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Background The Swedish Physical Activity on Prescription (PAP-S) is a method for healthcare to promote physical activity for prevention and treatment of health disorders. Despite scientific support and education campaigns, the use has been low. The aim of this study was to perform a process evaluation of an implementation intervention targeting the use of the PAP-S method in primary healthcare (PHC). Specifically, we wanted to evaluate feasibility of the implementation intervention, and its effect on the implementation process and the outcome (number of PAP-S prescriptions).

Methods This was a longitudinal study using the Medical Research Council guidance for process evaluation of a 9-month implementation intervention among healthcare staff at three PHC centres in Sweden. Data was collected by: participatory observations of the implementation process; questionnaires to the staff before, after and 6 months after the implementation intervention; interviews after the implementation intervention; and number of PAP-S prescriptions.

Results During the implementation intervention, the workplaces’ readiness-to-change and the healthcare staff’s confidence in using the PAP-S method were favourably influenced, as was the number of PAP-S prescriptions. After the implementation intervention, the number of PAP-S prescriptions decreased to about the same number as before the implementation intervention, at two out of three PHC centres. Four of the six implementation strategies appeared to impact on the implementation process: external facilitation; leadership engagement by a committed workplace management; local PAP-S coordinator taking a leading role and acting as local champion; educational outreach concerning how to use the PAP-S method.

Conclusion The implementation intervention was not sufficient to produce sustained change of the healthcare staff’s behaviour, nor did it achieve favourable long-term outcome on the number of PAP-S prescriptions. The healthcare staffs’ sparse knowledge of the PAP-S method prior to the implementation intervention hampered the implementation. More hands-on education in how to use the PAP-S method introduced early in the implementation process is imperative for successful implementation of the PAP-S method. The findings also suggest that committed workplace management and local PAP-S coordinators, taking leading roles and acting as local champions, need to be firmly established at the PHC centres before the external facilitator withdraws.

Low priority of disease prevention and health promotion in medical education may contribute to lack of lifestyle-counseling in clinical practice. Pharmacology-related knowledge is valued 5 times higher compared to lifestyle-related knowledge in examinations on noncommunicable diseases (NCDs) in undergraduate medical education in Sweden. This study aims to establish (i) whether medical licensing examinations are biased to favor pharmacology- over lifestyle-related knowledge and (ii) whether such a bias is present in both Sweden and the US. We identified 204 NCD-related questions from previous Swedish licensing examinations, and 77 cases from a U.S. question bank commonly used to prepare for the United States Medical Licensing Examination® (USMLE®) Step 3. With the help of expected correct answers, we determined distribution of points attainable for knowledge in the respective category (lifestyle / pharmacology / other) for 5 major NCDs: coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and stroke. The percentage of points attainable for lifestyle-related knowledge was 6.7 (95% CI 4.1-9.3) in Sweden and 4.6 (95%CI 0.0-9.1) in the U.S. The respective percentages for pharmacology-related knowledge were 32.6 (95% CI 26.3-38.8) and 44.5 (95% CI 33.2-55.8) percent. The pharmacology vs. lifestyle-quotas were 4.9 in Sweden and 9.8 in the U.S. Likelihoods of equal emphasis on lifestyle and pharmacology in NCDs was < 0.001 in both countries. There is a marked preference for pharmacology over lifestyle in medical licensing examinations in both Sweden and the U.S. Newly qualified doctors may be inadequately prepared to address preventable causes of NCDs.

AIMS: To examine if personnel resources and organisational features in Swedish primary health-care centres (PHCCs) are associated to all-cause mortality (ACM) in people with type 2 diabetes mellitus (T2DM).

METHODS: A total of 187,570 people with T2DM registered in the Swedish National Diabetes Register (NDR) during 2013 were included in this nationwide cohort study. Individual NDR data were linked to data from a questionnaire addressing personnel resources and organisational features for 787 (68%) PHCCs as well as to individual data on socio-economic status and comorbidities. Furthermore, data on ACM were obtained and followed up until 30 January 2018. Hierarchical Cox regression analyses were applied.

RESULTS: After a median follow-up of 4.2 years, 27,136 (14.5%) participants had died. An association was found between number of whole-time-equivalent (WTE) general practitioner's (GP's) devoted to diabetes care/500 people with T2DM and lower risk of early death (hazard ratio 0.919 [95% confidence interval 0.895-0.945] per additional WTE GP; p = 0.002). No other personnel resources or organisational features were significantly associated with ACM.

CONCLUSIONS: This nationwide register-based cohort study suggests that the number of WTE GPs devoted to diabetes care have an impact on the risk of early death in people with T2DM.

Background

Research suggests that social status in school plays an important role in the social lives of adolescents and that their social status is associated with their health. Additional knowledge about adolescents? understanding of social hierarchies could help to explain inequalities in adolescents? health and guide public health interventions.

Objective

The study aimed to explore what contributes to subjective social status in school and the strategies used for social positioning.

