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PURPOSE: In this study, a comprehensive analysis of costs of chronic kidney disease (CKD) was performed, to understand factors associated with the economic burden of the disease in a multicentre international framework.

METHODS: The impact on costs of demographics, socio-economics, clinical, and functional variables was tested in 2204 subjects aged 75 years or more attending outpatient clinics in Europe using a multicentre 2-year prospective cohort study. By means of collected resources consumption and unit cost data a comprehensive cost database was built and then investigated using multilevel regression modeling.

RESULTS: Overall, hospitalization, medications and specialist visits were the main cost items, with a notable variability among countries. Estimated yearly costs were 4478€ ± 9804€, rising up to 6683€ ± 10,953€ for subjects with estimated Glomerular Filtration Rate (eGFR) < 30. Costs increased significantly according to the severity of the disease, gender and age. Clinical and functional covariates were also significantly associated with CKD-related total costs, even after correcting for the inter-country variability.

CONCLUSION: Findings corroborate the importance of multidimensional assessment of participants with CKD, as multimorbidity and functional disability produce a detrimental impact on participant's prognosis and cost of care. Preservation of functional impairment and adequate management of comorbidities may thus help decreasing the overall consumption on health care resources in CKD patients, especially in older people.

Skiftande vårdkvalité hotar patientsäkerheten inom ambulanssjukvården. Nu måste regeringen och Socialstyrelsen skapa nationella riktlinjer, skriver Nätverket för utbildning av ambulanssjuksköterskor.

The purpose of this Bachelor ́s thesis is to highlight which attributes who are significant in Region Dalarnas work to attract and retain specialist nurses within the operations. The theoretical frame of reference form the basic for previous research in the areas of Employer Brand and Employer Value Proposition (EVP). Furthermore, the theoretical frame has analyzed previous research for the study's identified themes: Leadership, Wage Policy and Skills supply/Skills development.

The study has a qualitative approach where eight semistructured interviews were conducted with previously or currented employed specialist nurces within Region Dalarna. The results shows that Region Dalarna ́s main significant attributes for attracting and retaining specialist nurses are the three themes mentioned above which has been idenified by the present study.

As a contribution to the practitioner community, Region Dalarna can suggest paying attention to the results of the study to delvelope the work for attracting and retaining specialist nurses in the operations. The present study can also be seen as a contribution to previous research.

Background: Identifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden.

Methods: A multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children < 18 years of age between July 1, 2011 and October 31, 2012. Univariate and multivariate analysis were undertaken to determine factors predictive of hospital admission.

Results: Of the 151,647 ED presentations made during the study period, 22% resulted in hospital admission. Admission rate varied by site; the children's EDs in Australia had higher admission rates (South Australia: 26%, Queensland: 23%) than the mixed (adult and children's) EDs (South Australia: 13%, Queensland: 17%, Sweden: 18%). Factors most predictive of hospital admission for children, after controlling for triage category, included hospital type (children's only) adjusted odds ratio (aOR):2.3 (95%CI: 2.2-2.4), arrival by ambulance aOR:2.8 (95%CI: 2.7-2.9), referral from primary health aOR:1.5 (95%CI: 1.4-1.6) and presentation with a respiratory or gastrointestinal condition (aOR:2.6, 95%CI: 2.5-2.8 and aOR:1.5, 95%CI: 1.4-1.6, respectively). Predictors were similar when each site was considered separately.

Conclusions: Although the characteristics of children varied by site, factors predictive of hospital admission were mostly similar. The awareness of these factors predicting the need for hospital admission can support the development of clinical pathways.

BACKGROUND: Over the past decades, informal care has increased in most OECD-countries. Informal care is costly to caregivers and to society in the form of lost income and direct costs of providing care. Existing evidence suggests that providing informal care affects caregivers' overall health. However, estimates of the social costs of informal care based on national data on individuals are currently scarce.

OBJECTIVE: This study contributes to the existing evidence on the costs of informal care by estimating the direct and indirect costs to caregivers using a purposive national household survey from Sweden.

METHODS: Adopting a bottom-up, prevalence approach, the direct and indirect costs are estimated using the survey data and the value of working time and leisure time from existing sources.

RESULTS: The results suggest that around 15% of the adult population of Sweden provide informal care and that such care costs around SEK 152 billion per year (around 3% of GDP; USD 16,3 billion; EUR 14,5 billion), or SEK 128000 per caregiver. Around 55% of costs are in the form of income loss to caregivers. The largest cost items are reduced work hours and direct costs of providing informal care. Replacing informal caregivers with professional care providers would be costly at around SEK 193,6 billion per year.

CONCLUSIONS: Findings indicate that, even in a country with a relatively generous welfare system, significant resources are allocated toward providing informal care. The costing analysis suggests that effective support initiatives to ease the burden of informal caregivers may be cost-effective.

Numerous endeavours to ensure that day-to-day healthcare is both evidence-based and person-centred have generated extensive, although partial, comprehension of what guarantees quality improvement. To address quality issues, researchers and clinicians have developed several strategies as well as implementation theories, models, and frameworks. However, more progress is needed regarding how to facilitate guideline and policy implementation that guarantees effective changes take place in a timely and safe manner. This paper considers experiences of engaging and supporting local facilitators in knowledge implementation. Drawing on several interventions, considering both training and support, this general commentary discusses whom to engage and the length, content, quantity, and type of support along with expected outcomes of facilitators' activities. In addition, this paper suggests that patient facilitators could help produce evidence-based and person-centred care. We conclude that research about the roles and functions of facilitators needs to include more structured follow-ups and also improvement projects. This can increase the speed of learning with respect to what works, for whom, in what context, why (or why not), and with what outcomes when it comes to facilitator support and tasks.

Objectives: While national quality registries (NQRs) are suggested to provide opportunities for systematic follow-up and learning opportunities, and thus clinical improvements, features in registries and contexts triggering such processes are not fully known. This study focuses on one of the world's largest stroke registries, the Swedish NQR Riksstroke, investigating what aspects of the registry and healthcare organisations facilitate or hinder the use of registry data in clinical quality improvement.

