Background

This study evaluated and compared the extent, duration, contents, experiences and effects of alcohol conversations in healthcare in the Netherlands and Sweden in 2017.

Methods

Survey data in the Netherlands and Sweden were collected through an online web panel. Subjects were 2996 participants (response rate: 50.8%) in Sweden and 2173 (response rate: 82.2%) in the Netherlands. Data was collected on socio-demographics, alcohol consumption, healthcare visits in the past 12 months, number of alcohol conversations, and characteristics of alcohol conversations (duration, contents, experience, effects).

Results

Results showed that Swedish respondents were more likely to have had alcohol conversations (OR = 1.99; 95%CI = 1.64–2.41; p = < 0.001) compared to Dutch respondents. In Sweden, alcohol conversations were more often perceived as routine (p = < 0.001), were longer (p = < 0.001), and more often contained verbal information about alcohol’s health effects (p = 0.007) or written information (p = 0.001) than in the Netherlands. In Sweden, 40+ year-olds were less likely to report a positive effect compared to the youngest respondents. In the Netherlands, men, sick-listed respondents, and risky drinkers, and in Sweden those that reported “other” occupational status such as parental leave, were more likely to have had alcohol conversations.

Conclusions

The results suggest that alcohol conversations are more common in healthcare practice in Sweden than in the Netherlands. However, positive effects of alcohol conversations were less likely to be reported among older respondents in Sweden. Our results indicate that alcohol preventative work should be improved in both countries, with more focus on risky drinkers and the content of the conversations in Sweden, and expanding alcohol screening in the Netherlands.

Introduction Entry-level students conceptualizations of clinical reasoning can provide a starting point for program planning related to clinical reasoning development with a focus on patient-centered care Objective The aim of the study is to explore how physiotherapy students understand clinical reasoning midway through their education. Nine physiotherapy students were interviewed at the end of their third semester Methods Semi-structured individual interviews were conducted, recorded and transcribed verbatim. A phenomenographic approach to qualitative data analysis, seeking to explore variations in students conceptions was applied Results The students ways of understanding clinical reasoning could be described as: 1) the cognitive process of the physiotherapist; and 2) the relational process of the collaborative partnership between the physiotherapist and the patient. A contrastive analysis shows how the cognitive and relational perspectives are developed through the relationships among three dimensions of clinical reasoning: 1) problem-solving; 2) context of working; and 3) own learning Conclusion By identifying the critical variation in students conceptions of clinical reasoning, focus can be placed on pedagogical arrangements to facilitate students progression toward a person-centered approach.

Background Youth handball players are vulnerable to injuries. Because there is no available injury prevention training specifically developed for youth handball players targeting both upper and lower limbs or incorporating psychological aspects of injury, we undertook the Implementing injury Prevention training ROutines in TEams and Clubs in youth Team handball (I-PROTECT) project. We used an ecological participatory design incorporating the perspectives of multiple stakeholders (health beneficiaries, programme deliverers and policy makers). The aim of this paper was to describe the process of developing the I-PROTECT model, featuring injury prevention training and an accompanying implementation strategy. Design We used the generalisable six-step intervention development process, outlined to guide researchers when developing implementable, evidence-based sports injury prevention interventions, to develop the I-PROTECT model. The six-step process involves establishing a research-stakeholder collaborative partnership to (1) identify and synthesise research evidence and clinical experience; (2) consult with relevant experts; (3) engage end users to ensure their needs, capacity and values are considered; (4) test the feasibility and acceptability of the intervention; (5) evaluate the intervention against theory; and (6) obtain feedback from early implementers. Two community handball clubs in southern Sweden, offering organised training for youth male and female players, and the district handball federation, participate in the intervention development. Drafts of the I-PROTECT model will be developed and revised with key stakeholder advice and input throughout all six steps. Conclusion The I-PROTECT model described will be an end user-driven intervention, including evidence-based, theory-informed and context-specific injury prevention training for youth handball, and an associated implementation strategy.

Objectives Incident reporting (IR) systems have the potential to improve patient safety if they enable learningfrom the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council.

Methods The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012. One hundred correctly classified patient injuries were randomly sampled from 3 injury severity levels: injuries leading to deaths, permanent harm, and temporary harm. Three aspects were analyzed: handling of the incident, causes of the incident, and actions taken to prevent its recurrence.

Results Of the 300 injuries, 79% were handled in the departments where they occurred. The department head decided what actions should be taken to prevent recurrence in response to 95% of the injuries. A total of 448 causes were identified for the injuries; problems associated with procedures, routines, and guidelines were most common. Decisions taken for 80% of the injuries could be classified using the IR system documentation and root cause analysis. The most commonly pursued type of action was change of work routine or guideline.

Conclusions The handling, causes, and actions taken to prevent recurrence were similar for injuries of different severity levels. Various forms of feedback (information, education, and dialogue) were an integral aspect of the IR system. However, this feedback was primarily intradepartmental and did not yield much organizational learning.

Syftet med att delta i utbildning är att lära, men lärande kan inbegripa många olika fenomen och förklaras på olika sätt. Hur kan man förstå vuxnas lärande? Det är frågan vi ställer oss i detta kapitel.  

The present cross-sectional study examined the actor-partner interdependence effect of fear of COVID-19 among Iranian pregnant women and their husbands and its association with their mental health and preventive behaviours during the first wave of the COVID-19 pandemic in 2020. A total of 290 pregnant women and their husbands (N = 580) were randomly selected from a list of pregnant women in the Iranian Integrated Health System and were invited to respond to psychometric scales assessing fear of COVID-19, depression, anxiety, suicidal intention, mental quality of life, and COVID-19 preventive behaviours. The findings demonstrated significant dyadic relationships between husbands and their pregnant wives fear of COVID-19, mental health, and preventive behaviours. Pregnant wives actor effect of fear of COVID-19 was significantly associated with depression, suicidal intention, mental quality of life, and COVID-19 preventive behaviours but not anxiety. Moreover, a husband actor effect of fear of COVID-19 was significantly associated with depression, anxiety, suicidal intention, mental quality of life, and COVID-19 preventive behaviours. Additionally, there were significant partner effects observed for both the pregnant wives and their husbands concerning all outcomes. The present study used a cross-sectional design and so is unable to determine the mechanism or causal ordering of the effects. Also, the data are mainly based on self-reported measures which have some limitations due to its potential for social desirability and recall biases. Based on the findings, couples may benefit from psychoeducation that focuses on the effect of mental health problems on pregnant women and the foetus.

Vaccination is the most effective way to control the COVID-19 pandemic, but vaccination hesitancy threatens this effort worldwide. Consequently, there is a need to understand what influences individuals intention to get a COVID-19 vaccine. Restriction of information gathering on societal developments to social media may influence attitudes towards COVID-19 vaccination through exposure to disinformation and imbalanced arguments. The present study examined the association between problematic social media use and intention to get the COVID-19 vaccine, taking into account the mediating roles of cyberchondria, fear of COVID-19, and COVID-19 risk perception. In a cross-sectional survey study, a total of 10,843 residents of Qazvin City, Iran completed measures on problematic social media use, fear of COVID-19, cyberchondria, COVID-19 risk perception, and intention to get a COVID-19 vaccine. The data were analyzed using structural equation modeling (SEM). The results showed that there was no direct association between problematic social media use and intention to get a COVID-19 vaccine. Nonetheless, cyberchondria, fear of COVID-19, and COVID-19 risk perception (each or serially) mediated associations between problematic social media use and intention to get a COVID-19 vaccine. These results add to the understanding of the role of problematic social media use in COVID-19 vaccine hesitancy, i.e., it is not the quantity of social media use per se that matters. This knowledge of the mediating roles of cyberchondria, fear of COVID-19, and COVID-19 risk perception can be used by public health experts and policymakers when planning educational interventions and other initiatives in COVID-19 vaccination programs.

