Patients and Professionals as Partners in Hypertension Care: Qualitative Substudy of a Randomized Controlled Trial Using an Interactive Web-Based System Via Mobile Phone.

BACKGROUND: The use of technology has the potential to support the patient´s active participation regarding treatment of hypertension. This might lead to changes in the roles of the patient and health care professional and affect the partnership between them. OBJECTIVE: The aim of this qualitative study was to explore the partnership between patients and health care professionals and the roles of patients and professionals in hypertension management when using an interactive web-based system for self-management of hypertension via the patient's own mobile phone. METHODS: Focus group interviews were conducted with 22 patients and 15 professionals participating in a randomized controlled trial in Sweden aimed at lowering blood pressure (BP) using an interactive web-based system via mobile phones. The interviews were audiorecorded and transcribed and analyzed using thematic analysis. RESULTS: Three themes were identified: the technology, the patient, and the professional. The technology enabled documentation of BP treatment, mainly for sharing knowledge between the patient and the professional. The patients gained increased knowledge of BP values and their relation to daily activities and treatment. They were able to narrate about their BP treatment and take a greater responsibility, inspired by new insights and motivation for lifestyle changes. Based on the patient's understanding of hypertension, professionals could use the system as an educational tool and some found new ways of communicating BP treatment with patients. Some reservations were raised about using the system, that it might be too time-consuming to function in clinical practice and that too much measuring could result in stress for the patient and an increased workload for the professionals. In addition, not all professionals and patients had adopted the instructions regarding the use of the system, resulting in less realization of its potential. CONCLUSIONS: The use of the system led to the patients taking on a more active role in their BP treatment, becoming more of an expert of their BP. When using the system as intended, the professionals experienced it as a useful resource for communication regarding BP and lifestyle. Patients and professionals described a consultation on more equal grounds. The use of technology in hypertension management can promote a constructive and person-centered partnership between patient and professional. However, implementation of a new way of working should bring benefits and not be considered a burden for the professionals. To establish a successful partnership, both the patient and the professional need to be motivated toward a new way of working. TRIAL REGISTRATION: ClinicalTrials.gov NCT03554382; https://clinicaltrials.gov/ct2/show/NCT03554382.

Biosafety considerations and risk reduction strategy for a new veterinary faculty building and teaching hospital in Sweden.

INTRODUCTION: This paper describes a hazard- and risk-based strategy and recommendations on relevant biosafety levels in facility design of a new veterinary faculty building including a veterinary medical teaching hospital. Both animal and human health were considered. MATERIALS AND METHODS: Agents listed in the regulatory frameworks on animal and human health were identified as the main potential hazards. Suggestions on biosafety level and facility design were based on the official risk grouping of those agents, the associated risk management procedures, and biosafety experiences from previous faculty buildings. RESULTS AND DISCUSSION: It was suggested that VHC should not be designed for work with agents requiring facilities at biosafety levels 3 and 4, and that actions in cases of accidental exposure to notifiable infections should follow the regulatory requirements. Facilities requiring biosafety level 2 were identified from risk scenarios and transmission routes.Experiences from the first five years of operation revealed good prevention of spread of infection from patients in isolation facilities and successful elimination of Salmonella and MRSA from the large animal clinic. CONCLUSION: In order to avoid costly construction mistakes, an overall biosafety strategy should be formulated and used as guidance for architects and other relevant stakeholders designing facilities for the animal health sector. Regulatory requirements on infectious diseases must be complied with.

PERson-centredness in hypertension management using information technology (PERHIT): a protocol for a randomised controlled trial in primary health care.

Purpose: For primary health care (PHC), hypertension is the number one diagnosis for planned health care visits. The treatment of high blood pressure (BP) and its consequences constitutes a substantial economic burden. In spite of efficient antihypertensive medications, a low percentage of patients reach a well-controlled BP. The PERson-centredness in Hypertension management using Information Technology (PERHIT) Study is a multicentre randomised controlled trial. PERHIT is designed to evaluate the effect of supporting self-management on systolic blood pressure by the use of information technology in Swedish primary health care.Materials and Methods: After inclusion, 900 patients from 36 PHC centres are randomised to two groups. In the intervention group, patients are provided with a self-management support system including a home-BP monitor and further requested to perform self-reports and measure BP every evening for eight consecutive weeks. In the control group, patients receive treatment as usual.Results: The primary outcome will be the change in systolic blood pressure in patients with hypertension. In addition, person-centredness, daily life activities, awareness of risk and health care costs will also be evaluated.Conclusion: The results of this randomised controlled trial with assessment of blood pressure and same-day self-reports will provide patients a tool to understand the interplay between blood pressure and lifestyle applicable to primary health care. The self-management support system may be of importance for improved adherence to treatment and persistence to treatment recommendations.

