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Background: Hypertension is an important cardiovascular risk factor with potentially harmful consequences. Home blood pressure monitoring is a promising method for following the effect of hypertension treatment. The use of technology-enabled care and increased patient involvement might contribute to more effective treatment methods. However, more knowledge is needed to explain the motivations and consequences of patients engaging in what has been called ‘do-it-yourself healthcare’. Aim: This study aimed to investigate patients’ experiences of home blood pressure monitoring through the theoretical frame of the Unified Theory of Acceptance and Use of Technology (UTAUT 2). Methods: The study had a qualitative design, with focus group interviews using the web-based platform Zoom. The data were analysed using qualitative deductive content analysis, inspired by Graneheim and Lundman. Results: The results are presented using the seven theoretical constructs of UTAUT 2: Performance Expectancy, Effort Expectancy, Social Influence, Facilitating Conditions, Hedonistic Motivation, Price Value and Habit. We found one overarching theme ‒ ‘It’s all about the feeling of security’. The patients were influenced by relatives or healthcare personnel and experienced the home monitoring process as being easy to conduct. The patients emphasised that the quality of the blood pressure monitor was more important than the price. Patients reported home monitoring of blood pressure as a feasible method to follow-up care of their hypertension. Discussion: This study indicates that among motivated patients, home blood pressure measurement entails minimal effort, increases security, and leads to better communication about blood pressure between healthcare personnel and patients.

Abstract Background Evidence concerning health care use related to virtual visits is conflicting. More research has been called for regarding the effectiveness of text-based virtual visits (eVisits). Therefore, we investigated patient characteristics, diagnoses, and subsequent health care contacts after eVisits to primary care. Methods We conducted a register-based cohort study of eVisits to an all-virtual public primary care unit in Sweden and subsequent health care contacts within 14 days. Data for 2021 were acquired from the regional health care databases. Diagnoses were sorted into relevant diagnostic groups, such as skin diagnoses and respiratory tract diagnoses. Multiple logistic regression was performed with subsequent health care contact as the outcome variable and diagnostic group for the eVisit as the predictor variable. Analyses were adjusted for age, sex, and socioeconomic index. Results There were 5817 eVisits to a nurse and 4267 eVisits to a general practitioner (N = 10 084). Most patients were 20 to 39 years of age (41.8%). Skin diagnoses were most frequent (47.3%), followed by respiratory tract diagnoses (19.9%). Approximately one-fourth (25.8%) of the patients who completed an eVisit with a nurse or a general practitioner had a subsequent face-to-face visit within 14 days, mostly in primary care. Subsequent contacts were more frequent after an eVisit to a nurse than to a general practitioner. After an eVisit to a general practitioner, patients with infections (especially respiratory tract but also urinary tract) and unspecified diagnoses (especially skin-related) were more likely to require further health care contact compared to a group with various other diagnoses. Conclusions eVisits to an all-virtual primary care unit may be appropriate for uncomplicated medical complaints. Nonetheless, the effectiveness of eVisits in terms of substitution of physical visits, and resource utilization in relation to the more complex care needs of a primary care population, should be further studied.

Purpose Cancer survivors experience barriers to primary healthcare (PHC) services. The aim was to explore reactions to and opinions about perceived challenges associated with PHC access and quality among cancer survivors in Sweden, including how they have acted to adapt to challenges. Methods Five semi-structured focus group interviews were conducted with cancer survivors (n = 20) from Skåne, Sweden, diagnosed with breast, prostate, lung, or colorectal cancer or malignant melanoma. Focus groups were mixed in regard to diagnosis. Data were analysed using a descriptive template analysis approach. Results In light of perceived challenges associated with access to adequate PHC, participants experienced that they had been forced to work hard to achieve functioning PHC contacts. The demands for self-sufficiency were associated with negative feelings such as loneliness and worry. Participants believed that cancer survivors who lack the ability to express themselves, or sufficient drive, risk missing out on necessary care due to the necessity of being an active patient. Conclusions The findings highlight negative patient experiences. They have implications for the organization of care for cancer survivors as they indicate a need for more efficient post-treatment coordination between cancer specialist care and PHC providers, as well as increased support for patients leaving primary cancer treatment.

