From office to digital primary care services: analysing income-related inequalities in utilization.

The use of digital technologies to deliver primary health care has increased over the past decade. While some technologies have been shown to be medically effective and efficient, the effects of digital primary care on the policy goal of equality in the use of such types of care have not been studied using large register data. The aim of this study was to analyse how digital contacts differ from officebased visits by income as an indicator of socioeconomic status. Specifically, we estimated differences in primary care utilization across income, factors of contribution to these inequalities, and applied a needs-based standardisation of utilization to estimate differences in equity.We used a purposively built consultation level dataset with 726 000 Swedish adult patients diagnosed with an infection, including clinical and sociodemographic variables. Applying concentration indexes (CI) and graphical illustrations we measured how the two types of services are distributed relative to income. We estimated how much of the inequalities were attributed to different sociodemographic factors by decomposing the concentration indexes. Standardised utilization for sex, age and comorbidity allowed for the estimation of horizontal inequity indexes for both types of services.Utilization by the two types of care showed large income inequalities. Office-based visits were propoor (CI -0.116), meaning lowincome patients utilized relatively more of these services, while digital contacts were prorich (CI 0.205). However, within the patient group who had at least one digital contact, the utilization was also propoor (CI -0,101), although these patients had higher incomes on average. The standardised utilization showed a smaller prorich digital utilization (CI 0.143), although large differences remained. Decomposing the concentration indexes showed that education level and being born in Sweden were strong attributes of prorich digital service utilization.The prorich utilization effects of digital primary care may risk undermining the policy goals of access and utilization to services regardless of socioeconomic status. As digital health technologies continue to expand, policy makers need to be aware of the risk.

The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence.

BACKGROUND: Low- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries. METHODS: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies. RESULTS: A total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment. CONCLUSION: The introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries' progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status. TRIAL REGISTRATION: This study was registered with Prospero (CRD42021285776).

Physicians' intentions to use digital tools - a comparative survey, before and after the COVID-19 pandemic, in Southern Sweden.

OBJECTIVES: To describe changes in Swedish primary care physicians' use of, attitudes and intentions toward digital tools in patient care between 2019 and 2022. DESIGN: A survey using a validated questionnaire measuring physician's intentions to use digital tools based on the theory of planned behavior. SETTING: Sample of primary health care centers in southern Sweden. SUBJECTS: Primary care physicians. MAIN OUTCOME MEASURES: Self-reported use and intentions to use, digital tools including digital consultations by text or video, chronic disease monitoring and artificial intelligence (AI) and the associations between attitudes, subjective norms, perceived behavioral control and behavioral intentions to use digital tools, in 2019 compared to 2022. RESULTS: In both 2019 (n = 198) and 2022 (n = 93), physicians reported high intentions to use digital tools. Self-reported use of video was slightly higher in 2022 (p = .03). No other changes were seen in the self-reported use or behavioral intentions to use digital tools. CONCLUSION: The slow adoption of patient-related digital tools in Swedish primary health care does not seem to be explained by a low intention to use them among physicians. Future research on implementation of digital tools should include a focus on contextual factors such as organizational, technical and cultural barriers.

Based on the theory of planned behavior a survey was designed and applied in 2019 to measure physicians' use of, attitudes and intentions toward telemedicine (PAIT) and digital tools.A follow up study using PAIT was conducted in 2022.Physicians reported high intentions to use digital tools in both 2019 and 2022.Self-reported use of digital tools was low in both 2019 and 2022.

'It increases my ability to influence my ways of working': A qualitative study on digitally mediated patient management in primary healthcare.

BACKGROUND: Digitally mediated primary healthcare is increasingly influencing working conditions, raising questions about how digitally mediated patient management is experienced. AIM: The aim of this study was to generate insights, through the lens of postphenomenology, into how digitally mediated primary healthcare affects the work and working environment, by gathering perspectives from primary healthcare professionals who regularly manage patient errands through a digital platform. METHODS: Two rounds of interviews were conducted with a diversified sample of primary healthcare professionals at a primary healthcare centre. The first round of interviews was conducted during the initial phase of the deployment of a digital platform for patient management, with the second round conducted a year later (n = 24). The interview transcripts were analysed using reflexive thematic analysis. RESULTS: Four themes relating to digitally mediated care work were identified: 'positive feelings towards digitally mediated primary healthcare', 'seeing a positive work atmosphere as a prerequisite for change', 'experiencing increased control over the pace of workflow' and 'reconfiguration of previous problems'. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Building on postphenomenology, our study adds to the understanding of how material and symbolic aspects mutually affect the mediating role of a digital platform for patient management. Thus, the results indicate that the experience of using digitally mediated care processes is conditioned by the discourse towards digitalisation at the workplace and the management's approach to and inclusion of employees in the digital transition of primary healthcare, as well as the usefulness and usability of the digital platform. The findings can inform both practice and policy.

