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Objective: The aim of this study was to explore the school principal's role in promoting physical activity for inactive children in school settings. Design: Exploratory qualitative interview study. Setting: The study was conducted in seven elementary schools in central Sweden. Method: Data were collected by means of semi-structured interviews with eight school principals. Theories of bioecology and teacher agency informed the study and shed light on the environmental factors and resources affecting school principals' efforts to promote physical activity for inactive children. Result: The most common strategy school principals described was to delegate responsibility for planning organised activities to dedicated school personnel working with the children. In their leadership role, principals described having the power and opportunity to recruit school personnel with positive attitudes towards promoting physical activity, which likely increases inactive children's opportunities to engage in PA. Conclusion: When provided the adequate resources, and by virtue of their management position within the school, principals have the opportunity to make a difference to promote PA for inactive children. Delegating responsibility to school personnel may however create unequal PA opportunities, and if there are no initiators dedicated to this work, inactive children may be left out of PA opportunities in school.

Abstract Human-induced disturbances of the environment are rapid and often unpredictable in space and time, exposing wildlife to strong selection pressure favouring plasticity in specific traits. Measuring wildlife behavioural plasticity in response to human-induced disturbances such as hunting pressures is crucial in understanding population expansion in the highly plastic wild boar species. We collected GPS-based movement data from 55 wild boars during drive hunts over three hunting seasons (2019–2022) in the Czech Republic and Sweden to identify behavioural plasticity in space use and movement strategies over a range of experienced hunting disturbances. Daily distance, daily range, and daily range overlap with hunting area were not affected by hunting intensity but were clearly related to wild boar hunting experience. On average, the post-hunt flight distance was 1.80 km, and the flight duration lasted 25.8 h until they returned to their previous ranging area. We detected no relationship in flight behaviour to hunting intensity or wild boar experience. Wild boar monitored in our study showed two behavioural responses to drive hunts, “remain” or “leave”. Wild boars tended to “leave” more often with increasing hunting experience. Overall, this study highlights the behavioural plasticity of wild boar in response to drive hunts.

Abstract Background Studies examining post-race emotional experiences in the context of endurance races among recreational athletes are scarce. The purpose of this study was to describe how recreational athletes experience the time after completing an endurance race. Methods In this study, a qualitative study design was used, and data collection was carried out with semi-structured interviews. The selection of subjects was completed systematically through criterion selection. The selection criteria were men and women, aged 18 years or older, who had completed an endurance race, and finished, lasting at least 180 min within the past 12 months. The interviews were analyzed using conventional qualitative content analysis. Results Sixteen recreational endurance athletes who, within six months, had completed an endurance race of running, cycling, cross-country skiing or Ironman, participated and were interviewed. Four overarching themes emerged from the analysis: “High on life”, “Loss of energy, Ambivalence and Melancholy”, “Activity-charged emotions”, and “Dimensions of emotions over time and new goals”, describing the content of the interviews. Conclusions Endurance athletes experienced varied post-race emotions that were both physically and mentally challenging, suggesting a holistic approach to managing post-race emotions would be beneficial. From the athletes’ perspectives, post-race feelings were dependent on many factors, including time spent training for a specific race, and perceived inability to set new goals for an upcoming training period. Setting future goals prior to an event may be a tool for reducing the risk of negative post-race emotions, including post-race blues.

Physically inactive children in rural areas are overlooked in research because of the dominance of urban perspectives focusing on physical activity rather than inactivity. The aim of this article is to examine an emerging collective story of how physically inactive children (aged 9-11 years) in two rural areas experience their relationships with physical activity. Based on praxis-oriented sociocultural theorising, this study focuses on how practical physical activity is understood by rural children as part of their sociocultural environment. Five focus group interviews with 21 physically inactive rural children in western Sweden were conducted. Experiences and behaviours that the children emphasised as central to their inactivity were analysed as sociocultural expressions in a collective story about physical activity. To underline the importance of narratives for behaviour in the sociocultural environment, the collective story is presented through three composite narratives told by three fictional characters: 'Robin, the shy one', 'Kim, the farm kid', and 'Angry Alex'. Characteristic of these inactive rural children is a lack of self-confidence, a lack of meaning, and difficulties in managing social physical activities. Common to the behaviours that follow from the children's experiences is that they are perceived as deviating from what is expected of them in accordance with the cultural story about a physically active child. The analysis shows that the underlying cause is the discrepancy between the children's understanding of physical activity and the understanding conveyed via institutions informed by urban perspectives such as, for example, school. For instance, children view physical activity as part of daily labour at the same time that the school teaches physical activities intended for recreational purposes in spare time. Institutions should make room for more interpretations, including rural ones, of the meaning of physical activity and, thus, contribute to reconstructing the cultural narrative about physical activity.