Methods: Following particular qualitative studies, we performed a quantitative survey in an exploratory sequential design. The survey, including 50 items on context, processes and the registry, was sent to managers, physicians and nurses engaged in Riksstroke in all 72 Swedish stroke units. Altogether, 242 individuals were presented with the survey; 163 responded, representing all but two units. Data were analysed descriptively and through multiple linear regression.

Results: A majority (88%) considered Riksstroke data to facilitate detection of stroke care improvement needs and acknowledged that their data motivated quality improvements (78%). The use of Riksstroke for quality improvement initiatives was associated (R²=0.76) with ‘Colleagues’ call for local results’ (p=<0.001), ‘Management Request of Registry data’ (p=<0.001), and it was said to be ‘Simple to explain the results to colleagues’ (p=0.02). Using stepwise regression, ‘Colleagues’ call for local results’ was identified as the most influential factor. Yet, while 73% reported that managers request registry data, only 39% reported that their colleagues call for the unit's Riksstroke results.

Conclusions: While an NQR like Riksstroke demonstrates improvement needs and motivates stakeholders to make progress, local stroke care staff and managers need to engage to keep the momentum going in terms of applying registry data when planning, performing and evaluating quality initiatives.

BACKGROUND: Stroke significantly impacts individuals, leading to the need for long-lasting rehabilitation and adaptation to environmental demands. Rehabilitation after stroke is increasingly performed in patients' homes, and it is argued that rehabilitation in this context is more person-centred and positively impacts client outcomes. However, the role of environmental factors in this process is largely unknown. The aim of this study was to explore how multidisciplinary healthcare practitioners working with rehabilitation in the home after stroke consider possibilities and challenges in the environment and how environmental factors are documented in patients' records.

METHODS: Eight multidisciplinary healthcare practitioners working with home-based rehabilitation after stroke participated in two semistructured focus group sessions. Thematic analysis was used to analyse the transcripts of recorded focus group discussions. Data were also collected from patient history records (N = 14) to identify interventions to increase patients' opportunities to participate in activities inside and outside the home. These records were analysed using life-space mobility as a conceptual framework.

RESULTS: The analysis generated four overarching themes concerning possibilities and challenges in the environment: (1) the image of rehabilitation conflicts with place, (2) the person in the home reveals individual needs and capabilities, (3) environmental characteristics influence the rehabilitation practice, and (4) the person is integrated within a social context. The patient record analysis showed that most patients were discharged from hospital to home within four days. Assessments at the hospital mainly focused on basic activities of daily living, such as the patient's self-care and walking ability. Also at home, the assessments and actions primarily focused on basic activities with little focus on participation in meaningful activities performed in different life situations outside the home.

CONCLUSIONS: Our research suggests that one way to improve practice is to include the environment in the rehabilitation and consider the person´s life space. Interventions should focus on supporting out-of-home mobility and activities as part of person-centred stroke rehabilitation. This must be supported by clear documentation in the patient records to strengthen clinical practice as well as the communication between stakeholders.

The aim of this study was to examine changes in an organizational field over time when implementing a freedom of choice model. Main focus was on the range and characteristics of providers and services. Our findings suggest that the expected effects of the reform in terms of variety of providers and services within the organizational field did not materialise due to a lack of market competition. Providers complemented each other rather than competed with each other, and the logics of care, choice, and advocacy challenged each other within the quasi-market. All informants described financial conditions in the market as extremely strained. Strong personal commitment characterized providers entering and exiting the market. A gap was found between policy goals and experiences among stakeholders, and efficiency was found to be the policy goal achieved most often in practice. This raises the questions of how the Swedish community mental health service market will develop in the future and what the implications are for the participants.

BACKGROUND: Care transitions following stroke should be bridged with collaboration between hospital staff and home rehabilitation teams since well-coordinated transitions can reduce death and disability following a stroke. However, health services are delivered within organisational structures, rather than being based on patients' needs. The aim of this study protocol is to assess the feasibility, operationalised here as fidelity and acceptability, of a codesigned care transition support for people with stroke.

METHODS: This study protocol describes the evaluation of a feasibility study using a non-randomised controlled design. The codesigned care transition support includes patient information using videos, leaflets and teach back; what-matters-to me dialogue; a coordinated rehabilitation plan; bridged e-meeting; and a message system for cross-organisational collaboration. Patients with stroke, first time or recurrent, who are to be discharged home from hospital and referred to a rehabilitation team in primary healthcare for continued rehabilitation in the home will be included. One week after stroke, data will be collected on the primary outcome, namely satisfaction with the care transition support, and on the secondary outcome, namely health literacy and medication adherence. Data on use of healthcare will be obtained from a register of healthcare contacts. The outcomes of patients and significant others will be compared with matched controls from other geriatric stroke and acute stroke units, and with matched historic controls from a previous dataset at the intervention and control units. Data on acceptability and fidelity will be assessed through interviews and observations at the intervention units.

ETHICS AND DISSEMINATION: Ethical approvals have been obtained from the Swedish Ethical Review Authority. The results will be published open-access in peer-reviewed journals. Dissemination also includes presentation at national and international conferences.

DISCUSSION: The care transition support addresses a poorly functioning part of care trajectories in current healthcare. The development of this codesigned care transition support has involved people with stroke, significant other, and healthcare professionals. Such involvement has the potential to better identify and reconceptualise problems, and incorporate user experiences.

TRIAL REGISTRATION NUMBER: http://www.clinicaltrials.gov id: NCT02925871. Date of registration 6 October 2016.

PROTOCOL VERSION: 1.

BACKGROUND: Health risk assessment (HRAs) are commonly used by occupational health services (OHS) to aid workplaces in keeping their employees healthy, but for unknown reasons, many employees choose not to participate in the HRAs. The aim of the study was to explore whether demographic, lifestyle and health-related factors in employees are associated with non-participation in initial and repeated HRAs.