A comparison of spouse and non-spouse carers of people with dementia: a descriptive analysis of Swedish national survey data.

BACKGROUND: Being an informal carer of a person with dementia (PwD) can have a negative effect on the carer's health and quality of life, and spouse carers have been found to be especially vulnerable. Yet relatively little is known about the care provided and support received by spouse carers. This study compares spouse carers to other informal carers of PwDs regarding their care provision, the support received and the psychosocial impact of care. METHODS: The study was a cross-sectional questionnaire-based survey of a stratified random sample of the Swedish population aged 18 or over. The questionnaire explored how much care the respondent provided, the support received, and the psychosocial impact of providing care. Of 30,009 people sampled, 11,168 (37.7 %) responded, of whom 330 (2.95 %) were informal carers of a PwD. RESULTS: In comparison to non-spouse carers, spouse carers provided more care more frequently, did so with less support from family or the local authority, while more frequently experiencing negative impacts on their social life and psychological and physical health. Spouse carers also received more carer support and more frequently experienced a closeness in their relationship with the care-recipient. CONCLUSIONS: Spouse carers of PwD differed from non-spouse carers on virtually all aspects of their care situation. Policy and practice must be more sensitive to how the carer-care-recipient relationship shapes the experience of care, so that support is based on an understanding of the individual carer's actual needs and preferences rather than on preconceptions drawn from a generalised support model.

Cost analysis of informal care: estimates from a national cross-sectional survey in Sweden.

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.

Socioeconomic and clinical factors explaining the risk of unstructured antiretroviral therapy interruptions among Kenyan adult patients.

A cross-sectional study was conducted to assess the extent of unstructured HIV treatment interruptions (TIs) and investigate the effects of socioeconomic, socio-demographic, HIV treatment-related and clinical factors on the magnitude and rate of the same among adult patients at a Kenyan regional referral center. Four hundred and twenty-one adult patients actively receiving antiretroviral therapy at Nyeri County Referral Hospital since 2003 were randomly selected to complete a health survey questionnaire. Electronic records were used to obtain their HIV treatment utilization history. The marginal effects of selected determinants on prevalence and rate of TI were assessed by fitting multiple Poisson log-linear regression models. In total, 392 patients participated in the study. HIV TI was prevalent with 64.5% having had at least one TI of 3 months or more during treatment. The risk of TI was significantly higher in those longer on treatment (prevalence ratio = 1.2, 95% confidence interval [CI] 1.12-1.28). Greater risk of TI was also associated with lower income (prevalence rate ratio [PRR] = 0.9, 95% CI 0.83-1.00), low medication adherence (PRR = 0.3, 95% CI 0.13-0.72), inconsistent treatment engagement (PRR = 0.4, 95% CI 0.19-0.75) and, contrarily, fewer adverse drug reactions (PRR = 0.9, 95% CI 0.90-0.97). Unstructured HIV TIs appear to be fairly common at the study site. The results suggest that efforts to minimize HIV TI could benefit from treatment-continuity monitoring strategies that target the high-risk sub-samples identified.

Patient choice, Internet based information sources, and perceptions of health care: Evidence from Sweden using survey data from 2010 and 2013.

