From risk communication about asymptomatic atherosclerosis to cognitive and emotional reactions and lifestyle modification.

BACKGROUND: Non-adherence in the general population to preventive guidelines on cardiovascular disease calls for an interdisciplinary approach acknowledging psychological factors of relevance for risk communication and lifestyle modification. Evidence is building up regarding the advantage of sharing arterial imaging evidence of subclinical atherosclerosis with asymptomatic individuals, but there is limited understanding of how this relates to mechanisms of importance for behavioural change. Longitudinal studies on associations between patients' reactions and lifestyle modification are missing. The population-based randomized controlled trial VIPVIZA investigates the impact of pictorial information about subclinical atherosclerosis, added to traditional risk factor-based communication. The intervention includes a personalized, colour-coded and age-related risk communication strategy and a motivational conversation, and has been shown to reduce cardiovascular disease risk. METHODS: In the present study we assessed cognitive and emotional reactions to the intervention, and how these reactions are associated to lifestyle modification. The participants' evaluation of the risk communication was assessed in the intervention group (n = 1749). Lifestyle modification was assessed with a lifestyle index based on physical activity, diet, smoking and alcohol consumption at baseline and after 3 years. Associations between cognitive and emotional response and lifestyle modification were tested with analyses of covariance in a subset of participants (n = 714-857). RESULTS: The intervention increased understanding of personal CVD risk, the possibility to influence the risk, and how to influence the risk. Severity of atherosclerosis was associated with emotional reactions, but emotions of strong negative valence were uncommon. Cognitive response and emotional arousal evoked by the intervention were positively associated with lifestyle modification, whereas negative emotions in isolation were not. High level of cognitive response in combination with high level of emotional arousal was found to be most beneficial for lifestyle modification. CONCLUSIONS: The results demonstrate the potential of communicating asymptomatic atherosclerosis with a pictorial, colour-coded and age-related strategy, also including a motivational conversation. Furthermore, the results show the importance of CVD risk communication evoking engagement, and that an interaction between cognitive and emotional reactions might be central for sustained lifestyle modification. Our results also indicate that, in an asymptomatic population, atherosclerosis screening may strengthen disease prevention and health promotion. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01849575. Registration date 08/05/2013.

Does a multi-component intervention including pictorial risk communication about subclinical atherosclerosis improve perceptions of cardiovascular disease risk without deteriorating efficacy beliefs?

BACKGROUND: Pictorial communication about subclinical atherosclerosis can improve cardiovascular disease (CVD) risk, but whether it leads to long-term shifts in self-rated CVD risk (risk perception) and beliefs about possibility to influence personal risk (efficacy beliefs) is unknown. PURPOSE: To study the impact of personalized color-coded and age-related risk communication about atherosclerosis and motivational conversation, compared to traditional risk factor-based communication, on risk perception and efficacy beliefs. Also, whether risk perception increases with message severity. METHOD: The effect of the pragmatic RCT Visualization of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention (VIPVIZA) was analyzed using a linear mixed effects model with risk perception and efficacy believes at 1-year and 3-year follow up as dependent variables. Participants' (n = 3532) CVD risk perception and efficacy beliefs were assessed with visual analog scales (0-10). Fixed effects were group (intervention vs control), time point (1 year or 3 years) and interaction between group and time point. Further, the models were adjusted for corresponding baseline measurement of the dependent variable and a baseline × time point interaction. Effect of pictorial color-coded risk in the intervention group was investigated using a corresponding mixed effects model, but with pictorial risk group (message severity) as exposure instead of intervention group. RESULTS: After one year, the intervention group rated their CVD risk as higher (m = 0.46, 95% CI 0.32-0.59), with an effect also after 3 years (m = 0.57, 95% CI 0.43-0.70). The effect was consistent in stratified analyses by sex and education. Overall, no effect on efficacy beliefs was observed. In the intervention group, differences in CVD risk perception were found between participants with different color-coded risk messages on atherosclerosis status. CONCLUSION: Personalized, color-coded and age-related risk communication about atherosclerosis had an effect on risk perception with an effect also after 3 years, whereas overall, no effect on efficacy beliefs was observed.

Dietary amino acids and risk of stroke subtypes: a prospective analysis of 356,000 participants in seven European countries.