Methods

A qualitative research design with think-aloud interviews was used. The study included 57 adolescents in lower (7th grade) and upper secondary school (12th grade) in Sweden. Subjective social status was explored using a slightly modified version of the MacArthur Scale of Subjective Social Status in school. Data were analyzed using thematic network analysis.

Results

The participants were highly aware of their social status in school. Elements tied to gender, age, ethnicity and parental economy influenced their preconditions in the positioning. In addition, expectations on how to look, act and interact, influenced the pursue for social desirability. The way these different factors intersected and had to be balanced suggests that social positioning in school is complex and multifaceted.

Conclusions

Because the norms that guided social positioning left little room for diversity, the possible negative impact of status hierarchies on adolescents? health needs to be considered. In school interventions, we suggest that norms on e.g. gender and ethnicity need to be addressed and problematized from an intersectional approach.

AIMS: To describe and analyse the associations between primary health care centres' (PHCCs') quality of work (QOW) and individual HbA1c levels in people with Type 2 diabetes mellitus (T2DM).

METHODS: This cross-sectional study invited all 1152 Swedish PHCCs to answer a questionnaire addressing QOW conditions. Clinical, socio-economic and comorbidity data for 230,958 people with T2DM were linked to data on QOW conditions for 846 (73.4%) PHCCs.

RESULTS: Of the participants, 56% had controlled (≤52mmol/mol), 31.9% intermediate (53-69mmol/mol), and 12.1% uncontrolled (≥70mmol/mol) HbA1c. An explanatory factor analysis identified seven QOW features. The features having a call-recall system, having individualized treatment plans, PHCCs' results always on the agenda, and having a follow-up strategy combined with taking responsibility of outcomes/results were associated with lower HbA1c levels in the controlled group (all p<0.05). For people with intermediate or uncontrolled HbA1c, having individualized treatment plans was the only QOW feature that was significantly associated with a lower HbA1c level (p<0.05).

CONCLUSIONS: This nationwide study adds important knowledge regarding associations between QOW in real life clinical practice and HbA1c levels. PHCCs' QOW may mainly only benefit people with controlled HbA1c and more effective QOW strategies are needed to support people with uncontrolled HbA1c.

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

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

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

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

Ohälsosamma levnadsvanor är vanliga i befolkningen. Hälften av alla kvinnor och två tredjedelar av männen har minst en ohälsosam levnadsvana. Tobaksbruk, riskbruk av alkohol, ohälsosamma matvanor eller otillräcklig fysisk aktivitet utgör viktiga riskfaktorer för många av våra stora folksjukdomar som hjärt–kärlsjukdom, cancer och typ 2-diabetes. Tillsammans bidrar dessa levnadsvanor till cirka en femtedel av den samlade sjukdomsbördan i Sverige.

I juni 2018 presenterade Socialstyrelsen »Nationella riktlinjer för prevention och behandling vid ohälsosamma levnadsvanor« [1]. Riktlinjerna omfattar åtgärder för att stödja personer att förändra levnadsvanor i syfte att förbättra hälsa samt förebygga och behandla sjukdom.

Updated Swedish National Guidelines on prevention and lifestyle habits: physicians' role

The recently updated Swedish National Guidelines on prevention and lifestyle habits (tobacco use, hazardous use of alcohol, insufficient physical activity and unhealthy eating habits) emphasize the importance of supporting lifestyle changes among risk individuals, such as already affected by disease, carriers of risk factors that increase the risk of disease, and people with social vulnerability. More measures targeting youth are included, as well as measures to avoid smoking and alcohol use prior to surgery. Physicians have a key role in implementation of the new guidelines, as a great majority of patients who attend healthcare and discuss lifestyle habits do so with a physician.

Background: Social position, traditionally measured by objective data on socioeconomic status (SES), is linked to health status in adults. In adolescents, the association is more uncertain and there are some studies suggesting that subjective social status (SSS) might be more adequate in relation to health. This study aimed to examine associations between SSS in school, SES and self-rated health (SRH) in adolescent boys and girls.

Methods: A descriptive cross-sectional research design with quantitative survey data was used. The study involved 705 Swedish adolescents in upper secondary school (17–18-year-olds). SRH was measured with a single-item question and SSS by a question where adolescents were asked to assess their social position within their school. Formal education level of the parents was used as a proxy for objective SES. Univariable and multivariable ordinal regression analyses were conducted to assess the associations between SRH and SSS in school and SES.

Results: In the multivariable analysis, SSS in school was positively associated with SRH, whereas no significant association between SES and SRH was found. The proportion of adolescents with high SRH increased with higher steps on the SSS ladder. Significant gender differences were found in that boys rated their SRH and SSS in school higher than girls did.

Conclusions: The study shows that self-rated health in adolescents is related to perceived social position in school. Subjective social status in school seems to be a useful health-related measure of social position in adolescents.