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Abstract Middle-aged adults engaging in unhealthy lifestyle behaviors are at higher risk of chronic diseases. However, little is known about the co-occurrence of these behaviors and their determinants. This cohort study examined the co-occurrence of unhealthy lifestyle behaviors (alcohol consumption, diet, physical inactivity, and smoking) in 30,154 middle-aged adults and their associations with sociodemographic factors, social support, and disease history. Alcohol use was measured by the AUDIT, diet by the MiniMeal-Q, and physical inactivity and smoking by single questions. Participants had a mean age of 58 years, with 51% being female. Of them, 14% had no unhealthy behaviors, 38% had one, 36% had two, 10% had three, and 2% had all four. The most common co-occurrence was between physical inactivity and poor diet (38%). Higher education decreased the likelihood of having three or four unhealthy behaviors, while financial difficulties, having no one around who appreciated one’s efforts, and suffering of a lung disease increased it. In conclusion, middle-aged adults exhibit varying levels of unhealthy lifestyle behaviors. Higher education is linked to reduced engagement in multiple unhealthy behaviors, whereas financial strain, lower quality of social support, and lung disease increase the risk.

Abstract Background To understand how to improve care for patients with chronic diseases and multimorbidity we wanted to describe the prevalence of different chronic diseases and the pattern of multimorbidity and to analyse the associations between occurrence of diseases and primary care utilization, adherence to guideline-based pharmacotherapy, and continuity of care. Methods Retrospective cross-sectional study of routine care data of the general population in region Jönköping in Sweden (345 916 inhabitants using primary care services) covering 4.3 years. Participants Patients fulfilling the inclusion criteria of having ≥ 1 of 10 common chronic diseases and ≥ 3 visits to primary care between 2011 and 2015. Primary outcome measures In order to determine diseases and multimorbidity, primary care utilisation, adherence to guideline-based pharmacotherapy, frequencies and percentages, interval and ratio scaled variables were described using means, standard deviations, and various percentiles in the population. Two continuity indices were used (MMCI, COC) to describe continuity. Results Of the general population, 25 829 patients fulfilled the inclusion criteria (7.5% of the population). Number of diseases increased with increasing age, and multimorbidity was much more common than single diseases (mean 2.0 per patient). There was a slight positive correlation (0.29) between number of diseases and visits, but visits did not increase proportionally to the number of diseases. Patients with physical diseases combined with anxiety and/or depression made more visits than others. The number of diseases per patient was negatively associated with the adherence to pharmacotherapy guidelines. There was no association between continuity and healthcare utilisation or adherence to pharmacotherapy guidelines. Conclusions Multimorbid patients are common in primary care and for many chronic diseases it is more common to have other simultaneous diseases than having only one disease. This can make adherence to pharmacotherapy guidelines a questionable measure for aged multimorbid patients. Existing continuity indices also revealed limitations. Holistic and patient-centred measures should be used for quality assessment of care for multimorbid patients in primary care.

AbstractAim To investigate trends in the haemoglobin (Hb) level in middle-aged Swedish women from 1968 to 2017 and to examine the potential association between Hb and the use of hormonal contraceptives (HCs).Design A prospective observational population study of representative 38- and 50-year-old women of Gothenburg, Sweden.Setting The population study of women in Gothenburg started in 1968–1969 and has continued since then with new examinations every 12 years, including both follow-ups and new recruited cohorts. The study consists of both physical examinations and questionnaires.Subjects Two thousand four hundred eighty-eight women aged 38 and 50 participated in the study from 1968 to 2017.Statistical methods Linear regression model analyses were used to analyse linear and non-linear trends in the level of Hb. Linear and logistic regression models were used to analyse possible associations between HC and Hb and possible associations between the use of HC and anaemia, respectively.Main outcome measures and covariates Hb was measured in g/L. HC included any ongoing use of HC therapy. Covariates were smoking, body mass index (BMI), alcohol consumption and education.Results A non-linear U-shaped trend in mean Hb was seen in the two age groups, 38- and 50-years old. After adjusting for covariates, a significantly higher mean Hb was seen in the 2016–2017 examination compared to 1980–1981, 1992–1993 and 2004–2005. In 38-year-olds, using HC was associated with a reduced risk of anaemia (OR 0.35, 95% CI 0.13–0.75). In both age groups, the use of HC was significantly associated with having a higher Hb.Conclusions Mean levels of Hb in middle-aged women of the general population seem to be increasing again after lower levels in the 1980s and 1990s. The use of HC was associated with having a higher Hb and a lower risk of anaemia in 38-year-old women.

ObjectiveTo explore frontline employees' experiences of how to create a purposeful sick leave and rehabilitation process (SRP) with the best interest of patients' long-term health in focus.MethodsQualitative design based on focus group interviews in a primary care context in Region Västra Götaland, Sweden. Strategically selected professionals from different SRP organizations discussed sick leave outcomes and the rehabilitation process. Analysis was performed with Systematic text condensation.SubjectsGeneral practitioners (n = 6), rehabilitation coordinators and/or healthcare professionals from primary healthcare (n = 13), caseworkers from the Social Insurance Agency, the Employment Agency, and Social Services (n = 12).ResultsThe outcome of the SRP was described to depend upon the extent to which the process meets patients' bio-psycho-social needs. Aspects considered crucial were: 1) early bio-psycho-social assessments, including medical specialist consultations when needed, 2) long-term realistic planning of sick leave and rehabilitation alongside medical treatment, 3) access to a wide range of early rehabilitative and supportive interventions, including situation-based, non-medical practical problem solving, and 4) trusting relationships over time for all involved professions and roles to maximize process quality and person-centeredness. A gap between the desired scope of the SRP and existing guidelines was identified.ConclusionInterviewees perceived that successful outcomes from the sick leave and rehabilitation process in a primary care context depend on consensus, person-centeredness, and relationship continuity for all involved professions. An extended process scope and relationship continuity for all involved professionals were suggested to improve process outcomes.

