Prevalence of atherosclerosis in individuals with prediabetes and diabetes compared to normoglycaemic individuals-a Swedish population-based study.

BACKGROUND: Patients with type 2 diabetes have an increased risk of death and cardiovascular events and people with diabetes or prediabetes have been found to have increased atherosclerotic burden in the coronary and carotid arteries. This study will estimate the cross-sectional prevalence of atherosclerosis in the coronary and carotid arteries in individuals with prediabetes and diabetes, compared with normoglycaemic individuals in a large population-based cohort. METHODS: The 30,154 study participants, 50-64 years, were categorized according to their fasting glycaemic status or self-reported data as normoglycaemic, prediabetes, and previously undetected or known diabetes. Prevalence of affected coronary artery segments, severity of stenosis and coronary artery calcium score (CACS) were determined by coronary computed tomography angiography. Total atherosclerotic burden was assessed in the 11 clinically most relevant segments using the Segment Involvement Score and as the presence of any coronary atherosclerosis. The presence of atherosclerotic plaque in the carotid arteries was determined by ultrasound examination. RESULTS: Study participants with prediabetes (n = 4804, 16.0%) or diabetes (n = 2282, 7.6%) had greater coronary artery plaque burden, more coronary stenosis and higher CACS than normoglycaemic participants (all, p < 0.01). Among male participants with diabetes 35.3% had CACS ≥ 100 compared to 16.1% among normoglycaemic participants. For women, the corresponding figures were 8.9% vs 6.1%. The prevalence of atherosclerosis in the coronary arteries was higher in participants with previously undetected diabetes than prediabetes, but lower than in patients with known diabetes. The prevalence of any plaque in the carotid arteries was higher in participants with prediabetes or diabetes than in normoglycaemic participants. CONCLUSIONS: In this large population-based cohort of currently asymptomatic people, the atherosclerotic burden in the coronary and carotid arteries increased with increasing degree of dysglycaemia. The finding that the atherosclerotic burden in the coronary arteries in the undetected diabetes category was midway between the prediabetes category and patients with known diabetes may have implications for screening strategies and tailored prevention interventions for people with dysglycaemia in the future.

Plasma type I collagen α1 chain in relation to coronary artery disease: findings from a prospective population-based cohort and an acute myocardial infarction prospective cohort in Sweden.

OBJECTIVES: To investigate the association between type I collagen α1 chain (COL1α1) levels and coronary artery disease (CAD) by using absolute quantification in plasma. Also, to investigate the correlates of COL1α1 to clinical characteristics and circulating markers of collagen metabolism. DESIGN: Life conditions, Stress and Health (LSH) study: prospective cohort study, here with a nested case-control design.Assessing Platelet Activity in Coronary Heart Disease (APACHE) study: prospective cohort study. SETTING: LSH: primary care setting, southeast Sweden.APACHE: cardiology department, university hospital, southeast Sweden. PARTICIPANTS: LSH: 1007 randomly recruited individuals aged 45-69 (50% women). Exclusion criteria was serious disease. After 13 years of follow-up, 86 cases with primary endpoint were identified and sex-matched/age-matched to 184 controls. APACHE: 125 patients with myocardial infarction (MI), 73 with ST-elevation MI and 52 with non-ST-elevation MI. EXCLUSION CRITERIA: Intervention study participation, warfarin treatment and short life expectancy. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was the association between baseline COL1α1 and first-time major event of CAD, defined as fatal/non-fatal MI or coronary revascularisation after 13 years. Secondary outcomes were the association between the collagen biomarkers PRO-C1 (N-terminal pro-peptide of type I collagen)/C1M (matrix metalloproteinase-mediated degradation of type I collagen) and CAD; temporal change of COL1α1 after acute MI up to 6 months and lastly, correlates between COL1α1 and patient characteristics along with circulating markers of collagen metabolism. RESULTS: COL1α1 levels were associated with CAD, both unadjusted (HR=0.69, 95% CI=0.56 to 0.87) and adjusted (HR=0.55, 95% CI=0.41 to 0.75). PRO-C1 was associated with CAD, unadjusted (HR=0.62, 95% CI=0.47 to 0.82) and adjusted (HR=0.61, 95% CI=0.43 to 0.86), while C1M was not. In patients with MI, COL1α1 remained unchanged up to 6 months. COL1α1 was correlated to PRO-C1, but not to C1M. CONCLUSIONS: Plasma COL1α1 was independently and inversely associated with CAD. Furthermore, COL1α1 appeared to reflect collagen synthesis but not degradation. Future studies are needed to confirm whether COL1α1 is a clinically useful biomarker of CAD.