METHODS: In an OHS-based health project, 2022 municipal employees were asked to participate in three repeated HRAs. Multiple logistic regression analyses were used so as to determine associations between non-participating and demographic, lifestyle and health-related factors (e.g. biomarkers).

RESULTS: Among the employees who were asked to participate in the health project, more than half did not participate in any HRA and among those who did, more than one third did not participate in repeated HRAs. Young age, male sex and being employed in the Technical department or Health and Social Care department in comparison with being employed in the department for Childcare and Education were factors significantly associated with non-participation in the initial HRA. These factors, together with being on sick leave and having unhealthy dietary habits, were factors associated with non-participation in repeated HRAs.

CONCLUSIONS: Among the non-participators in initial HRAs and in repeated HRAs younger men and those already related to ill-health were overrepresented. This implicates that health care providers to a higher extent should focus on "those most needed" and that employers should be more engaged in results of repeated HRA's. Future studies should focus on modifiable variables that could make the HRAs more attractive and inclusive.

Small-scale enterprises face difficulties in fulfilling the regulations for organising Systematic Work Environment Management. This study compared three groups of small-scale manufacturing enterprises with and without support for implementing the provision. Two implementation methods, supervised and network method, were used. The third group worked according to their own ideas. Twenty-three enterprises participated. The effects of the implementation were evaluated after one year by semi-structured dialogue with the manager and safety representative. Each enterprise was classified on compliance with ten demands concerning the provision. The work environment was estimated by the WEST-method. Impact of the implementation on daily work was also studied. At the follow-up, the enterprises in the supervised method reported slightly more improvements in the fulfilment of the demands in the provision than the enterprises in the network method and the enterprises working on their own did. The effect of the project reached the employees faster in the enterprises with the supervised method. In general, the work environment improved to some extent in all enterprises. Extensive support to small-scale enterprises in terms of advise and networking aimed to fulfil the regulations of Systematic Work Environment Management had limited effect especially considering the cost of applying these methods.

Decommissioning programmes pose a substantial risk of failure compared to other change processes in healthcare. A better understanding of the challenges associated with change processes initiated by resource scarcity faced by healthcare managers is crucial. This study describes and compares department and unit managers' experiences during the implementation of a large-scale decommissioning programme in a Swedish region. A survey was developed and a cross-sectional study was performed, measuring 172 healthcare managers' experiences of (1) the region's leadership, (2) their own participation and (3) their own commitment and responsibility during the implementation of the decommissioning programme. Respondents were 50 department managers and 122 unit managers (93% and 58% response rate, respectively). There was a significant difference between department and unit managers in their experiences of the region's leadership and their own participation in the decommissioning programme. Unit managers were more dissatisfied with the way it developed compared to department managers. For example, unit managers reported a lower level of leadership support, incentives to participate, and that their knowledge and skills were not fully utilised. Involvement of unit managers in a more fruitful way might enhance the results of decommissioning programmes. This study highlights a key actor in this context: the unit manager.

Purpose A local healthcare organisation providing healthcare to 288,000 residents in Sweden struggled with a longstanding budget deficit. Several attempts to overcome the demanding financial situation have failed. A decommissioning programme was launched, and two years later, an evaluation indicated positive outcomes. The aim of this study was to explore factors politicians and public servants perceived as enablers to the successful implementation of the programme.

Design/methodology/approach A deductive content analysis approach using a framework of factors facilitating successful implementation of decommissioning decisions was applied to analyse interviews with 18 informants.

Findings Important factors were: (1) a review report contributing to the clarity of evidence, which (2) made the clarity of the rationale for change undeniable and (3) strengthened the political support for change. Additional factors were: (4) the strength of executive leadership, (5) the strength of clinical leadership supported by (6) the quality of project management and (7) a cultural and behavioural change seen as an important outcome for the path forward. A way to maximise the potential for a successful implementation of a large-scale decommissioning programme is to build a shared vision and a collaboration grounded in convincing evidence. Include public servants with a clinical background in the executive leadership team to contribute with legitimacy, competence, and trust in the decommissioning programme's intention.

Originality/value The paper addresses the limited knowledge of best practices in decommissioning processes and contributes empirical knowledge from a successful case.

BACKGROUND: As a response to many years of repetitive budget deficits, Region Dalarna in Sweden started a restructuring process in 2015, and implemented a decommissioning programme to achieve a balanced budget until 2019. Leading politicians and public servants took the overall decisions about the decommissioning programme, but the clinical decision-making and implementation was largely run by the clinic managers and their staff. As the decommissioning programme improved the finances, met relatively little resistance from the clinical departments, and neither patient safety nor quality of care were perceived to be negatively affected, the initial implementation could be considered successful. The aim of this study was to investigate clinic managers' experience of important factors enabling the successful implementation of a decommissioning programme in a local healthcare organization.

METHODS: Drawing on a framework of factors and processes that shape successful implementation of decommissioning decisions, this study highlights the most important factors that enabled the clinic managers to successfully implement the decommissioning programme. During 2018, an interview study was conducted with 26 clinic managers, strategically selected to represent psychiatry, primary care, surgery and medicine. A deductive content analysis was used to analyze the interviews. By applying a framework to the data, the most important factors were illuminated.

RESULTS: The findings highlighted factors and processes crucial to implementing the decommissioning programme: 1) create a story to get a shared image of the rationale for change, 2) secure an executive leadership team represented by clinical champions, 3) involve clinic managers at an early stage to ensure a fair decision-making process, 4) base the decommissioning decisions on evidence, without compromising quality and patient safety, 5) prepare the organisation to handle a process characterised by tensions and strong emotions, 6) communicate demonstrable benefits, 7) pay attention to the need of cultural and behavioral change and 8) transparently evaluate the outcome of the process.

CONCLUSIONS: From these findings, we conclude that in order to successfully implement a decommissioning programme, clinic managers and healthcare professions must be given and take responsibility, for both the process and outcome.