Background

Childhood overweight and obesity is currently estimated to affect 39 million children under the age of five worldwide. After the COVID-19 pandemic, further increases have been observed in several countries including Sweden, where an increased incidence was observed in 3- and 4-year-old children, especially in disadvantaged areas. This development emphasizes the urgent need for population-based childhood obesity prevention interventions, and Swedish primary child health care provides an ideal setting for primary preventive efforts during the preschool years. However, thus far, previous child health care-based obesity prevention interventions have demonstrated limited effectiveness. As previous interventions also have been face-to-face delivered and thus resource-demanding; new, and scalable ways of delivering interventions also need to be evaluated. Mobile health or mHealth refers to the use of mobile devices for medical and public health practice and provides opportunity for development and dissemination of digital interventions for various purposes and populations at scale. This thesis reports the results of the MINISTOP 2.0 project, which covers the development and evaluation of the MINISTOP 2.0 digital intervention, from adaptation and translation of the intervention to Somali, Arabic and English (Paper I), to evaluation of real-world effectiveness within the Swedish primary child health care setting (Paper II) followed by exploration of user experiences and implementation aspects (Paper III) and a cost-consequence analysis of the intervention costs (Paper IV).  

Aim

The overall aim of this thesis was to evaluate whether a 6-month parent-oriented mHealth intervention (MINISTOP 2.0 app), embedded in the routine services of Swedish primary child health care, can be used to improve diet and physical activity behaviors, and decrease the prevalence of over-weight and obesity in 2.5-to-3-year-old children.   

Methods

The MINISTOP 2.0 project utilized a hybrid type 1 effectiveness-implementation study design to enable simultaneous evaluation and exploration of intervention effectiveness, user experiences and implementation aspects. Paper I: A qualitative exploration of user requirements in an app-based parental support intervention was conducted through three focus group interviews with Somali- (n = 5), Arabic- (n = 4), and Swedish-speaking parents (n = 6), and individual interviews with child health care nurses (n = 15). Data was analyzed using thematic analysis.  Paper II: A two-arm parallel randomized controlled trial was conducted at 19 child health care centers located in six Swedish regions. Participating parents (n = 552) were invited during their routine visit at 2.5/3-years at their primary child health care center. All baseline and follow-up procedures were conducted by the nurses. Parents that were randomized to the control group received standard care, while the intervention group received access to the MINISTOP 2.0 app for six months, alongside standard care. Prior to randomization, nurses measured the child’s height and weight for assessment of BMI, and parents answered a questionnaire about their child’s intake of fruit and vegetables, sweet and savory treats, and sweet drinks; time spent in moderate-to-vigorous physical activity (MVPA) and screen time; and parental self-efficacy (PSE) for promoting healthy diet, physical activity, and screen time behaviors. These baseline procedures were then repeated at a 6-month follow-up visit to the child health care center.   Paper III: A qualitative exploration of user experiences, acceptability, and feasibility of the MINISTOP 2.0 intervention was conducted through individual interviews with parents (n = 24) with diverse backgrounds, and with child health care nurses (n = 15). Data was analyzed using content analysis. Paper IV: Data on all costs related to the MINISTOP 2.0 intervention, including costs for app and interface upkeep as well as salary costs for introduction and dissemination of the app by nurses, was collected retrospectively. A cost-consequence analysis was then performed to estimate the costs of the intervention.  

Results

Paper I: Parents expressed several challenges related to promoting healthy eating behaviors, such as worrying about their child not eating enough, and difficulties balancing different food cultures. There were also requests for the app content to be accessible through alternative modes of delivery (e.g., audio/video) for parents with low literacy. Nurses underlined the importance of supporting parents early with health behavior interventions, and the value of a shared digital platform, available in several languages, to facilitate communication with parents.  Paper II: Seventy-nine percent of the participating parents (n = 552) were mothers and 62% had a university degree. Among the children, 24% had two foreign-born parents. Children in the intervention group had lower in-takes of sweet and savory treats (-6.97 g/day; p = 0.001), sweet drinks (-31.52 g/day; p < 0.001), and screen time (-7.00 min/day; p = 0.012) com-pared to the control group at follow-up. Parents in the intervention group also reported higher total PSE (0.91; p = 0.006), PSE for promoting healthy diet behaviors (0.34; p = 0.008) and PSE for promoting healthy physical activity behaviors (0.31; p = 0.009) compared to the control group. For children’s MVPA or BMI z-score, no statistically significant effect was observed between groups. Finally, parents also reported high satisfaction with the app, and 54% reported using the app once a week or more.  Paper III: Findings indicated that the app was well accepted and appreciated, as it increased knowledge and awareness around current health behaviors. Furthermore, evidence-based information available in one place and from a trusted source, was highly valued, especially when living in a country with a different culture than your own. The app was also acknowledged as a feasible support tool and a suitable complement to the standard care offered during visits. Finally, due to the accessibility in different languages and the possibility of disseminating the app at scale, both nurses and parents described the app as an appropriate tool for reaching larger populations of parents as well as parents in need of additional support. Paper IV: The total cost for the MINISTOP 2.0 intervention was 437 439 SEK based on the 277 families in the intervention group. The cost for child health care nurses introducing and registering families for the app represented only 9% of the total cost per family, which was considerably lower in comparison to other similar childhood obesity prevention interventions. Also, notably, for upscaling, sharing running costs for the user interface for larger populations of children, would result in much lower total costs per family.    

Conclusions

Overall, qualitative findings for adapting the intervention highlighted the need for early access to information, as well as the importance of adapting interventions to also be accessible for parents with migrant background and parents with lower literacy. When disseminated through primary child health care, the MINISTOP 2.0 intervention resulted in statistically significant reduced intakes of sweet and savory treats, sweet drinks, and screen time in children (primary outcomes) as well as increased PSE for promoting healthy diet and activity behaviors (secondary outcome). The app was well accepted and perceived as a feasible support tool for parents. Furthermore, accessibility in different languages was also appreciated. Finally, the relatively low salary costs in comparison to face-to-face interventions suggest that the MINISTOP 2.0 app and caregiver interface may be an affordable preventive effort for early promotion of healthy lifestyle behaviors in children when scaled up on a population level. Altogether, the results from the papers in this thesis support the large-scale implementation of the MINISTOP 2.0 app within the Swedish primary child health care setting for promotion of healthy lifestyle behaviours in 2.5-to-3-year-old children. 

Background:Childhood overweight and obesity is a public health priority. We have previously reported the efficacy of a parent-oriented mobile health (mHealth) app-based intervention (MINISTOP 1.0) which showed improvements in healthy lifestyle behaviors. However, the effectiveness of the MINISTOP app in real-world conditions needs to be established. Objective:To evaluate the real-world effectiveness of a 6-month mHealth intervention (MINISTOP 2.0 app) on childrens intake of fruits, vegetables, sweet and savory treats, sweet drinks, moderate-to-vigorous physical activity, and screen time (primary outcomes), and on parental self-efficacy (PSE) for promoting healthy lifestyle behaviors, and childrens body mass index (BMI) (secondary outcomes). Methods:A hybrid type 1 effectiveness-implementation design was utilized. For the effectiveness outcomes, a two-arm, individually randomized controlled trial was conducted. Parents (n = 552) of 2.5-to-3-year-old children were recruited from 19 child health care centers across Sweden, and, randomized to either a control (standard care) or intervention group (MINISTOP 2.0 app). The 2.0 version was adapted and translated into English, Somali and Arabic to increase reach. All recruitment and data collection were conducted by the nurses. Outcomes were assessed at baseline and after six months, using standardized measures (BMI) and a questionnaire (health behaviors, PSE). Results:Among the participating parents (n = 552, age: 34.1 +/- 5.0 years), 79% were mothers and 62% had a university degree. Twenty-four percent (n = 132) of children had two foreign-born parents. At follow-up, parents in the intervention group reported lower intakes of sweet and savory treats (-6.97 g/day; p = 0.001), sweet drinks (-31.52 g/day; p &lt; 0.001), and screen time (-7.00 min/day; p = 0.012) in their children compared to the control group. The intervention group reported higher total PSE (0.91; p = 0.006), PSE for promoting healthy diet (0.34; p = 0.008) and PSE for promoting physical activity behaviors (0.31; p = 0.009) compared to controls. No statistically significant effect was observed for childrens BMI z-score. Overall, parents reported high satisfaction with the app, and 54% reported using the app at least once a week. Conclusion:Children in the intervention group had lower intakes of sweet and savory treats, sweet drinks, less screen time (primary outcomes) and their parents reported higher PSE for promoting healthy lifestyle behaviors. Our results from this real-world effectiveness trial support the implementation of the MINISTOP 2.0 app within Swedish child health care.