PURPOSE: Previously reported associations of protein-rich foods with stroke subtypes have prompted interest in the assessment of individual amino acids. We examined the associations of dietary amino acids with risks of ischaemic and haemorrhagic stroke in the EPIC study. METHODS: We analysed data from 356,142 participants from seven European countries. Dietary intakes of 19 individual amino acids were assessed using validated country-specific dietary questionnaires, calibrated using additional 24-h dietary recalls. Multivariable-adjusted Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of ischaemic and haemorrhagic stroke in relation to the intake of each amino acid. The role of blood pressure as a potential mechanism was assessed in 267,642 (75%) participants. RESULTS: After a median follow-up of 12.9 years, 4295 participants had an ischaemic stroke and 1375 participants had a haemorrhagic stroke. After correction for multiple testing, a higher intake of proline (as a percent of total protein) was associated with a 12% lower risk of ischaemic stroke (HR per 1 SD higher intake 0.88; 95% CI 0.82, 0.94). The association persisted after mutual adjustment for all other amino acids, systolic and diastolic blood pressure. The inverse associations of isoleucine, leucine, valine, phenylalanine, threonine, tryptophan, glutamic acid, serine and tyrosine with ischaemic stroke were each attenuated with adjustment for proline intake. For haemorrhagic stroke, no statistically significant associations were observed in the continuous analyses after correcting for multiple testing. CONCLUSION: Higher proline intake may be associated with a lower risk of ischaemic stroke, independent of other dietary amino acids and blood pressure.

Associations between emotional support and cardiovascular risk factors and subclinical atherosclerosis in middle-age.

OBJECTIVE: To test the hypothesis of low emotional support being associated with lifestyle and biomedical cardiovascular disease (CVD) risk factors, estimated risk of CVD morbidity and mortality, and subclinical atherosclerosis in middle-aged healthy adults. METHODS AND MEASURES: Cross-sectional data were obtained from participants aged 40-60 years who had one or more conventional CVD risk factor. They underwent assessment based on questionnaires, clinical examination, blood sampling, and carotid ultrasound of plaque formation and carotid intima-media wall thickness (cIMT). Based on the Interview Schedule for Social Interaction, the participants were categorised as either low in emotional support (n = 884) or as a referent (n = 2570). Logistic regression analyses were conducted to study the associations. RESULTS: Logistic regression analyses showed that low emotional support was significantly associated with smoking, alcohol consumption and physical inactivity (OR = 1.53 - 1.94), estimated risk of CVD morbidity and mortality (OR = 1.56 - 1.68), and plaque formation (OR = 1.39). No significant associations were found regarding biomedical CVD risk factors or cIMT. CONCLUSION: The findings suggest that low social support is associated with lifestyle CVD risk factors, estimated risk of CVD morbidity and mortality, and subclinical atherosclerosis in middle-aged healthy adults, encouraging causal evaluation with longitudinal data investigating an impact of emotional support on mechanisms underlying CVD.

Cognitive and emotional reactions to pictorial-based risk communication on subclinical atherosclerosis: a qualitative study within the VIPVIZA trial.

OBJECTIVES, SETTING AND SUBJECTS: Atherosclerosis screening with ultrasound is non-invasive and can be used as part of risk communication. The potential of personalised and pictorial-based risk communication is assessed in VIPVIZA, a population-based randomised controlled trial that aims at optimising cardiovascular disease (CVD) prevention by investigating the impact of visualisation of subclinical atherosclerosis. The present aim was to explore cognitive and emotional reactions evoked by the intervention as well as attitudes to any implemented life style changes in VIPVIZA participants in the intervention group with improved health status and furthermore to study possible interactions between these factors. Understanding mechanisms of action was central since non-adherence to preventive guidelines are often faced in clinical practice. DESIGN: In-depth interviews with 14 individuals were analysed with qualitative content analysis. RESULTS: Cognitive and emotional processes were highly interlinked and described by the main theme Cognitive and emotional reactions in strong interplay for orchestration of health oriented behavioural change. The informants' descriptions revealed two distinctly different psychological processes which constituted the two subthemes, Problem-focused coping and Encouragement-driven process. CONCLUSIONS: The results highlight that an interaction between emotional reactions and efficacy beliefs is important in facilitating behavioural change. Furthermore, the results underscore the importance of the risk message being perceived as clear, accurate, reliable and also emotionally engaging and thereby show why atherosclerosis screening and pictorial-based risk communication have the potential to contribute to effective CVD prevention strategies and shared decision making in primary care. Trial registration: ClinicalTrials.gov identifier: NCT01849575, registration 8 May 2013.Key pointsAtherosclerosis screening and pictorial-based risk communication have the potential to contribute to more effective CVD prevention strategies.Risk messages on atherosclerosis status were perceived as clear, accurate, reliable and emotionally engaging.An interplay between efficacy beliefs and emotional reactions facilitated behavioural change.Patients' understanding of CVD risk is important for shared decision-making and of relevance for non-adherence to preventive guidelines.