OBJECTIVES: Our aim was to describe the time and costs used during the implementation of a more person-centred care (PCC) approach as part of ordinary practice.

DESIGN: A case study with embedded units.

SETTING: Region Dalarna, Sweden.

PARTICIPANTS: The Department for Development (DD) staff who provided a central support function in the implementation and six healthcare units: nephrology, two geriatric care and rehabilitation units, two psychiatry units and primary care.

INTERVENTIONS: More PCC.

PRIMARY AND SECONDARY OUTCOME MEASURES: Working days and related salary costs reported by categories indicating costs for implementation strategies, service delivery, and research/development costs.

RESULTS: The healthcare units logged on average 5.5 working days per staff member. In the healthcare units, 6%-57% of the time reported was used for implementation strategies, 40%-90% for service delivery and 2%-12% for research/development. Of the time reported by the DD, 88% was assigned to implementation strategies. Costs associated with reported time indicated 23% of costs for this implementation occurred in the DD. Using the budgeted cost, this proportion increased to 48%. The budget for the DD corresponded to SEK 2.30 per citizen per year and 0.009% of the total healthcare budget of the region.

CONCLUSIONS: The study found that a large part of resources used for this implementation of more PCC occurred in the DD, although at least half of the costs occurred in the healthcare units. Moreover, the cost of providing a central support function corresponds to a tiny proportion of the total health budget.

Background How ambulance clinicians (ACs) handle a mass casualty incident (MCI) is essential for the suffered, but the training and learning for the ACs are sparse and they don't have the possibility to learn without realistic simulation training. In addition, it is unclear what type of dilemmas ACs process in their clinical reasoning during an MCI. With virtual reality (VR) simulation, the ACs clinical reasoning can be explored in a systematic way. Therefore, the objective was to explore ambulance clinicians' clinical reasoning when simulating a mass casualty incident using virtual reality.

Methods This study was conducted as an explorative interview study design using chart- stimulated recall technique for data collection. A qualitative content analysis was done, using the clinical reasoning cycle as a deductive matrix. A high-fidelity VR simulation with MCI scenarios was used and participants eligible for inclusion were 11 senior ACs.

Results/conclusion All phases of the clinical reasoning cycle were found to be reflected upon by the participants during the interviews, however with a varying richness of analytic reflectivity. Non-analytic reasoning predominated when work tasks followed specific clinical guidelines, but analytical reasoning appeared when the guidelines were unclear or non-existent. Using VR simulation led to training and reflection on action in a safe and systematic way and increased self-awareness amongst the ACs regarding their preparedness for MCIs. This study increases knowledge both regarding ACs clinical reasoning in MCIs, and insights regarding the use of VR for simulation training.

The emergency medical services (EMS) has been described as a challenging professional practice where the persons in need of care vary greatly in terms of age, symptoms and situations. There is limited research regarding the experience of being new to this line of work, and what support new professionals desire during their first year in a professional practice like the EMS. The overall aim of this thesis was to increase knowledge about the experience of being new to the EMS and to identify what support new professionals desire during their first year. This thesis is based on the findings from four studies. The theory of communities of practice has been used for interpreting, understanding and explanation of the synthesised findings of these four studies. Qualitative research approach was used in Studies I and II, the Delphi technique was used in Study III and a quantitative research approach was used in Study IV. Data was collected using interviews and questionnaires. The findings in this thesis show that the experience of being new to the EMS is a triality of the own identity, the community and the practice and the desirable support during the first year was summarized by 11 statements of support. The own identity refers to the experiences of transitioning into a new professional identity. It is a period of mixed emotions and low self-confidence where supports that aim at strengthen self-confidence is desired. The community refers to the experience of the colleagues in the EMS. Supportive climate and a trustworthy colleague have positive influence on the own professional development and help strengthening self-confidence. Unsupportive and harsh cultures, without mutual engagement around patient care, negatively affected the experience. Supports that contribute to the new professionals feeling welcome and respected in the new community was desired. The practice refers to the experiences of the EMS assignments and the EMS context. Being able to work independently and handle unpredictability was considered challenging, and sometimes this challenge was intensified when the colleague and the new professional did not share the same view of the situation. Supports that aim at creating a sense of stability and control was desired. The thesis concludes that the experience of being new to the EMS is a triality where the own personal development of a new identity, the EMS community and the EMS practice highly influence the experience. It is important to emphasis all three dimensions of this triality when supporting new professionals in the EMS. This thesis also concludes the importance of all members of the EMS community having mutual engagement and a shared view on what, when and how the patient care in the EMS should be provided. The findings in this thesis will contribute knowledge that will be of use when designing formal support- and introduction programs for professionals new to the EMS.

Issue addressed: The aim was to compare the cost-effectiveness of different ways to distribute a personal health document that was primarily aimed at supporting behaviour change. Personal health documents have been widely used in health-promoting efforts but their effective use is rather sparsely studied. Methods: Four types of distribution were tested in Sweden: primary health care centres (n=418); work site meetings (n=164); at an occupational health examination (n=279); by mail (n=445). Participant behaviour changes were measured by a questionnaire. Cost calculations were made based on the results of the study. Results: Between 10% and 26% of participants reported behaviour changes as a result of reading the booklet. A change in health situation was less likely using postal distribution. There were no significant differences between the other types of distribution. Cost-effective distribution at work sites and in occupational health was superior to distribution in primary health care when direct costs were used. Distribution at work sites was the least cost-effective when indirect costs, i.e. productivity losses of participants, were included. Conclusions: Cost-effectiveness analyses support distribution of personal health documents in occupational health. In primary health care, high training costs in combination with low distribution rates might be problematic. Providing information during distribution at work sites is time-consuming and might therefore be a problem if productivity losses are taken into account.