Early efforts for prevention of childhood overweight and obesity are needed. In order to adapt an app promoting healthy diet and physical activity behaviors in children (MINISTOP 1.0) for multi-ethnic communities, we explored: (1) needs and concerns among Somali-, Arabic-, and Swedish-speaking parents in terms of supporting healthy diet and activity behaviors in their children; (2) nurses perceptions of parental needs and concerns in relation to diet and physical activity behaviors; and (3) how the features and content of the MINISTOP 1.0 app could be refined to better support health behaviors in children, among both parents and nurses. Focus groups with Somali-, Arabic-, and Swedish-speaking parents (n = 15), and individual interviews with nurses (n = 15) were conducted. Parents expressed several challenges in supporting childrens health behaviors, the need for a tailored app, and alternative ways of accessing the content (audio/video). Nurses emphasized the need of supporting parents early, and the value of a shared platform in different languages, to facilitate communication. This study contributes valuable insights about parental needs and relevant adaptations to a parental support app, such as addition of audio/video files for increased accessibility. This adapted app version-MINISTOP 2.0, can be useful for childhood obesity prevention in multi-ethnic communities.

BackgroundPreventive and scalable interventions, accessible to all, to counteract childhood obesity are urgently needed. We have recently developed a novel, digital parental intervention (MINISTOP 2.0 app) available in Swedish, Somali, Arabic and English. We have previously reported its positive effects on childrens health behaviors and on parental self-efficacy. However, before introducing the app at scale in primary child healthcare, implementation aspects also need to be explored.AimThis study aims to explore and describe user experiences as well as acceptability and feasibility of the MINISTOP 2.0 app-based intervention in a diverse group of parents (end-users) and Swedish child healthcare nurses (implementers).MethodsIndividual interviews were conducted with Swedish- (n = 9), Somali- (n = 9), Arabic- (n = 5) and English-speaking (n = 1) parents as well as Swedish primary child healthcare nurses (n = 15). Data was analyzed using content analysis with an inductive latent approach.ResultsParents described how the app facilitated behavior change through increased awareness regarding current diet and physical activity behaviors. Furthermore, the evidence-based app content further facilitated trust and behavior change. Both parents and nurses acknowledged the apps preventive potential and the potential for reaching parents with diverse backgrounds or in need of extra support.ConclusionThe MINISTOP 2.0 app was perceived as a useful tool for health promotion both by parents and healthcare professionals, especially since it was adapted to several languages. These findings coupled with the previously shown beneficial effects on health behaviors support the large-scale implementation of the app in primary child healthcare.

Introduction

Dual antiplatelet therapy (DAPT), including potent P2Y12 inhibition after ST-elevation myocardial infarction (STEMI) is recommended in clinical guidelines. However, bleeding complications are common, and associated with worse outcomes. The aim of this study was to assess incidence of bleeding events with a clopidogrel-based compared to a ticagrelor-based DAPT strategy, in a real world population. Secondary aims were to assess ischemic complications and mortality.

Methods and Results

We identified 330 consecutive STEMI patients with a clopidogrel-based and 330 with a ticagrelor-based DAPT strategy. Patientś medical records were searched for bleeding and ischemic complications, over 6 months follow-up.

The two groups were well balanced in baseline characteristics, age (69 years inboth groups), sex (31% vs 32% females), history of diabetes (19% vs 21%), hypertension (43% in both) and MI (17% vs 15%). There was no difference in CRUSADE bleeding score (28 vs 29). After discharge, there were more than twice as many bleeding events with a ticagrelor-based compared with a clopidogrel-based strategy (13.3% vs. 6.5%, p = 0.005). Bleeding events included significantly more severe bleeding complications (TIMI major/minor [5.8 vs 1.0, p = 0.001]) during the ticagrelor-based period. There was no significant difference in the composite of death, MI or stroke (7.8% vs 7.1%, p = 0.76).

Conclusions

In this observational study, a ticagrelor-based DAPT strategy was associated with significantly more bleeding complications, without any significant change in death, MI or stroke. Larger studies are needed to determine whether bleeding complications off-sets benefits with a more potent DAPT strategy in older and more comorbid real-life patients.

Aims: The aims of this study are to describe informal care activities and to estimate the societal cost of informal care of community-dwelling frail elderly people in Sweden. Methods: This study was performed within the frame of the TREEE project that included 408 frail elderly patients. At index hospitalisation (baseline), primary informal caregivers of the patients were provided with a questionnaire on informal care during a period of three months. Questions concerning other (secondary) informal caregivers were also included. A rough estimate of the total cost of informal care of frail elderly people in Sweden was obtained by combining data from this study with published data and official statistics. Results: In total, 176 informal caregivers responded, and 89% had provided informal care. The informal caregivers (primary and secondary) provided care for an average of 245 hours over three months. Taking care of the home was the dominating activity. In total, the mean cost of informal care was estimated to approximately 18,000 SEK (euro1878) over three months, corresponding to an annual cost of approximately 72,000 SEK (euro7477) per frail elderly person. The total annual societal costs of informal care of community dwelling frail elderly people aged 75 years and older in Sweden was estimated to be approximately 11,000 million SEK (euro1150 million). Conclusions: The care of frail elderly people provided by informal caregivers is extensive and represents a great economic value. Although our calculations are associated with uncertainty, the size indicates that supporting informal caregivers should be a priority for society.

Background The study addresses knowledge gaps in research regarding influences of routine health care delivery of physical activity on prescription (PAP). The aim was to investigate if patient and health care characteristics are associated with increased physical activity 1 year after prescription among patients offered counselor support in addition to health care professionals prescription. The study was conducted in primary and secondary care in a Swedish health care region. Methods All PAP recipients during 1 year were invited (N = 1503) to participate in this observational prospective study. Data were collected from medical records and questionnaires (baseline and follow-up). Descriptive statistics and multiple logistic regression analysis were used. The outcome variable was increased physical activity after 1 year. Study variables were patient and health care characteristics. Results Three hundred and fifty-five patients with complete follow-up data were included. The mean age was 62 years (SD = 14; range, 18-90) and 68% were females. Almost half (47%) had increased physical activity 1 year after PAP. Multiple logistic regression analysis showed that increased physical activity at follow-up was positively associated with lower baseline activity, counselor use, and positive perception of support. Counselor users with low baseline activity had higher odds ratio for increased physical activity at follow-up than non-users (OR = 7.2, 95% CI = 2.2-23.5 vs. OR = 3.2, 95% CI = 1.4-7.5). Positive perception of support was associated with increased physical activity among counselor users but not among non-users. Conclusions An increase in physical activity after PAP was related to low baseline activity, positive perception of support, and use of counselor support after PAP. Qualified counseling support linked to PAP seems to be important for achieving increased physical activity among patients with lower baseline activity.