Objectives This study aimed to examine the association between anxiety disorders and/or major depression disorder (ADs/MDD) and all-cause mortality in a 50-year perspective and to examine specific risk and health factors that may influence such an association.Design Observational population study, 1968–2019.Setting The Population Study of Women in Gothenburg, Sweden (PSWG).Participants In 1968–1969, 899 (out of 1462) women from PSWG were selected according to date of birth for a psychiatric investigation, including diagnostic evaluation. Eight hundred (89%) were accepted. Twenty-two women were excluded. Of the 778 included, 135 participants (17.4 %) had solely ADs, 32 (4.1%) had solely MDD and 25 (3.2%) had comorbid AD/MDD.Primary and secondary outcome measures Associations between ADs, MDD, comorbid AD/MDD and all-cause mortality with adjustments for potential confounding factors. Differences between the groups concerning health and risk factors and their association with mortality.Results In a fully adjusted model, ADs were non-significantly associated with all-cause mortality (HR 1.17, 95% CI 0.98 to 1.41). When examining age during risk time as separate intervals, a significant association between mortality and AD was seen in the group of participants who died at the age of 65–80 years (HR 1.70, 95% CI 1.26 to 2.29). In the younger or older age interval, the association did not reach significance at the 95% level of confidence. Among confounding factors, smoking and physical activity were the strongest contributors. The association between smoking and mortality tended to be further increased in the group with ADs versus the group without such disorders (HR 2.10, 95% CI 1.60 to 2.75 and HR 1.82, 95% CI 1.56 to 2.12, respectively).Conclusions This study suggests potential links between ADs, age and mortality among women with 50 years of follow-up, but does not provide definitive conclusions due to the borderline significance of the results.

AbstractObjective Evaluate feasibility, partnerships, and study design of intervention to minimise sick leave.Design and setting The design was a pilot single arm intervention study in primary health care. Outcome measures at follow-ups for each participant were compared with baseline data for the same person.Subjects Twenty primary health care patients with recurrent or long-term sick leave or health-related unemployment.Intervention Patient education through interactive study groups that met half a day a week for eight subsequent weeks. Groups were led by experienced but not medically trained facilitators. The intervention was designed to improve participant health literacy, sense of coherence, health-related quality of life, and patient involvement in healthcare.Main outcome measures Primary outcome was the level of sick leave. Sick leave data were obtained from medical records when available, otherwise patient reported. Secondary outcomes regarding health literacy, sense of coherence, and health-related quality of life were measured with validated questionnaires at baseline and follow-ups.Results Level of sick leave decreased significantly and participation in work preparatory activities increased during follow-up. Health literacy, sense of coherence (subscale sense of meaningfulness), and health-related quality of life (subscale social functioning) showed statistically significant improvement. Intervention, partnerships, and study design were feasible.Conclusion An educational programme, conducted in cooperation between primary health care and partners outside the healthcare system, was feasible and showed an impact on sick leave, health literacy, sense of coherence, and health-related quality of life.KEY FINDINGSA pilot study to evaluate an educational programme with study groups conducted in cooperation between primary health care and partners outside the healthcare system showed good feasibility.Sick leave decreased significantly six months after baseline.Health literacy, sense of coherence (subscale sense of meaningfulness), and health-related quality of life (subscale social function) improved significantly 6 months after baseline.

Objectives To study whether early and enhanced cooperation within the primary care centres (PCC) combined with workplace cooperation via a person-centred employer dialogue meeting can reduce days on sick leave compared with usual care manager contact for patients on sick leave because of common mental disorders (CMD). Secondary aim: to study lapse of CMD symptoms, perceived Work Ability Index (WAI) and quality of life (QoL) during 12 months.Design Pragmatic cluster randomised controlled trial, randomisation at PCC level.Setting 28 PCCs in Region Västra Götaland, Sweden, with care manager organisation.Participants 30 PCCs were invited, 28 (93%) accepted invitation (14 intervention, 14 control) and recruited 341 patients newly sick-listed because of CMD (n=185 at intervention, n=156 at control PCCs).Intervention Complex intervention consisting of (1) early cooperation among general practitioner (GP), care manager and a rehabilitation coordinator, plus (2) a person-centred dialogue meeting between patient and employer within 3 months. Control group: regular contact with care manager.Main outcome measures 12 months net and gross number of sick leave days at group level. Secondary outcomes: 12 months depression, anxiety, stress symptoms, perceived WAI and QoL (EuroQoL-5 Dimensional, EQ-5D).Results No significant differences were found between intervention and control groups concerning days of sick leave (intervention net days of sick leave mean 102.48 (SE 13.76) vs control 96.29 (SE 12.38) p=0.73), return to work (HR 0.881, 95% CI 0.688 to 1.128), or CMD symptoms, WAI or EQ-5D after 12 months.Conclusions It is not possible to speed up CMD patients’ return to work or to reduce sick leave time by early and enhanced coordination among GP, care manager and a rehabilitation coordinator, combined with early workplace contact over and above what ‘usual’ care manager contact during 3 months provides.Trial registration number NCT03250026.

Abstract Background In previous studies, we investigated the effects of a care manager intervention for patients with depression treated in primary health care. At 6 months, care management improved depressive symptoms, remission, return to work, and adherence to anti-depressive medication more than care as usual. The aim of this study was to compare the long-term effectiveness of care management and usual care for primary care patients with depression on depressive symptoms, remission, quality of life, self-efficacy, confidence in care, and quality of care 12 and 24 months after the start of the intervention. Methods Cluster randomized controlled trial that included 23 primary care centers (11 intervention, 12 control) in the regions of Västra Götaland and Dalarna, Sweden. Patients ≥18 years with newly diagnosed mild to moderate depression (n = 376: 192 intervention, 184 control) were included. Patients at intervention centers co-developed a structured depression care plan with a care manager. Via 6 to 8 telephone contacts over 12 weeks, the care manager followed up symptoms and treatment, encouraged behavioral activation, provided education, and communicated with the patient’s general practitioner as needed. Patients at control centers received usual care. Adjusted mixed model repeated measure analysis was conducted on data gathered at 12 and 24 months on depressive symptoms and remission (MADRS-S); quality of life (EQ5D); and self-efficacy, confidence in care, and quality of care (study-specific questionnaire). Results The intervention group had less severe depressive symptoms than the control group at 12 (P = 0.02) but not 24 months (P = 0.83). They reported higher quality of life at 12 (P = 0.01) but not 24 months (P = 0.88). Differences in remission and self-efficacy were not significant, but patients in the intervention group were more confident that they could get information (53% vs 38%; P = 0.02) and professional emotional support (51% vs 40%; P = 0.05) from the primary care center. Conclusions Patients with depression who had a care manager maintained their 6-month improvements in symptoms at the 12- and 24-month follow-ups. Without a care manager, recovery could take up to 24 months. Patients with care managers also had significantly more confidence in primary care and belief in future support than controls. Trial registration ClinicalTrials.gov identifier: NCT02378272. Submitted 2/2/2015. Posted 4/3/2015.