Feasibility, reliability and validity of the health-related quality of life instrument Child Health Utility 9D (CHU9D) among school-aged children and adolescents in Sweden.

BACKGROUND: This study was conducted in a general population of schoolchildren in Sweden, with the aim to assess the psychometric properties of a generic preference-based health related quality of life (HRQoL) instrument, the Swedish Child Health Utility 9D (CHU9D), among schoolchildren aged 7-15 years, and in subgroups aged 7-9, 10-12 and 13-15 years. METHODS: In total, 486 school aged children, aged 7-15 years, completed a questionnaire including the CHU9D, the Pediatric quality of life inventory 4.0 (PedsQL), KIDSCREEN-10, questions on general health, long-term illness, and sociodemographic characteristics. Psychometric testing was undertaken of feasibility, internal consistency reliability, test-retest reliability, construct validity, factorial validity, concurrent validity, convergent validity and divergent validity. RESULTS: The CHU9D evidenced very few missing values, minimal ceiling, and no floor effects. The instrument achieved satisfactory internal consistency (Cronbach's Alfa > 0.7) and strong test-retest reliability (r > 0.6). Confirmatory factor analyses supported the proposed one-factor structure of the CHU9D. For child algorithm, RMSEA = 0.05, CFI = 0.95, TLI = 0.94, and SRMR = 0.04. For adult algorithm RMSEA = 0.04, CFI = 0.96, TLI = 0.95, and SRMR = 0.04. The CHU9D utility value correlated moderately or strongly with KIDSCREEN-10 and PedsQL total scores (r > 0.5-0.7). The CHU9D discriminated as anticipated on health and on three of five sociodemographic characteristics (sex, age, and custody arrangement, but not socioeconomic status and ethnic origin). CONCLUSIONS: This study provides evidence that the Swedish CHU9D is a feasible, reliable and valid measure of preference-based HRQoL in children. The study furthermore suggests that the CHU9D is appropriate for use among children 7-15 years of age in the general population, as well as among subgroups aged 7- 9, 10-12 and 13-15 years.

Impact of achievement and change in achievement of lifestyle recommendations in middle-age on risk of the most common potentially preventable cancers.

This study aimed to assess the association between achievement, and within-person change in achievement, of lifestyle recommendations in middle-age and incidence of the most common potentially preventable cancers. We used data from 44,572 participants from the Swedish Västerbotten Intervention Programme who had attended at least two health checks 9-11 years apart. We assessed the association between the mean number of healthy lifestyle recommendations achieved (lifestyle score), and change in lifestyle score between the health checks, and risk of one or more of the eight most common potentially preventable cancers using Cox regression. Participants were followed-up for 11.0 (SD 4.9) years. A higher mean lifestyle score was associated with a lower hazard of cancer in men (HR 0.81 (95%CI 0.74-0.90) per unit increase) and women (HR 0.90 (0.84-0.96)). There was no evidence of a linear association between change in lifestyle score and risk (HR 0.93 (0.85-1.03) and HR 1.004 (0.94-1.07) per unit change for men and women respectively). When comparing those with an increase in lifestyle score of ≥2 with those who improved less or declined in achievement the HR was 0.74 (0.54-1.00) and 1.02 (0.84-1.24) for men and women respectively. These findings support the inclusion of lifestyle recommendations in cancer prevention guidelines. They further suggest that interventions to change health behaviours in middle-age may reduce risk of the most common preventable cancers in men, but this association was not observed in women. Strategies to encourage healthy lifestyles earlier in the life course may be more effective.

