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Background: Youth mental health is a major health concern in almost every country. Mental health accounts for about 13% of the global burden of disease in the 10-to-19-year age group. Still there are significant gaps between the mental health needs of young people and the quality and accessibility of available services. Collaboration between health and social service actors is a recognized way of reducing gaps in quality and access. Yet there is little scientific evidence on how these collaborations are applied, or on the challenges of cross-boundary collaboration in the youth mental health space. This study aims to explore how collaboration is understood and practiced by professionals working in the Swedish youth mental health system. Methods: We conducted 42 interviews (November 2020 to March 2022) with health and social care professionalsand managers in the youth mental health system in Sweden. Interviews explored participants’ experience andunderstanding of the purpose, realization, and challenges of collaboration. Data were analysed under an emergentstudy design using reflexive thematic analysis. Results: The analysis produced three themes. The first shows that collaboration is considered as essential andimportant, and that it serves diverse purposes and holds multiple meanings in relation to professionals’ roles andresponsibilities. The second addresses the different layers of collaboration, in relation to activities, relationships, andtarget levels, and the third captures the challenges and criticisms in collaborating across the youth mental healthlandscape, but also in growing possibilities for future development. Conclusion: We conclude that collaboration serves multiple purposes and takes many shapes in the Swedish youth mental health system. Despite the many challenges, participants saw potential in further building collaboration. Interestingly our participants also raised concerns about too much collaboration. There was scepticism about collaboration dir

Introduction: Numerous studies globally confirmed that young prisoners are more susceptible to mental health problemscompared to adult prisoners and the general population. The lack of life skills has been reported as one of the main reasons forthis vulnerability. This study aimed to assess the effectiveness of a life skills education program on mental health and life skillsamong young prisoners in Cambodia. Method: This is an intervention study, applying a ‘difference-in-difference’ analysis. The life skills education program wasimplemented to promote essential skills for mental health and social competence among young prisoners. Mental health and lifeskills competence were evaluated using the Youth Self-Report and Life Skills Development – Adolescent Form scales, respectively.Four prisons were selected from a total of 24 prisons in Cambodia, a post-conflict country in Southeast Asia. A total of 412 youngprisoners aged 15–24 years participated in the study and were randomly assigned to intervention and control groups. Results: Both the intervention and control groups reported decreased mental health problems (DiD=3.78, p=0.34) and improvedlife skills competencies (DiD=0.39, p=0.80) after the intervention; however, the differences were not statistically significant. Conclusion: The life skills intervention program had no significant effect on young prisoners’ mental health and life skillscompetencies. Further studies should be conducted to evaluate the impact of the life skills education program in the prison setting,particularly in low- and middle-income countries (LMICs) such as Cambodia.

Introduction: Numerous studies globally confirmed that young prisoners are more susceptible to mental health problemscompared to adult prisoners and the general population. The lack of life skills has been reported as one of the main reasons forthis vulnerability. This study aimed to assess the effectiveness of a life skills education program on mental health and life skillsamong young prisoners in Cambodia. Method: This is an intervention study, applying a ‘difference-in-difference’ analysis. The life skills education program wasimplemented to promote essential skills for mental health and social competence among young prisoners. Mental health and lifeskills competence were evaluated using the Youth Self-Report and Life Skills Development – Adolescent Form scales, respectively.Four prisons were selected from a total of 24 prisons in Cambodia, a post-conflict country in Southeast Asia. A total of 412 youngprisoners aged 15–24 years participated in the study and were randomly assigned to intervention and control groups. Results: Both the intervention and control groups reported decreased mental health problems (DiD=3.78, p=0.34) and improvedlife skills competencies (DiD=0.39, p=0.80) after the intervention; however, the differences were not statistically significant. Conclusion: The life skills intervention program had no significant effect on young prisoners’ mental health and life skillscompetencies. Further studies should be conducted to evaluate the impact of the life skills education program in the prison setting,particularly in low- and middle-income countries (LMICs) such as Cambodia.