Objective To assess stroke incidence over 44 years and association with risk factors. To study total stroke incidence at 60–82 years of age and risk factors.Design Prospective population study.Setting Gothenburg, Sweden, with ∼450,000 inhabitants.Subjects A representative sample of a general population of women (1462 in total) in 5 age strata aged 38–60 years in 1968–1969 (the Population Study of Women in Gothenburg, PSWG) were followed up to the ages of 82–104 years in 2012. Further, analysis was also performed for the age interval 60–82 years.Main outcome measures Incidence of total stroke (TS), ischaemic (IS), haemorrhagic (HS), non-specified (NS) and fatal (FS) strokes and association with baseline classic risk factors (such as hypertension, atrial fibrillation, low physical activity, diabetes, high waist-hip-ratio, hyperlipidaemia, smoking), low education, mental stress, pre-eclampsia and oral health as expressed by loss of teeth and bone score. Blood pressure in levels 1–3 according to modern guidelines. Associations with atrial fibrillation, diabetes and myocardial infarction shown in survival analyses. The five cohorts contributed to risk time data concerning associations with TS in the 60–82 age interval from the examination performed when they were 60.Results Three hundred and thirty-seven (23%) women had a first-ever stroke, 64 (19%) fatal. TS was associated with physical inactivity, high triglycerides and low education in multivariable analysis. The main sub-type IS was associated with systolic blood pressure, physical inactivity and low education. Pre-eclampsia showed association with IS only in the univariable analysis. FS was associated with systolic blood pressure and smoking. During 60–82 years of age, having

Abstract Background The study is part of the ongoing Prospective Population Study of Women in Gothenburg, Sweden, initiated in 1968–1969 with the aim of characterising a total population of women who were representative of middle-aged females. The aim of the present study was to investigate the prevalence of actual analgesic use (prescribed and self-medication) and the possible association with perceived mental stress among women aged 38 and 50 years, respectively, in the Population Study of Women. Methods Two different cohorts of population-based samples of 38- and 50-year-old women examined in 2004–2005 and 2016–2017, respectively, were eligible participants. The women were representative for their age cohort at the time of the examinations. Use of medicines and especially analgesics, as well as perceived mental stress, was registered. Changes in medicine use among 38- and 50-year-old women between 2004 and 2005 and 38- and 50-year-old women in 2016–2017 were studied. Data were analysed using logistic regression. Use of analgesics and mental stress were analysed controlling for lifestyle factors, use of other medicines and pain. Results The overall sample size across the time periods was 1,073 individuals. The frequency of analgesic use in 38- and 50-year-old women was about 26% in 2004–2005 and 58% in 2016–2017. 28% of women who reported high mental stress in 2004–2005 used analgesics, compared to 60% in 2016–2017. There were no associations between self-perceived mental stress and the use of analgesics. Conclusion The higher use of analgesics among midlife women in 2016–2017 is in line with global findings and could be due to increased availability in Sweden of over the counter medicines. The impact of mental stress on analgesic use found previously by other researchers was not confirmed. However, medicine use as a potential coping strategy is an important public health issue that needs to be further explored.

AimTo assess the hypothesis that low internal health locus of control (IHLC) and psychological distress (PD) are associated with insulin resistance.Materials and methodsIn 2002-2005, a random population sample of 2,816 men and women aged 30-74 years participated (76%) in two municipalities in southwestern Sweden. This study included 2,439 participants without previously known diabetes or cardiovascular disease. IHLC was measured by a global scale and PD was measured by the 12-item General Health Questionnaire. Insulin resistance was estimated using HOMA-ir. General linear models were used to estimate differences in HOMA-ir between groups with low IHLC, PD, and both low IHLC and PD, respectively.ResultsFive per cent (n = 138) had both PD and low IHLC, 62 per cent of participants (n = 1509) had neither low IHLC nor PD, 18 per cent (n = 432) had PD, and 15 per cent (n = 360) low IHLC. Participants with both low IHLC and PD had significantly higher HOMA-ir than participants with neither low IHLC nor PD (Δ = 24.8%, 95%CI: 12.0-38.9), also in the fully adjusted model (Δ = 11.8%, 95%CI: 1.5-23.0). Participants with PD had significantly higher HOMA-ir (Δ = 12%, 95%CI: 5.7-18.7), but the significance was lost when BMI was included in the model (Δ = 5.3%, 95%CI:0.0-10.8). Similarly, participants with low IHLC had significantly higher HOMA-ir (Δ = 10.1%, 95%CI: 3.5-17.0) but the significance was lost in the fully adjusted model (Δ = 3.5%, 95%CI: -1.9-9.3).ConclusionsInternal health locus of control (IHLC) and psychological distress (PD) were associated with insulin resistance. Especially individuals with both PD and low IHLC may need special attention.

Background: GPs are an important part of collaboration around patients with common mental disorders (CMD) in primary care. The Co-Work-Care model was implemented to further improve collaboration, and emphasised working more closely with patients through active dialogues among care managers, rehabilitation coordinators, and GPs. This enhanced collaborative model also included a person-centred dialogue meeting with patients’ employers. Aim: The aim of this study was to explore GPs’ experiences of the Co-Work-Care model, an organisation of collaborative care at the primary care centre (PCC) that includes a person-centred dialogue meeting in the care of patients with CMD who need sick leave certification. Design & setting: Qualitative individual and group interviews were conducted with Swedish GPs with experience of the Co-Work-Care trial where the PCC was an intervention PCC with the enhanced collaboration model. Method: GPs were sampled purposefully from different Co-Work-Care intervention PCCs in Sweden. Focus group and individual, in-depth semi-structured interviews were conducted. All interviews were analysed by systematic text condensation (STC), according to Malterud. Results: The following three codes describing the GPs’ experiences of working in the Co-Work-Care model were identified: (1) a structured work approach; (2) competency of the care manager and the rehabilitation coordinator; and (3) gaining control through close collaboration. Conclusion: Overall, GPs’ experience was that the enhanced collaboration reduced their workload and enabled them to focus on medical care. Patient care was perceived as safer and more effective. These advantages may result in higher quality in medical and rehabilitation decisions, as well as a more sustainable and less stressful work situation for GPs.

Abstract Background Implementation of a care manager in a collaborative care team in Swedish primary care via a randomized controlled trial showed successful outcome. As four years have elapsed since the implementation of care managers, it is important to gain knowledge about the care managers’ long-term skills and experiences. The purpose was to examine how long-term experienced care managers perceived and experienced their role and how they related to and applied the care manager model. Method Qualitative study with a focus group and interviews with nine nurses who had worked for more than two years as care managers for common mental disorders. The analysis used Systematic Text Condensation. Results Four codes arose from the analysis: Person-centred; Acting outside the comfort zone; Successful, albeit some difficulties; Pride and satisfaction. The care manager model served as a handrail for the care manager, providing a trustful and safe environment. Difficulties sometimes arose in the collaboration with other professionals. Conclusion This study shows that long-term experience of working as a care manager contributed to an in-depth insight and understanding of the care manager model and enabled care managers to be flexible and act outside the comfort zone when providing care and support to the patient. A new concept emerged during the analytical process, i.e. the Anchored Care Manager, which described the special competencies gained through experience. Trial registration NCT02378272 Care Manager—Coordinating Care for Person Centered Management of Depression in Primary Care (PRIM—CARE).

