Women's experiences of remote video calls with a labour ward midwife during early labour.

BACKGROUND: In an increasingly strained maternity care system with a shortage of midwives and great demands for service, pregnant women in their early labour are at risk of receiving insufficient support. Women make calls and visit the labour ward on multiple occasions before being admitted. A video call with a labour ward midwife during early labour is an unknown practice but could support pregnant women and their partners during this uncertain period. AIM: The study aimed to describe women's experiences of remote video calls with a labour ward midwife during early labour. METHODS: A qualitative study comprising nine semi-structured interviews followed by an inductive thematic analysis was conducted. RESULTS: The results revealed that video calls prepared women and their partners by means of practical support. They received an assessment of early labour and the interaction with labour ward midwives prepared them for the impending birth. The participants reported feeling secure and strengthened by being met at their current stage of labour. Furthermore, they found the service accessible, easy to use and emphasised the need for increased availability and continuity. CONCLUSION: This study highlights the positive impact of video calls in early labour when conducted by competent labour ward midwives. The perceived accessibility and ease of use e-health system underscore a demand for extended availability. These findings indicate the potential benefits of integrating video calls in labour care to enhance support, security, accessibility and overall satisfaction for pregnant women and their partners.

Standing together at the helm - how employees experience employee-driven innovation in primary care.

Primary care needs to find strategies to deal with today's societal challenges and continue to deliver efficient and high-quality care. Employee-driven innovation is increasingly gaining ground as an accessible pathway to developing successful and sustainable organisations. This type of innovation is characterised by employees being engaged in the innovation process, based on a bottom-up approach. This qualitative study explores employees' experiences of employee-driven innovation at a primary care centre in Sweden. Data are collected by focus group interviews and analysed by inductive qualitative content analysis. The result is presented with the overarching theme "Standing together at the helm" followed by three categories: "Motivating factors for practising employee-driven innovation", "Challenges in practising employee-driven innovation" and "Benefits of employee-driven innovation", including nine subcategories. The study found that employee-driven innovation fosters organisational innovation, empowers employees, and enhances adaptability at personal and organisational levels. This enables individual and collective learning, and facilitates the shaping, development, and adaptation of working methods to meet internal and external requirements. However, new employees encountered difficulty grasping the concept of employee-driven innovation and recognising its long-term advantages. Additionally, the demanding and task-focused environment within primary care posed challenges in sustaining efforts in innovation work. The employees also experienced a lack of external support to drive and implement some innovative ideas.

Residual radiological opacities correlate with disease outcomes in ICU-treated COVID-19.

Background: Few studies consider both radiological and functional outcomes in COVID-19 survivors treated in the intensive care unit (ICU). We investigated clinical findings and pulmonary abnormalities on chest computed tomography (CT) and compared outcomes of severe versus mild-moderate acute respiratory distress syndrome (ARDS) on long-term follow-up. Methods: This longitudinal cohort study included 118 COVID-19 patients (median age, 58 years; 79% men). Thoracic CT scans were performed 4, 10, and 22 months after hospital discharge. Two independent blinded radiologists analyzed the 10 months scans and scored the radiology findings semi-quantitatively, as no/minor versus widespread opacities [low-radiology opacity grade (ROG) versus high-ROG]. ARDS severity was based on the PaO2/FiO2 ratio. The 6 min walk test (6MWT) was performed after 3 and 9 months, and lung diffusion capacity for carbon monoxide (DLCO) and lung volume measurement after 9 and 15 months. Dynamic spirometry was done at all time points. Residual symptoms and health-related quality-of-life (HRQL) were evaluated using validated questionnaires. Results: At 10 months, most patients (81/118; 69%) were classified as high-ROG, of which 70% had severe ARDS during hospitalisation; 69% of those with mild-moderate ARDS also had high-ROG. Patients with high-ROG had longer ICU stay and lower PaO2/FiO2 during hospitalisation (p < 0.01). At 9 months follow-up, patients with high-ROG had smaller lung volumes as % of predicted values [mean (±CI): 80 (77-84) vs. 93 (88-98) (p < 0.001)], lower DLCO as % of predicted values [74 (70-78) vs. 87 (82-92) (p < 0.001)], lower oxygen saturation during 6MWT (p = 0.02), and a tendency to more severe dyspnoea (p = 0.07), but no difference was found in HRQL compared with no/minor ROG (p = 0.92). A higher opacity score was related to lower DLCO at follow-up (r = -0.48, p < 0.001, Spearman rank test). Severe ARDS patients had slightly more severe fatigue at 9 months compared to mild-moderate, but no differences in dyspnoea or lung function at follow-up. Fibrotic-like changes were found in 93% of patients examined with CT scans at 2 years (55/118; 47%). Severe ARDS could predict widespread opacities (ROG > 25%) in most patients at follow-up at 10 months (AUC 0.74). Conclusion: Residual radiological abnormalities in ICU-treated COVID-19 patients, evaluated for up to 2 years, relate to persisting symptoms and impaired lung function, demanding careful follow-up regardless of ARDS severity at hospitalisation.