Links between blood pressure and medication intake, well-being, stress, physical activity and symptoms reported via a mobile phone-based self-management support system: a cohort study in primary care.

OBJECTIVES: To explore relationships between patients' self-monitoring of blood pressure (BP) and their concurrent self-reports of medication intake, well-being, stress, physical activity and symptoms. DESIGN: This study is a secondary analysis of a prospective study exploring the 8-week effectiveness of a mobile phone-based self-management support system for patients with hypertension. SETTING: Four primary healthcare centres situated in urban and suburban communities in Sweden. PARTICIPANTS: 50 patients undergoing treatment for hypertension. PRIMARY AND SECONDARY OUTCOME MEASURES: Associations between systolic (SBP) and diastolic blood pressure (DBP) and 10 self-report lifestyle-related variables were analysed using linear mixed effects modelling. RESULTS: Medication intake, better well-being, less stress and greater physical activity were associated variously with lower same-day SBP and DBP. The single strongest association was found between medication intake and SBP, where failure to take medications was associated with an estimated 7.44 mm Hg higher SBP. To a lesser degree, medication intake was also associated with DBP, where DBP was 4.70 mm Hg higher in cases where medications were not taken. Well-being and stress were consistently associated with SBP and DBP, whereas physical activity was associated with only SBP. None of the symptoms-dizziness, headache, restlessness, fatigue or palpitations-were significantly associated with BP. CONCLUSIONS: Our findings that BP was associated with patients' BP management behaviours and experiences of well-being and stress, but not symptoms suggest that enabling persons with hypertension to monitor and track their BP in relation to medication intake, physical activity, well-being, stress and symptoms may be a fruitful way to help them gain first-hand understanding of the importance of adherence and persistence to treatment recommendations. TRIAL REGISTRATION NUMBER: NCT01510301; Pre-results.

Experiences, expectations and challenges of an interactive mobile phone-based system to support self-management of hypertension: patients' and professionals' perspectives.

BACKGROUND: A well-controlled blood pressure (BP) reduces cardiovascular complications. Patient participation in care using technology may improve the current situation of only 13.8% of adults diagnosed with hypertension worldwide having their BP under control. OBJECTIVE: The objective of this study was to explore patients' and professionals' experiences of and expectations for an interactive mobile phone-based system to support self-management of hypertension. METHODS: The self-management system consists of: 1) a mobile phone platform for self-reports, motivational messages and reminders; 2) a device for measuring BP and 3) graphical feedback of self-reports. Patients diagnosed with high BP (n=20) and their treating professionals (n=7) participated in semi-structured interviews, after 8 weeks use of the system in clinical practice. Data were analyzed thematically. RESULTS: The self-reporting of BP, symptoms, medication use, medication side effects, lifestyle and well-being was perceived to offer insight into how daily life activities influenced BP and helped motivate a healthy lifestyle. Taking increased responsibility as a patient, by understanding factors affecting one's well-being, was reported as an enabling factor for a more effective care. Based on the experiences, some challenges were mentioned: for adoption of the system into clinical practice, professionals' educational role should be extended and there should be a reorganization of care to fully benefit from technology. The patients and professionals gave examples of further improvements to the system, for example, related to the visualization of graphs from self-reports and an integration of the system into the general technical infrastructure. These challenges are important on the path to accomplishing adoption. CONCLUSION: The potential of a more autonomous, knowledgeable and active patient, through use of the interactive mobile system would improve outcomes of hypertension treatment, which has been desired for decades. Documentation and visualization of patients' self-reports and the possibilities to communicate these with professionals may be a significant resource for person-centered care.

Screening of intact yeasts and cell extracts to reduce Scrapie prions during biotransformation of food waste.

Yeasts can be used to convert organic food wastes to protein-rich animal feed in order to recapture nutrients. However, the reuse of animal-derived waste poses a risk for the transmission of infectious prions that can cause neurodegeneration and fatality in humans and animals. The aim of this study was to investigate the ability of yeasts to reduce prion activity during the biotransformation of waste substrates-thereby becoming a biosafety hurdle in such a circular food system. During pre-screening, 30 yeast isolates were spiked with Classical Scrapie prions and incubated for 72 h in casein substrate, as a waste substitute. Based on reduced Scrapie seeding activity, waste biotransformation and protease activities, intact cells and cell extracts of 10 yeasts were further tested. Prion analysis showed that five yeast species reduced Scrapie seeding activity by approximately 1 log10 or 90%. Cryptococcus laurentii showed the most potential to reduce prion activity since both intact and extracted cells reduced Scrapie by 1 log10 and achieved the highest protease activity. These results show that select forms of yeast can act as a prion hurdle during the biotransformation of waste. However, the limited ability of yeasts to reduce prion activity warrants caution as a sole barrier to transmission as higher log reductions are needed before using waste-cultured yeast in circular food systems.