Sustainable Behavior Change for Health Supported by Person-Tailored, Adaptive, Risk-Aware Digital Coaching in a Social Context: Study Protocol for the STAR-C Research Programme.

Introduction: The Västerbotten Intervention Programme (VIP) in the Region Västerbotten Sweden is one of the very few cardiovascular disease (CVD) prevention programmes globally that is integrated into routine primary health care. The VIP has been shown as a cost-effective intervention to significantly reduce CVD mortality. However, little is known about the effectiveness of a digital solution to tailor risk communication strategies for supporting behavioral change. STAR-C aims to develop and evaluate a technical platform for personalized digital coaching that will support behavioral change aimed at preventing CVD. Methods: STAR-C employs a mixed-methods design in seven multidisciplinary projects, which runs in two phases during 2019-2024: (i) a formative intervention design and development phase, and (ii) an intervention implementation and evaluation phase. In the 1st phase, STAR-C will model the trajectories of health behaviors and their impact on CVDs (Project 1), evaluate the role of the social environment and social networks on behavioral change (Project 2) and assess whether and how social media facilitates the spread of health information beyond targeted individuals and stimulates public engagement in health promotion (Project 3). The findings will be utilized in carrying out the iterative, user-centered design, and development of a person-tailored digital coaching platform (Project 4). In the 2nd phase, STAR-C will evaluate the implementation of the coaching programme and its effectiveness for promoting behavioral change and the spreading of health information across social networks and via social media (Project 5). The cost-effectiveness (Project 6) and ethical issues (Project 7) related to the coaching programme intervention will be evaluated. Discussion: The STAR-C research programme will address the knowledge and practice research gaps in the use of information technologies in health promotion and non-communicable disease (NCD) prevention programmes in order to narrow the health inequality gaps. Ethics: STAR-C has received approval from the Swedish Ethical Review Authority (Dnr. 2019-02924;2020-02985). Dissemination: The collaboration between Umeå University and Region Västerbotten will ensure the feasibility of STAR-C in the service delivery context. Results will be communicated with decision-makers at different levels of society, stakeholders from other regions and healthcare professional organizations, and through NGOs, local and social media platforms.

Increased knowledge makes a difference! - general practitioners' experiences of pictorial information about subclinical atherosclerosis for primary prevention: an interview study from the VIPVIZA trial.

OBJECTIVES: To explore how pictorial information on subclinical atherosclerosis affects GPs' perception of patient cardiovascular disease (CVD) risk, their communication with patients, and GPs' attitude to the treatment of CVD risk factors. DESIGN, SETTING AND SUBJECTS: Fifteen individual interviews were conducted between March 2014 and December 2016, with GPs who had received pictorial information regarding their patients' subclinical atherosclerosis. The pictorial information was also received by the patients together with written information regarding atherosclerosis and CVD risk prior to the appointment with their GP. The interviews were recorded, transcribed and analyzed using qualitative content analysis. RESULTS: Three categories were identified in the analysis. Increased knowledge makes a difference: When patients had more in-depth knowledge regarding atherosclerosis, the consultation became more patient-centered and moved towards shared decision making. This is real, not just a number: GPs described their risk assessment and the patient's risk perception as more accurate with pictorial information about subclinical atherosclerosis. How to deal with the result - A passive to active approach: Some GPs acted promptly on the pictorial information while others took no action. CONCLUSION AND IMPLICATIONS: Pictorial information regarding patients' subclinical atherosclerosis affected GPs' assessment of CVD risk. The communication shifted towards shared decision-making although the GPs' attitude to the result and treatment of CVD risk factors varied. Informing patients about examination results, both in writing and pictures, prior to a consultation can facilitate shared decision making and enhance preventive measures. TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT01849575.KEY POINTSProviding pictorial information about carotid ultrasound results and information regarding atherosclerosis to GPs and patients affects primary prevention:•Informing patients about examination results prior to a consultation can be useful in clinical practice to enhance preventive measures•GPs experienced that increased patient knowledge resulted in a more patient-centered consultation and improved shared decision-making•GPs described their risk assessment and patients' risk perception as more accurate with pictorial information about subclinical atherosclerosis.