The Development and Evaluation of an Animated Video for Pre- and Postoperative Instructions for Patients with Osteoarthritis-A Design Science Research Approach.

Osteoarthritis (OA) is a condition in the hip or knee joints that develops during a long period of time and sometimes needs hip or knee joint replacement surgery when pain gets too intense for the patient. This paper describes how an animated video for pre- and postoperative instructions for patients with osteoarthritis was designed. The design science research (DSR) approach was followed by creating a web-based animated video. The web-based animated video is used to support surgical departments with education for patients suffering from OA. In the web-based animated video, information about OA surgical treatment and its pre- and post-arrangements was included. The relevance, the rigor, and the design cycles were focused on, with some iterations of and improvements in the animations. Even after implementation, there was a feedback-loop with comments from the surgeons and their patients. Moreover, as more departments will use the web-based animated video, they want to make their special mark on it, so that further changes will be made. This paper presents the design and successful implementation of an animated video for pre- and postoperative instructions for patients with osteoarthritis, tightly linked to the patient journey and the workflow of healthcare professionals. The animated video serves not only as a tool to improve care but also as a basis for further scientific research studies.

Implantable cardioverter defibrillator and cardiac resynchronization treatment in people with type 2 diabetes: a comparison with age- and sex matched controls from the general population.

BACKGROUND: Increased risk of severe tachyarrhythmias is reported in patients with type 2 diabetes mellitus (T2DM). The aim of this study was to explore if treatment with cardiac implantable electronic device (CIED) such as implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy- pacemaker and -defibrillator (CRT-P/CRT-D) differed in patients with vs. without T2DM. A secondary aim was to identify patient characteristics indicating an increased CIED treatment. METHOD: 416 162 adult patients with T2DM from the Swedish National Diabetes Registry and 2 081 087 controls from the Swedish population, matched for age, sex and living area, were included between 1/1/1998 and 31/12/2012 and followed until 31/12/2013. They were compared regarding prevalence of ventricular tachycardia (VT) at baseline and the risk of receiving a CIED during follow-up. Multivariable Cox regression analysis was performed to estimate the risk of CIED-treatment and factors identifying patients with such risk. RESULTS: Ventricular fibrillation (VF) (0.1% vs 0.0004%) and (VT) (0.2% vs. 0.1%) were more frequent among patients with T2DM compared to controls. CIED-treatment was significantly increased in patients with T2DM both in unadjusted and adjusted analyses. HR and 95% CI, after adjustment for sex, age, marital status, income, education, country of birth, coronary artery disease and congestive heart failure, were 1.32 [1.21-1.45] for ICD, 1.74 [1.55-1.95] for CRT-P and 1.69 [1.43-1.99] for CRT-D. Blood-pressure and lipid lowering therapies were independent risk factors associated to receiving CIED, while female sex was protective. CONCLUSIONS: Although the proportion of VT/VF was low, patients with T2DM had a higher prevalence of these conditions and increased risk for treatment with CIED compared to controls. This underlines the importance of recognizing that T2DM patients have an increased need of CIED.

Insights on microstructural evolution and capacity fade on diatom [Formula: see text] anodes for lithium-ion batteries.

