Association of education and feedback on hypertension management with risk for stroke and cardiovascular disease.

PURPOSE: Education and feedback on hypertension management has been associated with improved hypertension control. This study aimed to assess the effectiveness of such interventions to reduce the risk of stroke and cardiovascular events. MATERIALS AND METHODS: Individuals ≥18 years with a blood pressure (BP) recording in Västerbotten or Södermanland County during the study period 2001 to 2009 were included in 108 serial cohort studies, each with 24 months follow-up. The primary outcome was risk of first-ever stroke in Västerbotten County (intervention) compared with Södermanland County (control). Secondary outcomes were first-ever major adverse cardiovascular event (MACE), myocardial infarction, and heart failure, as well as all-cause and cardiovascular mortality. All outcomes were analysed using time-to-event data included in a Cox proportional hazards model adjusted for age, sex, hypertension, diabetes, coronary artery disease, atrial fibrillation, systolic BP at inclusion, marital status, and disposable income. RESULTS: A total of 121 365 individuals (mean [SD] age at inclusion 61.7 [16.3] years; 59.9% female; mean inclusion BP 142.3/82.6 mmHg) in the intervention county were compared to 131 924 individuals (63.6 [16.2] years; 61.2% female; 144.1/81.1 mmHg) in the control county. A first-ever stroke occurred in 2 823 (2.3%) individuals in the intervention county, and 3 584 (2.7%) individuals in the control county (adjusted hazard ratio 0.96, 95% CI 0.90 to 1.03). No differences were observed for MACE, myocardial infarction or heart failure, whereas all-cause mortality (HR 0.91, 95% CI 0.87 to 0.95) and cardiovascular mortality (HR 0.91, 95% CI 0.85 to 0.98) were lower in the intervention county. CONCLUSIONS: This study does not support an association between education and feedback on hypertension management to primary care physicians and the risk for stroke or cardiovascular outcomes. The observed differences for mortality outcomes should be interpreted with caution.

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.

Working with national quality registries in older people care: A qualitative study of perceived impact on assistant nurses' work situation.

Aim: The aim was to investigate assistant nurses' perceptions of how working with national quality registries affected their work situation in care of older people. Design: Qualitative interview study. Methods: Sixteen semi-structured interviews were conducted at four special housing units in Sweden, and a conventional content analysis, with elements of thematic analysis, was applied. Results: The introduction of national quality registries contributed to role clarifications and the development of new formal work procedures in terms of documentation and arenas and routines for communication. The increased systematics and effectiveness gained from these changes had a perceived positive effect on the work situation, workload, work satisfaction, staff interactions and learning and reflection.

Gender differences and determinants of prevalence, awareness, treatment and control of hypertension among adults in China and Sweden.

BACKGROUND: Failure to promote early detection and better management of hypertension will contribute to the increasing burden of cardiovascular diseases. This study aims to assess the gender differences in the prevalence, awareness, treatment and control of hypertension, together with its associated factors, in China and Sweden. METHODS: We used data from two cross-sectional studies: the Västerbotten Intervention Program in northern Sweden (n = 25,511) and the Shanghai survey in eastern China (n = 25,356). We employed multivariable logistic regression to examine the socio-demographics, lifestyle behaviours, and biological factors associated with the prevalence, awareness, treatment and control of hypertension. RESULTS: Men had a higher prevalence of hypertension (43% in Sweden, 39% in China) than their female counterparts (29 and 36%, respectively). In Sweden, men were less aware of, less treated for, and had less control over their hypertension than women. Chinese men were more aware of, had similar levels of treatment for, and had less control over their hypertension compared to women. Awareness and control of hypertension was lower in China compared to Sweden. Only 33 and 38% of hypertensive Chinese men and women who were treated reached the treatment goals, compared with a respective 48 and 59% in Sweden. Old age, impaired glucose tolerance or diabetes, a family history of hypertension or cardiovascular diseases, low physical activity and overweight or obesity were found to increase the odds of hypertension and its diagnosis. CONCLUSIONS: This study shows the age and gender differences in the prevalence, awareness, treatment and control of hypertension among adults in China and Sweden. Multisectoral intervention should be developed to address the increasing burden of sedentary lifestyle, overweight and obesity and diabetes, all of which are linked to the prevention and control of hypertension. Development and implementation of the gender- and context-specific intervention for the prevention and control of hypertension facilitates understanding with regard to the implementation barriers and facilitators.