The STAR-C Intelligent Coach: A Cross-Disciplinary Design Process of a Behavior Change Intervention in Primary Care.

A broad range of aspects are needed to be taken into consideration in the design and development of personalized coaching systems based on artificial intelligence methodologies. This research presents the initial phase of joining different professional and stakeholder perspectives on behavior change technologies into a flexible design proposal for a digital coaching system. The diversity and sometimes opposed views on content, behavior, purposes and context were managed using a structured argument-based design approach, which also feed into the behavior of the personalized system. Results include a set of personalization strategies that will be further elaborated with the target user group to manage sensitive issues such as ethics, social norms, privacy, motivation, autonomy and social relatedness.

Health Status and Health Care Needs of Drought-Related Migrants in the Horn of Africa-A Qualitative Investigation.

Somalia, Kenya and Ethiopia, situated in the Horn of Africa, are highly vulnerable to climate change, which manifests itself through increasing temperatures, erratic rains and prolonged droughts. Millions of people have to flee from droughts or floods either as cross-border refugees or as internally displaced persons (IDPs). The aim of this study was to identify knowledge status and gaps regarding public health consequences of large-scale displacement in these countries. After a scoping review, we conducted qualitative in-depth interviews during 2018 with 39 stakeholders from different disciplines and agencies in these three countries. A validation workshop was held with a selection of 13 interviewees and four project partners. Malnutrition and a lack of vaccination of displaced people are well-known challenges, while mental health problems and gender-based violence (GBV) are less visible to stakeholders. In particular, the needs of IDPs are not well understood. The treatment of mental health and GBV is insufficient, and IDPs have inadequate access to essential health services in refugee camps. Needs assessment and program evaluations with a patients' perspective are either lacking or inadequate in most situations. The Horn of Africa is facing chronic food insecurity, poor population health and mass displacement. IDPs are an underserved group, and mental health services are lacking. A development approach is necessary that moves beyond emergency responses to the building of long-term resilience, the provision of livelihood support and protection to reduce displacement by droughts.

Health counselling in dental care for expectant parents: A qualitative study.

OBJECTIVES: Interventions during pregnancy and early childhood have been shown to impact dental health. Thus, Antenatal Care and Dental Care collaborated in an intervention called Health Counselling in Dental Care (HCDC). HCDC was offered free of charge to first-time expectant parents and was aimed at reducing the frequency of dental caries in children and their parents. However, the intervention reached less than 50% of the parents. The aim of this study was to explore facilitators of, barriers to, and suggestions for increased participation in HCDC. METHODS: Data were collected through semi-structured, face-to-face interviews with expectant parents. Participants were purposively sampled based on having been invited to HCDC and to achieve a variation in socio-demographics. Interviews were audio recorded, transcribed verbatim and analysed using conventional qualitative content analysis. RESULTS: In total, 16 interviews were conducted (10 women, 6 men). Six categories representing three facilitators and three barriers for participation emerged. The facilitators were the midwife's crucial role for disseminating information about HCDC and motivating participation, that the parents perceived HCDC as valuable for themselves and their offspring, and a desire for new or more knowledge. The barriers included a shortage of information regarding the counselling, a perceived lack of value for the parents and offspring, and the timing of the counselling during pregnancy. CONCLUSIONS: The midwives were crucial in providing information and motivation for HCDC participation. To increase attendance, sufficient information regarding the benefits of counselling is required, and the timing needs to be flexible and family-centred.

Key factors for successful implementation of the National Rollover Protection Structure Rebate Program: A correlation analysis using the consolidated framework for implementation research.

Objectives On US farms, tractor overturns are the leading cause of death; however, these fatalities are preventable with the use of a rollover protection structure (ROPS). A ROPS rebate program was established in New York in 2006 to address these fatalities. Due to its success, the program expanded to six additional states before being implemented as the National ROPS Rebate Program (NRRP) in 2017. The aim of this study was to evaluate the success of the NRRP implementation using short- and long-term ROPS outcome measures and identify which components of the consolidated framework for implementation research (CFIR) correlate with these outcomes. Methods Stakeholders involved in the NRRP implementation were surveyed at four time points, beginning at the time of the NRRP launch and then every six months. These surveys measured 14 relevant CFIR constructs. Correlations between CFIR survey items (representing constructs) and three outcome measures (intakes, funding progress, and retrofits) were used to identify CFIR survey items that are predictive of the outcomes. Results Eight CFIR survey items were highly correlated (rho ≥0.50) with at least one of the three outcome measures. These eight CFIR survey items included four constructs: access to knowledge and information, leadership engagement, engaging (in fundraising and funding requests), and reflecting and evaluating. Conclusions The results of this study provide important guidance for continuing the implementation of the NRRP. Similarly, these findings can inform the evaluation of other similarly structured implementation efforts and the application of CFIR in a variety of settings.

Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk.

AIMS: Health literacy, the degree to which individuals understand and act upon health information, may have a pivotal role in the prevention of cardiovascular disease (CVD), with low health literacy potentially explaining poorer adherence to prevention guidelines. We investigated the associations between health literacy, ultrasound-detected carotid atherosclerosis and cardiovascular risk factors. METHODS: Baseline data (cross-sectional analysis) from a randomized controlled trial, integrated within the Västerbotten Intervention Program, Northern Sweden, was used. We included 3459 individuals, aged 40 or 50 years with ≥1 conventional risk factor or aged 60 years old. The participants underwent clinical examination, blood sampling, carotid ultrasound assessment of intima-media wall thickness (CIMT) and plaque formation, and answered a questionnaire on health literacy - the Brief Health Literacy Screen. The European Systematic Coronary Risk Evaluation and Framingham Risk Score were calculated. RESULTS: About 20% of the participants had low health literacy. Low health literacy was independently associated with the presence of ultrasound-detected carotid artery plaques after adjustment for age and education, odds ratio (95% confidence interval) 1.54 (1.28-1.85), demonstrating a similar level of risk as for smoking. Health literacy was associated with CIMT in men. Low health literacy was associated with higher CVD risk scores. Sensitivity analyses with low health literacy set to 9% or 30% of the study sample, respectively, yielded essentially the same results. CONCLUSIONS: Low health literacy was independently associated with carotid artery plaques and a high level of CVD risk scores. Presenting health information in a fashion that is understood by all patients may improve preventive efforts.

The realities of HIV prevention. A closer look at facilitators and challenges faced by HIV prevention programmes in Sudan and Yemen.

Background: HIV/AIDS prevention has historically encountered many obstacles. Understanding the factors affecting HIV/AIDS prevention is central to designing and implementing suitable context-specific interventions. Research relating to HIV prevention in the Middle East and North African region is required to address the gradually increasing HIV epidemic. Objective: This study aimed to explore the perspectives of employees/health care professionals who are working or have worked within HIV prevention in Sudan and Yemen on the challenges and facilitating factors facing HIV prevention. Methods: A qualitative approach was employed using an open-ended questionnaire. Sixteen stakeholders from governmental and non-governmental agencies participated in the study. The questionnaire focused on the various challenges and facilitating factors facing HIV prevention as well as proposed possible solutions from the perspectives of the participants. The data were analysed using thematic analysis. Results: The study illustrated the similarities in context and HIV prevention systems between Sudan and Yemen. Thematic analysis resulted in three main themes: I) much is achieved despite difficulties; II) a programme left to be paralysed; this theme addressed the main obstacles facing HIV prevention in Sudan and Yemen generating a total of six sub-themes; III) comprehensive change is needed. The participants drew focus and attention to vital changes required to improve the delivery of HIV prevention services. Conclusion: Increased financial support for HIV prevention in Sudan and Yemen is urgently needed. De-stigmatisation and increased political support, advocacy and improved legislation for people living with HIV (PLHIV) are required for the sustainability and effectiveness of HIV prevention programmes in Sudan and Yemen. Civil society organisations must be aided and supported in their role in engaging key populations.

An exploration of rollover protective structures (ROPS) rebate program media coverage: strategies for implementation and sustainment.