[Formula: see text] is a promising material for developing high-capacity anodes for lithium-ion batteries (LIBs). However, microstructural changes of [Formula: see text] anodes at the particle and electrode level upon prolonged cycling remains unclear. In this work, the causes leading to capacity fade on [Formula: see text] anodes were investigated and simple strategies to attenuate anode degradation were explored. Nanostructured [Formula: see text] from diatomaceous earth was integrated into anodes containing different quantities of conductive carbon in the form of either a conductive additive or a nanometric coating layer. Galvanostatic cycling was conducted for 200 cycles and distinctive trends on capacity fade were identified. A thorough analysis of the anodes at selected cycle numbers was performed using a toolset of characterization techniques, including electrochemical impedance spectroscopy, FIB-SEM cross-sectional analysis and TEM inspections. Significant fragmentation of [Formula: see text] particles surface and formation of filigree structures upon cycling are reported for the first time. Morphological changes are accompanied by an increase in impedance and a loss of electroactive surface area. Carbon-coating is found to restrict particle fracture and to increase capacity retention to 66%, compared to 47% for uncoated samples after 200 cycles. Results provide valuable insights to improve cycling stability of [Formula: see text] anodes for next-generation LIBs.

Resilience in keeping the balance between demand and capacity in the COVID-19 pandemic, a case study at a Swedish middle-sized hospital.

BACKGROUND: In pandemics, it is critical to find a balance between healthcare demand, and capacity, taking into consideration the demands of the patients affected by the pandemic, as well as other patients (in elective or emergency care). The purpose of this paper is to suggest conceptual models for the capacity requirements at the emergency department, the inpatient care, and intensive care unit as well as a model for building staff capacity in pandemics. METHODS: This paper is based on a qualitative single case study at a middle-sized hospital in Sweden. The primary data are collected from 27 interviewees and inductively analyzed. RESULTS: The interviewees described a large difference between the immediate catastrophe scenario described in the emergency plan (which they had trained for), and the reality during the COVID-19 pandemic. The pandemic had a much slower onset and lasted longer compared to, for example, an accident, and the healthcare demand fluctuated with the societal infection. The emergency department and inpatient care could create surge capacity by reducing elective care. Lower inflow of other emergency patients also helped to create surge capacity. The number of intensive care beds increased by 350% at the case hospital. At the same time, the capacity of the employees decreased due to infection, exhaustion, and fear. The study contributes to knowledge of conceptional models and key factors affecting the balance between demand and capacity. CONCLUSION: The framework suggests conceptual models for balancing surge capacity during a pandemic Health care practitioners need to provide assumptions of the key factors to find the balance between the demand and capacity corresponding to the reality and maintain the delivery of high-quality healthcare services.

Experiences of using surveillance cameras as a monitoring solution at nursing homes: The eldercare personnel's perspectives.

BACKGROUND: As the number of older people increases, so does the need for care. However, the workforce in eldercare cannot increase at the rate required to match the needs. Welfare technologies, such as surveillance cameras, can replace physical visits and be used at night to monitor older people in order to keep them safe, while not disturbing their sleep. The aim of the paper is to analyze obstacles and opportunities associated with implementation and use of surveillance cameras at nursing homes from the perspectives of the practitioners who use the technology, their working environment and the conditions of the older people with cognitive impairment who live in nursing homes. METHODS: Individual semi-structured interviews were conducted with the eldercare personnel at nursing homes to understand their experiences of implementation and use of surveillance cameras. The transcribed interviews were analyzed using qualitative content analysis. The consolidated criteria for reporting qualitative research (COREQ) was used as a guidance tool. RESULTS: The results show that the eldercare personnel experienced lack of adequate information, education and support related to using surveillance cameras. Several benefits are highlighted, such as better working environment and that the residents were not unnecessarily disturbed at night. However, the results also show that it is important to clarify that surveillance cameras cannot replace the human presence. CONCLUSIONS: The conclusions from this study are the importance of prerequisites for implementation, and that using surveillance cameras contributed to improvements in the working environment at night and created possibilities to maintain security and integrity for older people living in nursing homes.

Real-world study of flash glucose monitoring among adults with type 2 diabetes within the Swedish National Diabetes Register.

