Swedish Regions Research Articles

Envisioning sustainable rural development: A narrative on accessibility and infrastructure from a Swedish region

Infrastructure developments depend on decision makers' perceptions of the particular policy issue and a preferred future state. The complex relationship between accessibility and rural development and the long periods from problem recognition to transport infrastructure realisations bring further uncertainty into regional planning. Therefore, government and public administration tend to rely on narratives to explain the policy issue and to transfer their perspectives into the policy process. However, oversimplified narratives unduly limit the understanding of the problem and so the choice of solutions. This paper aims therefore to contribute to an understanding of the recognition of accessibility and transport infrastructure as a policy problem for sustainable regional development in rural areas. It investigates the narrative that emerges from local officials' perceptions about a future society, reasons for sustainable growth and the collaboration at the local and regional levels in central Sweden. The analysis details the four key perspectives of the narrative: local people, work and leisure, an urban neighbourhood and public transport services. The findings stress the narrative's lack of oversight and inclusion that accounts for societies' heterogeneity. In particular, the analysis expounds a remarkable faceless story that conveys a prevalent lack of understanding of stakeholder needs and the role of critical infrastructure for societal development in rural areas.

Collaboration in the return-to-work process after sick leave due to common mental disorders: a qualitative study of stakeholders’ views on goals and roles

BackgroundThis study explores how the goals of collaboration in the return-to-work (RTW) process for people with common mental disorders are described by the stakeholders involved, and how they experience stakeholders’ roles and responsibilities in relation to these goals.MethodsInterviews were conducted with 41 participants from three Swedish regions. Nine of the participants were workers, six employer representatives, four occupational health professionals, four social insurance officers, 18 RTW coordinators and five physicians. Thematic analysis was conducted.ResultsThree main themes and overarching goals when collaborating on RTW were identified. In the first theme, ‘creating an informative environment’, all stakeholders emphasised clear roles and responsibilities. The second theme, ‘striving for consensus in an environment of negotiations’, addressed negotiations about when and how to collaborate, on what and with whom, and reveal different views on stakeholders’ goals, roles and responsibilities in collaboration. The third theme identified goals for ‘creating a supportive environment’ for both workers and other stakeholders. Coordinators are found to have an important role in achieving a supportive environment, and in neutralising power imbalances between workers and their employers and social insurance officers.ConclusionsCompeting goals and priorities were identified as hindering successful collaboration, contributing to a spectrum of complex versus easy RTW collaboration. This study suggests some basic conditions for achieving a collaborative arena that is neutral in terms of power balance, where all stakeholders can share their views.

Capability to identify and manage critical conditions: effects of an interprofessional training intervention

BackgroundThe burden of critical illness is a global issue. Healthcare systems often fail to provide essential emergency and critical care for deteriorating patients, and the optimal strategy for ensuring safe care is not fully known. This study aimed to explore the capability to identify and manage critical conditions and to evaluate how an interprofessional training intervention that included theory as well as high-fidelity simulation (proACT) in the short and long term affected the capability.MethodsA questionnaire study was performed. A cross-sectional survey of all in-hospital nurses and physicians in a Swedish region (n538) and a longitudinal cohort of participants entering the proACT course during a six-month period (n99) were included. Descriptive and comparative statistics were generated. Additionally, qualitative content analysis was performed for free text answers.ResultsThe findings demonstrated that the intervention improved the individual healthcare professionals’ competence with a sustained effect over time. The coverage of proACT trained staff increased from 13.2% to 26.5%, but no correlation was observed with workplace conditions that support safe care. Collaboration and workplace climate were perceived to be mainly positive, but for safer care, an overall need for improved competence and staffing was emphasized.ConclusionsThe present study confirms previously identified issues and the need for improvements in the care of critically ill patients in general hospital wards. It supports the notion that a training intervention, such as proACT, can increase the capability to identify and manage patients with critical conditions. All healthcare professions increased the competence. Hence, more effort is needed to enable staff of all professions to participate in such training. Studies of interventions cover higher number of trained staff in the setting are warranted to clarify whether the training can also improve workplace conditions that support safe care of deteriorating and critically ill patients.