Folkhälsomyndigheten (Fohm) har sedan 2018 regeringens uppdrag att bidra med kunskapshöjande insatser för att minska stigmatiseringen av psykisk ohälsa och suicid. Avtal har inledningsvis slutits med tre regioner för att stärka dessas främjande och preventiva arbete för att minska stigmatisering av psykisk ohälsa och suicid. Umeå universitet har fått uppdraget att genomföra en processutvärderingmed implementeringsperspektiv under 2021. Utvärderingen har syftat till att bidra med en fördjupad förståelse för implementeringen av det regionala utvecklingsarbetet. Utvärderingen vilar på analyser av dokument, enkäter och fokusgruppsintervjuer från de medverkande regionerna. Utvärderingen har delvis tagit sin utgångspunkt i det teoretiska ramverket the Consolidated Framework for Implementation Research (CFIR). CFIR sammanfattar befintlig litteratur om faktorer som påverkar implementeringsprocesser och utfall. Resultaten visar att de undersökta faktorerna, av de allra flesta medverkande aktörerna, betraktas som viktiga förutsättningar för utvecklingsarbetets implementering. Det råder viss variation i deltagarnas uppfattningar om i vilken utsträckning dessa förutsättningar finns på plats och hur väl de fungerar idag. Förutsättningar och utmaningar har varierat i regionerna. De faktorer som en övervägande del respondenter skattat som extra utmanande i genomförandet av utvecklingsarbetet återfinns i organisationernas inre kontext och utgörs av Utvecklingsarbetets givna prioritet; Målens tydlighet och hur dessa kommunicerats; Utvecklingsarbetets organisering och; Hur kända mottagarkontextens behov är i organisationen. Gemensamma framgångsfaktorer som beskrivits är en god samverkan mellan olika aktörer; en ökad medvetenhet i regionerna om vikten av att arbeta med stigma av psykisk ohälsa och suicid; ett yttre tryck från nationella aktörer som bidrar till att prioritera dessa frågor; samt att det finns en bred förankring i politisk- och tjänstemannaledning som ger ett tydligt man

Background: Sweden has provided around 300 youth clinics (YCs) to address the health needs of young people since the 1970s. During the last few years, and as part of an effort to strengthen mental healthcare for young people, YCs’ role in the provision of mental healthcare has been widely debated. With such debates as background, the aim of this study is to analyse Swedish YCs’ responses to the mental (ill) healthcare needs of young people, from the perspective of national level stakeholders. Methods: We used thematic analysis of interviews with eight national level stakeholders in the field of youth mental health in Sweden. Building upon the concept of biomedicalization we examined the discourses on mental (ill) health, healthcare and youth that such responses reproduce. Results: YCs engage in the three simultaneous, but at times contradictory, responses of protecting, managing and bending boundaries. Remaining true to their mission as a health-promotion service compels them to protect their boundaries and limit the type of mental health issues they address. However, the perceived malfunctioning of specialized services has led them to bend these boundaries to allow in more young people with severe mental health problems. Caught between protecting and bending boundaries, the response of managing boundaries to decide who should be allowed in and who should be sent elsewhere has emerged as a middle-way response. However, it is not free from conflicts. Conclusion: Building upon the concept of biomedicalization, this study poses two questions. The first relates to whether it is possible to support young people and their health without reinforcing discourses that represent young people as collectively at risk, and if so how this can be done. The second relates to the provision of mental healthcare for young people, and the need to identify conditions for integrating diagnosis and treatment within YCs, without hindering their holistic and youth-centred approach.

Objective: Several studies have reported that Somalis have negative attitudes about using modern contraceptives. However, little attention has been paid to the differences in Somali women's attitudes toward contraceptives across generations and the attitude change happening overtime in Somali women's attitudes toward contraception. This study explores attitudes toward contraceptives and factors influencing contraceptive use, among first- and second-generation Somali women living in Finland. Methods: The study follows a qualitative design with data collection using in-depth interviews. Sixteen women were interviewed regarding their knowledge of, attitude toward, and use of contraceptives. Eight of the study participants were first-generation and eight were second-generation Somali women living in Finland. The data were analyzed using a thematic approach guided by a cultural anthropology framework. Results: Three main themes emerged in the data analysis: (1) Culture influencing Somali women's attitudes toward contraceptives; (2) information sources can work differently within the same cultural group; and (3) Somali women's perspectives on contraceptives change over time. Cultural, religion, taboo, and knowledge resources are used to understand the whole concept of Somali women's attitude toward and use of contraceptives. Hence, the study shows the diverse opinions of Somali women. According to the informants the main underlying factors influencing Somali women's attitudes toward contraceptives were education, culture, misinterpreted religion, and social pressure. Conclusions: According to the Finish resident women interviewed for this study, Somali culture do not support the use of modern contraceptives. Even though attitudes towards contraceptives are slowly changing, there is a need for SRH education, particularly among first-generation Somalis. Second-generation women are generally more open to the use of modern contraceptives. The study also draws attention to the