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.

Living alone and mortality among older people in Västerbotten County in Sweden: a survey and register-based longitudinal study.

BACKGROUND: Living alone is increasingly common and has been depicted as an important cause of mortality. We examined the association between living alone and mortality risks among older men and women in northern Sweden, by linking two unique longitudinal datasets. METHODS: We used the Linnaeus database, which links several population registers on socioeconomic and health. This register-based study included 22,226 men and 23,390 women aged 50 and 60 years in Västerbotten County who had participated in the Västerbotten Intervention Program (VIP) during 1990-2006, with a total of 445,823 person-years of observation. We conducted Cox-proportional hazard regression to assess the risk of living alone on the mortality that was observed between 1990 and 2015, controlling for socio-demographic factors, chronic disease risk factors and access to social capital. RESULTS: Older men and women who lived alone with no children at home were at a significantly higher risk of death compared to married/cohabiting couples with children at home (with an adjusted hazard ratio of 1.38, 95% CI of 1.26-1.50 in men and 1.27, 95% CI of 1.13-1.42 in women). Living alone was an even stronger factor than the well-established chronic disease risk factors and a lack of access to social capital. CONCLUSIONS: A significant association between living alone and mortality among the older adult population in Sweden was observed. Providing good social support for older people is important in preventing the negative health impact of living alone.

Association of Physician Education and Feedback on Hypertension Management With Patient Blood Pressure and Hypertension Control.

Importance: Elevated systolic blood pressure (SBP) is the most important risk factor for premature death worldwide. However, hypertension detection and control rates continue to be suboptimal. Objective: To assess the association of education and feedback to primary care physicians with population-level SBP and hypertension control rates. Design, Setting, and Participants: This pooled series of 108 population-based cohort studies involving 283 079 patients used data from primary care centers in 2 counties (Västerbotten and Södermanland) in Sweden from 2001 to 2009. Participants were individuals aged 18 years or older who had their blood pressure (BP) measured and recorded in either county during the intervention period. All analyses were performed in February 2019. Exposures: An intervention comprising education and feedback for primary care physicians in Västerbotten County (intervention group) compared with usual care in Södermanland County (control group). Main Outcomes and Measures: Difference in mean SBP levels between counties and likelihood of hypertension control in the intervention county compared with the control county during 24 months of follow-up. Results: A total of 136 541 unique individuals (mean [SD] age at inclusion, 64.6 [16.1] years; 57.0% female; mean inclusion BP, 142/82 mm Hg) in the intervention county were compared with 146 538 individuals (mean [SD] age at inclusion, 65.7 [15.9] years; 58.3% female; mean inclusion BP, 144/80 mm Hg) in the control county. Mean SBP difference between counties during follow-up, adjusted for inclusion BP and other covariates, was 1.1 mm Hg (95% CI, 1.0-1.1 mm Hg). Hypertension control improved by 8.4 percentage points, and control was achieved in 37.8% of participants in the intervention county compared with 29.4% in the control county (adjusted odds ratio, 1.30; 95% CI, 1.29-1.31). Differences between counties increased during the intervention period and were more pronounced in participants with higher SBP at inclusion. Results were consistent across all subgroups. Conclusions and Relevance: This study suggests that SBP levels and hypertension control rates in a county population may be improved by educational approaches directed at physicians and other health care workers. Similar strategies may be adopted to reinforce the implementation of clinical practice guidelines for hypertension management.

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.

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.

Prevalence and the Association of Body Mass Index and Other Risk Factors with Prediabetes and Type 2 Diabetes Among 50,867 Adults in China and Sweden: A Cross-Sectional Study.