BACKGROUND: Media advocacy plays an important role in public health initiatives, as it can provide vital information to target populations, policy makers, or other relevant stakeholders. Unfortunately, little is currently known about the use of media advocacy to promote occupational safety and health programs. This study explores media coverage related to the Rollover Protection Structure (ROPS) Rebate Programs, which were designed to encourage the use of rollover protection on agricultural tractors, thus reducing the risk of tractor overturn fatalities. The Program's portrayal in the media, as well as the role that the media has played in implementing and sustaining these Programs. METHODS: Media articles pertaining to any of the state-based or National ROPS Rebate Programs and published between November 1, 2006 and October 31, 2018 were included for review. Discourse analysis was used to understand the messages portrayed by the media and how those messages shaped the outcomes of the ROPS Rebate Programs. RESULTS: During the study period, 212 unique articles were published about the ROPS Rebate Programs. While these articles all portrayed the ROPS Rebate Programs in a largely positive light, they were used at different stages, from pre-implementation through sustainment of the ROPS Rebate Programs, and to different extents. CONCLUSIONS: Media articles have played an important role in implementing and sustaining the ROPS Rebate Programs. Based on the results of this study, more robust and continuous media coverage are important for the longevity and success of public health programs.

Sex-specific associations between body mass index and death before life expectancy: a comparative study from the USA and Sweden.

BACKGROUND: Understanding the impact of obesity on premature mortality is critical, as obesity has become a global health issue. OBJECTIVE: To contrast the relationship between body mass index (BMI) and premature death (all-cause; circulatory causes) in New York State (USA) and Northern Sweden. METHODS: Baseline data were obtained between 1989 and 1999 via questionnaires (USA) and health exams (Sweden), with mortality data from health departments, public sources (USA) and the Swedish Death Register. Premature death was death before life expectancy based on sex and year of birth. Within country and sex, time to premature death was compared across BMI groups (18.5-24.9 kg/m2 (reference), 25-29.9 kg/m2, 30.0-34.9 kg/m2, ≥35.0 kg/m2) using Proportional Hazards regression. Absolute risk (deaths/100,000 person-years) was compared for the same stratifications among nonsmokers. RESULTS: 60,600 Swedish (47.8% male) and 31,198 US subjects (47.7% male) were included. Swedish males with BMI≥30 had increased hazards (HR) of all-cause premature death relative to BMI 18.5-24.9 (BMI 30-34.9, HR = 1.71 (95% CI: 1.44, 2.02); BMI≥35, HR = 2.89 (2.16, 3.88)). BMI≥25 had increased hazards of premature circulatory death (BMI 25-29.9, HR = 1.66 (1.32, 2.08); BMI 30-34.9, HR = 3.02 (2.26, 4.03); BMI≥35, HR = 4.91 (3.05, 7.90)). Among US males, only BMI≥35 had increased hazards of all-cause death (HR = 1.63 (1.25, 2.14)), while BMI 30-34.9 (HR = 1.83 (1.20, 2.79)) and BMI≥35 (HR = 3.18 (1.96, 5.15)) had increased hazards for circulatory death. Swedish females showed elevated hazards with BMI≥30 for all-cause (BMI 30-34.9, HR = 1.42 (1.18, 1.71) and BMI≥35, HR = 1.61 (1.21, 2.15) and with BMI≥35 (HR = 3.11 (1.72, 5.63)) for circulatory death. For US women, increased hazards were observed among BMI≥35 (HR = 2.10 (1.60, 2.76) for all-cause and circulatory HR = 3.04 (1.75, 5.30)). Swedish males with BMI≥35 had the highest absolute risk of premature death (762/100,000 person-years). CONCLUSIONS: This study demonstrates a markedly increased risk of premature death associated with increasing BMI among Swedish males, a pattern not duplicated among females.

Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open-label, randomised controlled trial.