Abstract Background Social and geographical inequity in access to primary healthcare is an ongoing concern in Sweden. Digital care can potentially decrease geographical inequity. This study aimed to evaluate how urbanicity affects the utilization of a public digital primary healthcare service - PHC Online. Methods We performed an ecological cross-sectional study of 4,482 PHC Online visits grouped by 83 public primary healthcare centers. Multiple linear regression analysis was performed with PHC Online visits per 1,000 registered patients as the dependent variable and urbanicity (municipalities grouped by number of inhabitants), socioeconomic status (Care Need Index), and morbidity (Adjusted Clinical Groups) per primary healthcare center as independent variables. Results Utilization of PHC Online was more common among those of a younger age (median 32 years) and among women (65%). Urbanicity did not affect utilization. Lower socioeconomic status and higher morbidity had negative effects on utilization (B -3.289, p = 0.001, B -7.728, p = 0.045). Conclusions Geographical differences based on urbanicity do not seem to affect the utilization of PHC Online. Further studies are needed to clarify a possible association to geographical barriers in access to primary healthcare, specifically accounting for factors associated with urbanicity and distance to physical clinics, and how age and sex affect such an association. Lower utilization of PHC Online in low socioeconomic status and high morbidity populations raises questions on the effect of digital primary care on equitable access to primary healthcare.

AbstractObjective Cardiovascular disease can be prevented through lifestyle changes, but such changes are often hard to attain. Text message interventions with lifestyle advice have shown small but promising effects. Our objective was to explore participant experience of a text message lifestyle intervention for patients with hypertension, and implications for future lifestyle interventions.Design and subjects Fourteen participants were purposefully selected for telephone interviews after completion of a text message lifestyle intervention. A semi-structured interview guide with open-ended questions was used. Interviews were recorded and transcribed verbatim. The material was analyzed through systematic text condensation as described by Malterud, a data-driven analysis style that includes deductive elements.Setting Primary care in three regions in southern Sweden.Results The analysis resulted in three themes. ‘Blood pressure and lifestyle, how seriously to take it?’ revealed a remaining need for knowledge regarding to what extent lifestyle affects risk for cardiovascular disease. ‘The text messages – a useful reminder in need of tailoring’ described that the design of the intervention was satisfactory, but suggested improvements through increased individualization. Finally, ‘Water off a duck’s back or a kick in the pants – when does behavior change?’ showed how some participants responded to the push to change while others did not, supplying material for further analysis in a framework of behavioral change theory.Conclusion A key to adoption was advice that was applicable in daily life. Timing in relation to a diagnosis of hypertension or other motivational factors, and tailoring to prior knowledge, habits, and limitations could increase effectiveness.

Abstract Background Patients with mental illness have an increased risk of cardiovascular morbidity and mortality compared to the rest of the population, which is partly related to unhealthy lifestyle habits. To individualise lifestyle counselling in primary care, the Swedish-developed Health Dialogue (HD) can be used as an educative tool at recurrent measurement points with the goal to improve non-healthy lifestyle habits. HD has not been aimed specifically at patients with mental illness, and the effect of a systematic approach with repeated HDs in patients with mental illness in primary care has not been previously studied. The aim of this pilot study was to assess the feasibility of the study design for a larger-scale cohort study using repeated HDs focused on the improvement of lifestyle habits in patients seeking primary care due to anxiety, depression, sleeping problems or stress-related symptoms. Methods Patients were recruited after a visit to a Primary Health Care Center due to mental illness between October 2019 until November 2021 and received a Health Dialogue, including an assessment of cardiovascular risk factors through a Health Curve. Specific feasibility objectives measured were dropout rate, time to follow-up, and risk improvement rate for different lifestyle changes. Results A total of 64 patients were recruited and 29 (45%) attended a second HD, with a mean follow-up time of 15 months. All participants had at least one elevated cardiovascular risk level on the Health Curve for the assessed lifestyles. Risk level improvement rate was good except for tobacco use. Conclusion Despite a higher dropout rate than expected, we suggest that the proposed methodology for a full cohort study within general practice of patients with mental illness in primary care is both acceptable to practice and feasible. Trial registration NCT05181254 . Registered January 6th, 2022. Retrospectively registered.

Objective: Individuals with psychiatric illness suffer from poorer physical health compared with the general population and have a higher risk of developing cardiovascular and metabolic diseases. This cross-sectional study aims to describe the prevalence of lifestyle and cardiovascular risk factors and the association with self-reported psychiatric symptoms in a population of 40-year-old individuals screened with targeted Health Dialogues in southern Sweden. Methods: All 40-year-old individuals registered at 99 primary healthcare centers in southern Sweden were invited to participate. Self-reported lifestyle habits on a web questionnaire, anthropometric measurements, blood pressure, and blood tests were collected. The Health Dialogue resulted in a risk level assessment for different lifestyle habits and a meeting with a trained coach. Results: A total of 1831 individuals completed a Health Dialogue between 1st January 2021 and 30th June 2022. There were more individuals with high-risk levels for several lifestyle habits in the group with self-reported psychiatric illness compared with the rest of the study population. The analysis showed that physical inactivity, unhealthy diet, high-risk alcohol intake, tobacco use, psychosocial strain, higher BMI, and waist-hip ratio were associated with increased levels of psychiatric symptoms after adjustment for sex and socioeconomic factors. Conclusion: Unhealthy lifestyle habits were associated with self-reported psychiatric symptoms in 40-year-old individuals assessed with targeted Health Dialogues in a primary care context. Organized screening might contribute to early detection of modifiable risk factors for cardiovascular disease. Individuals with psychiatric symptoms should be prioritized for screening of unhealthy lifestyle behaviors.