A high incidence of injuries has been reported in young athletes. Several factors have been associated with athletes’ sports injuries. However, scientific evidence is lacking, particularly for adolescent athletes. Hence, the Healthy Injury-Free Adolescent Athletes (HIFAA) was designed to evaluate sports injuries and examine associations with risk factors related to physical load and mental health. Secondary aims are to evaluate differences between sex, age, high school year and sports and examine injuries and the athletic situation 5 to 10 years after graduation. Adolescent athletes aged 15–19 years enrolled in high school and competing in sports to reach a national or international level of sports will be included. At inclusion, athletes will sign an informed consent form and fill out a baseline questionnaire addressing potential risk factors (eg, sports, training and competing health and injuries, and psychosocial status). Athletes will then prospectively be monitored weekly regarding injuries, physical (training/match/competing, perceived exertion) and psychological (fatigue, sleep, mental stress, recovery) load until graduation. A shortened version of the baseline questionnaire will be filled out every year, and a follow-up questionnaire regarding injuries, sporting situations and mental health will be filled out 5–10 years after graduation.Injuries are frequent among adolescent athletes, with consequences ranging from shorter interruptions in sports performance to mental health problems and early termination of sports. A reduction of these injuries is warranted. This study will provide a detailed understanding of risk factors, a prerequisite to introducing appropriate preventive measures.

Aim: As more children become increasingly physically inactive, efforts to reverse this negative trend are growing. Research has indicated, however, that we know relatively little about the pedagogical processes built into programmes and interventions. This is especially true in respect of how children view the process of becoming more physically active. This article therefore explores developmental processes as they unfold in the context of alternative sports programmes through children's voices. Methods: Theoretically, children's development is approached from a bioecological perspective focusing on the interaction between the child and its environment. This article builds on material collected from 5 focus groups conducted with 16 children in total (aged 11-15 years) after participating in an alternative sports programme. The data were analysed abductively using a qualitative content analysis technique. Findings: Findings illustrate how children develop physically active behaviours internally, as they acquire certain skills and knowledge, as well as between children and a multisystemic environment. In this study, children experienced that exploring practical activities in authentic situations could contribute to better understanding of the relationship between themselves and physical activities in their local community. Conclusion: To enable development in interventions, paying attention to the extent to which exo- and mesosystems influence children's relationships with the outside world is key. Participation may lead to an improved understanding of the surrounding world and the ability to further develop in an increasingly complex reciprocal process with the environment.

Abstract Efficient techniques for separating target cells from undiluted blood are necessary for various diagnostic and research applications. This paper presents acoustic focusing in dense media containing iodixanol to purify peripheral blood mononuclear cells (PBMCs) from whole blood in a label-free and flow-through format. If the blood is laminated or mixed with iodixanol solutions while passing through the resonant microchannel, all the components (fluids and cells) rearrange according to their acoustic impedances. Red blood cells (RBCs) have higher effective acoustic impedance than PBMCs. Therefore, they relocate to the pressure node despite the dense medium, while PBMCs stay near the channel walls due to their negative contrast factor relative to their surrounding medium. By modifying the medium and thus tuning the contrast factor of the cells, we enriched PBMCs relative to RBCs by a factor of 3600 to 11,000 and with a separation efficiency of 85%. That level of RBC depletion is higher than most other microfluidic methods and similar to that of density gradient centrifugation. The current acoustophoretic chip runs up to 20 µl/min undiluted whole blood and can be integrated with downstream analysis.