Patient contributions during primary care consultations for hypertension after self-reporting via a mobile phone self-management support system.

OBJECTIVE: This paper reports on how the clinical consultation in primary care is performed under the new premises of patients' daily self-reporting and self-generation of data. The aim was to explore and describe the structure, topic initiation and patients' contributions in follow-up consultations after eight weeks of self-reporting through a mobile phone-based hypertension self-management support system. DESIGN: A qualitative, explorative study design was used, examining 20 audio- (n = 10) and video-recorded (n = 10) follow-up consultations in primary care hypertension management, through interaction analysis. Clinical trials registry: ClinicalTrials.gov NCT01510301. SETTING: Four primary health care centers in Sweden. SUBJECTS: Patients with hypertension (n = 20) and their health care professional (n = 7). RESULTS: The consultations comprised three phases: opening, examination and closing. The most common topic was blood pressure (BP) put in relation to self-reported variables, for example, physical activity and stress. Topic initiation was distributed symmetrically between parties and BP talk was lifestyle-centered. The patients' contributed to the interpretation of BP values by connecting them to specific occasions, providing insights to the link between BP measurements and everyday life activities. CONCLUSION: Patients' contribution through interpretations of BP values to specific situations in their own lives brought on consultations where the patient as a person in context became salient. Further, the patients' and health care professionals' equal contribution during the consultations showed actively involved patients. The mobile phone-based self-management support system can thus be used to support patient involvement in consultations with a person-centered approach in primary care hypertension management Key points The clinical consultation is important to provide opportunities for patients to gain understanding of factors affecting high blood pressure, and for health care professionals to motivate and promote changes in life-style. This study shows that self-reporting as base for follow-up consultations in primary care hypertension management can support patients and professionals to equal participation in clinical consultations. Self-reporting combined with increased patient-health care professional interaction during follow-up consultations can support patients in understanding the blood pressure value in relation to their daily life. These findings implicate that the interactive mobile phone self-management support system has potential to support current transformations of patients as recipients of primary care, to being actively involved in their own health.

Improved Blood Pressure Control Using an Interactive Mobile Phone Support System.

This explorative, longitudinal study evaluated the effect of the daily use of a mobile phone-based self-management support system for hypertension in reducing blood pressure (BP) among 50 primary care patients with hypertension over 8 weeks. The self-management system comprises modules for (1) self-reports of BP, pulse, lifestyle, symptoms, and well-being; (2) delivery of reminders and encouragements; and (3) graphical feedback of self-reports. Daily use of the support system significantly reduced BP (systolic BP -7 mm Hg, diastolic BP -4.9 mm Hg) between baseline and week 8, with daily improvements leveling off as the study progressed. Three homogenous subsets of patients were identified who, despite different initial BP levels, showed similar decreases in BP during the study, indicating that patients benefited irrespective of baseline BP. In showing significant reductions in BP, our results suggest that the self-management support system may be a useful tool in clinical practice to help patients self-manage their hypertension.

Phases in development of an interactive mobile phone-based system to support self-management of hypertension.

Hypertension is a significant risk factor for heart disease and stroke worldwide. Effective treatment regimens exist; however, treatment adherence rates are poor (30%-50%). Improving self-management may be a way to increase adherence to treatment. The purpose of this paper is to describe the phases in the development and preliminary evaluation of an interactive mobile phone-based system aimed at supporting patients in self-managing their hypertension. A person-centered and participatory framework emphasizing patient involvement was used. An interdisciplinary group of researchers, patients with hypertension, and health care professionals who were specialized in hypertension care designed and developed a set of questions and motivational messages for use in an interactive mobile phone-based system. Guided by the US Food and Drug Administration framework for the development of patient-reported outcome measures, the development and evaluation process comprised three major development phases (1, defining; 2, adjusting; 3, confirming the conceptual framework and delivery system) and two evaluation and refinement phases (4, collecting, analyzing, interpreting data; 5, evaluating the self-management system in clinical practice). Evaluation of new mobile health systems in a structured manner is important to understand how various factors affect the development process from both a technical and human perspective. Forthcoming analyses will evaluate the effectiveness and utility of the mobile phone-based system in supporting the self-management of hypertension.

Developing an interactive mobile phone self-report system for self-management of hypertension. Part 2: content validity and usability.