BACKGROUND: Several countries have increased patients' abilities to choose their health care providers, frequently under the assumption that patients are themselves the best agents to make such decisions. In parallel, national and regional health authorities have enhanced access to Internet based information sources (IBIS) to assist patients in making an informed choice. Relatively little, however, is known about the effect that the use of such sources has on key outcomes, including patients' perceptions of care. The aim of this study is to analyze the role of the Internet for patients' confidence in the provider and perceived access to care in the context of choice based reforms in Sweden. METHODS: The study uses a regional, population health survey from the southern part of Sweden. Non-parametric chi-square tests are used to assess the nature of Internet users, including their gender, age and socioeconomic status. Logistic regression models are specified to analyze the role of IBIS on patient perceptions of care while controlling for other factors. RESULTS: Actual use of Internet based information sources for health care was relatively low in 2010 and only somewhat higher in 2013. The characteristics of IBIS users varied significantly across different population groups, such that they were younger, more educated, female, and also considered themselves to be in better health compared with those who reported not using this source of health care information. Finally, the average IBIS user was less likely to report having a high level of satisfaction with respect to their primary care use; OR 0.69 [95 % CI: 0.54-0,87] and OR 0.52 [95 % CI: 0,41-0,66], for confidence in provider and perceived access to care, respectively, in 2013. CONCLUSIONS: Despite health agencies' attempts to make information on health care providers available on the Internet, this source of health care information is not used to any large extent in the current sample. The fact that some people use this source of information more compared with others suggests the need to consider alternative ways of informing the general public about choice options. The use of Internet based sources may also be linked with the experience of actually using health services, which suggests a need to further analyze this complex consumer behavior process.

Association between patient engagement in HIV care and antiretroviral therapy medication adherence: cross-sectional evidence from a regional HIV care center in Kenya.

Consistent individual effort in engagement in HIV medical services has been associated with positive health outcomes in people living with HIV (PLHIV). However, whether these benefits are facilitated by improved medication adherence has not been widely studied. This study aimed to investigate the marginal effect of engagement in HIV care on medication adherence at a public health facility in Kenya. Between February and April 2013, 392 patients on HIV care at Nyeri Provincial General Hospital participated in this study. Data were collected using a self-administered health survey questionnaire assessing health and sociodemographic statuses. A manual stepwise general linear model was specified to measure the effect of engagement in HIV and other associated predictors on medication adherence. Engagement in HIV care was significantly associated with log-transformed medication adherence in the sample (100·ß = 9.2%, 95% CI 3.2-15.1) irrespective of gender and other selected predictors. Longer duration on antiretroviral therapy was also a significant predictor of better medication adherence (100·ß = 3.2%, 95% CI 2.3-4.1). Despite inter-gender differences in adherence and engagement determinants, gender's independent effect on medication adherence and engagement in care were not statistically significant. Poor medication adherence was associated with lower patient engagement in HIV care services, suggesting that interventions which remove obstacles to regular observance of scheduled clinic appointments and eventual retention may have a beneficial impact on medication adherence and, accordingly, health outcomes in PLHIV.

The effect of audit and feedback and implementation support on guideline adherence and patient outcomes in cardiac rehabilitation: a study protocol for an open-label cluster-randomized effectiveness-implementation hybrid trial.

BACKGROUND: Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs. METHODS: The study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation. DISCUSSION: Optimizing cardiac rehabilitation centres' delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT05889416 . Registered 2023-03-23.

Smoking behavior and sociodemographic differences among young people: further evidence from southern Sweden based on public health survey data.

AIMS: Tobacco-smoking behaviours of young people between the age of 18 and 25 years are less understood than those of middle-aged people. The aim of this study is to contribute to improved knowledge of some of the factors that are associated with smoking and cessation among young people. METHODS: We use the most recently available public health survey data from the southern region of Skåne in Sweden to analyze these factors. The survey is a cross-sectional study with a total sample size of 28,198 individuals with 2801 in the age category of interest. We apply statistical measures of association between smoking and gender and also model the relationship between smoking and smoking cessation and the role of a set of sociodemographic determinants by means of logistic regression to estimate odds ratios. RESULTS: The findings include significant differences between the younger age group and the older group with respect to the odds of smoking and method of cessation. We also find differences between young women and men with regard to smoking prevalence, intensity and cessation methods. In particular, young women attempt to quit smoking by means of unassisted methods to a significantly higher extent than do young men. CONCLUSIONS: There are significant differences between young people and older individuals with respect to a range of smoking behaviours. There are also strong gender effects within the group of young people. Policy development and anti-smoking interventions need to take such differences into consideration for improved effectiveness.

Extending universal health coverage to informal workers: A systematic review of health financing schemes in low- and middle-income countries in Southeast Asia.