BACKGROUND: The Swedish National Diabetes Register (NDR) initiated registration of the FreeStyle Libre® system and other continuous glucose monitoring (CGM) systems in June 2016. We investigated change in HbA1c for people with type 2 diabetes (T2DM) using FreeStyle Libre in Sweden. METHODS: We included adults with T2DM, registered in the NDR after January 1, 2014, and an index date for first use of FreeStyle Libre of June 2016 or later. Methodology was a before/after comparison of HbA1c within 6 months before the index date versus HbA1c around 6 and 12 months after the index date. RESULTS: 711 adults with T2DM using FreeStyle Libre had HbA1c measurements within the study period. Mean HbA1c was significantly reduced at 6 months (-0.50%-unit) and at 12 months (-0.52%-unit) in this group. Degree of change was negatively correlated to baseline HbA1c. Reductions in HbA1c were observed in incident users of FreeStyle Libre with T2DM who were truly naïve to CGM or had unknown prior experience of CGM, and aged 25-74 years. CONCLUSIONS: This real-world study on the Swedish NDR shows that people with T2DM using FreeStyle Libre system for 6 and 12 months significantly reduced their HbA1c.

Nurses' experiences of person-centred care planning using video-conferencing.

AIM: The aim was to illuminate how nurses experience person-centred care planning using video conferencing upon hospital discharge of frail older persons. DESIGN: Care planning via video conferencing requires collaboration, communication and information transfer between involved parties, both with regard to preparing and conducting meetings. Participation of involved parties is required to achieve a collaborative effort, but the responsibilities and roles of the involved professions are unclear, despite the existence of regulations. METHOD: A qualitative content analysis was conducted based on 11 individual semi-structured interviews with nurses from hospitals, municipalities and primary care in Sweden. RESULTS: This study provides valuable insights into challenges associated with care planning via video conferencing. The meeting format, that is video conferencing, is perceived as a barrier that makes the interaction challenging. Shortcomings in video technology make a person-centred approach difficult. The person-centred approach is also difficult for nurses to maintain when the older person or relatives are not involved in the planning.

A ROR1 Small Molecule Inhibitor (KAN0441571C) Induced Significant Apoptosis of Mantle Cell Lymphoma (MCL) Cells.

The receptor tyrosine kinase orphan receptor 1 (ROR1) is absent in most normal adult tissues but overexpressed in various malignancies and is of importance for tumor cell survival, proliferation, and metastasis. In this study, we evaluated the apoptotic effects of a novel small molecule inhibitor of ROR1 (KAN0441571C) as well as venetoclax (BCL-2 inhibitor), bendamustine, idelalisib (PI3Kδ inhibitor), everolimus (mTOR inhibitor), and ibrutinib (BTK inhibitor) alone or in combination in human MCL primary cells and cell lines. ROR1 expression was evaluated by flow cytometry and Western blot (WB). Cytotoxicity was analyzed by MTT and apoptosis by Annexin V/PI staining as well as signaling and apoptotic proteins (WB). ROR1 was expressed both in patient-derived MCL cells and human MCL cell lines. KAN0441571C alone induced significant time- and dose-dependent apoptosis of MCL cells. Apoptosis was accompanied by decreased expression of MCL-1 and BCL-2 and cleavage of PARP and caspase 3. ROR1 was dephosphorylated as well as ROR1-associated signaling pathway molecules, including the non-canonical WNT signaling pathway (PI3Kδ/AKT/mTOR). The combination of KAN0441571C and ibrutinib, venetoclax, idelalisib, everolimus, or bendamustine had a synergistic apoptotic effect and significantly prevented phosphorylation of ROR1-associated signaling molecules as compared to KAN0441571C alone. Our results suggest that targeting ROR1 by a small molecule inhibitor, KAN0441571C, should be further evaluated particularly in combination with other targeting drugs as a new therapeutic approach for MCL.

A randomised, open-label, parallel-group, multicentre, comparative study to compare the efficacy and safety of Exufiber® with Aquacel® Extra™ dressings in exuding venous and mixed aetiology leg ulcers.

The performance and safety of Exufiber® gelling fibre and Aquacel® Extra™ Hydrofiber® wound dressings were compared for the management of chronic, exuding leg ulcers. The 6-week study (≤ 24 weeks in a subgroup of subjects) was a randomised, open-label, parallel-group, multicentre, non-inferiority design. Adults (n = 248, 30-97 years of age) were randomised to either Exufiber® or Aquacel® Extra™ dressing. The dressings were applied at baseline and evaluations of wound condition and performance of the dressing were recorded at 1, 2, 3, 4, and 6 weeks. The primary efficacy endpoint was the percentage reduction in wound area at 6 weeks relative to baseline, in the per protocol (PP) population. A median relative reduction of 50% for Exufiber® (n = 100) vs 42% for Aquacel® Extra™ (n = 107) was demonstrated in the PP population (P = 0.093) and confirmed in the intention-to-treat population. As the mean and 95% confidence interval for the difference in relative wound area reduction between groups at 6 weeks was -29.4% (-63.5; 3.2), and the lower limit did not exceed 12%, non-inferiority of Exufiber® was concluded. Both dressings were well tolerated and no safety concerns were identified in both groups. Clinicians' satisfaction with the dressings was higher for Exufiber® than for Aquacel® Extra™ in terms of ease of use and management of exudate, slough, and blood.