The Web Accessibility Directive (WAD) is part of the European Union’s work for digital inclusion. The WAD obligates that public sector bodies’ websites meet accessibility standards and provide an accessibility statement on the website informing about inaccessible content, and a feedback mechanism for reporting accessibility issues or requesting inaccessible content in an accessible format. The objective of this study was to evaluate how healthcare providers in Sweden have applied accessibility statements on their websites as regulated by law. A descriptive study using a mixed methods approach was conducted, by quantitative descriptive data analysis of the healthcare providers’ accessibility statements compliance to requirements and qualitative data analysis of the written information provided in the accessibility statement. All but one of the 37 evaluated healthcare providers published an accessibility statement. None of the healthcare providers fully met the requirements for accessibility statements, and no one complied with the intention of the law, i.e. to provide accessible health information and eHealth services. There was no or minor progress between the first and the latest published accessibility statement. The possibility to declare no or partial compliance with the law, or claim disproportionate burden, and the lack of enforcement procedures, risk producing symbolic actions e.g., publishing accessibility statements without intention to abide by the law. We suggest that the directives for accessibility statements should be advanced regarding comprehensiveness, understandability, and usefulness. It is suggested that the assessment protocol developed for this study may be used for future evaluations of accessibility statements. © 2023, The Author(s).

BACKGROUND: Accessibility is acknowledged as a key to inclusion in the Convention of Rights for People with Disabilities. An inaccessible design can result in exclusion from eHealth and cause disability among people who have impairments. OBJECTIVE: This scoping literature review aimed to investigate how eHealth services have been developed and evaluated regarding accessibility for people with impairments. METHODS: In line with Arksey and O'Malley's framework for scoping studies and using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a search in 4 databases (PubMed, Scopus, IEEE, and Web of Science) in October 2020 and an update of the search in June 2022. The search strategy was structured according to the PICO model as follows: Population/Problem, digital accessibility for users with impairment; Intervention, health care delivered by any digital solution; Comparison, not applicable; Outcome, use of and adherence to (1) Web Content Accessibility Guidelines (WCAG), (2) other accessibility guidelines, and (3) other means, for designing or evaluating accessibility in eHealth services. A Boolean search was conducted by combining terms related to accessibility and eHealth. All authors participated in screening abstracts according to the eligibility criteria. Each publication, containing a potentially relevant abstract, was read (full text) and assessed for eligibility by 2 authors independently and pairwise. Publications deemed eligible were read by all authors and discussed for consensus. RESULTS: A total of 8643 publications were identified. After abstract screening, 131 publications remained for full-text reading. Of those, 116 publications were excluded as they did not meet the eligibility criteria. Fifteen publications involving studies of 12 eHealth services were included in the study. Of the 15 publications, 2 provided a definition of accessibility, 5 provided an explanation of accessibility, and 8 did not provide any explanation. Five publications used the WCAG to evaluate accessibility when developing eHealth services. One publication used International Organization for Standardization (ISO) 29138, ISO 2941, and ISO/International Electrotechnical Commission (IEC) 30071-1 standards together with the Spanish Association for Standardization (UNE) 139803 standard. Eleven publications used other means to address accessibility, including text-level grading; literature review about accessibility; user tests, focus groups, interviews, and design workshops with target groups of patients, relatives, and health care professionals; and comparative analysis of existing technical solutions to provide information about useful requirements. CONCLUSIONS: Although a clear definition of accessibility can enhance operationalization and thus measurability when evaluating accessibility in eHealth services, accessibility was insufficiently defined in most of the included studies. Further, accessibility guidelines and standards were used to a very limited extent in the development and evaluation of eHealth services. Guidelines for developing complex interventions that include guidance for accessibility are motivated to ensure that accessibility will be considered systematically in eHealth services. ©Marika Jonsson, Stefan Johansson, Dena Hussain, Jan Gulliksen, Catharina Gustavsson. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 17.08.2023.

Lifestyle factors are crucial for prevention and management of many non-communicable diseases such as hypertension, stroke, diabetes, coronary heart disease and chronic obstructive pulmonary disease. Lifestyle medicine is included in national learning outcomes for undergraduate medical education in Sweden. Since assessment drives learning, we reviewed questions from 124 written examinations from all 7 medical schools in Sweden, conducted between 2012 and 2015. There is up to a 5-fold difference between different universities in the weight attached to lifestyle-related knowledge compared to knowledge related to pharmacological treatments.

BACKGROUND: A global trend is to move rehabilitation closer to people's neighborhoods and homes. Still, little attention has been given to how the built environment outside the hospital setting might impact rehabilitation and recovery for stroke survivors.

OBJECTIVE: The overarching objective of this project is to develop conceptual models of built environments that support stroke rehabilitation and recovery outside the hospital setting. Specifically, the project will explore factors and characteristics of the built environment that support people with stroke and their families and identify innovative built environments that can be designed for local health care. The project will examine facilitators and obstacles for implementing built environmental solutions and evaluate the potential benefits, feasibility, and acceptability.

METHODS: The project uses a mixed methods design approach with 3 phases. In phase 1, factors and characteristics of the built environment for rehabilitation will be identified. Based on the results from phase 1, phase 2 will involve co-designing prototypes of environments to support the rehabilitation process for people with stroke. Finally, the prototypes will be evaluated in phase 3. Qualitative and quantitative methods will include a literature review, a concept mapping (CM) study, stakeholder interviews, prototype development, and testing. The project will use multidimensional scaling, hierarchical cluster analysis, descriptive statistics for quantitative data, and content analysis for qualitative data. Location analysis will rely on the location-allocation model for network problems, and the rule-based analysis will be based on geographic information systems data.

RESULTS: As of the submission of this protocol, ethical approval for the CM study and the interview study has been obtained. Data collection is planned to start in September 2023 and the workshops later in the same year. The scoping review is ongoing from January 2023. The CM study is ongoing and will be finalized in the spring of 2024. We expect to finish the data analysis in the second half of 2024. The project is a 3-year project and will continue until December 2025.