BACKGROUND: Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasound-based pictorial information about subclinical carotid atherosclerosis, targeting both primary care physicians and individuals, improves prevention. METHODS: Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) is a pragmatic, open-label, randomised controlled trial that was integrated within the Västerbotten Intervention Programme, an ongoing population-based cardiovascular disease prevention programme in northern Sweden. Individuals aged 40, 50, or 60 years with one or more conventional risk factors were eligible to participate. Participants underwent clinical examination, blood sampling, and ultrasound assessment of carotid intima media wall thickness and plaque formation. Participants were randomly assigned 1:1 with a computer-generated randomisation list to an intervention group (pictorial representation of carotid ultrasound plus a nurse phone call to confirm understanding) or a control group (not informed). The primary outcomes, Framingham risk score (FRS) and European systematic coronary risk evaluation (SCORE), were assessed after 1 year among participants who were followed up. This study is registered with ClinicalTrials.gov, number NCT01849575. FINDINGS: 3532 individuals were enrolled between April 29, 2013, and June 7, 2016, of which 1783 were randomly assigned to the control group and 1749 were assigned to the intervention group. 3175 participants completed the 1-year follow-up. At the 1-year follow-up, FRS and SCORE differed significantly between groups (FRS 1·07 [95% CI 0·11 to 2·03, p=0·0017] and SCORE 0·16 [0·02 to 0·30, p=0·0010]). FRS decreased from baseline to the 1-year follow-up in the intervention group and increased in the control group (-0·58 [95% CI -0·86 to -0·30] vs 0·35 [0·08 to 0·63]). SCORE increased in both groups (0·13 [95% CI 0·09 to 0·18] vs 0·27 [0·23 to 0·30]). INTERPRETATION: This study provides evidence of the contributory role of pictorial presentation of silent atherosclerosis for prevention of cardiovascular disease. It supports further development of methods to reduce the major problem of low adherence to medication and lifestyle modification. FUNDING: Västerbotten County Council, the Swedish Research Council, the Heart and Lung Foundation, the Swedish Society of Medicine, and Carl Bennet Ltd, Sweden.

Adapting the T0-T4 implementation science model to occupational health and safety in agriculture, forestry, and fishing: A scoping review.

BACKGROUND: Despite much research to develop life-saving innovations for the agriculture, forestry, and fishing workforce, these populations continue to face the highest fatal and non-fatal injury rates in the United States, as many of these solutions are not fully adopted. METHODS: A scoping review was conducted to provide an overview of research to practice efforts in this field. The language used to describe these initiatives, the utility of the NIH T0-T4 model, and the progress along the research to practice continuum were examined. RESULTS: Fourteen eligible references demonstrated that progress in implementation science is lacking and that there is little consistency in how researchers apply the T0-T4 model; thus, a new model is presented. CONCLUSIONS: Researchers in this field face several challenges when moving from research to practice. While some challenges are addressed with the proposed model, additional resources and infrastructure to support such initiatives are necessary.

Comparisons of weight change, eating habits and physical activity between women in Northern Sweden and Rural New York State- results from a longitudinal study.

BACKGROUND: Previous research has focused exclusively on weight loss or weight maintenance following weight loss, i.e. secondary weight maintenance (SWM). The long-term results of SWM have been modest, suggesting that preventing initial weight gain among normal weight or overweight individuals, i.e. primary weight maintenance (PWM), may be more successful. The aim of this study was to compare the pattern of weight change between Swedish and US women and to contrast eating and physical activity between the two countries. METHODS: A questionnaire of attitudes, strategies and behaviours regarding physical activity, food habits, body image and demands to maintain weight was mailed to 4021 Swedish and 3199 US individuals. Subjects had weight measurements taken 10 years apart in the Västerbotten Intervention Programme in northern Sweden, and self-reported weight as part of the Upstate Health and Wellness Study in Upstate New York. The mean 10-year percent weight change, and weight change in kilograms, were calculated between the two countries for nine female age (30, 40, 50 years at baseline) by BMI (20-25, 25-30, 30-35) groups. For the Swedish/US pair showing the largest differences in these two endpoints, analysis of variance, correlations and chi-square tests identified likely contributors to the observed differences in weight change. RESULTS: For all subgroups combined, the mean percent weight changes for Swedish women and US women were 4.9% (SD = 5.8) and 9.1% (SD = 13.7) respectively (p<0.001). Differences in 10 year weight change between the two countries were largest among normal weight 30 year olds. Eight variables were identified as likely contributors to this difference. A significantly higher proportion of Swedish women selected the healthy alternatives for these eight variables. Percent weight change varied considerably over healthy versus unhealthy response levels in the US, but not in Sweden. CONCLUSIONS: The prevalence of obesity among the Swedish women did not progress as rapidly as among the US. The greatest weight gain occurred predominantly among the 30 year old groups. The Swedish women tended to select healthier alternatives than their US counterparts, and women in the US appeared to be more vulnerable to the effects of unhealthy habits than women in Sweden.