Abstract Background Direct-to-consumer telemedicine (TM), with patients having access to a physician via video or text chat, has gradually been introduced into Swedish primary care during the last two decades. Earlier studies have concluded that patients were generally satisfied with TM and the satisfaction rate was consistently above 80% and comparable with in-person visits. Despite the number of studies looking at user experience, studies assessing what factors influence patient satisfaction are lacking. To further develop digital care, it is important to explore the patients’ opinions of this relatively new phenomenon. The primary aim of this study was to explore patient opinions regarding satisfaction with TM-provided care, based on different age groups, sex, symptoms, and which type of health care professional they were assessed by. Methods The study was a quantitative web survey performed in 2020–2021 in which 688 patients using a TM provider in Southern Sweden responded. The results were analysed using Chi-2 test with the main outputs; satisfaction level and percentage that would use TM for similar symptoms in the future. Results The results from the survey population show that patients that were assessed by a doctor were more likely to intend to use TM in the future and were more satisfied with the visit than patients assessed by a nurse. Our results also show that patients older than 70 years of age were less likely to use TM again compared to the total population. Conclusion This study shows that patient satisfaction with TM varied depending on the patient’s age. The older patients were less satisfied than their younger equivalents. For patient satisfaction to be high, it was also crucial which health care provider the patient had been assessed by. The patients were more satisfied when assessed by a doctor than by a nurse. In addition, the study shows that patient satisfaction with TM was generally comparable to traditional care.

AbstractObjective Gestational diabetes mellitus (GDM) is an established risk factor for developing type 2 diabetes mellitus (T2DM) that is possible to prevent by systematic follow-up and preventive measures. The aim of this study was to examine whether women with previous GDM were offered follow-up in primary care, according to Swedish national guidelines.Design Retrospective review of electronic medical records.Setting Primary care in southern Sweden, Skåne county.Subjects Women who received a GDM diagnosis in 2018 at the Endocrinology department, Skåne University Hospital in Lund. The study population consisted of a total number of 161 patients, whereof 83 patients were included.Main outcome measures Whether primary care offered follow-up for T2DM after GDM and if any communication took place between secondary and primary care. Furthermore, it was examined whether the quality of the follow-up was in accordance with the national guidelines.Results Of the study population, a total of 29% (n = 24) had been followed-up by primary care. In 55% (n = 46) of the cases, there was no communication between secondary and primary care. Plasma glucose was checked in all (n = 20) cases where follow-up could be evaluated. Conversations about lifestyle habits took place in 70% (n = 14) of the cases. Weight and risk factors for cardiovascular disease were controlled in less than half (n = 9) of the patients. Lifestyle advice was offered in two cases and in 24% (n = 20) of the cases an annual check-up was planned.Conclusions The follow-up of women with previous GDM in primary care in southern Sweden was lacking in seven out of 10 cases and showed great potential for improvement.Key PointsGestational diabetes is an established risk factor for developing type 2 diabetes.Earlier research has recognized that risk reduction is possible by systematic follow-up and preventive measures, but the extent of follow-up in primary care in southern Sweden remains unknown.This study demonstrates a lack of follow-up according to national guidelines for women with previous gestational diabetes in primary care in southern Sweden.There is great potential to improve the care of these patients with relatively simple means.

AbstractObjective To explore how cancer survivors have experienced their contacts with primary care after being diagnosed with cancer, focusing on the integration between cancer specialist and primary care, and participants’ views on what could make primary care services better at catering to the needs of cancer survivors.Design A qualitative study in which data was collected through semi-structured digital focus group interviews and analyzed using a template analysis approach.Setting and subjects Adult residents of Skåne, Sweden, who had been diagnosed with and initiated treatment for either of five common cancer forms, recruited through patient advocacy groups.Main outcome measures A qualitative description of participants’ experiences and perceptions as expressed in focus group interview data.Results Most participants felt that primary care services had not played a significant role for them, despite patterns of both increased and unmet health needs. Insufficient coordination and communication with specialist cancer care, low availability, lacking personal continuity, low cancer competence and lacking commitment to cancer-related needs were presented as barriers to satisfactory primary care. A strengthened bond between cancer and primary care services, privileged access, and holistic perspectives were all suggested as measures to make primary care more suitable to cancer survivors’ needs.Conclusion The study suggests that cancer survivors experience a range of issues that hinders primary care services from playing a productive role in the cancer care process. The results speak for a need for interventions to remove barriers to satisfactory primary care contacts in this group of patients.KEY POINTSThe growing number of cancer survivors highlights the role of primary care services in the cancer care continuum.Despite the presence of unmet needs, few cancer survivors felt that primary care services had been significant to their care.Survivors identified a number of barriers to satisfactory primary care, including lacking coordination and communication between cancer and primary care.Strengthened links between healthcare services, privileged access, and holistic perspectives were suggested to improve primary care delivery for cancer survivors.