Achieving universal health coverage (UHC) is a priority of most low- and middle-income countries, reflecting governments' commitments to improved population health. However, high levels of informal employment in many countries create challenges to progress toward UHC, with governments struggling to extend access and financial protection to informal workers. One region characterized by a high prevalence of informal employment is Southeast Asia. Focusing on this region, we systematically reviewed and synthesized published evidence of health financing schemes implemented to extend UHC to informal workers. Following PRISMA guidelines, we systematically searched for both peer-reviewed articles and reports in the grey literature. We appraised study quality using the Joanna Briggs Institute checklists for systematic reviews. We synthesized extracted data using thematic analysis based on a common conceptual framework for analyzing health financing schemes, and we categorized the effect of these schemes on progress towards UHC along the dimensions of financial protection, population coverage, and service access. Findings suggest that countries have taken a variety of approaches to extend UHC to informal workers and implemented schemes with different revenue raising, pooling, and purchasing provisions. Population coverage rates differed across health financing schemes; those with explicit political commitments toward UHC that adopted universalist approaches reached the highest coverage of informal workers. Results for financial protection indicators were mixed, though indicated overall downward trends in out-of-pocket expenditures, catastrophic health expenditure, and impoverishment. Publications generally reported increased utilization rates through the introduced health financing schemes. Overall, this review supports the existing evidence base that predominant reliance on general revenues with full subsidies for and mandatory coverage of informal workers are promising directions for reform. Importantly, the paper extends existing research by offering countries committed to progressively realizing UHC around the world a relevant updated resource, mapping evidence-informed approaches toward accelerated progress on the UHC goals.

Exploring patient perspectives: A qualitative inquiry into healthcare perceptions, experiences and satisfaction in Lebanon.

BACKGROUND: Patient perspectives have received increasing importance within health systems over the past four decades. Measures of patient experience and satisfaction are commonly used. However, these measures do not capture all the information that is available through engaging with patients. An improved understanding of the various types of patient perspectives and the distinctions between them is needed. The lack of such knowledge limits the usefulness of including patient perspectives as components within pay-for-performance initiatives. This study aimed to explore patient perspectives on hospital care in Lebanon. It also aimed to contribute insights that may improve the national pay-for-performance initiative and to the knowledge on engaging patients towards person-centered health systems. METHODS: We conducted a qualitative study using focus group discussions with persons recently discharged after hospitalization under the coverage of the Lebanese Ministry of Public Health. This study was implemented in 2017 and involved 42 participants across eight focus groups. Qualitative content analysis was used to analyze the information provided by participants. RESULTS: Five overall themes supported by 17 categories were identified, capturing the meaning of the participants' perspectives: health is everything; being turned into second class citizens; money and personal connections make all the difference; wanting to be treated with dignity and respect; and tolerating letdown, for the sake of right treatment. The most frequently prioritized statement in a ranking exercise regarding patient satisfaction was regular contact with the patient's doctor. CONCLUSIONS: Patient perspectives include more than what is traditionally incorporated in measures of patient satisfaction and experience. Patient valuing of health and their perceptions on each of the health system, and access and quality of care should also be taken into account. Hospital pay-for-performance initiatives can be made more responsive through a broader consideration of these perspectives. More broadly, health systems would benefit from wider engagement of patients. We propose a framework relating patient perspectives to value-based healthcare and health system performance.

Assessing progress towards universal health coverage in Cambodia: Evidence using survey data from 2009 to 2019.

Over the past decades, many low- and middle-income countries have implemented health financing and system reforms to progress towards universal health coverage (UHC). In the case of Cambodia, out-of-pocket expenditure (OOPE) remains the main source of current health expenditure after several decades of reform, exposing households to financial risks when accessing healthcare and violating UHC's key tenet of financial protection. We use pre-pandemic data from the nationally representative Cambodia Socio-Economic Surveys of 2009 to 2019 to assess progress in financial protection to evaluate the reforms and obtain internationally comparable estimates. We find that following strong improvements in financial protection between 2009 and 2017, there was a reversal in the trend thereafter. The OOPE budget share rose, and the incidence of catastrophic spending and impoverishment increased in nearly all geographical and socioeconomic strata. For example, 17.7% of households experienced catastrophic health expenditure in 2019 at the threshold of 10% of total household consumption expenditure, and 3.9% of households were pushed into poverty by OOPE. The distribution of all financial protection indicators varied strongly across socioeconomic and geographical strata in all years. Fundamentally, the demonstrated trend reversal may jeopardize Cambodia's ability to progress towards UHC. To improve financial protection in the short term, there is a need to address the burden created by OOPE through targeted interventions to household groups that are most affected. In the medium term, our findings emphasize the importance of expanding health pre-payment schemes to currently uncovered vulnerable groups, specifically the near-poor. The government also needs to consider extending the scope of services covered and the range of providers to include the private sector under these schemes to reduce reliance on OOPE.