Heart rate from intermittent home measurements within an atrial fibrillation screening program is associated with mortality

Abstract Introduction A high resting heart rate is a predictor of cardiovascular disease and cardiovascular mortality. Studies on the association between heart rate and outcomes often measure heart rate at a single time point, even though multiple measurements may be a stronger predictor of cardiovascular risk. Indeed, the association between short-term home heart rate measurements and outcomes has not been extensively studied. Purpose This sub study of the STROKESTOP trial explores the association of baseline and home resting heart rate measurements with all-cause and cardiovascular mortality. Methods The STROKESTOP randomised controlled trial consisted of an atrial fibrillation (AF) screening program among the 75- and 76-year-old inhabitants of two Swedish regions. Participants in the intervention group were invited to a two week intermittent screening program, consisting of twice daily measurements with an ECG-based handheld device. For this sub analysis, baseline heart rate, the median of 5 home morning heart rates and the median of 5 home evening heart rates were evaluated. Associations were evaluated by heart rate quintiles (41-63 bpm, 64-70 bpm, 71-76 bpm, 77-84 bpm and ≥85 bpm), with 64-70 bpm as the reference category. Hazard rations were obtained by Cox regression analysis. The full multivariable model included demograhic factors such as sex and educational level, medical history of several diseases and the use of cardiovascular medication. Both all-cause mortality and cardiovascular mortality were evaluated. Results In total, 5873 individuals were included in this analysis. Overall, 55.6% were women and the median baseline heart rate was 73 [65-81] bpm, whereas the median of morning heart rates was 71 [64-78] bpm and that of evening heart rates 71 [65-79] bpm. Having a baseline heart rate in the highest quintile compared to the reference quintile, showed a hazard ratio (HR) for all-cause mortality in unadjusted analysis of 1.39 (1.11-1.73) (p=0.004), and of 1.51 (1.20-1.90) in the fully adjusted analysis (p<.001). For cardiovascular mortality, HRs were 1.78 (1.21-2.63) (p=0.004) and 2.13 (1.42-3.20) (p=<.001), respectively. The association between the highest heart rate and all-cause mortality and cardiovascular mortality were substantially strengthened when median morning heart rates were considered (HR 2.03 (1.61-2.56) and 2.18 (1.72-2.76), p<.001 for all-cause mortality on univariable and multivariable analysis, HR 2.35 (1.57-3.51) and 2.59 (1.72-3.92), p<.001) for cardiovascular mortality). Associations between home evening heart rates and all-cause and cardiovascular mortality were not substantially stronger compared to the associations with baseline heart rate. Conclusion Our study shows that home-measured morning heart rate is more strongly associated with all-cause and cardiovascular mortality compared to a single time-point office heart rate.Hazard ratios for mortality

National Centralization of Hirschsprung's Disease in Sweden:A Comparison of Preoperative Management and Outcomes

BackgroundSurgical treatment of Hirschsprung's disease (HSCR) in Sweden was centralized to two tertiary pediatric surgery centers 1st of July 2018. Although complex surgical care in adults seems to benefit from centralization there is little evidence to support centralization of pediatric surgical care. The aim of this study was to assess centralization of HSCR in Sweden, with special consideration to preoperative management and outcomes in this group of patients. MethodsThis study retrospectively analyzed data of patients with HSCR that had undergone or were planned to undergo pull-through at our center, from 1st of July 2013 to 30th of June 2023. Patients managed from 1st of July 2013 to 30th of June 2018 were compared with patients managed from 1st of July 2018 to 30th of June 2023 regarding diagnostic procedures, preoperative treatment, complications and time to definitive surgery. ResultsThirty-six patients were managed during the first five-year period compared to 57 during the second period. There was an increased number of patients referred from other Swedish regions to our center following the centralization. Time from diagnosis to pull-through increased from 33 to 55 days after centralization. There were no significant differences in pre-operative management or complications, general or related to stoma. ConclusionsDespite increasing patient volumes and longer time from diagnosis to pull through, centralization of care for HSCR does not seem to change the preoperative management and risk of complications. With access to support from the specialist center, transanal irrigations remain a safe mode of at home management until surgery, regardless of distance to index hospital. Level of EvidenceLevel III.