Systematic Coronary Risk Evaluation estimated risk and prevalent subclinical atherosclerosis in coronary and carotid arteries: A population-based cohort analysis from the Swedish Cardiopulmonary Bioimage Study.

BACKGROUND: It is not clear if the European Systematic Coronary Risk Evaluation algorithm is useful for identifying prevalent subclinical atherosclerosis in a population of apparently healthy individuals. Our aim was to explore the association between the risk estimates from Systematic Coronary Risk Evaluation and prevalent subclinical atherosclerosis. DESIGN: The design of this study was as a cross-sectional analysis from a population-based study cohort. METHODS: From the general population, the Swedish Cardiopulmonary Bioimage Study randomly invited individuals aged 50-64 years and enrolled 13,411 participants mean age 57 (standard deviation 4.3) years; 46% males between November 2013-December 2016. Associations between Systematic Coronary Risk Evaluation risk estimates and coronary artery calcification and plaques in the carotid arteries by using imaging data from a computed tomography of the heart and ultrasonography of the carotid arteries were examined. RESULTS: Coronary calcification was present in 39.5% and carotid plaque in 56.0%. In men, coronary artery calcium score >0 ranged from 40.7-65.9% and presence of carotid plaques from 54.5% to 72.8% in the age group 50-54 and 60-65 years, respectively. In women, the corresponding difference was from 17.1-38.9% and from 41.0-58.4%. A doubling of Systematic Coronary Risk Evaluation was associated with an increased probability to have coronary artery calcium score >0 (odds ratio: 2.18 (95% confidence interval 2.07-2.30)) and to have >1 carotid plaques (1.67 (1.61-1.74)). CONCLUSION: Systematic Coronary Risk Evaluation estimated risk is associated with prevalent subclinical atherosclerosis in two major vascular beds in a general population sample without established cardiovascular disease or diabetes mellitus. Thus, the Systematic Coronary Risk Evaluation risk chart may be of use for estimating the risk of subclinical atherosclerosis.

Associations of Psychosocial Factors with Multiple Health Behaviors: A Population-Based Study of Middle-Aged Men and Women.

Background: The health behaviors smoking, risky alcohol consumption, insufficient physical activity, and poor diet constitute the main contributors to non-communicable diseases. Clustering of risk behaviors is common and increases the risk of these diseases. Despite health benefits, it is difficult to change health behaviors. Psychosocial factors could play a role in health behavior change, with research showing relationships between unfavorable psychosocial factors and health risk behaviors. However, many studies only investigated one or two health behaviors at a time. The present study, therefore, aimed to investigate associations between a broad range of psychosocial factors and multiple health risk behaviors in a general middle-aged population in Sweden. Methods: A cross-sectional design was used to investigate a random sample from the general population in Sweden (n = 1007, 45-69 years, 50% women). Questionnaire data on health behaviors (smoking, alcohol consumption, physical activity, and fruit/vegetable intake) and psychosocial factors, with both psychological and social resources (social integration, emotional support, perceived control, self-esteem, sense of coherence and trust) and psychological risk factors (cynicism, vital exhaustion, hopelessness and depressiveness), were analyzed. Logistic and ordinal logistic regression were used to analyze associations between psychosocial factors and multiple (0-1, 2 or 3-4) health risk behaviors. Results: A total of 50% of the sample had two health risk behaviors and 18% had three health risk behaviors. After adjusting for age, sex, education, employment status, and immigrant status, eight out of 10 psychosocial factors (exceptions: social integration and self-esteem) showed significant odds ratios (ORs) in the expected directions; low levels of psychosocial resources and high levels of psychosocial risk factors were associated with multiple risk behaviors. The strongest associations with multiple risk behaviors were seen for vital exhaustion (adjusted (adj.) OR 1.28; confidence interval (CI) 1.11-1.46), depressiveness (adj. OR 1.32, CI 1.14-1.52), and trust (adj. OR 0.80, CI 0.70-0.91). When controlling for all psychosocial factors in the same model, only the association with trust remained statistically significant (adj. OR 0.89, CI 0.73-1.00, p = 0.050). Associations with individual health behaviors were fewer and scattered, with no psychosocial factor being related to all four behaviors. Conclusions: Examining associations between a broad range of psychosocial factors and multiple health risk behaviors revealed consistent and significant associations for almost all psychosocial factors. These associations were stronger compared to associations to single health risk behaviors. Our findings support the relevance of considering psychosocial aspects in interventions aimed at health behavior change, especially for people with multiple health risk behaviors.