Inequalities in reproductive, maternal, newborn and child health in Vietnam: a retrospective study of survey data for 1997-2006.

BACKGROUND: Vietnam has achieved considerable success in economic development, poverty reduction, and health over a relatively short period of time. However, there is concern that inequalities in health outcomes and intervention coverage are widening. This study explores if inequalities in reproductive, maternal, newborn and child health and nutrition changed over time in Vietnam in 1997-2006, and if inequalities were different depending on the type of stratifying variable used to measure inequalities and on the type of outcome studied. METHODS: Using data from four nationally representative household surveys conducted in 1997-2006, we study inequalities in reproductive, maternal, newborn and child health and nutrition outcomes and intervention coverage by computing concentration indices by living standards, maternal education, ethnicity, region, urban/rural residence, and sex of child. RESULTS: Inequalities in maternal, newborn and child health persisted in 1997-2006. Inequalities were largest by living standards, but not trivial by the other stratifying variables. Inequalities in health outcomes generally increased over time, while inequalities in intervention coverage generally declined. The most equitably distributed interventions were family planning, exclusive breastfeeding, and immunizations. The most inequitably distributed interventions were those requiring multiple service contacts, such as four or more antenatal care visits, and those requiring significant support from the health system, such as skilled birth attendance. CONCLUSIONS: Three main policy implications emerge. First, persistent inequalities suggest the need to address financial and other access barriers, for example by subsidizing health care for the poor and ethnic minorities and by support from other sectors, for example in strengthening transportation networks. This should be complemented by careful monitoring and evaluation of current program design and implementation to ensure effective and efficient use of resources. Second, greater inequalities for interventions that require multiple service contacts imply that inequalities could be reduced by strengthening information and service provision by community and village health workers to promote and sustain timely care-seeking. Finally, larger inequalities for interventions that require a fully functioning health system suggest that investments in health facilities and human resources, particularly in areas that are disproportionately inhabited by the poor and ethnic minorities, may contribute to reducing inequalities.

Inclusion of Essential Universal Health Coverage Services in Essential Packages of Health Services: A Review of 45 Low- and Lower- Middle Income Countries.

Expanding service coverage and achieving universal health coverage (UHC) is a priority for many low- and middle-income countries. Though UHC is a long-term goal, its importance and relevance have only increased since the start of the COVID-19 pandemic. The first step on the road to UHC is to define and develop essential packages of health services (EPHSs), a list of clinical and public health services that a government has deemed a priority and is to provide. However, the nature of these lists of services in low- and lower-middle-income countries is largely unknown. This study examines the contents of 45 countries' EPHSs to determine the inclusion of essential UHC (EUHC) services as defined by the Disease Control Priorities, which comprises 21 specific essential packages of interventions. EPHSs were collected from publicly available sources and their contents were analyzed in two stages, firstly, to determine the level of specificity and detail of the content of EPHSs and, secondly, to determine which essential UHC services were included. Findings show that there are large variations in the level of specificity among EPHSs and that though EUHC services are included to a large extent, variations exist regarding which services are included between countries. The results provide an overview of how countries are designing EPHSs as a policy tool and are progressing toward providing a full range of EUHC services. Additionally, the study introduces new tools and methods for UHC policy analysts and researchers to study the contents of EPHSs in future investigations.

Exercise-based cardiac rehabilitation after acute myocardial infarction in Sweden - standards, costs, and adherence to European guidelines (The Perfect-CR study).