CONCLUSIONS: We aim to determine how new environments could better support a person's control over their day, environment, goals, and ultimately control over their recovery and rehabilitation activities. This "taking charge" approach would have the greatest chance of transferring the care closer to the patient's home. By co-designing with multiple stakeholders, we aim to create solutions with the potential for rapid implementation. The project's outcomes may target other people with frail health after a hospital stay or older persons in Sweden and anywhere else. The impact and social benefits include collaboration between important stakeholders to explore how new environments can support the transition to local health care, co-design, and test of new conceptual models of environments that can promote health and well-being for people post stroke.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52489.

OBJECTIVE: Prior to a multifaceted implementation strategy for a healthy lifestyle-promoting practice the expectations of primary health care managers, appointed internal facilitators and health care professionals on supporting change was explored.

DESIGN: This study had an explorative qualitative design using data gathered from individual interviews and focus groups. Qualitative content analysis with a deductive category development was applied using the Consolidated Framework for Implementation Research.

SETTING AND PARTICIPANTS: The study was conducted in a primary care setting in central Sweden as a part of the Act in Time research project. Prior to a multifaceted implementation strategy, we held 16 individual interviews with managers and appointed facilitators and five focus groups with 26 health care professionals.

RESULTS: Managers, facilitators, and professionals held similar expectations, where their expressed need for support corresponded to three constructs: Readiness for implementation, Implementation climate, and Engaging. Our findings indicate the need for strong leadership engagement to focus on how the healthy lifestyle-promoting practice can be anchored among the professionals. Managers at all levels should communicate the vision and goals, enable facilitators and professionals to improve their competencies, build inter-professional teams, and jointly plan the new practice.

CONCLUSION: To change to a healthy lifestyle promoting practice professionals request support from their managers, who in turn need support from the middle and top managers. The requested support includes helping to prioritise health promotion and enabling the primary care centres to build competence and take ownership of the implementation.

TRIAL REGISTRATION: ClinicalTrials.gov NCT04799860.

INTRODUCTION: The use of adequate self-management strategies for people with chronic obstructive pulmonary disease (COPD) reduces healthcare use, improves health-related quality of life (HRQoL) and recovery after acute exacerbations. However, not many people with COPD receive support that promotes the use of such strategies and therefore new methods to facilitate and promote the use of self-management strategies are highly warranted. This pilot trial aims to evaluate the feasibility of the study design and study procedures considering effectiveness of the novel intervention, the COPD-web. METHODS AND ANALYSIS: The overall design is a pragmatic controlled pilot trial with preassessments and postassessments and a parallel process evaluation. Patients with the diagnosis of COPD will be eligible for the study. The intervention group will be recruited when visiting one of the six participating primary care units in Sweden. The control group will be identified from the unit's computerised registers. The intervention, the COPD-web, is an interactive web page with two sections; one directed at people with COPD and one at healthcare professionals. The sections aim to support patients' self-management skills-and to facilitate the provision of support for self-management strategies, respectively. Effectiveness with regard to patients' symptoms, HRQoL, knowledge of and readiness for COPD-related self-management, health literacy, self-efficacy for physical activity and time spent in physical activity and time being sedentary, and further, healthcare professionals' knowledge of and readiness to support COPD-related self-management strategies will be assessed using questionnaires at 3 and 12 months. The process evaluation will include observations and interviews.

ETHICS AND DISSEMINATION: Ethical approval has been obtained. Findings will be presented at conferences, submitted for publication in peer-reviewed publications and presented to the involved healthcare professionals, patients and to patient organisations.

TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02696187.

BACKGROUND: Parenting programs can be economically attractive interventions for improving the mental health of both parents and their children. Few attempts have been made to analyse the value of children's and parent's outcomes simultaneously, to provide a qualified support for decision making.

METHODS: A within trial cost-effectiveness evaluation was conducted, comparing Ladnaan, a culturally tailored parenting program for Somali-born parents, with a waitlist control. Quality-adjusted life years (QALY) for parents were estimated by mapping the General Health Questionnaire-12 to Euroqol's EQ-5D-3L to retrieve utilities. Behavioural problems in children were measured using the Child Behaviour Checklist (CBCL). Intervention costs were estimated for the trial. A net benefit regression framework was employed to study the cost-effectiveness of the intervention, dealing with multiple effects in the same analysis to estimate different combinations of willingness-to pay (WTP) thresholds.

RESULTS: For a WTP of roughly €300 for a one point improvement in total problems on the CBCL scale (children), Ladnaan is cost-effective. In contrast, the WTP would have to be roughly €580,000 per QALY (parents) for it to be cost-effective. Various combinations of WTP values for the two outcomes (i.e., CBCL and QALY) may be used to describe other scenarios where Ladnaan is cost-effective.

CONCLUSIONS: Decision-makers interested in multiple effects must take into account combinations of effects in relation to budget, in order to obtain cost-effective results. A culturally adapted parenting program may be cost-effective, depending on the primary outcome, or multiple outcomes of interest. Trial registration clinicaltrials.gov, NCT02114593. Registered 15 April 2014-prospectively registered, https://www.clinicaltrials.gov/ct2/results?recrs=&cond=&term=NCT02114593&cntry=&state=&city=&dist=.

Rationale: To ensure optimal patient care based on evidence, it is crucial to understand how to implement new methods in practice. However, intervention studies often overlook parts of the implementation process. A comprehensive process evaluation is necessary to understand why interventions succeed or fail in specific contexts and to integrate new knowledge into daily practice. This evaluation examines the full implementation of the Co-Work-Care model in Swedish primary healthcare to identify strengths and weaknesses. 

Aim: This study aimed to evaluate the process of implementing the CO-WORK-CARE model that focuses on close collaboration and the use of a person-centred dialogue meeting in primary healthcare for patients on sick leave due to common mental disorders. 