The global data center (DC) sector has expanded rapidly during the last decades, due to the rising demand for digital services. In the Nordic region, Sweden has emerged as a global hub, attracting leading technology companies like Amazon, Facebook, Microsoft, and Google. Server halls of DCs are energy intensive buildings, which puts pressure on local water resources and contributes to global greenhouse gas emissions. This study aims to, firstly, quantify the environmental impact of DCs, based on energy usage, water consumption, and greenhouse gas (GHG) emissions. Secondly, it develops a planning tool by employing a multi-criteria approach to optimally locate new DCs and to assess the site suitability of existing ones in Sweden. Data of various performance indicators (geographical data on renewable energy accessibility, free cooling conditions, excess heat receivers, and resilience to water shortages) of DCs was collected through different means, e.g., questionnaire surveys, permit applications, company websites, and other open online data repositories. ArcGIS Pro was employed for spatial analysis, and 68 DCs with a site suitability index (SSI) ≤ 45 % were identified as less ideally located. The principal findings are centered on Sweden, and thereby primarily benefit stakeholders engaged in decision-making for evaluating existing or strategic planning of new DCs by incorporating a comprehensive environmental perspective. Given the rapidly changing climate, strategically siting DCs will become crucial for minimizing the sector's environmental impact.

Abstract Background Applying the knowledge gained through implementation science can support the uptake of research evidence into practice; however, those doing and supporting implementation (implementation practitioners) may face barriers to applying implementation science in their work. One strategy to enhance individuals’ and teams’ ability to apply implementation science in practice is through training and professional development opportunities (capacity-building initiatives). Although there is an increasing demand for and offerings of implementation practice capacity-building initiatives, there is no universal agreement on what content should be included. In this study we aimed to explore what capacity-building developers and deliverers identify as essential training content for teaching implementation practice. Methods We conducted a convergent mixed-methods study with participants who had developed and/or delivered a capacity-building initiative focused on teaching implementation practice. Participants completed an online questionnaire to provide details on their capacity-building initiatives; took part in an interview or focus group to explore their questionnaire responses in depth; and offered course materials for review. We analyzed a subset of data that focused on the capacity-building initiatives’ content and curriculum. We used descriptive statistics for quantitative data and conventional content analysis for qualitative data, with the data sets merged during the analytic phase. We presented frequency counts for each category to highlight commonalities and differences across capacity-building initiatives. Results Thirty-three individuals representing 20 capacity-building initiatives participated. Study participants identified several core content areas included in their capacity-building initiatives: (1) taking a process approach to implementation; (2) identifying and applying implementation theories, models, frameworks, and approaches; (3) learning implementation steps and skills; (4) developing relational skills. In addition, study participants described offering applied and pragmatic content (e.g., tools and resources), and tailoring and evolving the capacity-building initiative content to address emerging trends in implementation science. Study participants highlighted some challenges learners face when acquiring and applying implementation practice knowledge and skills. Conclusions This study synthesized what experienced capacity-building initiative developers and deliverers identify as essential content for teaching implementation practice. These findings can inform the development, refinement, and delivery of capacity-building initiatives, as well as future research directions, to enhance the translation of implementation science into practice.

Abstract Objective To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems. Data sources and study setting Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability. Study design A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker’s Quality Assessment Tool. Data collection/extraction methods A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies. Results Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation. Conclusions This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area. Trial registration https://bmjopen.bmj.com/content/7/11/e018568 .