Objective: Expressions of emotional and behavioral symptoms in preschool age can predict mental health problems in adolescence and adulthood. The Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) has been successful in detecting social and emotional problems in young children in some countries but had not been tested in Sweden. The objective of this study was to determine the optimal cut-off for the ASQ:SE instrument when administered to 3-year-old children in a northern Swedish setting, using the Strengths and Difficulties Questionnaire (SDQ) as the reference. Methods: The ASQ:SE (36-month interval, first edition) was administered at routine 3-year-olds' visits to Child Health Care centers in Region Västerbotten, Sweden. During the study period (September 2017 to March 2018) parents were invited to also fill out the SDQ (2–4 year version). In the final analyses 191 children fulfilled the criteria for inclusion in the study sample. Non-parametric Receiver Operating Characteristic analysis was performed to quantify the discriminatory accuracy of ASQ:SE based on SDQ. Results: The Pearson correlation between ASQ:SE and SDQ indicated strong correlation between the two instruments. The Receiver Operating Characteristic curve showed good accuracy of ASQ:SE in relation to SDQ. However, our results suggest that the existing ASQ:SE cut-off score of 59 was not optimal in the Swedish context. Changing the cut-off from 59 to 50 would allow us to detect 100% (n = 14) of children with problems according to SDQ, compared to 64% (n = 9) when the cut-off was 59. However, the proportion of false positives would be higher (9% compared to 3%). Conclusion: The main finding was that for 3-year-olds in Sweden a decreased ASQ:SE cut-off score of 50 would be optimal. This would increase the detection rate of at-risk children according to SDQ (true positive), thus prioritizing sensitivity. Our conclusion is that, although this change would result in more false positives, this would b

Introduction: Capability-adjusted life years Sweden (CALY-SWE) are a new Swedish questionnaire-based measure for quality of life based on the capability approach. CALY-SWE are targeted towards use in cost-effectiveness evaluations of social welfare consequences. Here, we first motivate the measure both from a theoretical and from a Swedish policy-making perspective. Then, we outline the core principles of the measure, namely the relation to the capability approach, embedded equity considerations inspired by the fair-innings approach, and the bases for which capabilities should be considered. The aims were to 1) the most vital capabilities for individuals in Sweden, 2) to define a sufficient level of each identified capability to lead a flourishing life, and to 3) develop a complete questionnaire for the measurement of the identified capabilities. Material and methods: For the selection of capabilities, we used a Delphi process with Swedish civil society representants. To inform the questionnaire development, we conducted a web survey in three versions, with each Swedish 500 participants, to assess the distribution of capabilities that resulted from the Delphi process in the Swedish population. Each version was formulated with different strictness so that less strict wordings of a capability level would apply to a larger share of participants. All versions also included questions on inequality aversion regarding financial, educational, and health capabilities. Results: The Delphi process resulted in the following six capabilities: Financial situation & housing, health, social relations, occupations, security, and political & civil rights. We formulated the final phrasing for the questionnaire based on normative reasons and the distribution of capabilities in the population while taking into account inequality aversion. Conclusion: We developed a capability-based model for cost effectiveness economic evaluations of broader social consequences, specific to the

PURPOSE: To examine how rural municipalities develop services to people with serious mental illness in relation to evidence-based practice and national guidelines. Additional sources of knowledge and strategies used by the municipalities in relation to their development needs were explored as well. METHOD: Qualitative multiple-case approach, with 43 deep-interviews involving 84 informants representing selected social psychiatric services from 11 sites. RESULTS: National guidelines and evidence-based practices have a limited impact on how rural municipalities develop services to the target group. The municipalities favor other sources of knowledge, including regional networks, pragmatic problem-solving approaches and community-based knowledge. DISCUSSION AND CONCLUSION: Most of the informants expressed a need for more systematic and evidence-based knowledge in order to meet their clients’ needs. A major challenge to improve the utilization of these methods, is to make adaptions to match the rural municipalities’ needs and actual resources without risking the quality of these evidence-based services.