Method: The CO-WORK-CARE model emphasises collaboration among the GP, rehabilitation coordinator and care manager, along with person-centred dialogue meetings involving employers. Following UK Medical Research Council guidelines, we conducted a process evaluation. Data from previous studies were reanalysed. We also analysed field notes and meeting notes using Malterud's qualitative method. 

Results: The evaluation identified key facilitators for model implementation, including regular visits by facilitators and guidance from the research physician. Peer support meetings also bolstered implementation. However, challenges emerged due to conflicts with existing structures and limitations in person-centred dialogue meetings. 

Conclusion: Adapting the CO-WORK-CARE model to Swedish primary care is feasible and beneficial, with collaboration among the care manager, rehabilitation coordinator and GP and person-centred dialogue meetings. Thorough preparations, ongoing facilitator and peer support and integrated information enhanced implementation efficiency, despite challenges posed by existing structures. 

BACKGROUND: The growing concern about a dwindling healthcare workforce, exacerbated by demographic changes, calls for innovative solutions. One viable approach involves implementing new professional roles and restructuring existing healthcare teams within hospital care units.

OBJECTIVES: To evaluate the implementation of an innovative task-shifting concept, care-related services (CRS), from the managers' perspective in somatic care units across the hospitals in a region in Sweden.

METHODS: The qualitative study was conducted in 2022, after the implementation of CRS. Individual interviews were conducted with 24 key stakeholders, including 14 care unit managers, six CRS managers, and four process managers. A qualitative content analysis was performed, utilizing the Consolidated Framework of Implementation Research (CFIR).

RESULTS: The implementation of CRS involved collaboration between care unit managers, CRS managers, and project managers, alongside CRS staff, registered nurses (RNs), and licensed vocational nurses (LVNs). In particular, their roles encompassed defining boundaries, establishing routines, and managing personnel. Throughout the implementation process, challenges emerged, stemming from undefined goals, difficulties in recruiting qualified CRS staff, and issues associated with seamlessly integrating CRS into existing work routines. These challenges arose due to a constrained timeframe, widespread team apprehension, shortcomings in the training of CRS staff, unclear task allocation, and an increased workload for care unit managers. Factors associated with successful CRS implementation included effective cooperation among managers and an open-minded approach.

CONCLUSIONS: Our findings highlight the crucial role of clear communication, effective recruitment, integration of CRS staff, clarification of roles, responsibilities, and defined goals for successful CRS implementation.

The care of older people living in residential care facilities (RCFs) should promote dignity and well-being, but research shows that these aspects are lacking in such facilities. To promote dignity and well-being, it is important to understand which associated factors to target. The aim of this study was to examine the associations between perceived dignity and well-being and factors related to the attitudes of staff, the care environment and individual issues among older people living in RCFs. A national retrospective cross-sectional study was conducted in all RCFs for older people within 290 municipalities in Sweden. All older people 65 years and older (n = 71,696) living in RCFs in 2018 were invited to respond to the survey. The response rate was 49%. The survey included the following areas: self-rated health, indoor-outdoor-mealtime environment, performance of care, attitudes of staff, safety, social activities, availability of staff and care in its entirety. Data were supplemented with additional data from two national databases regarding age, sex and diagnosed dementia. Descriptive statistics and ordinal logistic regression models were used to analyse the data. Respondents who had experienced disrespectful treatment, those who did not thrive in the indoor-outdoor-mealtime environment, those who rated their health as poor and those with dementia had higher odds of being dissatisfied with dignity and well-being. To promote dignity and well-being, there is a need to improve the prerequisites of staff regarding respectful attitudes and to improve the care environment. The person-centred practice framework can be used as a theoretical framework for improvements, as it targets the prerequisites of staff and the care environment. As dignity and well-being are central values in the care of older people worldwide, the results of this study can be generalised to other care settings for older people in countries outside of Sweden.

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

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

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

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

Background There is growing evidence that context mediates the effects of implementation interventions intended to increase healthcare professionals’ use of research evidence in clinical practice. However, conceptual clarity about what comprises context is elusive. The purpose of this study was to advance conceptual clarity on context by developing the Implementation in Context Framework, a meta-framework of the context domains, attributes and features that can facilitate or hinder healthcare professionals’ use of research evidence and the effectiveness of implementation interventions in clinical practice.

Methods We conducted a meta-synthesis of data from three interrelated studies: (1) a concept analysis of published literature on context (n = 70 studies), (2) a secondary analysis of healthcare professional interviews (n = 145) examining context across 11 unique studies and (3) a descriptive qualitative study comprised of interviews with heath system stakeholders (n = 39) in four countries to elicit their tacit knowledge on the attributes and features of context. A rigorous protocol was followed for the meta-synthesis, resulting in development of the Implementation in Context Framework. Following this meta-synthesis, the framework was further refined through feedback from experts in context and implementation science.

Results In the Implementation in Context Framework, context is conceptualized in three levels: micro (individual), meso (organizational), and macro (external). The three levels are composed of six contextual domains: (1) actors (micro), (2) organizational climate and structures (meso), (3) organizational social behaviour (meso), (4) organizational response to change (meso), (5) organizational processes (meso) and (6) external influences (macro). These six domains contain 22 core attributes of context and 108 features that illustrate these attributes.

Conclusions The Implementation in Context Framework is the only meta-framework of context available to guide implementation efforts of healthcare professionals. It provides a comprehensive and critically needed understanding of the context domains, attributes and features relevant to healthcare professionals’ use of research evidence in clinical practice. The Implementation in Context Framework can inform implementation intervention design and delivery to better interpret the effects of implementation interventions, and pragmatically guide implementation efforts that enhance evidence uptake and sustainability by healthcare professionals.

BACKGROUND: There is moderate to strong evidence of the effectiveness of health-promotion interventions, but implementation in routine primary health care (PHC) has been slow. In the Act in Time project implementation support is provided for a health promotion practice using individually targeted lifestyle interventions in a PHC setting. Identifying health care professionals' (HCPs') perceptions of barriers and facilitators helps adapt implementation activities and achieve a more successful implementation. This study aimed, at a pre-implementation stage, to describe the expectations of managers, appointed internal facilitators (IFs) and HCPs on implementing a healthy lifestyle-promoting practice in PHC.