Measuring psychosocial factors in health surveys using fewer items.

The present study investigated the possibility of reducing length of psychosocial scales, while maintaining validity, using easily manageable techniques. Data were collected 2003-2004 in a Swedish general population; n = 1007, ages 45-69, 50% women. Eight psychosocial scales were reduced from 6-20 to 3-7 items maintaining Cronbach's alpha >0.7 and correlation coefficients between full and reduced scales > 0.85. Relationships to biomarkers for inflammation, self-rated health and 8-year incidence of coronary heart disease showed no difference between full and reduced scales. It was possible, using these easily manageable methods, to reduce scale length without threatening validity for use in population surveys.

Usefulness of Certain Protein Biomarkers for Prediction of Coronary Heart Disease.

Identification of biomarkers can help monitor and prevent cardiovascular disease (CVD) risk. We performed an exploratory analysis to identify potential biomarkers for coronary heart disease (CHD) in participants from the Life Conditions, Stress, and Health study. A total of 1,007 participants (50% women), randomly selected from the general population, were followed for incident CHD at 8 and 13 years of follow-up. Plasma levels of 184 CVD-related biomarkers were measured in samples collected at baseline in 86 cases with CHD and 184 age- and sex-matched controls by proximity extension assay. Biomarker levels were presented as normalized protein expression values (log 2 scale). After adjusting for confounding factors, 6 biomarkers showed significant association with incident CHD at 13 years. In a sensitivity analysis, this association remained significant at 8 years for 3 biomarkers; collagen α-1(I) chain (COL1A1), bone morphogenetic protein-6 (BMP-6), and interleukin-6 receptor α chain (IL-6Rα). When entering these biomarkers in the full adjustment model simultaneously, their association with incident CHD at 13 years remained significant, hazards ratio being 0.671, 0.335, and 2.854, respectively per unit increase in normalized protein expression values. Subjects with low COL1A1, low BMP-6, and high IL-6Rα levels had a hazards ratio of 5.097 for incident CHD risk (p = 0.019), compared with those without. In conclusion, we identified COL1A1, BMP-6 and IL-6Rα as biomarkers for incident CHD over a long-term follow-up in this exploratory analysis. For COL1A1 and BMP-6 this has not been previously reported. Further studies are needed to confirm our findings and establish their clinical relevance.

SF-36 predicts 13-year CHD incidence in a middle-aged Swedish general population.

PURPOSE: To study the predictive ability of each of the eight scales of SF-36 on 13-year all-cause mortality and incident coronary heart disease (CHD) in a general middle-aged population. METHODS: The population-based, longitudinal "Life-conditions, Stress and Health" study, in 2003-2004 enrolled 1007 persons aged 45-69 years (50% female), randomly sampled from the general population in Östergötland, Sweden. Variables at baseline included the SF-36 (health-related quality of life, HRQoL) and self-reported disease. Incident CHD (morbidity and mortality) and all-cause mortality data for the study population during the first 13 years from baseline were obtained from national Swedish registries. RESULTS: Seven of the eight SF-36 scales predicted CHD (sex- and age-adjusted Hazard Ratios up to 2.15; p ≤ 0.05), while only the Physical Functioning scale significantly predicted all-cause mortality. Further adjustments for presence of (self-reported) disease did not, in most cases, alter these significant predictions. CONCLUSION: Low SF-36 scores predict risk of CHD, also after adjustment for present disease, supporting the biopsychosocial model of health and disease. Measures of HRQoL yield important information and can add to the cardiopreventive toolbox, including primary prevention efforts, as it is such a simple and relatively inexpensive tool.

People diagnosed with dementia in Sweden: What type of home care services and housing are they granted? A cross-sectional study.