Abstract Objectives To study the cost-effectiveness of a care manager organization for patients with mild to moderate depression in Swedish primary care in a 12-month perspective. Methods Cost-effectiveness analysis of the care manager organization compared to care as usual (CAU) in a pragmatic cluster randomised controlled trial including 192 individuals in the care manager group and 184 in the CAU group. Cost-effectiveness was assessed from a health care and societal perspectives. Costs were assessed in relation to two different health outcome measures: depression free days (DFDs) and quality adjusted life years (QALYs). Results At the 12-month follow-up, patients treated at the intervention Primary Care Centres (PCCs) with a care manager organization had larger health benefits than the group receiving usual care only at control PCCs. Mean QALY per patient was 0.73 (95% CI 0.7; 0.75) in the care manager group compared to 0.70 (95% CI 0.66; 0.73) in the CAU group. Mean DFDs was 203 (95% CI 178; 229) in the care manager group and 155 (95% CI 131; 179) in the CAU group. Further, from a societal perspective, care manager care was associated with a lower cost than care as usual, resulting in a dominant incremental cost-effectiveness ratio (ICER) for both QALYs and DFDs. From a health care perspective care manager care was related to a low cost per QALY (36,500 SEK / €3,379) and DFD (31 SEK/€3). Limitations A limitation is the fact that QALY data was impaired by insufficient EQ-5D data for some patients. Conclusions A care manager organization at the PCC to increase quality of care for patients with mild-moderate depression shows high health benefits, with no decay over time, and high cost-effectiveness both from a health care and a societal perspective. Trial registration details: The trial was registered in ClinicalTrials.com ( https://clinicaltrials.gov/ct2/show/NCT02378272 ) in 02/02/2015 with the registration number NCT02378272. The first patient was enrolled in 11/20/2014.

Objective The aim was to determine symptom patterns of depression, anxiety and stress-related mental disorders in newly sick listed due to common mental disorders in Swedish primary care patients and to examine associations with sick leave diagnosis, also in relation to socioeconomic, work-related and demographic factors.Design Cross-sectional study.Setting Primary care in western Sweden.Participants From a randomised controlled trial, patients aged 18–67, seeking primary care and on sick leave due to depression, anxiety and/or mental stress, in total 341 individuals, during 2018–2020.Primary outcome measures Patterns of depressive, anxiety and stress symptoms measured via self-assessment questionnaires (Montgomery Asberg Depression Rating Scale-Self (MADRS-S), General Anxiety Disorder Scale-7 (GAD-7), Karolinska Exhaustion Disorder Scale (KEDS)), sick leave diagnosis, perception of Work Ability Index and job strain via the job strain model.Results A combination of high levels of depressive and stress-related symptoms was more frequent than single symptom clusters among persons with common mental disorders (CMD) on sick leave: 7% of the patients had scores above cut-off for one of the instruments MADRS-S, GAD-7 and KEDS, 12% above cut-off for two and 80% had above cut-off for all three instruments. There was no significant association between low socioeconomic status, high-job strain or working in healthcare/education and having scores above cut-off level for two or more of the instruments. Only perception of own poor work ability showed association with having scores above cut-off level for all three of the assessment instruments of CMD (OR 9.45, 95% CI 2.41 to 37.04).Conclusion The diagnosis on the sick certificate is not always congruent with the dominating symptom score level. In patients sick-leaved for CMDs, possible negative factors such as low socioeconomic status, low social support, high-work strain or working in healthcare/education sector did not show significant associations with self-assessment instruments of anxiety, depression and stress. Only patient’s perception of own poor work ability was associated with high scores on all three domains.Trial registration number NCT03250026.

Abstract Background In an earlier study, PRIM-CARE RCT, a care manager implementation at the primary care centre showed improved return to work and reduced sick leave for patients with CMD. To further improve return to work, the project Co-Work-Care added a person-centered dialogue meeting between the patient, the employer and the rehabilitation coordinator, preceded by an increased collaboration between care manager, rehabilitation coordinator and GP. In this first qualitative study of the Co-Work-Care project, we explored how care managers and rehabilitation coordinators experienced the Co-Work-Care model. The purpose of this study was to explore care managers’ and rehabilitation coordinators’ perceptions and experiences of a close collaboration and the use of the person-centred dialogue meeting. Methods From an ongoing RCT with 20 primary care centres, care managers (CMs) (n = 13) and rehabilitation coordinators (RCs) (n = 12) participated in a qualitative study with focus groups. The study was conducted in the primary health care in a Swedish region. The data was analysed with Systematic Text Condensation by Malterud. Results Seven codes describing the participants’ experiences of the Co-Work-Care model were identified: 1) The importance of collaboration at the primary care centre, 2) Collaboration and division of roles between the RC and the CM, 3) Collaboration with the General practitioner (GP), 4) The person-centred dialogue meeting, 5) Initiating the person-centred dialogue meeting, 6) The person-centred dialogue meeting to improve collaboration with the employer, and 7) The person-centred dialogue meeting to teach about the return to work process. Conclusion The increased collaboration within the Co-Work-Care model created a common picture and understanding of the patient’s situation. The person-centred dialogue meeting in the rehabilitation process became a bridge between the employer and the patient. Trial registration NCT03250026 (registered August 15, 2017).

Objective: To longitudinally evaluate the impact of change in physical activity or change in body mass index (BMI) over time on the risk of developing heart failure (HF) in women without a previous diagnosis of HF. Design and setting: Longitudinal, observational, prospective study of women in Gothenburg, Sweden. Data on BMI and level of physical activity were collected from examinations 1968–1992 and hospital diagnoses and mortality data were ascertained from 1980 to 2012. Subjects: Data were obtained from 1749 women included in the Prospective Population Study of Women in Gothenburg. Main outcome measures: Hazard ratio (HR) for HF was calculated, using a Cox regression model. Results: Women with stable high physical activity during 1968–1980 and 1980–1992 reduced their risk of subsequent HF compared to the non-active women (for 1968–1980 HR 0.66, 95% Confidence Interval (CI) 0.44–0.99 and for 1980–1992 HR 0.47, 95% CI 0.29–0.74). Women with increasing levels of physical activity during 1980–1992 reduced their risk of HF compared to the non-active women (HR 0.40, 95% CI 0.22–0.72). Increase in BMI from overweight to obesity during 1968–1980 predicted increased risk of developing HF (HR 1.93, 95% CI 1.18–3.14). Conclusions: Reduced risk of future HF in healthy women may be achieved by remaining physically active from young middle age and throughout life or by increasing the level of physical activity. This is particularly important for sedentary women in middle age. The role of physical activity in preventing the development of obesity must be taken into account.Key points A sedentary lifestyle and obesity are risk factors for developing heart failure (HF) in women. The risk of developing HF may be reduced by increasing the level of activity in sedentary middle-aged women. For younger women, avoiding obesity is most important to reduce the risk of later HF. Primary care has a key role in guiding women towards the most effective lifestyle changes to prevent development of HF.