The effectiveness of counsellor support in addition to physical activity on prescription (PAP) from health care professionals has rarely been evaluated. This observational follow-up study investigated differences in physical activity levels and health-related quality of life (HRQoL) one year after PAP regarding patients use of counsellor support in addition to PAP in routine care. The study was conducted in a Swedish health care region in which all patients receiving PAP from health care professionals were offered counsellor support. Data were collected from medical records and questionnaires (baseline and follow-up). Of the 400 study participants, 37% used counsellor support. The group of counsellor users attained a higher level of physical activity one year after receiving PAP compared to the group of non-users (p&lt; 0.001). The level of physical activity was measured by a validated index (score 3-19) calculated from weekly everyday activity and exercise training. Comparison of the change in scores between baseline and follow-up showed a significant difference between the two groups, (p&lt; 0.001). The median difference in the PAP + C group was 2.0 (interquartile range, 7.0) and 0.0. among non-users (interquartile range, 4.0). Significant differences in HRQoL were due to positive improvements among counsellor users, with the main improvement in general health. The conclusion is that patients using counsellor support after receiving PAP from health care professionals had higher physical activity and better HRQoL one year after compared with patients who did not use this support.

Objectives This study evaluates whether initiation rates, completion rates, response patterns and prevalence of psychiatric conditions differ by level of personal integrity information given to prospective participants in an online mental health self-report survey. Methods A three-arm, parallel-group, single-blind experiment was conducted among students from two Swedish universities. Consenting participants following e-mail invitation answered the World Health Organization (WHO) World Mental Health-International College Student (WMH-ICS) mental health self-report survey, screening for eight psychiatric conditions. Random allocation meant consenting to respond (1) anonymously; (2) confidentially, or (3) confidentially, where the respondent also gave consent for collection of register data. Results No evidence was found for overall between-group differences with respect to (1) pressing a hyperlink to the survey in the invitation email; and (2) abandoning the questionnaire before completion. However, participation consent and self-reported depression were in the direction of higher levels for the anonymous group compared to the two confidential groups. Conclusions Consent to participate is marginally affected by different levels of personal integrity information. Current standard participant information procedures may not engage participants to read the information thoroughly, and online self-report mental health surveys may reduce stigma and thus be less subject to social desirability bias.

Objective The present study investigates if symptoms of COVID-19 contagion in different social contexts (cohabitants, family, acquaintances, and others) are associated with university students own self-reported symptoms of COVID-19 contagion, mental health, and study capacity. This was investigated by a cross-sectional survey administrated in Sweden during the first wave of the COVID-19 pandemic, at the time when universities were locked down to limit viral spread and contagion. Results Mild to moderate symptoms of COVID-19 in cohabitants and family members were associated with students self-reported symptoms of contagion, while no associations could be seen in relation to mental health and study capacity. Symptoms of COVID-19 contagion in acquaintances and others were not associated with students self-reported symptoms, nor with their mental health and study capacity. To conclude, during the initial lockdown of universities students self-reported symptoms of contagion were mainly associated with cohabitants and family members, while symptoms of contagion in different social contexts were not associated with mental health and study capacity. Findings suggest that lockdown of universities may have contributed to limiting infection pathways, while still allowing students to focus on their studies despite significant contagion among others known to the student.

Objective: During the COVID pandemic, government authorities worldwide have tried to limit the spread of the virus. Swedens distinctive feature was the use of voluntary public health recommendations. Few studies have evaluated the effectiveness of this strategy. Based on data collected in the spring of 2020, this study explored associations between compliance with recommendations and observed symptoms of contagion in others, using self-report data from university students. Results: Compliance with recommendations ranged between 69.7 and 95.7 percent. Observations of moderate symptoms of contagion in "Someone else I have had contact with" and "Another person"were markedly associated with reported self-quarantine, which is the most restrictive recommendation, complied with by 81.2% of participants. Uncertainty regarding the incidence and severity of contagion in cohabitants was markedly associated with the recommendation to avoid public transportation, a recommendation being followed by 69.7%. It is concluded that students largely followed the voluntary recommendations implemented in Sweden, suggesting that coercive measures were not necessary. Compliance with recommendations were associated with the symptoms students saw in others, and with the perceived risk of contagion in the students immediate vicinity. It is recommended that voluntary recommendations should stress personal relevance, and that close relatives are at risk.

Objective: To investigate perceived changes in academic self-efficacy associated with self-reported symptoms of COVID-19, changes in mental health, and trust in universities management of the pandemic and transition to remote education during lockdown of Swedish universities in the spring of 2020. Methods: 4495 participated and 3638 responded to self-efficacy questions. Associations were investigated using multinomial regression. Results: Most students reported self-experienced effects on self-efficacy. Lowered self-efficacy was associated with symptoms of contagion, perceived worsening of mental health and low trust in universities capacity to successfully manage the lockdown and transition to emergency remote education. Increased self-efficacy was associated with better perceived mental health and high trust in universities. Conclusion: The initial phase of the pandemic was associated with a larger proportion of students reporting self-experienced negative effects on academic self-efficacy. Since self-efficacy is a predictor of academic performance, it is likely that students academic performance will be adversely affected.

Objective This study used causal inference to estimate the longitudinal effects of contagion in cohabitants and family members on university students' mental health and academic self-efficacy during the COVID-19 pandemic.Design A prospective longitudinal study including a baseline online measurement in May 2020, and online follow-ups after 5 months and 10 months. Participants were recruited through open-access online advertising.Setting Public universities and university colleges in Sweden.Participants The analytical sample included 2796 students.Outcome measures Contagion in cohabitants and in family members was assessed at baseline and at the 5-month follow-up. Mental health and academic self-efficacy were assessed at the 5-month and 10-month follow-ups.Results Mild symptoms reported in cohabitants at baseline resulted in negative mental health effects at follow-up 5 months later, and mild baseline symptoms in family members resulted in negative effects on academic self-efficacy at follow-ups both 5 and 10 months later.Conclusions Notwithstanding the lack of precision in estimated effects, the findings emphasise the importance of social relationships and the challenges of providing students with sufficient support in times of crisis.

In higher education, students' trust in the university management may affect both mental health and academic self-efficacy. This longitudinal study, conducted during the most challenging course of the COVID-19 pandemic, uses multinomial regression and causal inference to estimate the effects of students' trust in their universities' strategies for managing the pandemic, on students' self-reported changes in mental health and academic self-efficacy. The analyzed sample (N = 2796) was recruited through online advertising and responded to a baseline online survey in the late spring of 2020, with two follow-up surveys five and ten months later. Results show that positive trust in university management of the pandemic protected against experiencing one's mental health and academic self-efficacy as worse rather than unchanged, both five and ten months after the baseline assessment. The findings emphasize the importance of developing and maintaining trust-building measures between academia and students to support students' mental health and academic self-efficacy in times of uncertainty.

Background: The literature on upper extremity injuries in professional soccer players is scarce, and further insight into the onset and cause of these injuries as well as potential differences between goalkeepers and outfield players is important. Purpose: To investigate the epidemiology of hand, wrist, and forearm injuries in male professional soccer players between 2001 and 2019. Study Design: Descriptive epidemiology study. Methods: Between the 2001-2002 and 2018-2019 seasons, 120 European male soccer teams were followed prospectively for a varying number of seasons (558 team-seasons in total). Time-loss injuries and player-exposures to training sessions and matches were recorded on an individual basis in 6754 unique players. Injury incidence was reported as the number of injuries per 1000 player-hours, and between-group differences were analyzed using Z statistics and rate ratios (RRs) with 95% CIs. Between-group differences in layoff time were analyzed. Results: In total, 25,462 injuries were recorded, with 238 (0.9%) of these affecting the hand (71.4%; n = 170), wrist (16.8%; n = 40), and forearm (11.8%; n = 28), producing an incidence of 0.065 injuries per 1000 hours. A majority of the injuries were traumatic with an acute onset (98.7%; n = 235). Fractures were the most common injuries recorded (58.8%; n = 140), often involving the metacarpal bones (25.2%; n = 60) and phalanges (10.1%; n = 24). The injury incidence was significantly higher for goalkeepers (115 injuries; 0.265 per 1000 hours) compared with outfield players (123 injuries; 0.038 per 1000 hours) (RR, 7.0 [95% CI, 5.4-9.0]). Goalkeepers also had a significantly longer mean layoff time than outfield players (23 +/- 27 vs 15 +/- 27 days; P = .016). Conclusion: Injuries to the hand, wrist, and forearm constituted less than 1% of all time-loss injuries in male professional soccer players. Fractures were most common and constituted more than half of all injuries. Goalkeepers had a 7-fold higher incidence and an over 1-week longer mean layoff time compared with outfield players.