BACKGROUND: Mental health problems are one of the most pressing public health concerns of our time. Sweden has seen a sharp increase in mental disorders among children and youth during the last decade. The evidence base for treatment of psychiatric conditions has developed strongly. Clinical practice guidelines aim to compile such evidence and support healthcare professionals in evidence-based clinical decision-making. In Sweden, the national guidelines for the treatment of depression and anxiety disorders in children and adolescents were launched in 2010. The aim of this study was two folded, (i) to explore to what extent these guidelines were known and adhered to by health professionals in Child and Adolescent Mental Health Services and (ii) to investigate factors influencing implementation of the guidelines informed by the Consolidated Framework for Implementation Research. METHODS: A qualitative approach was used, and data were collected through interviews with 18 health professionals in Child Mental Health Services in Sweden and a combination of conventional and directed content analyses was used. The Consolidated Framework for Implementation Research guided and structured data collection and analysis. RESULTS: The guidelines were largely unknown by health professionals in Child Mental Health Services in all the clinics investigated. Adherence to guideline recommendations was reported as very low. Barriers to implementation were found in relation to the characteristics of the intervention, outer setting, inner setting and characteristics of the individuals involved. CONCLUSIONS: The government initiative to develop and disseminate the guidelines seems to have made very little impact on health professionals' clinical practice. The guidelines were poorly aligned with the health professionals' knowledge and beliefs about effective mental health services for children and youth with depression and anxiety disorders. Suggestions for future efforts to improve the deve

Introduction: Strengthening first-line mental healthcare services for youth remains a priority for the Swedish government. The government is currently investigating how different sectors involved can be strengthened, butevidence is scarce. Youth clinics play a key role in these discussions, being one of the most trusted services for youth. However, analysis of organisational functions andcoordination with other services is important to strengthen youth clinics’ role in first-line mental healthcare. This study investigates these challenges and aims to analysethe integration of mental healthcare within youth clinics to identify strategies to strengthen first-line mental healthcare for youth in Sweden. Methods and analysis: This study adopts a health policyand systems approach. In the first phase, a formative realist evaluation is conducted to ascertain what works in terms of integrating mental healthcare services within youth clinics, for what type of youth subpopulations and under what circumstances. National-level stakeholders will be interviewed to elicit the programme theory that explains how the intervention is supposed to work. The programme theory will then be tested in three–five cases. The cases will be comprised of youth clinics and their stakeholders. Quantitative and qualitative information will be gathered,including via visual methodologies and questionnaires. The second phase includes a concept mapping study, engaging stakeholders and young people to build consensuson strategies to strengthen the integration of menta lhealthcare into youth clinics.

Background: Incarceration and mental health problems are known to have a strong empirical association. Many studies have confirmed the high prevalence of mental health problems among young prisoners in particular, yet none has been conducted in Cambodia. Objectives: This study aimed to assess the level of mental health problems and suicidal expressions, and determine the associated risk factors among young prisoners in Cambodia. Method: This was a cross-sectional study among 572 young prisoners between the ages of 15 and 24 from three prisons. Sociodemographic data and detailed information on participants’ profiles were gathered, and mental health problems and suicidal expressions were assessed using the Youth Self-Report (YSR) and the Attitude Towards Suicide (ATTS) questionnaires, respectively. Results: Mental health problems as revealed by the mean YSR scores were: 25.97 for internalizing and 18.12 for externalizing problems; 11.88 for anxiety/depression, 9.97 for aggressive behaviours and 7.53 for somatic complaints. Social problems, attention problems and rule breaking behaviour were in the range of 8.10 to 8.49. Withdrawal depression and thought problems mean scores were 6.55 and 6.66, respectively. Mental health problems were associated with younger age, lower educational background, and shorter duration of incarceration. Around 16% had thought about their own death, and 12% expressed wish to die. Suicide ideation, planning, and attempts were reported by almost 7%, 2%, and 3% of participants respectively. Prior drugs users thought about death significantly more than their counterparts while suicide ideation was significantly lower among prisoners with higher education. Conclusion: Mental health problems and suicidal expressions among young prisoners warrant well-planned mental health services that are integrated into the current prison health system. A contextualised intervention that takes into account age, education, duration of incarceration and previous d