ObjectivesCommon mental disorders in combination with work-related stress are widespread in the western world, not least in Sweden. Various interactive factors, primarily work-related, have impact on the return to work process, for example; a supportive communicative function between the person on sick leave and the employer may facilitate this process. The aim was to investigate experiences of being part of a collaborative care model including a person-centered dialogue meeting with the employer and with a rehabilitation coordinator as the moderator.MethodsA qualitative design based on individual interviews with 13 persons diagnosed with common mental disorders who participated in an extensive collaborative care model, called the Co-Work-Care model. Persons were recruited as a heterogeneous sample with respect to age, gender, work background, and time since the intervention. All interviews were analyzed with Systematic Text Condensation.ResultsFive codes synthesized the results: 1) A feeling of being taken care of, 2) Collaboration within the team was perceived as supportive, 3) An active and sensitive listener, 4) Structure and planning in the dialogue meeting, 5) The person-centered dialogue meeting was supportive and provided increased understanding.ConclusionsParticipants experienced the close collaborative contact with the care manager and the rehabilitation coordinator as highly valuable for their rehabilitation process. Participants valued a well-structured dialogue meeting that included initial planning and a thorough communication involving the patient, the employer, and coordinator. Further, participants appreciated having an active role during the meeting, also empowering the return to work process.

Objective To examine height changes in middle-aged northern European women in relation to overall and cardiovascular mortality.Design Population-based cohort studies with longitudinally measured heights and register-based mortality.Setting Sweden and Denmark.Participants Population-based samples of 2406 Swedish and Danish women born on selected years in 1908–1952, recruited to baseline examinations at ages 30–60, and re-examined 10–13 years later.Main outcome measure Total and cardiovascular disease (CVD) specific mortality during 17–19 years of follow-up after last height measure.Results For each 1 cm height loss during 10–13 years, the HR (95% CI) for total mortality was 1.14 (1.05 to 1.23) in Swedish women and 1.21 (1.09 to 1.35) in Danish women, independent of key covariates. Low height and high leisure time physical activity at baseline were protective of height loss, independent of age. Considering total mortality, the HR for major height loss, defined as height loss greater than 2 cm, were 1.74 (1.32 to 2.29) in Swedish women and 1.80 (1.27 to 2.54) in Danish women. Pooled analyses indicated that height loss was monotonically associated with an increased mortality, confirming a significant effect above 2 cm height loss. For cause-specific mortality, major height loss was associated with a HR of 2.31 (1.09 to 4.87) for stroke mortality, 2.14 (1.47 to 3.12) for total CVD mortality and 1.71 (1.28 to 2.29) for mortality due to causes other than CVD.Conclusion Height loss is a marker for excess mortality in northern European women. Specifically the hazard of CVD mortality is increased in women with height loss during middle age, and the results suggest that the strongest cause-specific endpoint may be stroke mortality. The present findings suggest attention to height loss in early and mid-adulthood to identify women at high risk of CVD, and that regular physical activity may prevent early onset height loss.

Objective: Explore general practitioners’ (GPs’) views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs’ views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members’ roles must be clear.KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs’ experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

Abstract Aim To explore experiences among patients with depression of contact with a care manager at a primary care centre. Design A qualitative explorative study. Methods During spring and summer 2016, 20 individual face‐to‐face interviews were conducted with patients with experience of care manager contact. The material was analysed using systematic text condensation. Results The participants described that having contact with a care manager was a support in their recovery process. Care became more available, and the structured continuous contact and the care manager's availability contributed to a trusting relationship. Having someone to share their burden with was a relief. However, it was described as negative when the care manager was perceived as inflexible and not open to issues that the participants felt a need to discuss. For the care manager contact to be successful, there is a need for flexibility and individually tailored contact.

We herein outline the rationale for a Swedish cohort consortium, aiming to facilitate greater use of Swedish cohorts for world-class research. Coordination of all Swedish prospective population-based cohorts in a common infrastructure would enable more precise research findings and facilitate research on rare exposures and outcomes, leading to better utilization of study participants’ data, better return of funders’ investments, and higher benefit to patients and populations. We motivate the proposed infrastructure partly by lessons learned from a pilot study encompassing data from 21 cohorts. We envisage a standing Swedish cohort consortium that would drive development of epidemiological research methods and strengthen the Swedish as well as international epidemiological competence, community, and competitiveness.

Background: An increasing number of patients are on sick leave because of common mental disorders (CMD), with or without antidepressant therapy. There is a lack of long-term follow-up studies in the primary care context, where most of the patients are treated. The importance of identifying potential factors associated with work ability for CMD patients is increasingly in focus. Objective: To investigate the associations between using antidepressants, sick leave duration, reported work ability and psychological symptoms among patients with CMD during a two-year observation period in the primary care context. Methods: Longitudinal observational cohort study at 28 Primary Care Centers in Region Västra Götaland, Sweden, including 182 patients with an employment and on sick leave for CMD. The following outcomes were assessed: work ability measured with WAI, depressive symptoms with MADRS-S, anxiety symptoms with BAI, fatigue symptoms with KEDS, quality of life with EQ-5D, and days of sick leave. The data were compared between the groups that used and did not use antidepressants, during the 24-months observation period. Results: Work ability and health-related quality of life increased over time in both groups. A steeper decrease of depressive symptoms, anxiety symptoms as well as an increased health-related quality of life at 3, 6 and 12 months was found in the group without antidepressants, although both groups levelled off at 24 months. In both groups, a higher work ability at baseline was associated with less two-year sick leave. Conclusion: Our study indicates that a high work ability at baseline has a strong association with a lower total net and gross sick leave duration during the entire two-year follow-up period for patients with CMD in primary health care, irrespective of use of antidepressants. Using WAI in primary health care could therefore be helpful in predicting return to work. Use of antidepressants during the CMD episode could indicate initially a more pronounced overall symptom pattern, motivating introduction of antidepressants, rather than prolonging the sick leave period.