Most sports science research revolves around male subjects. As a result, most of the knowledge and practices within sports are male-centric. Failing to take the biological, psychological and social (biopsychosocial) particularities of females into account is believed to hinder optimal sports participation, development and performance, with potential negative effects on the health and well-being of females. To close the knowledge gap and alleviate these issues, we aim to develop and evaluate a 12-video educational intervention that addresses female-specific subject matter: the FIDES Athlete Development Programme. The study is designed as an embedded multiple case study where at least 1320 Swedish female athletes aged 13–16 will participate, in addition to their parents and their coaches. The girls will be recruited through their sports clubs, with half being exposed to the FIDES Athlete Development Programme and the other half serving as control cases. The primary outcomes are well-being and sporting experience. To further increase our understanding of the intervention and its implications, interviews and focus group interviews with a reference group of girls and focus group interviews with a randomly selected subsample of coaches and parents will also be performed. The project is approved by the Swedish ethics committee (number: 2023-05264-01) and will be carried out in compliance with the Declaration of Helsinki. Results from the project will be published open access in peer-reviewed journals, at national and international conferences, in mass media, and a PhD thesis. The anonymised data will be made openly available in a data repository.

Abstract Background Approximately 50% of the patients who globally seek help in psychiatry have been assessed with problematic substance use or been diagnosed with substance use disorder (SUD). Given the high treatment gap for mental health care, in particular SUD, these individuals risk poorer treatment outcomes in psychiatry. Integrated treatment for psychiatric and SUD disorders has been proposed to reduce the treatment gap for SUD, but access to integrated treatment is low. Digital interventions addressing SUD in psychiatry could potentially make treatment available to patients who otherwise would not have access. In this study “digital interventions” comprise an umbrella term covering all kinds of interventions from minimal motivational app-based interventions to internet-based interventions with and without human guidance, up to remote sessions in telepsychiatry. This study aims to explore healthcare staff perceptions of referring patients to digital interventions for reducing problematic substance use, whether or not diagnosed as SUD, in the psychiatric outpatient setting. Method The study was exploratory with a qualitative design. Data were collected in the Swedish outpatient psychiatry setting, via individual semi-structured interviews with managers, and focus groups with healthcare staff. An adapted form of phenomenological hermeneutical analysis was used to analyze the data. Results Three themes emerged from the analysis. The first theme was Encountering obstacles on the path to future implementation of digital interventions, with sub-themes: Lacking resources and Feeling concerned about technical solutions. The second theme was Searching for ways forward to achieve increased access to care, with sub-themes: Blended care could facilitate integrated care and Addressing variations in patients’ technical skills. The third theme was Taking steps towards the future, with sub-themes: Wanting to know more about digital interventions and Formulating a vision for the future. Conclusions The study reveals a concern that implementing digital interventions in psychiatry will create additional work or be technically challenging. The staff see significant advantages from the patient perspective, but they feel that they themselves need training in implementing digital interventions. In order to establish constructive implementation of digital interventions for SUD in psychiatry, staff attitudes and concerns need to be considered and addressed. This study was conducted within the Swedish healthcare system and the findings may not generalize to other countries with differing healthcare systems.

Data on the strength ratio between agonist and antagonist muscles are frequently examined in sports testing, given its correlation with athletic performance. The purpose of this study was to determine the agonist-to-antagonist ratio of upper body strength in female and male elite Swedish track and field throwers using a new push (bench press) and pull (supine bench row) test device, and to determine its reliability. The study involved eight female and nine male athletes, aged 19–29 years, engaging, respectively, in discus, hammer, and shot put competitions at both national and international levels. The athletes’ maximum isometric force was assessed during the bench press (push) and supine bench row (pull) exercises, respectively, using a custom-built test device. The test–retest reliability of the device was also examined. The total push-to-pull strength ratio for the female throwers was 1.15, whereas male throwers demonstrated a ratio of 1.22. Total push and pull force for the female throwers was significantly less than for the male throwers (5511 N vs. 8970 N, p < 0.001). Intraclass correlation coefficients ranged from 0.93 to 0.96 for the bench press and supine bench row exercise, indicating that the push and pull test device was highly reliable. The main findings of this study were that elite female and male discus, hammer, and shot put throwers exhibited 15% and 22% more pushing (bench press) than pulling (supine bench row) strength. Push and pull strength in the female throwers ranged from 47% to 71% of that of the male throwers. The push and pull test device is a reliable tool in establishing the agonist-to-antagonist ratio of upper body strength of athletes. Coaches and athletes may benefit from examining upper body push and pull strength ratios for training planning and prescription.