[Myositis-related interstitial lung disease - a systemic autoimmune desease often overlooked]. / Interstitiell lungsjukdom med myositantikroppar ofta förbisedd.

Interstitial lung disease can be the first sign of systemic autoimmune disease. If associated with myositis, interstitial lung disease may be the only symptom, with no presence of muscular weakness or other extramuscular manifestations. ANA-testing performed with indirect immune fluorescence may be negative. Testing for myositis antibodies should be considered as a step in the diagnostic process when strong clinical suspicion of interstitial lung disease of unknown origin is present. If interstitial lung disease is suspected, the patients should be referred to a specialist clinic for further investigation and, if possible, for discussion within a multidisciplinary team. Early suspicion of systemic inflammatory disease, rapid diagnosis and early start of treatment are crucial for future prognosis, quality of life and survival.

Association and Familial Coaggregation of Childhood-Onset Type 1 Diabetes With Depression, Anxiety, and Stress-Related Disorders: A Population-Based Cohort Study.

OBJECTIVE: To estimate the association and familial coaggregation of childhood-onset type 1 diabetes with depression, anxiety, and stress-related disorders. RESEARCH DESIGN AND METHODS: This was a population-based cohort study with use of data from Swedish nationwide registers. A total of ∼3.5 million individuals born in Sweden 1973-2007 were linked to their biological parents, full siblings and half-siblings, and cousins. Cox models were used to estimate the association and familial coaggregation of type 1 diabetes with depression, anxiety, and stress-related disorders. RESULTS: Individuals diagnosed with childhood-onset type 1 diabetes (n = 20,005) were found to be at greater risks of all outcomes: any psychiatric diagnosis (adjusted hazard ratio [aHR] 1.66 [95% CI 1.59-1.72]) or specific diagnoses of depression (1.85 [1.76-1.94]), anxiety (1.41[1.33-1.50]), and stress-related disorders (1.75 [1.62-1.89]), as well as use of antidepressants or anxiolytics (1.30 [1.26-1.34]), compared with individuals without type 1 diabetes. Overall, relatives of individuals with type 1 diabetes were at elevated risks of developing these outcomes, with the highest risks seen in parents (aHRs 1.18-1.25), followed by full siblings (aHRs 1.05-1.20), and the magnitudes of risk estimates appear proportional to familial relatedness. CONCLUSIONS: These results support existing evidence that children and adolescents with type 1 diabetes are at greater risks of developing depression, anxiety, and stress-related disorders and indicate that shared familial factors might contribute to these elevated risks. Our findings highlight the need for psychological consulting for children and their families in diabetes care. Quantitative and molecular genetic studies are warranted to further understand the etiology of these psychiatric disorders in type 1 diabetes.

Nurses' experiences of using AsthmaTuner - an eHealth self-management system for healthcare of patients with asthma.

Objective: This study describes nurses' experiences of using eHealth for assessment in the healthcare of patients with asthma. Methods: Five nurses with experience of using AsthmaTuner in the healthcare of patients with asthma participated in the study. Individual semi-structured interviews were conducted with the nurses to understand their experiences of using the eHealth system. The transcribed interviews were analyzed using qualitative content analysis. Results: The results show that nurses as well as patients find the tool useful and easy-to-handle. AsthmaTuner gives the nurses access to more and better information about the patients, which facilitates assessments and makes their work more efficient. The patients become more involved in their care, gain increased control and take more responsibility for their illness and treatment. Conclusions: The nurses appreciate eHealth in asthma care. Using AsthmaTuner makes the nurses' work more efficient and the patients become more involved in their care.

On the Durability of Protective Titania Coatings on High-Voltage Spinel Cathodes.