Self-management support tools using technology may improve adherence to hypertension treatment. There is a need for user-friendly tools facilitating patients' understanding of the interconnections between blood pressure, wellbeing and lifestyle. This study aimed to examine comprehension, comprehensiveness and relevance of items, and further to evaluate the usability and reliability of an interactive hypertension-specific mobile phone self-report system. Areas important in supporting self-management and candidate items were derived from five focus group interviews with patients and healthcare professionals (n = 27), supplemented by a literature review. Items and response formats were drafted to meet specifications for mobile phone administration and were integrated into a mobile phone data-capture system. Content validity and usability were assessed iteratively in four rounds of cognitive interviews with patients (n = 21) and healthcare professionals (n = 4). Reliability was examined using a test-retest. Focus group analyses yielded six areas covered by 16 items. The cognitive interviews showed satisfactory item comprehension, relevance and coverage; however, one item was added. The mobile phone self-report system was reliable and perceived easy to use. The mobile phone self-report system appears efficiently to capture information relevant in patients' self-management of hypertension. Future studies need to evaluate the effectiveness of this tool in improving self-management of hypertension in clinical practice.

Developing an interactive mobile phone self-report system for self-management of hypertension. Part 1: patient and professional perspectives.

Low adherence remains a struggle in hypertension management, despite improvement efforts. Presuming that increased patient participation is a possible approach, we collaborated with patients and healthcare professionals to design a self-report system to support self-management. The study aimed to explore and describe relevant aspects of hypertension and hypertension treatment, for use in the development of an interactive mobile phone self-report system. It further aimed to suggest which clinical measures, lifestyle measures, symptoms and side-effects of treatment would be meaningful to include in such a system. Five focus group interviews were performed with 15 patients and 12 healthcare professionals, and data was analysed using thematic analysis. Patients suggested trust, a good relationship with caregivers, and well-being as important aspects of hypertension self-management. Furthermore, they regarded blood pressure, dizziness, stress, headache and tiredness as important outcomes to include. Patients sought to understand interconnections between symptoms and variations in blood pressure, whilst healthcare professionals doubted patients' ability to do so. Healthcare professionals emphasized accessibility, clear and consistent counselling, complication prevention and educational efforts. The study presents aspects of importance for follow-up to understand the interplay between blood pressure and daily life experiences for patients with hypertension.

Harmonization of European laboratory response networks by implementing CWA 15793: use of a gap analysis and an "insider" exercise as tools.

Laboratory response networks (LRNs) have been established for security reasons in several countries including the Netherlands, France, and Sweden. LRNs function in these countries as a preparedness measure for a coordinated diagnostic response capability in case of a bioterrorism incident or other biocrimes. Generally, these LRNs are organized on a national level. The EU project AniBioThreat has identified the need for an integrated European LRN to strengthen preparedness against animal bioterrorism. One task of the AniBioThreat project is to suggest a plan to implement laboratory biorisk management CWA 15793:2011 (CWA 15793), a management system built on the principle of continual improvement through the Plan-Do-Check-Act (PDCA) cycle. The implementation of CWA 15793 can facilitate trust and credibility in a future European LRN and is an assurance that the work done at the laboratories is performed in a structured way with continuous improvements. As a first step, a gap analysis was performed to establish the current compliance status of biosafety and laboratory biosecurity management with CWA 15793 in 5 AniBioThreat partner institutes in France (ANSES), the Netherlands (CVI and RIVM), and Sweden (SMI and SVA). All 5 partners are national and/or international laboratory reference institutes in the field of public or animal health and possess high-containment laboratories and animal facilities. The gap analysis showed that the participating institutes already have robust biorisk management programs in place, but several gaps were identified that need to be addressed. Despite differences between the participating institutes in their compliance status, these variations are not significant. Biorisk management exercises also have been identified as a useful tool to control compliance status and thereby implementation of CWA 15793. An exercise concerning an insider threat and loss of a biological agent was performed at SVA in the AniBioThreat project to evaluate implementation of the contingency plans and as an activity in the implementation process of CWA 15793. The outcome of the exercise was perceived as very useful, and improvements to enhance biorisk preparedness were identified. Gap analyses and exercises are important, useful activities to facilitate implementation of CWA 15793. The PDCA cycle will enforce a structured way to work, with continual improvements concerning biorisk management activities. Based on the activities in the AniBioThreat project, the following requirements are suggested to promote implementation: support from the top management of the organizations, knowledge about CWA 15793, a compliance audit checklist and gap analysis, training and exercises, networking in LRNs and other networks, and interinstitutional audits. Implementation of CWA 15793 at each institute would strengthen the European animal bioterrorism response capabilities by establishing a well-prepared LRN.