AIMS: Information on standards including structure- and process-based metrics and how exercise-based cardiac rehabilitation (EBCR) is delivered in relation to guidelines is lacking. The aims of the study were to evaluate standards and adherence to guidelines at Swedish CR centers and to conduct a cost analysis of the physiotherapy-related activities of EBCR. METHODS AND RESULTS: EBCR standards at all 78 CR centers in Sweden in 2016 were surveyed. The questions were based on guideline-recommended core components of EBCR for patients after a myocardial infarction (MI). The cost analysis included the identification, quantification, and valuation of EBCR-related cost items. Patients were offered a pre-discharge consultation with a physiotherapist at n = 61, 78% of the centers. A pre-exercise screening visit was routinely offered at n = 64, 82% of the centers, at which a test of aerobic capacity was offered in n = 58, 91% of cases, most often as a cycle ergometer exercise test n = 55, 86%. A post-exercise assessment was offered at n = 44, 56% of the centers, with a functional test performed at n = 30, 68%. Almost all the centers n = 76, 97% offered supervised EBCR programs. The total cost of delivering physiotherapy-related activities of EBCR according to guidelines was approximately 437 euro (4,371 SEK) per patient. Delivering EBCR to one MI patient required 11.25 hours of physiotherapy time. CONCLUSION: While the overall quality of EBCR programs in Sweden is high, there are several areas of potential improvement to reach the recommended European standards across all centers. To improve the quality of EBCR, further compliance with guidelines is warranted.

Informal care provision among male and female working carers: Findings from a Swedish national survey.

INTRODUCTION: Informal carers in paid employment-working carers (WKCs)-have complex support needs. However, little is known about WKCs' pattern of informal care provision, the support they receive, the impact providing care has on their employment, and how these vary between male and female WKCs. This study describes the pattern of informal care provision and received support among Swedish WKCs. RESEARCH METHOD/DESIGN: The study was a cross-sectional questionnaire-based survey of a stratified random sample of the Swedish population aged 18 or over. The questionnaire addressed the type and extent of informal care provided, support received and the impact of care provision on employment. Of the 30,009 people who received the questionnaire, 11,168 (37.3%) responded, providing an analytic sample of 818 (7.32% of respondents) employed or self-employed informal carers. FINDINGS: A typical Swedish WKC was a middle-aged female, providing weekly or daily care to a non-cohabitant parent, who experiences care as sometimes demanding and receives no formal support as a carer. Female WKCs were more likely than males to care alone and with higher intensity, to report a need for help in meeting their care-recipient's needs, and to experience care as demanding. Approximately 17% of WKCs reported their employment had been affected due to caring, 40% their ability to work, and 31% their career development opportunities. Female WKCs' ability to work was affected more than males', and they were more commonly prevented from applying for work. CONCLUSION: Swedish female WKCs compared to males provide more hours of informal care, across more care domains, more often alone. This places them in a challenging situation when combining paid work and care. Greater recognition of the challenges faced by WKCs is required in Sweden and other countries, as are policies to reduce gender inequalities in informal care provision in this group.

Embedding and Integrating a Digital Patient Management Platform Into Everyday Primary Care Routines: Qualitative Case Study.

BACKGROUND: Traditional primary care is characterized by patient consultations via phone and physical visits. However, the current development in Swedish primary care is to blend digital solutions with traditional solutions. This paper addresses this development by examining the normalization of embedding and integrating a digital health care platform into everyday care routines in a primary care clinic. The digital health care platform enables both synchronous (video calls) and asynchronous (chat) communication, as well as self-registration of patient data using automated questions and forms requiring the patient's input. OBJECTIVE: This study aims to explore the work that health care professionals (HCPs) have to undertake to implement and sustain a digital health care platform as part of their everyday work practice. METHODS: HCPs were observed and interviewed to assess their individual and collective engagement and the mechanisms involved in the implementation of the digital platform and its effects on everyday work routines. The normalization process theory (NPT) was used to frame the data analysis. RESULTS: The analysis identified several themes related to the four NPT constructs: coherence, cognitive participation, collective action, and reflexive monitoring. The use of these constructs enabled the analysis to identify ways of supporting implementation. For example, it showed the benefits of having implementation champions and scheduling work hours for HCPs to use the platform. The analysis also revealed a theme of materiality that deviated from the NPT constructs, as NPT gives ontological priority to human actors and social structures. CONCLUSIONS: Digital health care platform implementation is a complex process. Our findings provide insights into how individual and collective actions can be supported to embed and integrate a digital platform into everyday care routines. Primary health care organizations need to involve HCPs throughout the implementation process by reorganizing work and providing frequent feedback loops. HCPs are more likely to engage with and commit to changing practices if they perceive the digital platform to be beneficial compared with the current practice. However, they also need resources (eg, time, training, and continuous support) to put the platform into practice. Patient engagement and appraisal are important elements in implementation. Unless patients are willing to use the platform, there is no motivation for HCPs to embed the digital platform into everyday care practice.