Background: Chronic obstructive pulmonary disease (COPD) and infections are risk factors for venous thromboembolism (VTE), but the reasons behind the associations are not fully known. Few studies have investigated whether lung function and respiratory symptoms in individuals without COPD are associated with VTE. Objectives: To study the incidence of VTE in individuals without COPD and other major VTE risk factors, in relation to baseline lung function and respiratory symptoms, through a 44-year follow-up prospective cohort study. Methods: As part of a health screening program, a total of 20,253 men and 7361 women underwent a baseline examination from 1974 to 1992, including a spirometry test and a self-administered questionnaire about respiratory symptoms, e.g., chronic bronchitis, cough, phlegm, and dyspnoea. Lung function was assessed through quartiles of forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC). Through linkage with national registers, all individuals were followed for incidence of VTE. Results: Respiratory symptoms (cough and dyspnoea) at baseline were associated with an increased risk of incident VTE in women after adjustments for age, height, BMI, smoking status, varicose veins, and FEV1/FVC. The adjusted hazard ratio in relation to chronic bronchitis was 1.57 (95% confidence interval 1.17–2.11). Poor lung function was not associated with an increased risk of VTE after adjustments for potential confounders. Conclusion: Women with respiratory symptoms of cough and dyspnoea without COPD have an increased risk of VTE, independent of lung function and major VTE risk factors. Further studies are needed to confirm the association and to study the clinical applicability of the results.

Abstract The association between type 2 diabetes (T2D) and ischemic heart disease (IHD) is well established but the potential causal association needs further studying. In an attempt to elucidate the causal effect of T2D on IHD, we used three different analytical approaches in two different datasets. A well-defined cohort of 6047 women aged 50–59 years were included at baseline (1995 to 2000) and followed until 2015 for IHD. The median follow-up was 16.3 years. We used a Marginal Structural Cox model (MSM Cox) to account for time-varying exposure (time at onset of T2D) and for ten confounders (using inverse probability weighting, IPW). We also compared the MSM-Cox models with traditional Cox regression modelling in the cohort. Finally, we analyzed information on individuals from Swedish population-based registers with national coverage in a comprehensive co-relative design and extrapolated the results to MZ twins. The Hazard Ratio (HR) for IHD in relation to T2D at baseline and T2D occurring during the follow-up in the MSM Cox model weighted by IPW (based on the ten included confounders) was 1.43 (95% confidence interval [CI] 1.07–1.92). The corresponding HR from the traditional Cox regression model was of similar effect size. The average extrapolated MZ twin estimate from our co-relative model was 1.61 (95% CI 1.48–1.86). Our findings, based on a triangular approach, support the existence of a causal association between T2D and IHD and that preventive long-term measures in order to avoid or postpone IHD should include monitoring and treatment of both the T2D itself as well as other cardiovascular risk factors.

Abstract Background A distorted blood lipid profile is an important risk factor for ischemic heart disease (IHD) but the predictive ability of the different lipid measures has rarely been studied. Our aim was to examine and compare, in a large sample of women, the predictive ability of total cholesterol/HDL cholesterol ratio (TC/HDL-C) and non-HDL-C in relation to IHD, adjusted for age, exercise, smoking, waist-hip ratio, blood pressure, and diabetes mellitus. Methods Between 1995 and 2000, a total of 6537 women aged 50–59 years from the Women’s Health in Lund area (WHILA) study in southern Sweden were included and underwent a baseline examination. The women were followed through national registers for incidence of IHD during a mean follow-up of 17 years. The prediction accuracy was estimated through Harrell’s C and Akaike Information Criterion (AIC). Results Increasing TC/HDL-C as well as non-HDL-C showed strong associations with IHD, with the highest risk in the 5th quintile, where the HR was 2.30 (95% CI: 1.70–3.11) for TC/HDL-C and 1.67 (95% CI: 1.25–2.24) for non-HDL-C, after adjustments. Comparisons using Harrell’s C and AIC indicated that TC/HDL-C has a slightly higher predictive ability than that of non-HDL-C (Harrell’s C 0.62 and 0.59 respectively, p = 0.003 for difference, age-adjusted model; AIC for TC/HDL-C