TiO2 -coating of LiNi0.5-x Mn1.5+x O4 (LNMO) by atomic layer deposition (ALD) has been studied as a strategy to stabilize the cathode/electrolyte interface and mitigate transition metal (TM) ion dissolution. The TiO2 coatings were found to be uniform, with thicknesses estimated to 0.2, 0.3, and 0.6 nm for the LNMO powders exposed to 5, 10, and 20 ALD cycles, respectively. While electrochemical characterization in half-cells revealed little to no improvement in the capacity retention neither at 20 nor at 50 °C, improved capacity retention and coulombic efficiencies were demonstrated for the TiO2 -coated LNMO in LNMO||graphite full-cells at 20 °C. This improvement in cycling stability could partly be attributed to thinner cathode electrolyte interphase on the TiO2 -coated samples. Additionally, energy-dispersive X-ray spectroscopy revealed a thinner solid electrolyte interphase on the graphite electrode cycled against TiO2 -coated LNMO, indicating retardation of TM dissolution by the TiO2 -coating.

Risk factors for nephropathy in persons with type 1 diabetes: a population-based study.

AIMS: Albuminuria is strongly associated with risk of renal dysfunction, cardiovascular disease and mortality. However, clinical guidelines diverge, and evidence is sparse on what risk factor levels regarding blood pressure, blood lipids and BMI are needed to prevent albuminuria in adolescents and young adults with type 1 diabetes. METHODS: A total of 9347 children and adults with type 1 diabetes [mean age 15.3 years and mean diabetes duration 1.4 years at start of follow-up] from The Swedish National Diabetes Registry were followed from first registration until end of 2017. Levels for risk factors for a risk increase in nephropathy were evaluated, and the gradient of risk per 1 SD (standard deviation) was estimated to compare the impact of each risk factor. RESULTS: During the follow-up period, 8610 (92.1%) remained normoalbuminuric, 737 (7.9%) individuals developed micro- or macroalbuminuria at any time period of whom 132 (17.9% of 737) individuals developed macroalbuminuria. Blood pressure ≥ 140/80 mmHg was associated with increased risk of albuminuria (p ≤ 0.0001), as were triglycerides ≥ 1.0 mmol/L (p = 0.039), total cholesterol ≥ 5.0 mmol/L (p = 0.0003), HDL < 1.0 mmol/L (p = 0.013), LDL 3.5- < 4.0 mmol/L (p = 0.020), and BMI ≥ 30 kg/m2 (p = 0.033). HbA1c was the strongest risk factor for any albuminuria estimated by the measure gradient of risk per 1 SD, followed by diastolic blood pressure, triglycerides, systolic blood pressure, cholesterol and LDL. In patients with HbA1c > 65 mmol/mol (> 8.1%), blood pressure > 140/70 mmHg was associated with increased risk of albuminuria. CONCLUSIONS: Preventing renal complications in adolescents and young adults with type 1 diabetes need avoidance at relatively high levels of blood pressure, blood lipids and BMI, whereas very tight control is not associated with further risk reduction. For patients with long-term poor glycaemic control, stricter blood pressure control is advocated.

Aspects of Expansive Learning in the Context of Healthy Ageing-A Formative Intervention between Dental Care and Municipal Healthcare.

There are great risks of diseases in the ageing population, and oral diseases are no exception. Poor oral health has profound negative impacts on the quality of life. It is therefore crucial to include the oral health perspective in the care for older adults. To meet the challenges associated with oral health in the ageing population, a formative intervention was launched. The intervention, called the TAIK project (="Dental hygienist in a municipality organization", in Swedish: Tandhygienist i kommunal verksamhet), meant that six dental hygienists served non-clinically as oral health consultants in five Swedish municipal organizations. The intervention formed an infrastructure and platform for work that benefits the ageing population and created a new basis for decisions regarding oral health in homecare. The aim of this paper is to explore how aspects of collaboration in an interprofessional and interorganizational intervention may lead to expansive learning. Expansive learning forms the theoretical framework of this study. The dental hygienists and the local head nurses were interviewed individually in-depth. Reflection documents from the dental hygienists were also part of the analyzed data. The conclusion is that the formative intervention was reliant of change which created a foundation for reciprocal understanding that led to expansive learning between dental care and municipal healthcare, with resilience and empowerment as crucial factors.