AIMS: This study aims to examine what types of home care services and housing are granted to people with a dementia diagnosis and how these types are associated with socio-demographic factors (sex, age, marital status, native or foreign born, and regional area). METHODS: A cross-sectional study of all people diagnosed with dementia in three Swedish counties was conducted from the medical records in 2012. Logistic regression analysis was carried out to investigate associations between home care services and housing and socio-demographic variables. RESULTS: In total, 17,405 people had a dementia diagnosis, and the majority were women, aged 80+ years, and unmarried. Some 72% were living in ordinary housing and 28% lived in special housing. Of those who lived in ordinary housing, 50% did not receive any home care service. Not receiving any type of home care services was less common for older people and was also associated with being married and living in rural municipalities. The most common home care services granted were home help and personal care. Special housing was more common for older people, unmarried persons, and those living in rural municipalities. CONCLUSIONS: Most people with a dementia diagnosis were living in ordinary housing, and, surprisingly, half of those did not receive any type of home care service. This knowledge is essential for making the living conditions and needs of people living with dementia more visible and to provide good home care services for people with dementia and their families.

Choice of measure matters: A study of the relationship between socioeconomic status and psychosocial resources in a middle-aged normal population.

Psychosocial resources may serve as an important link to explain socioeconomic differences in health. Earlier studies have demonstrated that education, income and occupational status cannot be used interchangeably as indicators of a hypothetical latent social dimension. In the same manner, it is important to disentangle the effect of measuring different constructs of psychosocial resources. The aim of this study was therefore to analyse if associations between socioeconomic status (SES) and psychosocial resources differ depending on the measures used. A cross-sectional population-based study of a random sample (n = 1007) of middle-aged individuals (45-69 years old, 50% women) in Sweden was performed using questionnaire and register data. SES was measured as education, occupation, household income and self-rated economy. Psychosocial resources were measured as social integration, social support, mastery, self-esteem, sense of coherence (SOC) and trust. Logistic regression models were applied to analyse the relationships controlling for the effects of possible confounders. The measures of SES were low or moderately correlated to each other as were the measures of psychosocial resources. After controlling for age, sex, country of birth and employment status, household income and self-rated economy were associated with all six psychosocial resources; occupation was associated with three (social integration, self-esteem and trust) and education with two (social integration and self-esteem). Social integration and self-esteem showed a significant and graded relationship with all SES measures; trust was associated with all SES measures except education, whereas SOC and mastery were only associated with household income and self-rated economy. After controlling for other SES measures, no associations with psychosocial resources remained for education or occupation. In conclusion, associations between SES and psychosocial resources did differ depending on the measures used. The findings illustrate the importance of the choice of measure when investigating SES as well as psychosocial resources.

Blood pressure and all-cause mortality: a prospective study of nursing home residents.

AIM: to explore the natural course of blood pressure development and its relation to mortality in a nursing home cohort. METHODS: a cohort of 406 nursing home residents in south east Sweden was followed prospectively for 30 months. Participants were divided into four groups based on systolic blood pressure (SBP) at baseline. Data were analysed using a Cox regression model with all-cause mortality as the outcome measurement; paired Student t-tests were used to evaluate blood pressure development over time. RESULTS: during follow-up, 174 (43%) people died. Participants with SBP < 120 mmHg had a hazard ratio for mortality of 1.56 (95% confidence interval, 1.08-2.27) compared with those with SBP 120-139 mmHg, adjusted for age and sex. Risk of malnutrition or present malnutrition was most common in participants with SBP < 120 mmHg; risk of malnutrition or present malnutrition estimated using the Mini Nutritional Assessment was found in 78 (71%). The levels of SBP decreased over time independent of changes in anti-hypertensive medication. CONCLUSIONS: in this cohort of nursing home residents, low SBP was associated with increased all-cause mortality. SBP decreased over time; this was not associated with altered anti-hypertensive treatment. The clinical implication from this study is that there is a need for systematic drug reviews in elderly persons in nursing homes, paying special attention to those with low SBP.

Association between organizational climate and perceptions and use of an innovation in Swedish primary health care: a prospective study of an implementation.