Abstract Background Obesity prevalence is increasing globally. Bariatric surgery is an effective treatment for severe and complex obesity resulting in significant and sustained weight loss. In Sweden, most bariatric surgery patients are referred by primary care physicians. We aimed to explore barriers for physicians to refer patients with severe and complex obesity for bariatric surgery. Methods A questionnaire survey was in 2019 emailed to 1100 primary care physicians in the Skåne and Kronoberg regions in south Sweden. The survey focused on referral patterns, knowledge and attitudes towards bariatric surgery and concerns about postoperative complications. We created different statistical indices for referral patterns, knowledge, attitudes and concerns about bariatric surgery. To analyze the correlation between these indices, we did Spearman’s correlations and regression analyses. Results Of 1100 email respondents, we received 157 (14%) completed surveys. Among 157 physician respondents, 73% answered that they had good knowledge about the referral criteria for bariatric surgery, whereas 55 and 60% answered correctly to two items on criteria for bariatric surgery. A majority of respondents (84%) stated that their patients initiated referral to bariatric surgery. Half of the respondents had concerns about postoperative medical and surgical complications, but another half had a positive attitude to bariatric surgery as a treatment for obesity comorbidities. Almost half of the respondents (44%) answered that they needed to learn more about bariatric surgery. We found significant positive correlations between high knowledge and referral patterns (r = 0.292, p

Abstract Increased physical activity can have health benefits among inactive individuals. In Sweden, the healthcare system uses physical activity on prescription (PAP) to motivate patients to increase their physical activity level. Mindfulness may further heighten the internal motivation to engage in physical activity. However, previous research has not demonstrated clear evidence of such an association. Aim Examine the feasibility of the study design as a preparation for a full-scale study, and examine the differences, between three interventions, in change over time in physical activity levels and in related variables. Method Comparison between three different interventions in an ordinary primary health care setting: PAP, mindfulness, and a combination of PAP and mindfulness. Physical activity was measured with self-report and ACTi Graph GT1X activity monitor. Statistical analysis was performed with a mixed-effect model to account for repeated observations and estimate differences both within groups and between groups at 3- and 6-months follow-up. Results Between September 2016 and December 2018, a total of 88 participants were randomised into three groups. The total dropout rate was 20.4%, the attendance rate to the mindfulness courses (52% > 6 times) and the web-based mindfulness training (8% > 800 min) was low according to the stated feasibility criteria. Eleven participants were excluded from analysis due to low activity monitor wear time. Neither the activity monitor data nor self-reported physical activity showed any significant differences between the groups. Conclusion The study design needs adjustment for the mindfulness intervention design before a fully scaled study can be conducted. A combination of PAP and mindfulness may increase physical activity and self-rated health more than PAP or mindfulness alone. Trial registration ClinicalTrials.gov, registration number NCT02869854 . Regional Ethical Review Board in Lund registration number 2016/404.

Objective To evaluate the feasibility of a randomized controlled pilot study with lifestyle-promoting text messages as a treatment for hypertension in primary care. Design Randomized controlled pilot trial. Setting Three primary health care centers in southern Sweden. Subjects Sixty patients aged 40–80 years with hypertension were included. Main outcome measures Feasibility of the pilot study, i.e. recruitment rate, dropout rate and eligibility criteria. Secondary outcomes were change in blood pressure and other cardiovascular risk factors. Methods Thirty participants were randomized to the intervention group with four lifestyle-promoting text messages sent every week for six months. The control group received usual care. The baseline and follow-up visits for all 60 patients included measurements of blood pressure, anthropometrics, blood tests and a self-reported questionnaire. Results All feasibility criteria (recruitment rate (≥55%), dropout rate (≤15%) and eligibility (60 eligible patients during the four-month inclusion period) for the pilot study were fulfilled. This means that a larger study with a similar design may be conducted. After six months, there were no significant improvements in cardiovascular risk factors. However, we found favorable trends for all secondary outcomes in the intervention group as compared to the control group. Conclusion Lifestyle modification in patients with hypertension is important to reduce cardiovascular risk. However, primary healthcare has limited resources to work with modifying lifestyle habits. This is the first pilot study to test the feasibility of text message-based lifestyle intervention in patients with hypertension in Swedish primary healthcare. Whether significant improvement in cardiovascular risk factors may be achieved in a larger study population remains to be evaluated.Key points This pilot randomized controlled trial (RCT) is the first study to evaluate the feasibility of text message-based lifestyle advice to patients with hypertension in Swedish primary healthcare. •All feasibility criteria for the pilot study were fulfilled. This outcome means that a larger study with a similar design may be conducted. •The study was not powered to find significant changes in cardiovascular risk factors. Nevertheless, after six months we found favorable trends for all secondary outcomes in the intervention group compared to control. •If a future larger study can show significant results, this intervention could serve as a useful tool in everyday primary healthcare.