Clear effects on root system architecture of winter wheat cultivars (Triticum aestivum L.) from cultivation environment and practices

Roots play a pivotal role in the adaption of a plant to its environment, with different root traits adapting the plant to different stresses. The environment affects the Root System Architecture (RSA), but the genetic factors determine to what extent, and whether stress brought about by extreme environmental conditions is detrimental to a specific crop. This study aimed to identify differences in winter wheat RSA caused by cultivation region and practice, in the form of preceding crop (precrop), and to identify if modern cultivars used in Sweden differ in their reaction to these environments. This was undertaken using high-throughput phenotyping to assess the RSA. Clear differences in the RSA were observed between the Swedish cultivation regions, precrop treatments, and interaction of these conditions with each other and the genetics. Julius showed a large difference between cultivars, with 9.3–17.1% fewer and 12–20% narrower seminal roots. Standardized yield decreased when grown after wheat, 23% less compared to oilseed rape (OSR), and when grown in the Southern region, 14% less than the Central region. Additionally, correlations were shown between the root number, angle, and grain yield, with different root types being correlated depending on the precrop. Cultivars on the Swedish market show differences that can be adapted to the region-precrop combinations. The differences in precrop effect on RSA between regions show global implications and a need for further assessment. Correlations between RSA and yield, based on root-type × precrop, indicate different needs of the RSA depending on the management practices and show the potential for improving crop yield through targeting genotypic and environmental conditions in a holistic manner. Understanding this RSA variance, and the mechanisms of conditional response, will allow targeted cultivar breeding for specific environments, increasing plant health and food security.

Brief admission by self-referral for individuals with self-harm and suicidal ideation: a qualitative study based on focus groups exploring relatives’ experiences

ABSTRACT Purpose Brief Admission by self-referral (BA) is a standardized crisis-management intervention for individuals with self-harm and risk for suicide. This study explored relatives’ experiences of BA. Relatives’ perspectives may contribute to an increased understanding of the effects of BA given the relatives’ role as support and informal caregivers as well as being co-sufferers. Methods Fourteen relatives to adults with access to BA within one Swedish region participated in focus groups analysed with reflexive thematic analysis. Results We generated themes evolving around three meaning-based concepts: access (A low threshold to a safe back-up is crucial and obstacles may easily break faith), independence (Trust in their ability with care and respect), and recovery (The rest and relational recovery we all get are needed and invaluable). Conclusions BA brings considerable value to users and relatives, by supporting them to take care of themselves and each other. Communication and involvement of relatives may enhance users’ ability to overcome obstacles to accessing BA. Implementation and adherence may be strengthened by supervision of BA staff and education of emergency care staff. Resources are needed to improve access. Mapping hurdles to BA, support through peers and targeted psychoeducation may improve recovery for BA users and their relatives.

Digital dermatitis in Swedish dairy herds assessed by ELISA targeting Treponema phagedenis in bulk tank milk

BackgroundDigital dermatitis (DD) is a contagious hoof infection affecting cattle worldwide. The disease causes lameness and a reduction in animal welfare, which ultimately leads to major decreases in milk production in dairy cattle. The disease is most likely of polymicrobial origin with Treponema phagedenis and other Treponema spp. playing a key role; however, the etiology is not fully understood. Diagnosis of the disease is based on visual assessment of the feet by trained hoof-trimmers and veterinarians, as a more reliable diagnostic method is lacking. The aim of this study was to evaluate the use of an enzyme-linked immunosorbent assay (ELISA) on bulk tank milk samples testing for the presence of T. phagedenis antibodies as a proxy to assess herd prevalence of DD in Swedish dairy cattle herds.ResultsBulk tank milk samples were collected in 2013 from 612 dairy herds spread across Sweden. A nationwide DD apparent prevalence of 11.9% (8.1–14.4% CI95%) was found, with the highest proportion of test-positive herds in the South Swedish regions (31.3%; 19.9–42.4% CI95%).ConclusionsThis study reveals an underestimation of DD prevalence based on test results compared to hoof trimming data, highlighting the critical need for a reliable and accurate diagnostic method. Such a method is essential for disease monitoring and the development of effective control strategies. The novelty of ELISA-based diagnostic methods for DD, coupled with the disease’s polymicrobial origin, suggests an avenue for improvement. Developing an expanded ELISA, incorporating antigens from various bacterial species implicated in the disease, could enhance diagnostic accuracy. The significance of this study is underscored by the extensive analysis of a substantial sample size (612). Notably, this investigation stands as the largest assessment to date, evaluating the application of ELISA on bulk tank milk for DD diagnosis at the herd level.