Throughout the COVID-19 pandemic, media and policymakers openly speculated about the number of immune citizens needed to reach a herd immunity threshold. What are the effects of such numerical goals on the willingness to vaccinate? In a large representative sample (N = 1540) of unvaccinated Swedish citizens, we find that giving a low (60%) compared to a high (90%) threshold has direct effects on beliefs about reaching herd immunity and beliefs about how many others that will get vaccinated. Presenting the high threshold makes people believe that herd immunity is harder to reach (on average about half a step on a seven-point scale), compared to the low threshold. Yet at the same time, people also believe that a higher number of the population will get vaccinated (on average about 3.3% more of the population). Since these beliefs affect willingness to vaccinate in opposite directions, some individuals are encouraged and others discouraged depending on the threshold presented. Specifically, in mediation analysis, the high threshold indirectly increases vaccination willingness through the belief that many others will get vaccinated (B = 0.027, p = 0.003). At the same time, the high threshold also decreases vaccination willingness through the belief that the threshold goal is less attainable (B = -0.053, p &lt; 0.001) compared to the low threshold condition. This has consequences for ongoing COVID-19 vaccination and future vaccination campaigns. One message may not fit all, as different groups can be encouraged or discouraged from vaccination.

BackgroundReports of an increased proportion of complicated appendicitis during the Covid-19 pandemic suggest a worse outcome due to delay secondary to the restrained access to health care, but may be explained by a concomitant decrease in uncomplicated appendicitis. We analyze the impact of the pandemic on the incidences of complicated and uncomplicated appendicitis.MethodWe did a systematic literature search in the PubMed, Embase and Web Of Science databases on December 21, 2022 with the search terms (appendicitis OR appendectomy) AND ("COVID" OR SARS-Cov2 OR "coronavirus"). Studies reporting the number of complicated and uncomplicated appendicitis during identical calendar periods in 2020 and the pre-pandemic year(s) were included. Reports with indications suggesting a change in how the patients were diagnosed and managed between the two periods were excluded. No protocol was prepared in advance. We did random effects meta-analysis of the change in proportion of complicated appendicitis, expressed as the risk ratio (RR), and of the change in number of patients with complicated and uncomplicated appendicitis during the pandemic compared with pre-pandemic periods, expressed as the incidence ratio (IR). We did separate analyses for studies based on single- and multi-center and regional data, age-categories and prehospital delay.ResultsThe meta-analysis of 100,059 patients in 63 reports from 25 countries shows an increase in the proportion of complicated appendicitis during the pandemic period (RR 1.39, 95% confidence interval (95% CI 1.25, 1.53). This was mainly explained by a decreased incidence of uncomplicated appendicitis (incidence ratio (IR) 0.66, 95% CI 0.59, 0.73). No increase in complicated appendicitis was seen in multi-center and regional reports combined (IR 0.98, 95% CI 0.90, 1.07).ConclusionThe increased proportion of complicated appendicitis during Covid-19 is explained by a decrease in the incidence of uncomplicated appendicitis, whereas the incidence of complicated appendicitis remained stable. This result is more evident in the multi-center and regional based reports. This suggests an increase in spontaneously resolving appendicitis due to the restrained access to health care. This has important principal implications for the management of patients with suspected appendicitis.

Objectives:To increase the proportion of individuals with hypertension obtaining a blood pressure (BP) of less than 140/90 mmHg by improving the management of hypertension in daily life from a person-centred perspective.Methods:In this unblinded randomized controlled trial, we tested an interactive web-based self-management system for hypertension. A total of 949 patients with hypertension from 31 primary healthcare centres (PHCCs) in Sweden were randomized 1 : 1 to either the intervention or usual care group. The intervention included daily measurement - via the participants mobile phone - of BP and pulse and reports of well being, symptoms, lifestyle, medication intake and side effects for eight consecutive weeks. It also included reminders and optional motivational messages. The primary outcome was the proportion of participants obtaining BP of less than 140/90 mmHg at 8 weeks and 12 months. Significance was tested by Pearsons chi(2)-test.Results:A total of 862 patients completed the trial, 442 in the intervention group and 420 in the control group. The primary outcome (BP &lt;140/90 mmHg) at 8 weeks was achieved by 48.8% in the intervention group and 39.9% in the control group (P = 0.006). At 12 months, 47.1% (intervention) and 41.0% (control group) had a BP less than 140/90 mmHg (P = 0.071).Conclusion:The proportion of participants with a controlled BP of less than 140/90 mmHg increased after using the interactive system for self-management of hypertension for 8 weeks compared with usual care. Although the trend continued, there was no significant difference after 12 months. The results indicate that the effect of the intervention is significant, but the long-term effect is uncertain.

Objectives To investigate long-term effects of a 1-year problem-based learning (PBL) on self-management and cardiac risk factors in patients with coronary heart disease (CHD).Design A prospective, randomised, parallel single centre trial.Settings Primary care settings in Sweden.Participants 157 patients with stable CHD completed the study. Subjects with reading and writing impairments, mental illness or expected survival less than 1 year were excluded.Intervention Participants were randomised and assigned to receive either PBL (intervention) or home-sent patient information (control group). In this study, participants were followed up at baseline, 1, 3 and 5 years.Primary and secondary outcomes Primary outcome was patient empowerment (Swedish Coronary Empowerment Scale, SWE-CES) and secondary outcomes General Self-Efficacy Scale (GSES), self-rated health status (EQ-VAS), high-density lipoprotein cholesterol (HDL-C), body mass index (BMI), weight and smoking. Outcomes were adjusted for sociodemographic factors.Results The PBL intervention group resulted in a significant improved change in SWE-CES over the 5-year period (mean (M), 39.39; 95% CI 37.88 to 40.89) compared with the baseline (M 36.54; 95% CI 35.40 to 37.66). PBL intervention group increased HDL-C level (M 1.39; 95% CI 1.28 to 1.50) compared with baseline (M 1.24; 95% CI 1.15 to 1.33) and for EQ-VAS (M 77.33; 95% CI 73.21 to 81.45) compared with baseline (M 68.13; 95% CI 63.66 to 72.59) while these outcomes remained unchanged in the control group. There were no significant differences in BMI, weight or scores on GSES, neither between nor within groups over time. The overall proportion of smokers was significantly higher in the control group than in the experimental group.Conclusion One-year PBL intervention had positive effect on patient empowerment, health status and HDL-C at a 5-year follow-up compared with the control group. PBL education aiming to improve patient empowerment in cardiac rehabilitation should account for sociodemographic factors.

Aims: The COVID-19 containment strategy in Sweden uses public health recommendations relying on personal responsibilityfor compliance. Universities were one of few public institutions subject to strict closure, meaning that students had toadapt overnight to online teaching. This study investigates the prevalence of self-reported recommendation compliance andassociations with self-reported symptoms of contagion, self-experienced effects on mental health and academic self-efficacyamong university students in Sweden in May–June 2020. Methods: This was a cross-sectional 23 question online survey inwhich data were analysed by multinomial regression, taking a Bayesian analysis approach complemented by null hypothesistesting. Results: A total of 4495 students consented to respond. Recommendation compliance ranged between 70% and 96%.Women and older students reported higher compliance than did men and younger students. Mild to moderate COVID-19symptoms were reported by 30%, severe symptoms by fewer than 2%; 15% reported being uncertain and half of theparticipants reported no symptoms. Mental health effects were reported by over 80%, and changes in academic self-efficacywere reported by over 85%; in both these areas negative effects predominated. Self-reported symptoms and uncertaintyabout contagion were associated with non-compliance, negative mental health effects, and impaired academic self-efficacy.Conclusions: Students generally followed public health recommendations during strict closure of universities,but many reported considerable negative consequences related to mental health and academic self-efficacy.Digital interventions should be developed and evaluated to boost coping skills, build resilience and alleviatestudent suffering during the pandemic and future similar crises.