BackgroundRemote assessment of respiratory tract infections (RTIs) has been a controversial topic during the fast development of private telemedicine providers in Swedish primary health care. The possibility to unburden the traditional care has been put against a questionable quality of care as well as risks of increased utilization and costs. The COVID-19 pandemic has contributed to a changed management of patient care to decrease viral spread, with an expected shift in contact types from in-person to remote ones. ObjectiveThe main aim of this study was to compare health care consumption and type of contacts (in-person or remote) for RTIs before and during the COVID-19 pandemic. The second aim was to study whether the number of follow-up contacts after an index contact for RTIs changed during the study period, and whether the number of follow-up contacts differed if the index contact was in-person or remote. A third aim was to study whether the pattern of follow-up contacts differed depending on whether the index contact was with a traditional or a private telemedicine provider. MethodsThe study design was an observational retrospective analysis with a description of all index contacts and follow-up contacts with physicians in primary care and emergency rooms in a Swedish region (Skåne) for RTIs including patients of all ages and comparison for the same periods in 2018, 2019, and 2020. ResultsCompared with 2018 and 2019, there were fewer index contacts for RTIs per 1000 inhabitants in 2020. By contrast, the number of follow-up contacts, both per 1000 inhabitants and per index contact, was higher in 2020. The composition of both index and follow-up contacts changed as the share of remote contacts, in particular for traditional care providers, increased. ConclusionsDuring the COVID-19 pandemic in 2020, fewer index contacts for RTIs but more follow-up contacts were conducted, compared with 2018-2019. The share of both index and follow-up contacts that were conducted remotely increased. Further studies are needed to study the reasons behind the increase in remote contacts, and if it will last after the pandemic, and more clinical guidelines for remote assessments of RTI are warranted.

Abstract Background Identifying variables predictive of acute myocardial infarction (AMI) in women is important. The use of the ratio of total cholesterol-to-high density lipoprotein cholesterol (TC/HDL-C) is often overlooked. The aim was to study TC/HDL-C in relation to later AMI, in a large sample of women, adjusted for age, educational status, smoking, waist-hip ratio, blood pressure, and neighbourhood socioeconomic status. The hypothesis was that increasing TC/HDL-C is associated with an increased risk of later AMI. Methods From December 1995 to February 2000, 6147 women aged 50–59 years from the Womens’ Health in Lund area (WHILA) study in southern Sweden underwent a physical examination, laboratory tests and filled in a questionnaire. The women were followed through national registers for incidence of AMI during a mean follow up of 17 years. Results An increasing TC/HDL-C showed a strong relationship with AMI, with the lowest hazard ratio (HR = 1) in women with a ratio of ≤3.5. The HR for AMI was 1.14 (95% CI: 0.73–1.78) for those with a ratio between 3.5 and 4.0; in those with a ratio between 4.0 and 5.0 the HR for AMI was 1.46 (95% CI: 1.00–2.13) and in those with a ratio > 5.0 the HR was 1.89 (95% CI 1.26–2.82), after adjusting for potential confounding factors. Conclusions TC/HDL-C ratio is a powerful predictor of AMI in middle-aged women. The results indicate that this variable should be used in clinical practice and is important for early identification of individuals at risk of AMI.

Abstract Background Bariatric surgery is considered to be the most effective method of weight loss today. The aim of the present Swedish study, which was performed in a country that has universal health care, was to investigate if there is an association between socioeconomic factors and bariatric surgery by taking body mass index (BMI) into account. Methods In this prospective cohort study, BMI data were collected for the period 1985–2010 from the Military Service Conscription Register (for men) and from the Medical Birth Register in the first trimester (for women). The follow-up period started in 2005 and continued until 2012. Age-standardized cumulative incidence rates (CR) of bariatric surgery were compared between different BMI groups by considering individual variables. We analyzed the association between the individual variables and bariatric surgery using Cox proportional hazard models. Results In the study population of 814,703 women and 787,027 men, a total of 7433 women and 1961 men underwent bariatric surgery. In women, the hazard ratios (HRs) for bariatric surgery were higher for low and middle income and educational levels, compared to high income and educational levels. In men, the highest HR for bariatric surgery was found among those with a high income. The HRs when comparing the different socioeconomic groups in those with BMI > 40 kg/m2 showed no significant results, except for middle education in women. Conclusion Differences in bariatric surgery between socioeconomic groups were found, favoring those with a low socioeconomic status. However, very few socioeconomic differences were found amongst those who had a BMI > 40 kg/m2. This indicates that the Swedish healthcare system seems to have achieved equal access to health care for bariatric surgery.