Swedish crisis preparedness planners' understanding and sense‐making of preparedness work in a public organisation: Implications for future development

AbstractThe sometimes rapid development of (new) threats and extraordinary events calls for a robust, flexible, and well‐equipped civil crisis preparedness system to respond and limit the damage of crisis events. To achieve this, Swedish municipalities and regions are required by law to regularly perform and report risk and vulnerability analysis ‘bottom up’ to governmental agencies. When performed in large and complex public organisations, crisis preparedness planning activities require negotiation, coordination, and cooperation among large numbers of people. Crisis preparedness planners facilitate and produce this proactive crisis preparedness work. However, research has revealed that preparedness planners face organisational and practical challenges when performing their work.This study aims at increasing the knowledge of crisis preparedness planners' understandings and sense‐making of their work in one Swedish region when fulfilling the requirements set by the Swedish national regulations. The objectives of this paper are to present findings on (1) how the preparedness planners understand and make sense of their crisis preparedness work; (2) which major enablers and barriers that affect their work; and, based on the results, (3) forward possibilities for improvement.Semi‐structured interviews were conducted with the 10 crisis preparedness planners. A narrative stepwise analysis approach was applied. The analysis results revealed challenges in the crisis preparedness work due to uncommitted managers, unclear goalsetting, and the planners' sometimes limited skills in crisis preparedness work. It also report on managers' autonomy and varying focus on crisis preparedness, planners' unclear individual work space, and many different and sometimes strong voices about the work performance and content. This raises the question whose interest that in practice sets the agenda for crisis preparedness planning in the organisation.The study demonstrates needs for increased organisational sense‐making on the concept of crisis preparedness and how it should be performed, and for conceptual and technical skills to perform the preparedness work. To increase sense‐making and strengthen generic subjectivity on crisis preparedness work, further discussions are needed about enablers and barriers in preparedness work and an increased joint focus on possible internal and external threats. There are also needs for increased manager‐coworker‐planner cooperation when developing the preparedness work, and strategic changes in the organisational development involving goalsetting for crisis preparedness ‘top‐down’ as well as ‘bottom‐up’.

“Navigating in a maze without a map“. Partners’ experiences of hyperemesis gravidarum- a qualitative study

ObjectiveA supportive environment for women with Hyperemesis Gravidarum is crucial but not always provided. There is a lack of research regarding Hyperemesis Gravidarum, its impact on the family, and the partner's perception of supporting their spouse. Thus, this study aims to explore partners’ experiences of Hyperemesis Gravidarum during their spousés pregnancy. MethodsData were gathered through 13 individual, semi-structured, in-depth, digital interviews with partners of women who had experienced Hyperemesis Gravidarum and analysed with Qualitative Content Analysis. The partners were recruited through advertisement on a social media platform and were exclusively males, representing 8 of 21 Swedish regions. The mean age was 34, and they had, on average, 1 previous child. The mean time from the experience to the interview was 12 months. FindingsThe main theme, “Navigating in a maze without a map”, explains partners’ situation as stressful and demanding when their spouse suffers from Hyperemesis Gravidarum, with insufficient support and guidance from healthcare providers. The analysis resulted in three themes: “Standing alone with a demanding responsibility”, “Being in a lottery when facing healthcare”, and “Climbing the mountain together.” The themes display challenges within everyday life and healthcare, as well as strained relations within the family. ConclusionPartners experience a need to support their spouse in every aspect of daily life and advocate for adequate healthcare. Healthcare professionals must support and acknowledge the partners' struggles during the demanding situation with Hyperemesis Gravidarum.

Disclosing the logics of non-statutory regional planning: the case of Sweden

ABSTRACT In many European countries, regional planning is an established institutional framework. In recent years we have observed a resurgent research interest in regional planning with a specific focus on governance and institutional design and on the strategic and practical relevance of regional planning in pursuing sustainable development. However, in Sweden, regional planning traditionally has a weak position in practice as well as in research. Yet over the past 15 years, we have seen an increasing political interest in experimenting with different forms and formats of regional planning. In this paper, we explore the emerging logics of non-statutory regional planning, which the majority of Swedish regions have chosen. Drawing upon a qualitative research design we identify, compare and discuss three different logics and their inherent rationales, practices, challenges and prospects. Our analysis shows that our three case regions can do very little non-statutory regional planning unless they are part of properly working multi-level networks, and have well-established regional informal arenas for interaction and political backing. More specifically, we point at a number of tensions caused by the large degree of freedom to design non-statutory regional planning, which foster conflicts, confusion and insecurity.

Serious adverse drug events associated with psychotropic treatment of bipolar or schizoaffective disorder: a 17-year follow-up on the LiSIE retrospective cohort study.