BACKGROUND: There is a need for new knowledge regarding determinants of a successful implementation of new methods in health care. The role of a receptive context for change to support effective diffusion has been underlined, and could be studied by assessing the organizational climate. The aim of this study was to assess the association between organizational climate when a computer-based lifestyle intervention tool (CLT) was introduced in primary health care (PHC) and the implementation outcome in terms of how the tool was perceived and used after 2 years. METHODS: The CLT was offered to 32 PHC units in Sweden, of which 22 units agreed to participate in the study. Before the introduction of the CLT, the creative climate at each participating unit was assessed. After 24 months, a follow-up questionnaire was distributed to the staff to assess how the CLT was perceived and how it was used. A question on the perceived need for the CLT was also included. RESULTS: The units were divided into three groups according to the creative climate: high, medium and low. The main finding was that the units identified as having a positive creative climate demonstrated more frequent use and more positive perceptions regarding the new tool than those with the least positive creative climate. More positive perceptions were seen at both individual and unit levels. CONCLUSIONS: According to the results from this study there is an association between organizational climate at baseline and implementation outcome after 2 years when a tool for lifestyle intervention is introduced in PHC in Sweden. Further studies are needed before measurement of organizational climate at baseline can be recommended in order to predict implementation outcome.

Consequences of high-sensitivity troponin T testing applied in a primary care population with chest pain compared with a commercially available point-of-care troponin T analysis: an observational prospective study.

BACKGROUND: There is a demand for a highly sensitive and specific point-of care test to detect acute myocardial infarction (AMI). It is unclear if a high-sensitivity troponin assay will have enough discriminative power to become a decision support in primary care. The aim of this study was to evaluate a high-sensitivity troponin T assay performed in three primary health care centres in southeast Sweden and to compare the outcome with a point-of-care troponin T test. METHODS: This study included 115 patients who consulted their general practitioner for chest pain, dyspnoea on exertion, unexplained weakness and/or fatigue in the last 7 days. Troponin T was analysed by a point-of-care test and a high-sensitivity method together with N-terminal pro-B-type natriuretic peptide (NT-proBNP) and creatinine. All patients were checked for AMI or unstable angina (UA) within 30 days of study enrolment. Univariate and multivariate logistic regression was carried out to examine possible connections between troponin T ≥ 15 ng/L, clinical variables and laboratory findings at baseline. In addition, 21 patients with troponin T ≥ 15 ng/L and no signs of AMI or UA were followed up for 2-3 years. RESULTS: Three patients were diagnosed with AMI and three with UA. At the ≥ 15 ng/L cut-off, the troponin T method had 100% sensitivity, 75% specificity for AMI and a positive predictive value of 10%. The troponin T point-of-care test missed one case of AMI and the detection limit was 50 ng/L. Troponin T ≥ 15 ng/L was correlated to age ≥65 years (odds ratio (OR), 10.9 95% CI 2.28-51.8) and NT-proBNP in accordance with heart failure (OR 8.62 95% CI 1.61-46.1). Fourteen of the 21 patients, without signs of AMI or UA at baseline, still had increased troponin T at follow-up after 2-3 years. CONCLUSIONS: A high-sensitivity troponin T assay could become useful in primary care as a point-of-care test for patients <65 years. For patients older than 65-70 years, a higher decision limit than ≥15 ng/L should be considered and used in conjunction with clinical parameters and possibly with NT-proBNP.

Left ventricular diastolic function, assessed by echocardiography and tissue Doppler imaging, is a strong predictor of cardiovascular events, superior to global left ventricular longitudinal strain, in patients with type 2 diabetes.

AIMS: The aim of the study was to determine whether left ventricular systolic function, in terms of global left ventricular longitudinal strain (GLS), and diastolic function, expressed as the ratio between early diastolic transmitral flow and mitral annular motion velocities (E/e'), can predict cardiovascular events in patients with diabetes mellitus type 2. METHODS AND RESULTS: We prospectively investigated 406 consecutive patients, aged 55-65 years, with diabetes mellitus, who participated in the CARDIPP study. Echocardiography, pulse pressure (pp), and glycosylated haemoglobin (HbA1c) were analysed. Twelve cases of myocardial infarction and seven cases of stroke were identified during the follow-up period of 67 ± 17 months. Univariate Cox regression analysis showed that E/e' was a strong predictor of cardiovascular events (hazards ratio 1.12; 95% confidence interval 1.06-1.18, P < 0.001). E/e' was prospectively associated with cardiovascular events independent of age, sex, GLS, left ventricular ejection fraction (LVEF), pp, and HbA1c in multivariate analysis. Receiver operating characteristic curves showed that E/e' and HbA1c were the strongest predictors for cardiovascular events, both having an area under the curve (AUC) of 0.71 followed by LVEF with an AUC of 0.65 and GLS of 0.61. In a Kaplan-Meyer analysis, the cumulative probability of an event during the follow-up period was 8.6% for patients with an E/e' ratio >15 compared with 2.6% for patients with E/e' ≤15, P = 0.011. CONCLUSION: In middle-aged patients with type 2 diabetes, E/e' is a strong predictor of myocardial infarction and stroke, comparable with HbA1c and superior to GLS and LVEF.