Objective: The elderly are an increasing group and large consumers of care in Sweden. Development of mobile information technology shows promising results of interventions for prevention and treatment of chronic diseases. Exploring the elderly patients’ beliefs, attitudes, experiences and expectations of e-health services helps us understand the factors that influence adherence to such tools in primary care. Material and methods: We conducted focus group interviews with 15 patients from three primary health care centers (PHCCs) in Southern Sweden. Data were analysed with thematic content analysis with codes and categories emerged from data during analysis. Results: We found one comprehensive theme: ‘The elderly’s ambivalence towards e-health: reluctant curiosity, a wish to join and need for information and learning support’. Eight categories emerged from the text during analysis: ‘E-health – a solution for a non-existing problem?’, ‘The elderly’s experiences of e-health’, ‘Lack of will, skills, self-trust or mistrust in the new technology’, ‘Organizational barriers’, ‘Wanting and needing to move forward’, ‘Concerns to be addressed for making e-health a good solution’, ‘Potential advantages with e-health versus ordinary health care’ and ‘Need for speed, access and correct comprehensive information’. Conclusions: Elderly patients in Sweden described feelings of ambivalence towards e-health, raising concerns as accessibility to health care, mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.Key points Exploring the elderly patients’ beliefs, experiences, attitudes and expectations of the fast developing e-health services helps us understand the factors that influence adherence to such tools in primary care. Elderly patients in Sweden reported ambivalence and different experiences and attitudes towards e-health, raising concerns as accessibility to health care, costs and mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.

ObjectiveObesity is a well-known risk factor for coronary heart disease (CHD), but there is little evidence on the effect of long-term trajectories of body mass index (BMI) over the life course. By using repeated assessments, the aim was to study the risk of CHD in adults during 38 years in different trajectories of BMI.MethodsA sample of 2129 men and women, aged 20-59 years at baseline, took part in four repeated interviews between 1980 and 2005. Data on BMI, medical history, lifestyle and socioeconomy were collected. Based on the World Health Organization categories of BMI, life course trajectories of stable normal weight, stable overweight, stable obesity, increasing BMI and fluctuating BMI were created. The individuals were followed through national registers for first hospitalization of CHD (389 events) until the end of 2017, and Hazard Ratios (HRs) were calculated, adjusted for age, sex, socioeconomic factors, lifestyle factors and metabolic comorbidities.ResultsStable normal weight in all assessments was the reference group. Those who had an increase in BMI from normal weight in the first assessment to overweight or obesity in later assessments had no increased risk of CHD, HR 1.04 (95% CI: 0.70-1.53). The HR for individuals with fluctuating BMI was 1.25 (0.97-1.61), for stable overweight 1.43 (1.03-1.98), for stable obesity 1.50 (0.92-2.55), and for stable overweight or obesity 1.45 (1.07-1.97), after full adjustments.ConclusionHaving a stable overweight or obesity throughout adult life was associated with increased CHD risk but changing from normal weight at baseline to overweight or obesity was not associated with increased CHD risk. Prevention of obesity early in life may be particularly important to reduce CHD risk.

Objectives To explore staff experiences of working with a digital communication platform implemented throughout several primary healthcare centres in Sweden.Design A descriptive qualitative approach using focus group interviews. Qualitative content analysis was used to code, categorise and thematise data.Setting Primary healthcare centres across Sweden, in both rural and urban settings.Participants A total of three mixed focus groups, comprising 19 general practitioners and nurses with experience using a specific digital communication platform.Results Five categories emerged: ‘Fears and Benefits of Digital Communication’, ‘Altered Practice Workflow’, ‘Accepting the Digital Society’, ‘Safe and Secure for Patients’ and ‘Doesn't Suit Everyone and Everything’. These were abstracted into two comprehensive themes: ‘Adjusting to a novel medium of communication’ and ‘Digitally filtered primary care’, describing how staff experienced integrating the software as a useful tool for certain clinical contexts while managing the communication challenges associated with written communication.Conclusions Family medicine staff were ambivalent concerning the use of digital communication but, after a period of adjustment, it was seen as a useful communication tool especially when combined with continuity of care. Staff acknowledged limitations regarding use by inappropriate patient populations, information overload and misinterpretation of text by both staff and patients.

Abstract Background In the Swedish population aged between 50 and 64 years only 7.1% reach the recommended level of physical activity. Physical activity on prescription (PAP) has been used in Sweden since the beginning of the twenty-first century with moderate adherence of approximately 50%. Mindfulness seems to affect motivation to and satisfaction with physical activity. The aim is to test the feasibility of a study in routine care; i.e. to test if mindfulness can improve adherence to PAP, measured by changes in physical activity. Methods/design We will include 90 sedentary individuals, aged 40–65 years, from primary health care centres in Sweden. Individuals will be randomised to only PAP, mindfulness and PAP or mindfulness only. The PAP group will be based on patients’ preferences. The mindfulness groups will meet once a week for 8 weeks and practise 20 min of individual training per day. There will not be any motivational interview or physical activity on prescription in the group assigned to only mindfulness. The participants will complete the Five Facet Mindfulness Questionnaire, the Insomnia Severity Index and also answer questions concerning their lifestyle. Physical activity will be measured by ACTi Graph GT1X activity monitor at baseline and after 3 and 6 months. Patients with a severe psychological disease, unstable angina or a recent myocardial infarction will be excluded. The main outcome will be adherence to PAP in an ordinary primary health care setting. In this pilot study, we will also evaluate measures such as the recruitment rate, number of dropouts and adherence to mindfulness practice. Discussion This study is the first to explore the effect of mindfulness on adherence to PAP and test the feasibility of the study design. Trial registration ClinicalTrials.gov, NCT02869854. Registered on 26 August 2016.