Mood stabilisers and other psychotropic drugs can lead to serious adverse drug events (ADEs). However, the incidence remains unknown. We aimed to (a) determine the incidence of serious ADEs in patients with bipolar or schizoaffective disorders, (b) explore the role of lithium exposure, and (c) describe the aetiology. This study is part of the LiSIE (Lithium-Study into Effects and Side Effects) retrospective cohort study. Between 2001 and 2017, patients in the Swedish region of Norrbotten, with a diagnosis of bipolar or schizoaffective disorder, were screened for serious ADEs to psychotropic drugs, having resulted in critical, post-anaesthesia, or intensive care. We determined the incidence rate of serious ADEs/1,000 person-years (PY). In 1,521 patients, we identified 41 serious ADEs, yielding an incidence rate of 1.9 events per 1,000 PY. The incidence rate ratio (IRR) between ADEs with lithium present and causally implicated and ADEs without lithium exposure was significant at 2.59 (95% CI 1.20-5.51; p = 0.0094). The IRR of ADEs in patients <65 and ≥65 years was significant at 3.36 (95% CI 1.63-6.63; p = 0.0007). The most common ADEs were chronic lithium intoxication, oversedation, and cardiac/blood pressure-related events. Serious ADEs related to treatment of bipolar (BD) or schizoaffective disorder (SZD) were uncommon but not rare. Older individuals were particularly at risk. The risk was higher in individuals exposed to lithium. Serum lithium concentration should always be checked when patients present with new or unclear somatic symptoms. However, severe ADEs also occurred with other mood stabilisers and other psychotropic drugs.

Adaptive, Persistent, and Available Support: The Crucial Way in Healthcare during Covid-19

The aim of this study was to gain knowledge about the work of crisis managers in healthcare during the COVID-19 pandemic. A qualitative and exploratory approach was used with crisis managers who had worked at five different emergency hospitals in one of the Swedish metropolitan regions. An inductive thematic analysis was performed. Major emphasis was placed on the importance of work processes aiming for a high level of accessibility, including having a tangible physical presence in the workplace, plus actively reaching out to the staff. The crisis support provided was adapted to provide a stabilizing factor, promote stamina, and increase motivation. It also included a continuous assessment of mental health status and focused on strengthening management functions. Initially, the support was more focused on stress and anxiety, but then gradually shifted towards maintaining stamina and motivation

Improving cardiovascular control in a hypertensive population in primary care. Results from a staff training intervention

Objective A pilot study to evaluate a staff training intervention implementing a nurse-led hypertension care model. Design and setting Clinical and laboratory data from all primary care centres (PCCs) in the Swedish region Västra Götaland (VGR), retrieved from regional registers. Intervention started 2018 in 11 PCCs. A total of 190 PCCs served as controls. Change from baseline was assessed 2 years after start of intervention. Intervention Training of selected personnel, primarily in drug choice, team-based care, measurement techniques, and use of standardized medical treatment protocols. Patients Hypertensive patients without diabetes or ischemic heart disease were included. The intervention and control groups contained approximately 10,000 and 145,000 individuals, respectively. Main outcome measures Blood pressure (BP) <140/90 mmHg, LDL-cholesterol (LDL-C) <3.0 mmol/L, BP ending on −0 mmHg (digit preference, an indirect sign of manual measuring technique), choice of antihypertensive drugs, cholesterol lowering therapy and attendance patterns were measured. Results In the intervention group, the percentage of patients reaching the BP target did not change significantly, 56%–61% (control 50%–52%), non-significant. However, the percentage of patients with LDL-C < 3.0 mmol/L increased from 34%–40% (control 36%–36%), p = .043, and digit preference decreased, 39%−27% (control 41%−35%), p = 0.000. The number of antihypertensive drugs was constant, 1.63 − 1.64 (control 1.62 − 1.62), non-significant, but drug choice changed in line with recommendations. Conclusion Although this primary care intervention based on staff training failed to improve BP control, it resulted in improved cardiovascular control by improved cholesterol lowering treatment.

Outbreak of Salmonella Typhimurium linked to Swedish pre-washed rocket salad, Sweden, September to November 2022.