METHODS: In this qualitative study five focus group discussions with 27 HCPs and 16 individual interviews with managers and appointed IFs were conducted at five PHC centres in central Sweden. The PHC centres are participating in the Act in Time project, evaluating the process and outcomes of a multifaceted implementation strategy for a healthy lifestyle-promoting practice. A deductive qualitative content analysis based on the Consolidated Framework for Implementation Research (CFIR) was followed using inductive analysis.

RESULTS: Twelve constructs from four of five CFIR domains were derived: Innovation characteristics, Outer setting, Inner setting, and Characteristics of individuals. These domains are related to the expectations of HCPs to implement a healthy lifestyle-promoting practice, which includes facilitating factors and barriers. The inductive analysis showed that the HCPs perceived a need for a health-promotion approach to PHC. It serves the needs of the patients and the expectations of the HCPs, but lifestyle interventions must be co-produced with the patient. The HCPs expected that changing routine practice into a healthy lifestyle-promoting practice would be challenging, requiring sustainability, improved structures, cooperation in inter-professional teams, and a common purpose. A collective understanding of the purpose of changing practice was vital to successful implementation.

CONCLUSIONS: The HCPs valued implementing a healthy lifestyle-promoting practice in a PHC setting. However, changing routine methods was challenging, implying that the implementation strategy should address obstacles and facilitating factors identified by the HCPs.

TRIAL REGISTRATION: This study is part of the Act in Time project, registered in ClinicalTrials.gov with the number NCT04799860 . Registered 03 March 2021.

Purpose

To gain a deeper understanding of the development of a joint vision for Close Care, its obstacles and opportunities, in the region of Sörmland based on national health and social services reforms.

Design/methodology/approach

Seven semi-structured interviews were conducted with thirteen stakeholders. Documentation from the process was used to enhance the findings. A qualitative content analysis was performed.

Findings

Stakeholders described Close Care as entailing “person centeredness, cooperation, and resource sharing” but found it “too abstract”. Participation in developing the vision varied, with experiences of “external pressure” and low “readiness for organisational change”. Views on a regional vision’s “relevance and usability” differed. Participants highlighted several opportunities for the Close Care vision, such as: “a stepping-stone for implementation”, “harmonises with other health care visions” and “forming a cross municipal and regional network”. They also noted obstacles like “symbolic alienation”, “cognitive complexity”, “short-term economic reality” and “uncertainty around implementation”.

Practical implications

Opportunities and obstacles for the vision of Close Care can inform complex healthcare reforms that require stakeholder cooperation.Social implicationsUnderstanding Close Care may enable health system stakeholders to more effectively cooperate around the citizens’ needs.

Originality/value

Research on common ground has mainly focused on national or international policy levels and individual hospitals, professionals or patients. This study offers insights on regional and municipal cooperation in health care driven by a common vision.

OBJECTIVE: The objective of the study was to compare the total use of healthcare services in the course of the first year after a stroke between participants who, after the acute care, had received occupational therapy as a client-centred activities of daily living (ADL) intervention (CADL) and participants who had received usual ADL intervention (UADL).

DESIGN: A secondary analysis of a multicentre cluster-randomised controlled trial (RCT).

SETTING: Primary and secondary care in Sweden.

PARTICIPANTS: Participants were included if they: (1) had received CADL or UADL in the RCT, either as inpatients in geriatric rehabilitation units or in their own homes, and (2) data could be retrieved about their use of healthcare services provided by the county council from computerised registers.

INTERVENTIONS: CADL or UADL.

OUTCOME MEASURES: Inpatient and outpatient healthcare in the course of the first year after stroke.

RESULTS: Participants from 7 of the 16 units included in the RCT met the criteria. Participants in the CADL group (n=26) who received geriatric inpatient rehabilitation had a shorter length of hospital stay (p=0.03) than participants in the UADL group (n=46), and the CADL group with home rehabilitation (n=13) had fewer outpatient contacts (p=0.01) compared with the UADL group (n=25). Multiple regression analyses showed that in four of the models, a higher age was associated with a lower use of healthcare services. The use of healthcare services was also associated (some of the models) with dependence in ADL, stroke severity and type of rehabilitation received, CADL or UADL.

CONCLUSIONS: The provision of client-centred occupational therapy after stroke did not appear to increase the use of healthcare services during the first year after stroke.rrrrr TRIAL REGISTRATION NUMBER: NCT01417585.

Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation.

Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention.

Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation.

Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

BACKGROUND AND OBJECTIVE: To a large extent, people who have suffered a stroke report unmet needs for rehabilitation. The purpose of this study was to explore aspects of rehabilitation provision that potentially contribute to self-reported met needs for rehabilitation 12 months after stroke with consideration also to severity of stroke.

METHODS: The participants (n = 173) received care at the stroke units at the Karolinska University Hospital, Sweden. Using a questionnaire, the dependent variable, self-reported met needs for rehabilitation, was collected at 12 months after stroke. The independent variables were four aspects of rehabilitation provision based on data retrieved from registers and structured according to four aspects: amount of rehabilitation, service level (day care rehabilitation, primary care rehabilitation and home-based rehabilitation), operator level (physiotherapist, occupational therapist, speech therapist) and time after stroke onset. Multivariate logistic regression analyses regarding the aspects of rehabilitation were performed for the participants who were divided into three groups based on stroke severity at onset.

RESULTS: Participants with moderate/severe stroke who had seen a physiotherapist at least once during each of the 1st, 2nd and 3rd-4th quarters of the first year (OR 8.36, CI 1.40-49.88 P = 0.020) were more likely to report met rehabilitation needs.

CONCLUSION: For people with moderate/severe stroke, continuity in rehabilitation (preferably physiotherapy) during the first year after stroke seems to be associated with self-reported met needs for rehabilitation.