INTRODUCTION: Understanding socioeconomic differences for prediabetes and type 2 diabetes (T2DM) can offer guidance for the most effective development of both prevention and intervention programmes in different settings. This study aims to determine the prevalence and risk factors for prediabetes and T2DM and to explore the effect of high body mass index (BMI) on the probability of T2DM being present among adults in China and Sweden. METHODS: This study enrolled 25,356 adults (35-64 years old) from the Shanghai Survey in China and 25,511 adults (aged 40, 50, 60) from the Västerbotten Intervention Programme in Sweden. Data on haemoglobin A1c, capillary fasting plasma glucose, 2-h plasma glucose and self-reported diagnoses of T2DM were used in the analysis. Multinomial logistic regression was used to examine the determinants of prediabetes and T2DM. The average predicted probabilities of T2DM developing or presenting were determined for the different ages and levels of BMI in each population. RESULTS: Chinese participants had a higher adjusted prevalence of T2DM (men 12.8% vs. 4.6%; women 10.6% vs. 3.1%) and prediabetes (men 12.4% vs. 12.2%; women 14.4% vs. 12.2%) than Swedish participants. Age, overweightedness/obesity, hypertension and a family history of diabetes were significant risk factors for prediabetes and T2DM. In both populations, the predicted probability of T2DM increased as the BMI increased in all age groups. At the same BMI level, Chinese participants were more likely to have T2DM compared to their Swedish counterparts. The average predicted probability of T2DM was less than 20% in nearly all age groups among Swedish women. CONCLUSIONS: Chinese adults had the higher prevalence of prediabetes and T2DM and a higher probability of T2DM at the same BMI level compared with Swedish adults. These results indicate the importance of addressing the ongoing obesity epidemic as a matter of urgency in order to curb what has become an apparent diabetes epidemic in both countries.

Flawed conclusions on the Västerbotten Intervention Program by San Sebastian et .al.

An evaluation of Västerbotten Intervention Programme (VIP) was recently conducted by San Sebastian et al. (BMC Public Health 19:202, 2019). Evaluation of health care interventions of this kind require 1) an understanding of both the design and the nature of the intervention, 2) correct definition of the target population, and 3) careful choice of the appropriate evaluation method. In this correspondence, we review the approach used by San Sebastian et al. as relates to these three criteria. Within this framework, we suggest important explanations for why the conclusions drawn by these authors contradict a large body of research on the effectiveness of the VIP.

Health-Care Administrator Perspectives on Prevention Guidelines and Healthy Lifestyle Counseling in a Primary Care Setting in New York State.

INTRODUCTION: The incidence of chronic disease and treatment costs have been steadily increasing in the United States over the past few decades. Primary prevention and healthy lifestyle counseling have been identified as important strategies for reducing health-care costs and chronic disease prevalence. This article seeks to examine decision-makers' experiences and self-perceived roles in guideline and lifestyle counseling implementation in a primary care setting in the United States. METHODS: Qualitative interviews were conducted with administrators at a health-care network in Upstate New York and with state-level administrators, such as insurers. Decision-makers were asked to discuss prevention guidelines and healthy lifestyle counseling, as well as how they support implementation of these initiatives. Interviews were analyzed using a thematic analysis framework and relevant sections of text were sorted using a priori codes. RESULTS: Interviews identified numerous barriers to guideline implementation. These included the complexity and profusion of guidelines, the highly politicized nature of health-care provision, and resistance from providers who sometimes prefer to make decisions autonomously. Barriers to supporting prevention counseling included relatively time-limited patient encounters, the lack of reimbursement mechanisms for counseling, lack of patient resources, and regulatory complexities. CONCLUSIONS: Our research indicates that administrators and administrative structures face barriers to supporting prevention activities such as guideline implementation and healthy lifestyle counseling in primary care settings. They also identified several solutions for addressing existing primary prevention barriers, such as relying on nurses to provide healthy lifestyle support to patients. This article provides an important assessment of institutional readiness to support primary prevention efforts.

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.

[Updated Swedish National Guidelines on prevention and lifestyle habits: physicians' role]. / Läkaren har en nyckelroll i vårdarbetet med levnadsvanor - Socialstyrelsens nya Nationella riktlinjer betonar det rådgivande patientsamtalet.

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

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.

Implementation of clinical practice guidelines on lifestyle interventions in Swedish primary healthcare - a two-year follow up.