Objective To evaluate the long-term costs and health effects of the Swedish newborn screening program for classic phenylketonuria (PKU) alone and in combination with congenital hypothyroidism compared with no screening. Study design A decision-analytic model was developed to estimate and compare the long-term (80 years) costs and health effects of newborn screening for PKU and congenital hypothyroidism. Data were obtained from the liter-ature and translated to Swedish conditions. A societal perspective was taken, including costs falling on health care providers, municipal care and services, as well as production loss due to morbidity. Results Screening 100 000 newborns for PKU resulted in 73 gained quality-adjusted life-years (QALYs) compared with no screening. When adding congenital hypothyroidism, the number of gained QALYs was 232 compared with PKU alone, adding up to a total of 305 QALYs gained. Corresponding cost estimates were $80.8, $70.3, and $10.05 million USD for no screening, PKU screening, and PKU plus congenital hypothyroidism screening, respectively, indicating that screening for PKU plus congenital hypothyroidism was more effective and less costly compared with the other strategies. The majority of cost savings with PKU plus congenital hypothyroidism screening was due to reductions in productivity losses and municipal care and services costs. Conclusion The Swedish newborn screening program for PKU and congenital hypothyroidism saves substantial costs for society while generating additional QALYs, emphasizing the importance of public investments in early diagnosis and treatment. (J Pediatr 2023;256:38-43).

Background: Due to a clinical and public health interest of neck circumference (NC), a better understanding of this simple anthropometric measurement, as a valid marker of body composition is necessary. Methods: A total of 119 young healthy adults participated in this study. NC was measured over the thyroid cartilage and perpendicular to the longitudinal axis of the neck. Body weight, height, waist circumference (WC), and hip circumference were measured. A Dual X-ray absorptiometry (DXA) scan was used to determine fat mass, lean mass, and visceral adipose tissue (VAT). Additionally, body mass index (BMI) and triponderal mass index (TMI), the waist to hip and waist to height ratios, and the fat mass and lean mass indexes (FMI and LMI, respectively) were calculated. Results: NC was positively associated in women (W) and men (M), with BMI (rW = 0.70 and rM = 0.84, respectively), TMI (rW = 0.63 and rM = 0.80, respectively), WC (rW = 0.75 and rM = 0.86, respectively), VAT (rW = 0.74 and rM = 0.82, respectively), Waist/hip (rW = 0.51 and rM = 0.67, respectively), Waist/height (rW = 0.68 and rM = 0.83, respectively) and FMI (rW = 0.61 and rM = 0.81, respectively). The association between NC and indicators of body composition was however weaker than that observed by BMI, TMI, WC and Waist/height in both women and men. It is of note that in women, NC was associated with FMI, VAT and LMI independently of BMI. In men, adding NC to anthropometric variables did not improve the prediction of body composition, while slight improvements were observed in women. Conclusions: Taken together, the present study provides no indication for NC as a useful proxy of body composition parameters in young adults, yet future studies should explore its usefulness as a measure to use in combination with BMI, especially in women.

Som vi visat har utvecklingen av metoder och strukturer för öppna prioriteringar i Sverige kommit långt. Många frågor återstår likväl. Under vårt arbete med denna bok har vi identifierat ett antal förbättringsområden och utmaningar som vi avslutningsvis vill lyfta fram. Det rör sig om vilka som ska delta i prioriteringarna, tydliggörande av värdegrunden, behov av bättre kunskap, baserad på både vetenskaplig metod och erfarenhet, och fortsatt utveckling av prioriteringsprocesser på olika nivåer och i olika sammanhang. Även om vi i Sverige skulle nå en god enighet kring principer och kriterier för prioriteringar så kommer vi alltid finna många olika sätt att praktiskt lösa specifika prioriteringsproblem.

OBJECTIVE: To investigate whether adolescent elite female and male handball players with shoulder muscle weakness, deficits in shoulder rotation range of motion (ROM) or in joint position sense (JPS), or scapular dyskinesis in the preseason had a higher rate of new shoulder injuries compared to players without these characteristics. DESIGN: Prospective cohort study. METHODS: We studied 344 uninjured players (452 player-seasons, 50% female). We measured their shoulder strength in isometric external rotation (IER), isometric internal rotation (IIR), isometric abduction, and eccentric external rotation, as well as their shoulder ROM, JPS, and scapular dyskinesis, during the preseason. Players were monitored weekly regarding match and training hours and shoulder injuries during 1 or 2 seasons. We used multivariable Cox proportional hazard models to calculate hazard rate ratios related to the first injury and 95% confidence intervals (CIs). RESULTS: During 2 seasons, the participants reported 48 new shoulder injuries. In female players, the hazard ratio was 2.37 (95% CI: 103, 5.44) for IER weakness and 2.44 (95% CI: 106, 5.61) for IIR weakness. The hazard rate ratio was 0.85 (95% CI: 0.39,183) for an IER/IIR ratio of less than 0.75 and 1.53 (95% CI: 0.36, 6.52) for scapular dyskinesis. In male players, the hazard rate ratio was 1.02 (95% CI: 0.44, 2.36) for ER weakness, 0.74 (95% CI: 0.31,1.75) for IIR weakness, 2.0 (95% CI: 0.68, 5.92) for an IER/IIR rati of less than 0.75, and 3.43 (95% CI: 1.49, 7.92) for scapular dyskinesis. There were no associations between new shoulder injuries and deficits in ROM or JPS. CONCLUSION: In adolescent elite handball, male players with preseason scapular dyskinesis and female players with preseason IIR or IER shoulder weakness had an increased shoulder injury rate.

Background: Heart failure (HF) is a common chronic condition that affects over 26 million people worldwide. It is a progressive and debilitating disease with a broad symptom profile, intermittently marked by periods of acute decompensation. People with HF generally do not self-manage their condition well (eg, monitoring symptoms, taking medications regularly, physical activity, etc). A better understanding of self-care activities and what factors may indicate deterioration is warranted.Objective: The aim of this study was to determine the feasibility and acceptability of using wearable cameras to assess self-care activities in people with HF. The study objectives were to (1) explore whether changes in self-care activities could be identified prior to hospitalization and (2) determine the acceptability of wearable cameras to people with HF.Methods: A total of 30 people recently diagnosed with HF wore a camera for a maximum of 30 days; the camera took a photo every 30 seconds in the forward-facing direction. At the end of the study, all 30 participants were presented with 8 statements of acceptability, scored on a 5-point Likert scale. To determine whether camera images could identify changes in self-care activities and lifestyle risk factors before hospitalization, we analyzed images from participants (n=8) who were hospitalized during the 30-day study period. Images from the period immediately prior to hospitalization and a comparison were selected for each participant. Images were manually coded according to 9 different event categories relating to self-care and lifestyle risk factors, and events were compared between the 2 periods.Results: The participants reported high acceptability for wearing the cameras, as most strongly agreed or agreed that they were comfortable to wear (28/30, 93%) and easy to use (30/30, 100%). The results of the camera image analysis showed that participants undertook fewer activities of daily living (P=.008) and were more sedentary (P=.02) prior to being hospitalized, compared to a period nonadjacent to hospitalization.Conclusions: Adults with HF were accepting of using a wearable camera for periods within a 30-day time frame. Wearable cameras were a feasible approach for providing data on selected self-care activities and lifestyle risk factors for HF and offer the potential to be a valuable tool for improving our understanding of self-care.