In September 2022, the Public Health Agency of Sweden observed an increase in domestic Salmonella Typhimurium cases through the Swedish electronic notification system, and an outbreak strain was identified with whole genome sequencing. Overall, 109 cases with symptom onset between 17 September and 24 November 2022 were reported from 20 of 21 Swedish regions. The median age of cases was 52 years (range 4-87 years) and 62% were female. A case-control study found cases to be associated with consumption of rocket salad (adjusted odds ratio (aOR) = 4.9; 95% confidence interval (CI): 2.4-10, p value < 0.001) and bagged mixed salad (aOR = 4.0; 95% CI: 1.9-8.1, p value < 0.001). Trace-back, supported by Finnish authorities who identified the Swedish outbreak strain in a Finnish cluster during the same time period, identified rocket salad, cultivated, pre-washed and pre-packed in Sweden as the likely source of the outbreak. No microbiological analyses of rocket salad were performed. Our investigation indicates that bagged leafy greens such as rocket salad, regardless of pre-washing procedures in the production chain, may contain Salmonella and cause outbreaks, posing a health risk to consumers. We emphasise the need for primary producers of leafy greens to identify possible contamination points to prevent outbreaks.

A Capture-Recapture-based Ascertainment Probability Weighting Method for Effect Estimation With Under-ascertained Outcomes.

Outcome under-ascertainment, characterized by the incomplete identification or reporting of cases, poses a substantial challenge in epidemiologic research. While capture-recapture methods can estimate unknown case numbers, their role in estimating exposure effects in observational studies is not well established. This paper presents an ascertainment probability weighting framework that integrates capture-recapture and propensity score weighting. We propose a nonparametric estimator of effects on binary outcomes that combines exposure propensity scores with data from two conditionally independent outcome measurements to simultaneously adjust for confounding and under-ascertainment. Demonstrating its practical application, we apply the method to estimate the relationship between health care work and coronavirus disease 2019 testing in a Swedish region. We find that ascertainment probability weighting greatly influences the estimated association compared to conventional inverse probability weighting, underscoring the importance of accounting for under-ascertainment in studies with limited outcome data coverage. We conclude with practical guidelines for the method's implementation, discussing its strengths, limitations, and suitable scenarios for application.

Comparative modeling of cost-optimal energy system flexibility for Swedish and Austrian regions

This study develops a reproducible method for estimating the cost-efficient flexibility potential of a local or regional energy system. Future scenarios that achieve ambitious climate targets and estimate the cost-efficient flexibility potential of demonstration sites were defined. Flexible potentials for energy system assessment are upscaled from the demonstration sites in Eskilstuna (Sweden) and Lower Austria (Austria). As heat pumps (HPs) and district heating (DH) are critical for future heat demand, these sites are representative types of DH networks in terms of size and integration with the electricity grid. In both regions a TIMES model is used for energy system optimization, while for upscaling, Eskilstuna uses the building-stock model ECCABS, whereas Lower Austria uses a mixed integer linear programming optimization model, and the BALMOREL power system model. According to the modeling, HPs will dominate Eskilstuna’s heating sector by 2040. In Lower Austria, DH becomes more prevalent, in combination with wood biomass and HPs. These findings are explained by the postulated technological-economic parameters, energy prices, and CO2 prices. We conclude that future electricity prices will determine future heating systems: either a high share of centralized HPs (if electricity prices are low) or a high share of combined heat-and-power (if electricity prices are high). Large-scale energy storage and biomass can be essential solutions as may deliver increased cost-effectiveness, if available and under certain conditions.

We could help them in many ways. Health coaches’ experiences from targeted health dialogues with 70-year-olds: a qualitative study

BackgroundTargeted health dialogues (THDs) have been implemented in primary care in many Swedish regions in an attempt to prevent cardiovascular disease and type 2 diabetes. A THD is a counselling meeting with a specially educated health dialogue coach. It is preceded by blood tests (cholesterol, plasma glucose), blood pressure measuring, anthropometric measures, and a lifestyle questionnaire. Health advice is given based on an illustrative health profile. In southern Sweden, all 40- and 50-year-olds are invited to a THD. Recently, a pilot project with similar THDs for 70-year-olds was performed at 14 healthcare centers. The aim of the present study was to examine the health dialogue coaches’ experiences of THDs in 70-year-olds.MethodsSixteen of 22 coaches consented to participate in the study. Twelve of 14 healthcare centers were represented. Data were collected through three focus groups, and two individual interviews, which were audio-recorded and transcribed verbatim, thereafter analyzed inspired by systematic text condensation. The researchers conducted the analyses separately, whereafter differences were discussed until consensus was reached.ResultsSupport from all co-workers at the healthcare center and time for planning and reflection were mentioned as success factors for the implementation of THDs. The lifestyle questionnaire was perceived to be a bit too extensive for 70-year-olds, especially regarding physical activity and diet. Waist-hip ratio was perceived as a problematic measure. In particular, women often had high values despite a lean body composition and low BMI. Many coaches believed that the 70-year-old participants belonged to the healthier part of the population, and they also had the impression that there was a lower participation rate among immigrants, possibly due to language difficulties. The coaches enjoyed the THDs and believed that the 70-year-olds appreciated them as well. The THDs provided an opportunity to discuss not only cardiovascular risk factors but health issues and life in general.ConclusionsThe health dialogue coaches valued THDs with 70-year-olds highly, but minor adaptations of the information given, questionnaire and health profile were suggested in what the coaches thought could increase participation and facilitate the dialogues with this age group.