The aim of this study was to investigate how physical fitness performance, which is related to the strength and power of the lower extremities and core, as well as lateral agility, changes across 20 weeks of in-season training in youth female and male padel players. This study was conducted using a prospective cohort design on 16 Swedish high school padel players aged between 15 and 18 years old. The players were assessed at baseline with five tests of their physical fitness and followed prospectively, with the registration of their training load for 20 weeks, and then assessed at a follow-up, approximately five months later. The players increased their performance in all tests (p ≤ 0.02). The mean improvement in their Isometric squat test performance was 20% for peak force, 18% for relative strength value and 69% for average rate of force development. Their improvement in the squat jump test performance was 9%, whereas the improvement in their countermovement jump test was 6%. For the 30 second sit-up test, an improvement of 14% was observed. Improvements were also noted for the 30 second side hop test performance on both the right (9%) and left leg (11%). The effect size ranged from 0.31 to 1, respectively, for the tests, representing a small to large effect. The data from this study suggest that an improvement in physical fitness performance can be obtained during 20 weeks of padel training.

Abstract Background Long waiting times for health care services are a prominent health policy issue. Waiting time guarantees may limit time to assessment and treatment. Methods This study aims to investigate the information and support given to patients when the waiting time guarantee cannot be fulfilled from a care provider and administrative management perspective. Semi-structured interviews (N = 28) were conducted with administrative management and care providers (clinic staff and clinic line managers) in specialized clinics in the Stockholm Region, Sweden. Clinics were purposefully sampled for maximum variation in ownership (private, public), complexity of care, geographical location, volume of production, and waiting times. Thematic analysis was applied. Results Care providers reported that patients received inconsistent information and support with regard to the waiting time guarantee and that information was not adapted to health literacy or individual patient needs. Contrary to local law, they made some patients responsible for finding a new care provider or arranging a new referral. Furthermore, financial interests affected whether patients were referred to other providers. Administrative management steered care providers’ informing practices at specific time points (upon establishment of a new unit and after six months of operation). A specific regional support function, Region Stockholm’s Care Guarantee Office, helped patients change care providers when long waiting times occurred. However, administrative management perceived that there was no established routine to assist care providers in informing patients. Conclusions Care providers did not consider patients’ health literacy when informing them about the waiting time guarantee. Administrative management’s attempts to provide information and support to care providers are not producing the results they expect. Soft-law regulations and care contracts seem insufficient, and economic mechanisms undermine care providers’ willingness to inform patients. The described actions are unable to mitigate the inequality in health care that arises from differences in care-seeking behavior.

Background: Forced migrants are at risk of developing mental illness, yet challenges remain with underutilization of mental healthcare among this population. This study examined the implementation of the Refugee Health Screener-13 (RHS-13) in the health assessment for forced migrants in eight primary health care centres in Stockholm Region, Sweden. Methods: A mixed-methods convergent parallel design was used, combining nurses self-reported quantitative data on the levels and reasons for RHS-13 use in the health assessment with qualitative interview data on the barriers and facilitators for RHS-13 use. The Consolidated Framework for Implementation Research (CFIR) was used as a coding framework for the qualitative analysis. Results: Levels of RHS-13 use varied between primary health care centres, resulting in two groups: three centres with high-level (65–92%) and five centres with low-level (0–36%) implementation. Factors related to the tool itself, as well as the inner and outer context, influenced the use of RHS-13. Language barriers, insufficient time, and lack of trust in the validity and utility of RHS-13 were the main barriers, while its availability in many languages and that it was perceived as an important complement to the health assessment were the main facilitators. Conclusion: RHS-13 contributes to the standardization of assessing mental health in the health assessment. Identifying context-based implementation strategies and addressing language and time issues as well as nurses trust in the tool's utility are recommended to enhance the use of RHS-13.