Objective To evaluate the implementation of a care manager organisation for common mental disorders and its association with antidepressant medication patterns on primary care centre (PCC) level, compared with PCCs without this organisation. Moreover, to determine whether a care manager organisation is associated with antidepressant medication patterns that is more in accordance with treatment guidelines.Design Register-based study on PCC level.Setting Primary care in Region Västra Götaland, Sweden.Participants All PCCs in the region. PCCs were analysed in three subgroups: PCCs with a care manager organisation during 2015 and 2016 (n=68), PCCs without the organisation (n=92) and PCCs that shifted to a care manager organisation during 2016 (n=42).Outcome measures Proportion of inadequate medication users, defined as number of patients >18 years with a common mental disorder diagnosis receiving care at a PCC in the region during the study period and dispensed 1–179 defined daily doses (DDD) of antidepressants of total patients with at least 1 DDD. The outcome was analysed through generalised linear regression and a linear mixed-effects model.Results Overall, all PCCs had about 30%–34% of inadequate medication users. PCCs with a care manager organisation had significantly lower proportion of inadequate medication users in 2016 compared with PCCs without (−6.4%, p=0.02). These differences were explained by higher proportions in privately run PCCs. PCCs that shifted to a care manager organisation had a significant decrease in inadequate medication users over time (p=0.01).Conclusions Public PCCs had a more consistent antidepressant medication pattern compared with private PCCs that gained more by introducing a care manager organisation. It was possible to document a significant decrease in inadequate medication users, notwithstanding that PCCs in the region followed the guidelines to a comparatively high extent regardless of present care manager organisation.

Objectives To perform an analysis of collaborative care with a care manager implementation in a primary healthcare setting. The study has a twofold aim: (1) to examine clinicians’ and directors’ perceptions of implementing collaborative care with a care manager for patients with depression at the primary care centre (PCC), and (2) to identify barriers and facilitators that influenced this implementation.Design A cross-sectional study was performed in 2016–2017 in parallel with a cluster-randomised controlled trial.Setting 36 PCCs in south-west Sweden.Participants PCCs’ directors and clinicians.Outcome Data regarding the study’s aims were collected by two web-based questionnaires (directors, clinicians). Descriptive statistics and qualitative content analysis were used for analysis.Results Among the 36 PCCs, 461 (59%) clinicians and 36 (100%) directors participated. Fifty-two per cent of clinicians could cooperate with the care manager without problems. Forty per cent regarded to their knowledge of the care manager assignment as insufficient. Around two-thirds perceived that collaborating with the care manager was part of their duty as PCC staff. Almost 90% of the PCCs’ directors considered that the assignment of the care manager was clearly designed, around 70% considered the priority of the implementation to be high and around 90% were positive to the implementation. Facilitators consisted of support from colleagues and directors, cooperative skills and positive attitudes. Barriers were high workload, shortage of staff and extensive requirements and demands from healthcare management.Conclusions Our study confirms that the care manager puts collaborative care into practice. Facilitators and barriers of the implementation, such as time, information, soft values and attitudes, financial structure need to be considered when implementing care managers at PCCs.

Objective: The aim of this study was to explore nurses’ experiences and perceptions of working as care managers at primary care centers. Design: Qualitative, focus group study. Systematic text condensation was used to analyze the data. Setting: Primary health care in the region of Västra Götaland and region of Dalarna in Sweden. Subjects: Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support. Main outcome measures: The nurses’ experiences and perceptions of working as care managers at primary care centers. Results: The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression. Conclusion: The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care.Key Points The care managers described their role as an additional support to the already existing care at the primary care center. • They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression. • Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful. • Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.

Objective: To explore secular trends in physical activity in relation to socioeconomic position in middle-aged women, with focus on whether the social gaps have become wider, narrower, or remain unchanged. Design: Cohort comparisons between two representative samples of women, recruited in 1980–81 and 2004–05 as a part of the Population Study of Women in Gothenburg. Setting: Gothenburg, the second largest city of Sweden, with ≈ 450 000 inhabitants. Subjects: Population-based cohorts of 38- and 50-year-old women, invited in 1980–81 and 2004–05 to free health examinations. The study population in 1980 was n = 477, 38- and 50-year-old women born in 1930 (n = 355) and 1942 (n = 122), and in 2004 n = 500, 38- and 50-year- old women born in 1966 (n = 207) and 1954 (n = 293). Main outcome measure: Physical activity at work and leisure time. Socioeconomic position was defined based on socio-occupational group and level of education. Physical activity during work and leisure time was based on questionnaires. Results: On average 38- and 50-year-old women were more physically active at work and leisure time in 2004–05 compared to 1980–81; odds ratio (OR) for increase over time for physical activity at work for 38-year-olds: 2.59, (95% confidence interval (CI) 1.65–4.07), and for 50-year-olds: OR 2.09 (1.52–2.88); OR for increase physical activity leisure time in 38-year-olds: 1.93 (1.25–2.98), and in 50-year-olds 2.04 (1.49–2.79). There were no significant differences between socioeconomic groups in physical activity levels changes over time. Conclusion: Women in different socioeconomic groups improved their physical activity at work and leisure time to the same extent from 1980 to 2004, indicating that the socioeconomic gap in physical activity is neither increasing nor decreasing.Key Points The gap in physical activity levels between socioeconomic groups seems to have remained stable for middle-aged women the last 25 years. • However, women were more physically active in 2004 at work and during leisure time, independent of socioeconomic position, compared to 1980. • It remains a great challenge to create structures that enable these behaviours for all social groups.

Abstract Background Depression is one of the leading causes of disability and affects 10-15% of the population. The majority of people with depressive symptoms seek care and are treated in primary care. Evidence internationally for high quality care supports collaborative care with a care manager. Our aim was to study clinical effectiveness of a care manager intervention in management of primary care patients with depression in Sweden. Methods In a pragmatic cluster randomized controlled trial 23 primary care centers (PCCs), urban and rural, included patients aged ≥ 18 years with a new (