Change in avoidable hospitalizations for low-income elders following quasi-market reform in primary care – Evidence from a natural experiment in Sweden

Quasi-market reforms have been increasingly implemented in tax-funded health care, but their effects in terms of equity, quality and socioeconomic differentials in quality remain sparsely studied.We create a natural experiment setup exploiting the differential timing of a set of quasi-market reforms – including patient choice, free establishment of providers and changes in provider remuneration –, implemented in primary care in the two largest Swedish regions (Stockholm and Västra Götaland) in 2008–2009. Using a database with individual level data from 2005 to 2009, we construct a difference-in-difference-in-differences model that compares pre to post reform changes in avoidable hospitalizations (AHs) for low-income elders and a matched comparison group, in the region exposed to, versus unexposed to, reform (total N ∼ 200 000).The results show that for low-income elders – a group dominated by older women – reform led to higher AH rates, i.e., worse primary health care quality, than what would have been the case in absence of reform. Specifically, low-income elders exposed to reform missed out on improvements in AHs seen simultaneously in the unexposed region. At the same time, the reform had on average no effect for comparable, non-low-income, peers. The fact that this pattern was specific for avoidable hospitalizations – judged as amenable to interventions in primary care –, but not present for total hospitalizations, supports that it was driven by reform implementation rather than other factors.The study contributes with high-quality empirical evidence to a policy relevant but sparsely researched area and highlights the necessity to consider differential effects of organizational changes across socioeconomic groups.

Early suppression policies protected pregnant women from COVID-19 in 2020: A population-based surveillance from the Nordic countries.

The Coronavirus 2019 Disease (COVID-19) pandemic reached the Nordic countries in March 2020. Public health interventions to limit viral transmission varied across different countries both in timing and in magnitude. Interventions indicated by an Oxford Stringency Index ≥50 were implemented early (March 13-17, 2020) in Denmark, Finland, Norway and Iceland, and on March 26, 2020 in Sweden. The aim of the current study was to assess the incidence of COVID-19-related admissions of pregnant women in the Nordic countries in relation to the different national public health strategies during the first year of the pandemic. This is a meta-analysis of population-based cohort studies in the five Nordic countries with national or regional surveillance in the Nordic Obstetric Surveillance System (NOSS) collaboration: national data from Denmark, Finland, Iceland and Norway, and regional data covering 31% of births in Sweden. The source population consisted of women giving birth in the included areas March 1-December 31, 2020. Pregnant women with a positive SARS-CoV-2 PCR test ≤14 days before hospital admission were included, and admissions were stratified as either COVID-19-related or non-COVID (other obstetric healthcare). Information about public health policies was retrieved retrospectively. In total, 392 382 maternities were considered. Of these, 600 women were diagnosed with SARS-CoV-2 infection and 137 (22.8%) were admitted for COVID-19 symptoms. The pooled incidence of COVID-19 admissions per 1000 maternities was 0.5 (95% confidence interval [CI] 0.2 to 1.2, I2 = 77.6, tau2 = 0.68, P = 0.0), ranging from no admissions in Iceland to 1.9 admissions in the Swedish regions. Interventions to restrict viral transmission were less stringent in Sweden than in the other Nordic countries. There was a clear variation in pregnant women's risk of COVID-19 admission across countries with similar healthcare systems but different public health interventions to limit viral transmission. The meta-analysis indicates that early suppression policies protected pregnant women from severe COVID-19 disease prior to the availability of individual protection with vaccines.