Abstract Background Anxiety has been suggested to increase among young individuals, but previous studies on longitudinal trends are inconclusive. The aim of this study was to analyze longitudinally, the changes over time of prevalence of self-reported anxiety in the Swedish population between 1980/1981 and 2004/2005, in different birth cohorts and age groups. Methods A random sample of non-institutionalized persons aged 16–71 years was interviewed every eighth year. Self-reported anxiety was assessed using the question” Do you suffer from nervousness, uneasiness, or anxiety?” (no; yes, mild; yes, severe). Mixed models with random intercepts were used to estimate changes in rates of anxiety (mild or severe) within different age groups and birth cohorts and in males and females separately. In addition to three time-related variables – year of interview, age at the time of the interview, and year of birth –the following explanatory variables were included: education, urbanization, marital status, smoking, leisure time physical activity and body mass index. Results Overall prevalence of self-reported anxiety increased from 8.0 to 12.4% in males and from 17.8% to 23.6% in females, during the 25-year follow-up period. The increasing trend was found in all age groups except in the oldest age groups, and the highest increase was found in young adults 16–23 years, with more than a three-fold increase in females, and a 2.5-fold increase in males, after adjustments for covariates. Conclusions Between 1980/81 and 2004/05, there was an increasing prevalence of self-reported anxiety in all age groups except in the oldest, which indicates increased suffering for a large part of the population, and probably an increased burden on the health care system. Clinical efforts should focus particularly on young females (16–23 years), where the increase was particularly large; almost one third experienced anxiety at the end of the 25-year follow-up.

ObjectivesAlcohol use disorders (AUD) is well known to aggregate in families and is associated with socioeconomic status (SES). The objective was to study the effect of education, income and neighborhood SES in adulthood on AUD, and to explore whether the potential associations were confounded by shared familial factors, by using a co-relative control design.MethodsData on AUD was drawn from the Swedish inpatient and outpatient care registers; prescription drug register; and crime data. Through national population registers we collected information on income, education and neighborhood SES at age 25, 30, 35 and 40 years in all individuals born in Sweden between 1950 and 1980. Each sex-specific stratum consisted of approximately 750,000-1,200,000 individuals, who were followed for AUD for a mean follow-up time ranging between 10 and 15 years until the end of 2013. Cox proportional hazards models were used to investigate the risk of AUD as a function of income, education and neighborhood SES in the general population and in pairs of first cousins and full siblings within the same sex, who differed in their exposure to the SES measure.ResultsHigher educational level, higher income and higher neighborhood SES were all associated with a reduced risk for AUD for both males and females in all ages. The potentially protective effect remained but was attenuated when comparing pairs of first cousins and full siblings.ConclusionsHigh educational level and income in adulthood, as well as high neighborhood socioeconomic status, may represent protective factors against alcohol use disorders, even when shared familial factors, e.g. childhood socioeconomic status and genetic factors, have been taken into account.

Abstract Background Living in a socially deprived neighborhood is associated with lifestyle risk factors, e.g., smoking, physical inactivity and unhealthy diet, as well as an increased risk of cardiovascular disease, i.e., coronary heart disease and stroke. The aim was to study whether the odds of cardiovascular disease vary with the neighbourhood availability of potentially health-damaging and health-promoting resources. Methods A nationwide sample of 2 040 826 men and 2 153 426 women aged 35–80 years were followed for six years for first hospitalization of coronary heart disease or stroke. Neighborhood availability of health-damaging resources (i.e., fast-food restaurants and bars/pubs) and health-promoting resources (i.e., health care facilities and physical activity facilities) were determined by use of geographic information systems (GIS). Results We found small or modestly increased odds ratios (ORs) for both coronary heart disease and stroke, related to the availability of both health-damaging and health-promoting resources. For example, in women, the unadjusted OR (95 % confidence interval) for stroke in relation to availability of fast-food restaurants was 1.18 (1.15–1.21). Similar patterns were observed in men, with an OR = 1.08 (1.05–1.10). However, the associations became weaker or disappeared after adjustment for neighborhood-level deprivation and individual-level age and income. Conclusions This six year follow-up study shows that neighborhood availability of potentially health-damaging as well as health-promoting resources may make a small contribution to the risk of coronary heart disease and stroke. However, most of these associations were attenuated or disappeared after adjustment for neighborhood-level deprivation and individual-level age and income. Future studies are needed to further examine factors in the causal pathway between neighborhood deprivation and cardiovascular disease.