Primary health care staff's opinions about changing routines in practice: a cross-sectional study.

BACKGROUND: In health care organizations, there is a mutual interest from politicians, managers, practitioners and patients that the best available care is provided. Efforts are made to translate new knowledge and evidence-based practices into routine care, but there are a number of obstacles to this translation process. Factors related to the new practice as well as factors related to the implementation process are important, but there is still a knowledge gap regarding how to achieve effective implementation. The aim of the present study was to assess opinions about practice change among staff in primary health care (PHC), focusing on factors related to a new practice and factors related to the implementation process. METHODS: A questionnaire was sent to 470 staff members at 22 PHC centres where a new tool for lifestyle intervention had recently been implemented. Thirteen items regarding the characteristics of the new practice and nine items regarding the implementation process were to be judged from not at all important to very important. A factor analysis was performed, and statistical analysis was done using the Kruskal-Wallis nonparametric test. RESULTS: Four factors regarding the characteristics of the new practice were identified. Most important was Objective characteristics, followed by Evidence base, Subjectively judged characteristics and Organizational level characteristics. Two factors were identified regarding the implementation process: Bottom-up strategies were judged most important and Top-down strategies less important. The most important single items regarding characteristics were "easy to use" and "respects patient privacy", and the most important implementation process item was "information about the new practice". Nurses differed most from the other professionals, and judged the factors Evidence base and Organizational level characteristics more important than the others. Staff with more than 10 years experience in their profession judged the Evidence base factor more important than those who were less experienced. CONCLUSIONS: To incorporate new practices in PHC, objective characteristics of the new practice and the evidence base should be considered. Use of bottom-up strategies for the implementation process is important. Different opinions according to profession, gender and years in practice should be taken into account when planning the implementation.

What makes emergency department patients reduce their alcohol consumption?--a computer-based intervention study in Sweden.

OBJECTIVES: This study investigates the effectiveness of a computerized emergency department intervention for alcohol consumption and identifies explanation factors associated with reduced alcohol consumption from risk to non-risk drinking. METHODS: Patients aged 18-69 years registered at the ED triage answered alcohol-related questions on a touch-screen computer. Follow-up data were collected by means of a postal questionnaire that was mailed to the patients 6 months after their ED visit. RESULTS: There were four independent explanations for reduced alcohol consumption: being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider. 339 patients could be followed up and of these were 97 categorized as risk drinkers at baseline and 45 became non-risk drinker 6 month later. CONCLUSIONS: Being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider were predictors for change from risk to non-risk drinking 6 months later.

Quality indicators for implementation of safety promotion: towards valid and reliable global certification of local programmes.

The theoretical underpinnings of safety promotion have not yet been integrated with implementation practice to ascertain between-community programme quality. This study sets out to develop a framework for verifying of the quality of community-based safety-promotion programmes in the global context. We analysed the certification indicators deployed in the international Safe Community movement in light of systems theory. Data were collected from focus group interviews with representatives from 10 certified Swedish communities and then analysed by qualitative methods. The community representatives were found to have used the present indicators mainly for marketing the safety-promotion concept to stakeholders rather than as benchmarks for safety practice. When appraised in regard to systems theory, it was found that the indicators did not cover important aspects of health-services implementation. Attainment of outcomes at the population level was not included. Consequently, that information about programme effects in high-risk groups and in risk environments could be neglected. We conclude that programme processes and outcomes at both organisational and population levels must be assessed when the quality of safety-promotion programmes is being certified. A revised set of indicators for certification of safety-promotion programmes fulfilling these criteria is presented.

Acute alcohol consumption and motivation to reduce drinking among injured patients in a Swedish emergency department.