Objective: Internet-delivered cognitive behavioral therapy (ICBT) is recommended as an efficient treatment alternative for depression in primary care. However, only few previous studies have been conducted at primary care centers (PCCs). We evaluated long-term effects of ICBT treatment for depression compared to treatment as usual (TAU) in primary care settings. Design: Randomized controlled trial. Setting: Patients were enrolled at16 PCCs in south-west Sweden. Participants: Patients attending PCCs and diagnosed with depression (n = 90). Interventions: Patients were assessed by a primary care psychologist/psychotherapist and randomized to ICBT or TAU. The ICBT included an ICBT program consisting of seven modules and weekly therapist e-mail or telephone support during the 3-month treatment period. Main outcome measures: Questionnaires on depressive symptoms (BDI-II), quality of life (EQ-5D) and psychological distress (GHQ-12) were administered at baseline, with follow-ups at 3, 6 and 12 months. Antidepressants and sedatives use, sick leave and PCC contacts were registered. Results: Intra-individual change in depressive symptoms did not differ between the ICBT group and the TAU group during the treatment period or across the follow-up periods. At 3-month follow-up, significantly fewer patients in ICBT were on antidepressants. However, the difference leveled out at later follow-ups. There were no differences between the groups concerning psychological distress, sick leave or quality of life, except for a larger improvement in quality of life in the TAU group during the 0- to 6-month period. Conclusions: ICBT with weekly minimal therapist support in primary care can be equally effective as TAU among depressed patients also over a 12-month period. Clinical trial registration: The trial was registered in the Swedish Registry, researchweb.org, ID number 30511.

Objective: We aim to describe medical services provided by Nordic general practitioners (GPs), and to explore possible differences between the countries. Design and setting: We did a comparative analysis of selected data from the Nordic part of the study Quality and Costs of Primary Care in Europe (QUALICOPC). Subjects: A total of 875 Nordic GPs (198 Norwegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answered identical questionnaires regarding their practices. Main outcome measures: The GPs indicated which equipment they used in practice, which procedures that were carried out, and to what extent they were involved in treatment/follow-up of a selection of diagnoses. Results: The Danish GPs performed minor surgical procedures significantly less frequent than GPs in all other countries, although they inserted IUDs significantly more often than GPs in Iceland, Sweden and Finland. Finnish GPs performed a majority of the medical procedures more frequently than GPs in the other countries. The GPs in Iceland reported involvement in a more narrow selection of conditions than the GPs in the other countries. The Finnish GPs had more advanced technical equipment than GPs in all other Nordic countries. Conclusions: GPs in all Nordic countries are well equipped and offer a wide range of medical services, yet with a substantial variation between countries. There was no clear pattern of GPs in one country doing consistently more procedures, having consistently more equipment and treating a larger diversity of medical conditions than GPs in the other countries. However, structural factors seemed to affect the services offered.

Objective: The objective of this study was to explore primary care patients’ experiences of Internet mediated cognitive behavioural therapy (iCBT) depression treatment. Design: Qualitative study. Data were collected from focus group discussions and individual interviews. Setting: Primary care. Method: Data were analysed by systematic text condensation by Malterud. Subjects: Thirteen patients having received iCBT for depression within the PRIM-NET study. Main outcome measures: Analysis presented different aspects of patients’ experiences of iCBT. Results: The informants described a need for face-to-face meetings with a therapist. A therapist who performed check-ups and supported the iCBT process seemed important. iCBT implies that a responsibility for the treatment is taken by the patient, and some patients felt left alone, while others felt well and secure. This was a way to work in privacy and freedom with a smoothly working technology although there was a lack of confidence and a feeling of risk regarding iCBT. Conclusion: iCBT is an attractive alternative to some patients with depression in primary care, but not to all. An individual treatment design seems to be preferred, and elements of iCBT could be included as a complement when treating depression in primary care. Such a procedure could relieve the overall treatment burden of depression.Key points Internet mediated cognitive behavioural therapy (iCBT) can be effective in treating depression in primary care, but patients’ experiences of iCBT are rarely studied • Most patients express a need for human contact, real-time interaction, dialogue and guidance when treated for depression. • The patient’s opportunity to influence the practical circumstances about iCBT is a success factor, though this freedom brings a large responsibility upon the receiver. • An individual treatment design seems to be crucial, and elements of iCBT could be included as a complement to face-to-face meetings.

Summary: Background: To help adapt cardiovascular disease risk prediction approaches to low-income and middle-income countries, WHO has convened an effort to develop, evaluate, and illustrate revised risk models. Here, we report the derivation, validation, and illustration of the revised WHO cardiovascular disease risk prediction charts that have been adapted to the circumstances of 21 global regions. Methods: In this model revision initiative, we derived 10-year risk prediction models for fatal and non-fatal cardiovascular disease (ie, myocardial infarction and stroke) using individual participant data from the Emerging Risk Factors Collaboration. Models included information on age, smoking status, systolic blood pressure, history of diabetes, and total cholesterol. For derivation, we included participants aged 40–80 years without a known baseline history of cardiovascular disease, who were followed up until the first myocardial infarction, fatal coronary heart disease, or stroke event. We recalibrated models using age-specific and sex-specific incidences and risk factor values available from 21 global regions. For external validation, we analysed individual participant data from studies distinct from those used in model derivation. We illustrated models by analysing data on a further 123 743 individuals from surveys in 79 countries collected with the WHO STEPwise Approach to Surveillance. Findings: Our risk model derivation involved 376 177 individuals from 85 cohorts, and 19 333 incident cardiovascular events recorded during 10 years of follow-up. The derived risk prediction models discriminated well in external validation cohorts (19 cohorts, 1 096 061 individuals, 25 950 cardiovascular disease events), with Harrell's C indices ranging from 0·685 (95% CI 0·629–0·741) to 0·833 (0·783–0·882). For a given risk factor profile, we found substantial variation across global regions in the estimated 10-year predicted risk. For example, estimated cardiovascular disease risk for a 60-year-old male smoker without diabetes and with systolic blood pressure of 140 mm Hg and total cholesterol of 5 mmol/L ranged from 11% in Andean Latin America to 30% in central Asia. When applied to data from 79 countries (mostly low-income and middle-income countries), the proportion of individuals aged 40–64 years estimated to be at greater than 20% risk ranged from less than 1% in Uganda to more than 16% in Egypt. Interpretation: We have derived, calibrated, and validated new WHO risk prediction models to estimate cardiovascular disease risk in 21 Global Burden of Disease regions. The widespread use of these models could enhance the accuracy, practicability, and sustainability of efforts to reduce the burden of cardiovascular disease worldwide. Funding: World Health Organization, British Heart Foundation (BHF), BHF Cambridge Centre for Research Excellence, UK Medical Research Council, and National Institute for Health Research.

