between staff- and self-referred patient groups in the number who moved from risky drinking to nonrisky drinking at the followup were not statistically significant. Our results indicate that standalone computers with touchscreens that provide e-SBIs for risky drinking have the same effect on drinking behaviour in both staff-referred patients and self-referred patients.

Place, publisher, year, edition, pages
Hindawi Publishing Corporation, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-75303 (URN)10.1155/2011/918763 (DOI)21603024 (PubMedID)
Available from: 2012-02-24 Created: 2012-02-24 Last updated: 2017-12-07Bibliographically approved
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