Background: A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC.

Aim: The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care.

Methods: A scoping review was performed based on the framework by Arksey and O’Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group.

Results: In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research.

Conclusion: The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals’ fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC.

Background The de-implementation of low-value care (LVC) is important to improving patient and population health, minimizing patient harm and reducing resource waste. However, there is limited knowledge about how the de-implementation of LVC is governed and what challenges might be involved. In this study, we aimed to (1) identify key stakeholders activities in relation to de-implementing LVC in Sweden at the national governance level and (2) identify challenges involved in the national governance of the de-implementation of LVC. Methods We used a purposeful sampling strategy to identify stakeholders in Sweden having a potential role in governing the de-implementation of LVC at a national level. Twelve informants from nine stakeholder agencies/organizations were recruited using snowball sampling. Semi-structured interviews were conducted, transcribed and analysed using inductive thematic analysis. Results Four potential activities for governing the de-implementation of LVC at a national level were identified: recommendations, health technology assessment, control over pharmaceutical products and a national system for knowledge management. Challenges involved included various vested interests that result in the maintenance of LVC and a low overall priority of working with the de-implementation of LVC compared with the implementation of new evidence. Ambiguous evidence made it difficult to clearly determine whether a practice was LVC. Unclear roles, where none of the stakeholders perceived that they had a formal mandate to govern the de-implementation of LVC, further contributed to the challenges involved in governing that de-implementation. Conclusions Various activities were performed to govern the de-implementation of LVC at a national level in Sweden; however, these were limited and had a lower priority relative to the implementation of new methods. Challenges involved relate to unfavourable change incentives, ambiguous evidence, and unclear roles to govern the de-implementation of LVC. Addressing these challenges could make the national-level governance of de-implementation more systematic and thereby help create favourable conditions for reducing LVC in healthcare.

Background

Cost-effectiveness is important in the prioritisation between interventions in health care. Exercise is cost-effective compared to usual care during oncological treatment; however, the significance of exercise intensity to the cost-effectiveness is unclear. In the present study, we aimed to evaluate the long-term cost-effectiveness of the randomised controlled trial Phys-Can, a six-month exercise programme of high (HI) or low-to-moderate intensity (LMI) during (neo)adjuvant oncological treatment.

Methods

A cost-effectiveness analysis was performed, based on 189 participants with breast, colorectal, or prostate cancer (HI: n = 99 and LMI: n = 90) from the Phys-Can RCT in Sweden. Costs were estimated from a societal perspective, and included cost of the exercise intervention, health care utilisation and productivity loss. Health outcomes were assessed as quality-adjusted life-years (QALYs), using EQ-5D-5L at baseline, post intervention and 12 months after the completion of the intervention.

Results

At 12-month follow-up after the intervention, the total cost per participant did not differ significantly between HI (€27,314) and LMI exercise (€29,788). There was no significant difference in health outcome between the intensity groups. On average HI generated 1.190 QALYs and LMI 1.185 QALYs. The mean incremental cost-effectiveness ratio indicated that HI was cost effective compared with LMI, but the uncertainty was large.

Conclusions

We conclude that HI and LMI exercise have similar costs and effects during oncological treatment. Hence, based on cost-effectiveness, we suggest that decision makers and clinicians can consider implementing both HI and LMI exercise programmes and recommend either intensity to the patients with cancer during oncological treatment to facilitate improvement of health.

Background Exercise during oncological treatment is beneficial to patient health and can counteract the side effects of treatment. Knowledge of the societal costs associated with an exercise intervention, however, is limited. The aims of the present study were to evaluate the long-term resource utilisation and societal costs of an exercise intervention conducted during (neo)adjuvant oncological treatment in a randomised control trial (RCT) versus usual care (UC), and to compare high-intensity (HI) versus low-to-moderate intensity (LMI) exercise in the RCT. Methods We used data from the Physical Training and Cancer (Phys-Can) project. In the RCT, 577 participants were randomised to HI or to LMI of combined endurance and resistance training for 6 months, during oncological treatment. The project also included 89 participants with UC in a longitudinal observational study. We measured at baseline and after 18 months. Resource utilisation and costs of the exercise intervention, health care, and productivity loss were compared using analyses of covariance (RCT vs. UC) and t test (HI vs. LMI). Results Complete data were available for 619 participants (RCT HI: n = 269, LMI: n = 265, and UC: n = 85). We found no difference in total societal costs between the exercise intervention groups in the RCT and UC. However, participants in the RCT had lower rates of disability pension days (p < .001), corresponding costs (p = .001), and pharmacy costs (p = .018) than the UC group. Nor did we find differences in resource utilisation or costs between HI and LMI exercise int the RCT. Conclusion Our study showed no difference in total societal costs between the comprehensive exercise intervention and UC or between the exercise intensities. This suggests that exercise, with its well-documented health benefits during oncological treatment, produces neither additional costs nor savings.

Purpose This study aimed to evaluate the effect of high intensity (HI) vs low-to-moderate intensity (LMI) exercise on health-related quality of life (HRQoL) up to 18 months after commencement of oncological treatment in patients with breast, colorectal or prostate cancer. In addition, we conducted a comparison with usual care (UC). Methods Patients scheduled for (neo)adjuvant oncological treatment (n = 577) were randomly assigned to 6 months of combined resistance and endurance training of HI or LMI. A longitudinal descriptive study (UC) included participants (n = 89) immediately before the RCT started. HRQoL was assessed by EORTC QLQ-C30 at baseline, 3, 6 and 18 months (1 year after completed exercise intervention) follow-up. Linear mixed models were used to study the groups over time. Results Directly after the intervention, HI scored significant (P = 0.02), but not clinically relevant, higher pain compared with LMI. No other significant difference in HRQoL was found between the exercise intensities over time. Clinically meaningful improvements in HRQoL over time were detected within both exercise intensities. We found favourable significant differences in HRQoL in both exercise intensities compared with UC over time. Conclusion This study adds to the strong evidence of positive effect of exercise and shows that exercise, regardless of intensity, can have beneficial effects on HRQoL during oncological treatment and also for a substantial time after completion of an exercise intervention. In this study, for one year after. Implications for cancer survivors Patients can be advised to exercise at either intensity level according to their personal preferences, and still benefit from both short-term and long-term improvements in HRQoL.

Importance Patients with melanoma are selected for sentinel lymph node biopsy (SLNB) based on their risk of a positive SLN. To improve selection, the Memorial Sloan Kettering Cancer Center (MSKCC) and Melanoma Institute Australia (MIA) developed predictive models, but the utility of these models remains to be tested.Objective To determine the clinical utility of the MIA and MSKCC models.Design, Setting, and Participants This was a population-based comparative effectiveness research study including 10 089 consecutive patients with cutaneous melanoma undergoing SLNB from the Swedish Melanoma Registry from January 2007 to December 2021. Data were analyzed from May to August 2023.Main Outcomes and Measures, The predicted probability of SLN positivity was calculated using the MSKCC model and a limited MIA model (using mitotic rate as absent/present instead of count/mm(2) and excluding the optional variable lymphovascular invasion) for each patient. The operating characteristics of the models were assessed and compared. The clinical utility of each model was assessed using decision curve analysis and compared with a strategy of performing SLNB on all patients.Results Among 10 089 included patients, the median (IQR) age was 64.0 (52.0-73.0) years, and 5340 (52.9%) were male. The median Breslow thickness was 1.8 mm, and 1802 patients (17.9%) had a positive SLN. Both models were well calibrated across the full range of predicted probabilities and had similar external area under the receiver operating characteristic curves (AUC; MSKCC: 70.8%; 95% CI, 69.5-72.1 and limited MIA: 69.7%; 95% CI, 68.4-71.1). At a risk threshold of 5%, decision curve analysis indicated no added net benefit for either model compared to performing SLNB for all patients. At risk thresholds of 10% or higher, both models added net benefit compared to SLNB for all patients. The greatest benefit was observed in patients with T2 melanomas using a threshold of 10%; in that setting, the use of the nomograms led to a net reduction of 8 avoidable SLNBs per 100 patients for the MSKCC nomogram and 7 per 100 patients for the limited MIA nomogram compared to a strategy of SLNB for all.Conclusions and Relevance This study confirmed the statistical performance of both the MSKCC and limited MIA models in a large, nationally representative data set. However, decision curve analysis demonstrated that using the models only improved selection for SLNB compared to biopsy in all patients when a risk threshold of at least 7% was used, with the greatest benefit seen for T2 melanomas at a threshold of 10%. Care should be taken when using these nomograms to guide selection for SLNB at the lowest thresholds.

Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport-specific or setting-specific consensus statements on sports injury (and, eventually, illness) epidemiology to date. Our objective was to further strengthen consistency in data collection, injury definitions and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension. The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups and a 3-day consensus meeting in October 2019. This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems; severity of health problems; capturing and reporting athlete exposure; expressing risk; burden of health problems; study population characteristics and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE Extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS). The IOC encourages ongoing in- and out-of-competition surveillance programmes and studies to describe injury and illness trends and patterns, understand their causes and develop measures to protect the health of the athlete. Implementation of the methods outlined in this statement will advance consistency in data collection and research reporting.

Importance  Cardiovascular risk factors in youth have been associated with future cardiovascular disease (CVD), but conventional observational studies are vulnerable to genetic and environmental confounding.

Objective  To examine the role of genetic and environmental factors shared by full siblings in the association of adolescent cardiovascular risk factors with future CVD.

Design, Setting, and Participants  This is a nationwide cohort study with full sibling comparisons. All men who underwent mandatory military conscription examinations in Sweden between 1972 and 1995 were followed up until December 31, 2016. Data analysis was performed from May 1 to November 10, 2022.

Exposures  Body mass index (BMI), cardiorespiratory fitness, blood pressure, handgrip strength, and a combined risk z score in late adolescence.

Main Outcomes and Measures  The primary outcome was fatal or nonfatal CVD, as recorded in the National Inpatient Register or the Cause of Death Register before 2017.

Results  A total of 1 138 833 men (mean [SD] age, 18.3 [0.8] years), of whom 463 995 were full brothers, were followed up for a median (IQR) of 32.1 (26.7-37.7) years, during which 48 606 experienced a CVD outcome (18 598 among full brothers). All risk factors were associated with CVD, but the effect of controlling for unobserved genetic and environmental factors shared by full siblings varied. In the sibling analysis, hazard ratios for CVD (top vs bottom decile) were 2.10 (95% CI, 1.90-2.32) for BMI, 0.77 (95% CI, 0.68-0.88) for cardiorespiratory fitness, 1.45 (95% CI, 1.32-1.60) for systolic blood pressure, 0.90 (95% CI, 0.82-0.99) for handgrip strength, and 2.19 (95% CI, 1.96-2.46) for the combined z score. The percentage attenuation in these hazard ratios in the sibling vs total cohort analysis ranged from 1.1% for handgrip strength to 40.0% for cardiorespiratory fitness. Consequently, in the sibling analysis, the difference in cumulative CVD incidence at age 60 years (top vs bottom decile) was 7.2% (95% CI, 5.9%-8.6%) for BMI and 1.8% (95% CI, 1.0%-2.5%) for cardiorespiratory fitness. Similarly, in the sibling analysis, hypothetically shifting everyone in the worst deciles of BMI to the middle decile would prevent 14.9% of CVD at age 60 years, whereas the corresponding number for cardiorespiratory fitness was 5.3%.

Conclusions and Relevance  In this Swedish national cohort study, cardiovascular risk factors in late adolescence, especially a high BMI, were important targets for CVD prevention, independently of unobserved genetic and environmental factors shared by full siblings. However, the role of adolescent cardiorespiratory fitness in CVD may have been overstated by conventional observational studies.

Objectives

To investigate champion long-distance runners’ strategies for managing injury and illness symptoms and staying well.

Design

Qualitative research study.

Methods

Twelve long-distance runners were interviewed immediately after having competed in World Championships finals. Thematic analysis was used to categorise and structure the data. The results were presented as primary themes and overarching constructs representing connections between the primary themes.

Results

The champion runners’ basic tactic to manage symptoms of ill health was characterized by rapid adjustment of sports load and a strong incentive to learn from experience and professional advice. This tactic was named here educated flexibility. A secondary exigency tactic was associated with reaching short-term goals and a consequential acceptance of health hazards. The runners used economic and other environmental strain to explain use of the exigency tactic. Most champion runners’ long-term strategy to stay well included both tactics successfully combined to maintain a performance level assuring a regular income. Avoidance of letting environmental strain and health problems create vicious circles was at the centre of these strategies.

Conclusions

Champion runners’ main strategy to stay well and sustain their superiority in performance was characterized by constantly paying attention to symptoms of ill health, listening to medical advice, and not letting environmental strain interfere with adjustment of sports load. Many top-level runners originate from global regions where formal education programs and health insurance plans are poorly regulated and supported. Bio-psychosocial models including empowerment at individual and systems levels should be considered when health services are planned for professional runners.

In a recent extended essay, philosopher Daniel Hausman goes a long way towards dismissing severity as a morally relevant attribute in the context of priority setting in healthcare. In this response, we argue that although Hausman certainly points to real problems with how severity is often interpreted and operationalised within the priority setting context, the conclusion that severity does not contain plausible ethical content is too hasty. Rather than abandonment, our proposal is to take severity seriously by carefully mapping the possibly multiple underlying accounts to well-established ethical theories, in a way that is both morally defensible and aligned with the term’s colloquial uses.

In a recent extended essay, philosopher Daniel Hausman goes a long way towards dismissing severity as a morally relevant attribute in the context of priority setting in healthcare. In this response, we argue that although Hausman certainly points to real problems with how severity is often interpreted and operationalised within the priority setting context, the conclusion that severity does not contain plausible ethical content is too hasty. Rather than abandonment, our proposal is to take severity seriously by carefully mapping the possibly multiple underlying accounts to well-established ethical theories, in a way that is both morally defensible and aligned with the term’s colloquial uses.

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to todays severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda.

We investigate the antecedents of subjective financial well-being and general well-being during the ongoing COVID-19 pandemic. In an online survey conducted in the midst of COVID-19 pandemic with over 1000 Swedish participants we found that distrust in the government to cope with financial (but not healthcare) challenges of the pandemic was negatively related to the feeling of financial security. In a structural equation model, we also show that trust in government to deal with financial challenges of COVID-19 pandemic has a significant impact on general well-being through the mediating channel of financial well-being. In addition, trust in government to deal with healthcare challenges of COVID-19 pandemic has a significant direct impact on individuals’ general well-being. Our findings have important implications for public policy as they highlight the importance of citizens’ trust in well-functioning governmental institutions to help cope with not only healthcare, but also financial challenges of an ongoing pandemic.

Outcome editing refers to a set of mental rules that people apply when deciding whether to evaluate multiple outcomes jointly or separately, which subsequently affects choice. In a large-scale online survey (n = 2062) we investigate whether individuals use the same outcome editing rules for financial outcomes (e.g., a lottery win) and social outcomes (e.g., a party with friends). We also test the role of numeric ability in explaining outcome editing. Our results show that people’s preferences for combining or separating events depend on whether those events are in the financial or the social domain. Specifically, individuals were more likely to segregate social outcomes than monetary outcomes, except for when all outcomes were negative. Moreover, numeric ability was associated with preferences for outcome editing in the financial domain but not in the social domain. Our findings extend the understanding of the arithmetic operations underlying outcome editing and suggest that people rely more on calculations when making choices involving multiple financial outcomes and more on feelings when making choices involving social outcomes.