ObjectiveOur aim was to explore how the care managers put the complex care manager task into practice and how they perceived their task, which was to facilitate effective, person-centred treatment for stress-related disorder concordant with evidence-based guidelines in primary care.DesignThis was a qualitative study using examination reports from the course for care managers. Systematic text condensation according to Malterud was used for the analysis.SettingPrimary health care centres.SubjectTwenty-eight newly educated care managers in primary health care participated in the study. The median age was 50 (31-68) years. Twenty-seven were women and one was a man. Twenty-one were employed as nurses and seven as counsellors.ResultsThe informants perceived the role as care manager as meaningful but at times complicated. To participate in teams and to work closely with the general practitioner was experienced as important. The co-ordinating function was emphasised as especially important, as well as the increased continuity in care. The dual role as care manager and counsellor was sometimes experienced as problematic.ConclusionThe informants took advantage of the knowledge they had attained during the course. They perceived themselves as being a bridge between patients and other professionals. The result of having dual roles at the primary health care centre unexpectedly revealed difficulties for some professionals. The nurses seemed more familiar with the new way of working.

Background: Compared to other European countries, Sweden's yearly sick leave expenditures are moderate. Common mental disorders (CMD) are important causes of sick leave, affecting 10–15% of the adult population. A Swedish register based study indicates that antidepressant therapy for patients on long-term sick leave for CMD leads to longer sick leave and higher frequency of non-time-limited sickness compensation as compared to psychotherapy, work oriented rehabilitation, and other therapies. Aim: To verify if patients on antidepressant therapy and on long-term sick leave for depression, anxiety and stress-related mental disorders have a longer sick leave than patients treated with other therapies. Method: Prospective, observational study at 28 primary health care centers in the Region Västra Götaland, Sweden, including 192 patients on sick leave for CMD. Outcome measures were gross and net sick leave days. Interpretation: There were no significant differences in sick leave days (gross or net) due to CMD when comparing the patients treated and not treated with antidepressants during the 12 month observation period. The groups differed at baseline only concerning frequency of exhaustion disorder, with a higher frequency of exhaustion disorder in the group without antidepressants. Analysis of other possible factors associated with shorter or longer sick leave only showed associations with the patient's own perception of possibility of returning to work in near and distant future. An important factor associated with longer sick leave was the patient's own perception of possibility of return to present workplace. As CMD are important causes of sick leave and sick leave costs, this factor should be highlighted in future research on the rehabilitation process.

Objective: The aim of the current study was to better understand how patients with depression perceive the use of MADRS-S in primary care consultations with GPs. Design: Qualitative study. Focus group discussion and analysis through Systematic Text Condensation. Setting: Primary Health Care, Region Västra Götaland, Sweden. Subjects: Nine patients with mild/moderate depression who participated in a RCT evaluating the effects of regular use of the Montgomery-Åsberg Depression Self-assessment scale (MADRS-S) during the GP consultations. Main Outcome measure: Patients’ experiences and perceptions of the use of MADRS-S in primary care. Results: Three categories emerged from the analysis: (I) confirmation; MADRS-S shows that I have depression and how serious it is, (II) centeredness; the most important thing is for the GP to listen to and take me seriously and (III) clarification; MADRS-S helps me understand why I need treatment for depression. Conclusion: Use of MADRS-S was perceived as a confirmation for the patients that they had depression and how serious it was. MADRS-S showed the patients something black on white that describes and confirms the diagnosis. The informants emphasized the importance of patient-centeredness; of being listened to and to be taken seriously during the consultation. Use of self-assessment scales such as MADRS-S could find its place, but needs to adjust to the multifaceted environment that primary care provides.Key Points Patients with depression in primary care perceive that the use of a self-assessment scale in the consultation purposefully can contribute in several ways. The scale contributes to Confirmation: MADRS-S shows that I have depression and how serious it is. Centeredness: The most important thing is for the GP to listen to and take me seriously. Clarification: MADRS-S helps me understand why I need treatment for depression.

Objective: To explore whether a primary health care (PHC) health promotion programme reaches and engages socioeconomically vulnerable groups in a community to the same extent as higher socioeconomic groups. Design: Comparison of level of engagement and lifestyle improvements stratified by socioeconomic vulnerability level. Setting: Hisingen PHC catchment area (130,000 inhabitants) Gothenburg, Sweden. Participants: Men and women aged 18–79, visiting any of the eight public PHC centres during an eight-month period 2007–2008, were presented with a short intervention health questionnaire and offered a health dialogue with a nurse, including a health profile, p-glucose and blood pressure check. Participants were classified according to four socioeconomic vulnerability factors: education, employment, ethnicity and living situation. Results: Out of 3691 participants, 27% had low education (Hisingen community level 23%), 18% were unemployed (community level 22%), and 16% were born outside Scandinavia (community level 22%). At the one-year follow-up, 2121 (57%) attended. At baseline, 3% of the individuals in the sample had three out of four socioeconomic vulnerability factors, 17% had two vulnerability factors, 43% had one vulnerability factor, and 37% had no vulnerability factors. Improved biological markers were seen in all vulnerability groups (1–3) and odds ratios for improvement were significantly higher in the most socioeconomically vulnerable group for smoking and stress compared to the group with no vulnerability factors. Conclusion: Socioeconomically vulnerable groups were reached and lifestyle changes were accomplished to the same extent as in the higher socioeconomic groups in a PHC lifestyle intervention programme.KEY POINTS Primary care plays a major part in prevention of chronic diseases. However, non-pharmacological primary and secondary prevention is often less successful, especially concerning socioeconomically vulnerable groups. The health promoting intervention programme “Pro-Health” reached and engaged socioeconomically vulnerable groups. Participants from the socioeconomically vulnerable groups had comparable odds for lifestyle improvements after one year, compared to participants without vulnerability factors.

Background: The current knowledge of internet-based cognitive behavior therapy (ICBT) implemented in primary care settings is sparse. Our objective was to explore primary care therapists' experiences and attitudes of ICBT, the opportunities and conditions for research in primary care, and to identify potential barriers to the implementation of ICBT treatment in primary care. Methods: Eleven therapists (of 14) participating in the research and implementation project PRIM-NET completed a survey. Four of them were selected also for a detailed semi-structured interview. Data from the interviews were analyzed qualitatively and according to methods used in implementation science. Results: Six general themes were identified in which the therapists considered ICBT as a good treatment that ought to be introduced in primary care. To optimize procedure in primary care settings, several adaptations of ICBT were suggested. Integrating and blending ICBT and face-to-face therapies, for example, would render primary care psychology more efficient. The PRIM-NET study and research within primary care was seen as rewarding and necessary, but challenging. To a large extent primary care still revolves around the general practitioner, with a focus on production, finances, and a somatic aspect of the patients. Five possible barriers to implementation of ICBT were identified which perhaps explains why psychological procedures are not fully integrated into primary care. Conclusions: Although the implementation of new methods and routines is typically accompanied by challenges, the overall experience of the therapists supports the implementation of ICBT as an additional treatment in primary care.