Key Clinical Message Acquired inhibitors of blood coagulation are rare but of clinical importance. Prothrombin is a vitamin K‐dependent protein, and acquired antibodies toward prothrombin are often associated with the presence of lupus anticoagulant. We describe a previously healthy 70‐year‐old man presenting with both hemorrhage and thrombosis as well as a prolonged prothrombin time. At arrival at the hospital, he was diagnosed with deep venous thrombosis, and an enlarged lymph node in the left groin was noted (revealed as follicular lymphoma grade 1 by biopsy). Prothrombin activity and antibody titer were followed for 5 months with 15 sampling time points to monitor the treatment outcome of the patient. Diagnostic work‐up identified prothrombin deficiency as cause of bleeding. A nonneutralizing calcium‐dependent antiprothrombin antibody was found, suspected to increase the clearance of prothrombin, which has previously only occasionally been reported. Lupus anticoagulant was ruled out and thrombosis was judged to be caused by a combination of malignant disease and stagnant venous flow following enlarged lymph nodes in the groin. This report illustrates how investigation of prolonged global coagulation tests, triggered the diagnosis of a rare but critical condition, immune‐mediated prothrombin deficiency. The diagnosis is challenging and involves proper differential diagnosis.

Abstract Background Studies investigating ankle condition in subjects with chronic ankle instability (CAI) using an on-the-field test battery are scarce. Understanding which tests that are most challenging for these subjects has the potential to set realistic goals in rehabilitation and return-to-sports criteria. Thus, the primary aim of this study was to investigate CAI subjects regarding strength, balance and functional performance with an easily used test battery that required minimal equipment. Methods This study was conducted with a cross-sectional design. A total of 20 CAI subjects, engaged in sports, and 15 healthy subjects serving as a control group, were tested for assessment of strength, balance and functional performance. A test battery was developed accordingly; isometric strength in inversion and eversion, the single leg stance test (SLS), single leg hop for distance (SLHD) and side hop test. The limb symmetry index was calculated to determine whether a side-to-side lower limb difference could be classified as normal or abnormal. The sensitivity of the test battery was also calculated. Results The subjects were 20% weaker on the injured side compared with the non-injured side in eversion (p

The theory of Expansive learning and the change laboratory (CL) methodology has been developed and applied in many studies on workplace learning and educational change. There are fewer studies made on small-scale interventions, exploring the longitudinal development of expansive learning in an educational change effort. This article examines a CL intervention performed in an upper secondary school in Sweden, with a small group of teachers engaged in a participatory design project. By identifying and analysing the relationship of the seven learning actions posited by the theory of expansive learning, the aim was to contribute to the discussion of the CL methodology and the empirical usability of the theory. The results showed that the seven expansive learning actions functioned as analytical tools to map the teachers learning and development, but the analysis also showed many deviations, disruptions and occurrence of practical actions of design in the process. This challenge the notions of cyclicity and ascension in the theory of expansive learning. Cyclicity might be desirable but not necessary for expansive learning which questions the need to first grasp the problem at a conceptual level before generating concrete solutions. The Findings in this study suggests the opposite; that the entanglement and parallel movement between the abstract and the concrete was a driving force for the teachers expansive learning and the design of new curricular units.

We developed ordinary least squares regression models to predict uptake of cadmium and lead, two metals that are of public health significance because of their toxicity, in the edible tissues of lettuce. Models were parameterised using data on soil metal concentration, pH, and organic carbon. To assess the impact of physical contamination in form of aerial deposition and soil-splash on the metal concentration in lettuce, separate linear regression models were parameterised for indoor- and outdoor-grown lettuce, assuming the physical contamination to be negligible for indoor conditions. Both Cd models showed high model fit and strong predictive performance, when tested on an independent dataset, suggesting uptake via roots to be dominant. For Pb, the indoor model performed better than the outdoor model, indicating that physical contamination, contributes significantly to metal concentration in lettuce leaves. Our results highlight the importance of the parameterisation data when developing uptake models for predictions and risk assessment. Regression models for predicting Pb concentration in lettuce based on indoor data should not be used for predicting lettuce concentrations cultivated in outdoor conditions unless the contribution of physical contamination is explicitly accounted for.

AbstractAim The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC.Design Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis.Setting Six publicly owned primary health care centers in Stockholm.Subjects The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7.Main outcome measures Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC.Results Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient–physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. .Conclusion The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.