Injuries constitute a major public health problem. Millions of people are injured each year, and acute drinking is a well-known risk factor for injuries. Research suggests that acknowledgment of alcohol as a factor in an injury enhances willingness to change drinking behavior, possibly because the patient becomes aware of the negative consequences of their drinking. This study aims to investigate the prevalence of acute alcohol consumption (drinking before the event) among injury patients and to examine the importance of factors potentially associated with motivation to reduce alcohol consumption among these patients. All patients aged 18-69 years were requested to answer alcohol-related questions on a touchscreen computer. Fifteen percent of injured patients were categorized as acute drinkers, and of these, 64% reported that their injury was connected to alcohol. There were significant differences for all sociodemographic and drinking characteristics between acute drinkers and nonacute drinkers. Acute drinkers were categorized as risky drinkers to a much higher extent than nonacute drinkers. Acute drinkers had a considerably higher average weekly alcohol consumption and engaged far more frequently in heavy episodic drinking than nonacute drinkers. Acute drinkers were motivated to reduce their alcohol intake to a greater extent than nonacute drinkers; 51% were in the action, preparation, and contemplation stages, compared with 19% of the nonacute drinkers. Acute drinkers had considerably more detrimental alcohol consumption than nonacute drinkers, and the acute drinkers were more motivated to reduce their drinking than the nonacute drinkers.

Who is not adhering to physical activity referrals, and why?

OBJECTIVE: To analyse patients' self-reported reasons for not adhering to physical activity referrals (PARs). DESIGN AND SETTING: Data on 1358 patients who did not adhere to PARs were collected at 38 primary health care (PHC) centres in Sweden. INTERVENTION: PHC providers issued formal physical activity prescriptions for home-based activities or referrals for facility-based activities. SUBJECTS: Ordinary PHC patients whom regular staff believed would benefit from increased physical activity. MAIN OUTCOME MEASURE: Reasons for non-adherence to PARs: "sickness", "pain", "low motivation", "no time", "economic factors", and "other". RESULTS: Sickness and pain were the most common motives for non-adherence among older patients. The youngest patients blamed economic factors and lack of time more frequently than those in the oldest age group. Economic factors was a more common reason for non-adherence among those referred for facility-based activities compared with those prescribed home-based activities. Low motivation was a more frequent cause of non-adherence among those prescribed home-based activities compared with those referred for facility-based activities. Furthermore, lack of time was a more common reason for non-adherence among patients issued with PARs due to high blood pressure than other patients, while low motivation was a more common reason among patients issued with PARs because of a BMI of > 25. CONCLUSION: The reasons for non-adherence differ between patients prescribed home-based activities and referred for facility-based activities, as well as between patients with different specific characteristics. The information obtained may be valuable not only for the professionals working in PHC, but also for those who work to develop PARs for use in different contexts.

Reach and effectiveness of a computer-based alcohol intervention in a Swedish emergency room.

OBJECTIVES: This study evaluates a computerized alcohol intervention implemented in a Swedish emergency department (ED) with regard to the effectiveness of two different types of tailored brief feedback on patients' drinking patterns and the reach of the intervention. METHODS: The study was a prospective, randomized controlled trial of ED patients. The designated target population was the ED population aged 18-69 years who registered at the triage room before receiving care. Patients who were categorized as risky drinkers and completed the computerized test were randomized to either a long or a short feedback. The feedback was tailored on the basis of the individual patient's responses to questions on their drinking patterns. RESULTS: The computerized intervention reached 41% of the target population. Those who completed the computerized test and received the feedback were younger than those who did not receive the intervention. Among those who could be followed up, the feedback was effective in reducing the patient's weekly alcohol consumption and the number of heavy episodic drinking occasions. The long feedback was slightly more effective than the short feedback, but the differences were not statistically significant.

Factors associated with patients self-reported adherence to prescribed physical activity in routine primary health care.

BACKGROUND: Written prescriptions of physical activity have increased in popularity. Such schemes have mostly been evaluated in terms of efficacy in clinical trials. This study reports on a physical activity prescription referral scheme implemented in routine primary health care (PHC) in Sweden. The aim of this study was to evaluate patients' self-reported adherence to physical activity prescriptions at 3 and 12 months and to analyse different characteristics associated with adherence to these prescriptions. METHODS: Prospective prescription data were obtained for the general population in 37 of 42 PHC centres in Ostergötland County, during 2004. The study population consisted of 3300. RESULTS: The average adherence rate to the prescribed activity was 56% at 3 months and 50% at 12 months. In the multiple logistic regression models, higher adherence was associated with higher activity level at baseline and with prescriptions including home-based activities. CONCLUSIONS: Prescription from ordinary PHC staff yielded adherence in half of the patients in this PAR scheme follow-up.