BACKGROUND: Implementation of interventions concerning prevention and health promotion in health care has faced particular challenges resulting in a low frequency and quality of these services. In November 2011, the Swedish National Board of Health and Welfare released national clinical practice guidelines to counteract patients' unhealthy lifestyle habits. Drawing on the results of a previous study as a point of departure, the aim of this two-year follow up was to assess the progress of work with lifestyle interventions in primary healthcare as well as the uptake and usage of the new guidelines on lifestyle interventions in clinical practice. METHODS: Longitudinal study among health professionals with survey at baseline and 2 years later. Development over time and differences between professional groups were calculated with Pearson chi-square test. RESULTS: Eighteen percent of the physicians reported to use the clinical practice guidelines, compared to 58% of the nurses. Nurses were also more likely to consider them as a support in their work than physicians did. Over time, health professionals usage of methods to change patients' tobacco habits and hazardous use of alcohol had increased, and the nurses worked to a higher extent than before with all four lifestyles. Knowledge on methods for lifestyle change was generally high; however, there was room for improvement concerning methods on alcohol, unhealthy eating and counselling. Forty-one percent reported to possess thorough knowledge of counselling skills. CONCLUSIONS: Even if the uptake and usage of the CPGs on lifestyle interventions so far is low, the participants reported more frequent counselling on patients' lifestyle changes concerning use of tobacco and hazardous use of alcohol. However, these findings should be evaluated acknowledging the possibility of selection bias in favour of health promotion and lifestyle guidance, and the loss of one study site in the follow up. Furthermore, this study indicates important differences in physicians and nurses' attitudes to and use of the guidelines, where the nurses reported working to a higher extent with all four lifestyles compared to the first study. These findings suggest further investigations on the implementation process in clinical practice, and the physicians' uptake and use of the CPGs.

A cost-effectiveness analysis of a community based CVD program in Sweden based on a retrospective register cohort.

BACKGROUND: Several large scale community-based cardiovascular disease prevention programs were initiated in the 80s, and one was the Västerbotten Intervention Programme, Sweden. As an initial step in 1985, a pilot study was introduced in the Norsjö municipality that combined individual disease prevention efforts among the middle-aged population with community-oriented health promotion activities. All citizens at 30, 40, 50, and 60 years of age were invited to a physical examination combined with a healthy dialogue at the local primary health care centre. Västerbotten Intervention Program is still running following the same lines and is now a part of the ordinary public health in the county. The purpose of this study is to estimate the costs of running Västerbotten Intervention Programme from 1990 to 2006, versus the health gains and savings reasonably attributable to the program during the same time period. METHODS: A previous study estimated the number of prevented deaths during the period 1990-2006 which can be attributed to the programme. We used this estimate and calculated the number of QALYs gained, as well as savings in resources due to prevented non-fatal cases during the time period 1990 to 2006. Costs for the programmes were based on previously published scientific articles as well as current cost data from the county council, who is responsible for the programme. RESULT: The cost per QALY gained from a societal perspective is SEK 650 (Euro 68). From a health care sector perspective, the savings attributable to the VIP exceeded its costs. CONCLUSION: Our analysis shows that Västerbotten Intervention Programme is extremely cost-effective in relation to the Swedish threshold value (SEK 500000 per QALY gained or Euro 53,000 per QALY gained). Other research has also shown a favorable effect of Västerbotten Intervention Programme on population health and the health gap. We therefore argue that all health care organizations, acting in settings reasonably similar to Sweden, have good incentive to implement programs like Västerbotten Intervention Programme.

Lifestyle counseling in primary care in the United States and Sweden: a comparison of patients' expectations and experiences.

BACKGROUND: Despite various guidelines, shortcomings in lifestyle counseling in primary care have been demonstrated. Comparisons between countries may provide insight on how to improve such counseling. To the best of our knowledge, studies comparing patients' views of lifestyle counseling beween the United States (US) and European countries have not been reported. OBJECTIVES: To quantify and compare patients' perspectives in the US and Sweden on primary care providers' counseling on weight, eating habits, physical activity, smoking, and alcohol consumption. METHODS: In a cross-sectional study, 629 patients from Sweden and the US completed a telephone interview about their experiences after a visit to a physician in primary care. The survey focused on patients' perception of the importance of healthy lifestyle habits, their need to change, their desire to receive support from primary care, and the support they had actually received. Data were analyzed using chi-square or Fisher's exact test. RESULTS: For three of the four lifestyle habits, the proportion saying they needed to change was higher in the US. The exception was for alcohol, where Swedish subjects indicated a greater need to change. Among those stating a need to change, the proportion saying that they would like to have support from primary care was generally above 80% in both countries. The proportion of US patients reporting that their primary care provider had initiated a discussion of lifestyle modification was, with the exception of alcohol, roughly double the level reported by the Swedish patients. CONCLUSIONS: This study demonstrates high and quite similar patient expectations concerning lifestyle counseling in both countries, but more frequent initiation of discussions of most lifestyle issues in US primary care. Further studies, e.g. qualitative interviews with physicians, and medical record reviews, are required to better understand what can explain the differences between countries indicated by the study.

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.