Introduction: The Västerbotten Intervention Programme (VIP) in the Region Västerbotten Sweden is one of the very few cardiovascular disease (CVD) prevention programmes globally that is integrated into routine primary health care. The VIP has been shown as a cost-effective intervention to significantly reduce CVD mortality. However, little is known about the effectiveness of a digital solution to tailor risk communication strategies for supporting behavioral change. STAR-C aims to develop and evaluate a technical platform for personalized digital coaching that will support behavioral change aimed at preventing CVD. Methods: STAR-C employs a mixed-methods design in seven multidisciplinary projects, which runs in two phases during 2019–2024: (i) a formative intervention design and development phase, and (ii) an intervention implementation and evaluation phase. In the 1st phase, STAR-C will model the trajectories of health behaviors and their impact on CVDs (Project 1), evaluate the role of the social environment and social networks on behavioral change (Project 2) and assess whether and how social media facilitates the spread of health information beyond targeted individuals and stimulates public engagement in health promotion (Project 3). The findings will be utilized in carrying out the iterative, user-centered design, and development of a person-tailored digital coaching platform (Project 4). In the 2nd phase, STAR-C will evaluate the implementation of the coaching programme and its effectiveness for promoting behavioral change and the spreading of health information across social networks and via social media (Project 5). The cost-effectiveness (Project 6) and ethical issues (Project 7) related to the coaching programme intervention will be evaluated. Discussion: The STAR-C research programme will address the knowledge and practice research gaps in the use of information technologies in health promotion and non-communicable disease (NCD) prevention programmes in or

Background: In August 2018, the Swedish government appointed a special investigator to support a national ecosystem for evidence-based healthcare. In November 2019, the inquiry received an additional task now focusing on follow-up to enable a more strategic, evidence-based and long-term sustainable management of health care on a national level. Since healthcare systems around the world face similar challenges, we believe the results of the investigation are highly relevant for a broader audience. Objectives: To analyze how governmental agencies can better support a comprehensive follow-up of health care and thereby create a learning system on a national level. This includes following the effects of the government’s initiatives and reforms and analyzing where future governmental interventions are needed. Methods: The investigator and her team have worked with an expert committee including representatives of governmental agencies, healthcare professions and healthcare providers, as well as a reference group of patient representatives. Additional information has been collected through questionnaires, workshops and meetings with stakeholders and other governmental inquiries working on related topics. Background information was collected from published research, governmental reports, existing regulations etc. Results: Although roughly estimated more than 1000 full-time government employees work with followup in Sweden, the quality, effectiveness and equity in health care is not improving at the anticipated rate. Our findings suggest that a co-ordination of the different initiatives is a prerequisite for creating a learning system on a national level. Key challenges arise in the interface between evidence and policy. At the Colloquium, we will present possible solutions to these challenges using the Swedish healthcare system as an example. Conclusions: Although a lot of efforts are made in conducting and developing methods for evidence generation, implementation and follo, Supplement 1. "The abstracts in this Supplement to the Cochrane Database of Systematic Reviews were originally submitted for presentation at the Cochrane Colloquium that was planned to take place in Toronto, Canada, on 4-7 October 2020. In May 2020, as a result of the continuining spread and impact of COVID-19, Cochrane’s Governing Board and Cochrane Canada agreed to cancel the Toronto Colloquium. Despite the cancellation, the review process for the submitted abstracts continued, and this Supplement includes accepted abstracts of research that would have been presented as oral or poster presentations."

Ge Socialstyrelsen ett nationellt uppdrag att beställa och ersätta vårdgivare av digital vård, föreslår en grupp forskare med anledning av covid-19.

Background: Young children’s social-emotional problems can have a long-term effect if not treated early. In order to deepen our knowledge about children’s social and emotional functioning, we utilized the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) among 3-year-olds in Sweden aiming: 1) to identify ASQ:SE items that are most commonly endorsed by children with high level of social-emotional problems; and 2) to assess whether certain ASQ:SE items differs between boys and girls at the same level of social-emotional problems. Methods: During 2014-2017 data was collected from 7179 three-year-old children through Child Health Care in a northern county of Sweden within the Salut Child Health Promotion Programme. Item Characteristic Curve (ICC) and Differential Item Functioning (DIF) were used to identify the characteristics of children with high social-emotional problems and to determine whether an item exhibit uniform between boys and girls at the same level of social-emotional problems. Results: Items regarding interest in sexual words, too little sleep, disinterest in things around, unhappiness and self-injury were more commonly endorsed by children with high levels of social-emotional problems. Additionally, on the same level of social-emotional problem girls were more likely to score high in items regarding difficulties to occupy herself, clinging behaviour and repetitive behaviour while boys were more likely to score high in items regarding difficulty to name friends, difficulty to express feelings and destruction of things on purpose. Conclusions: This study has increased our knowledge about Swedish young children’s social emotional functioning already at the age of three by detecting which items are most closely connected to high level of social-emotional problems and differences between boys and girls. However, whether the results detected in this analysis are reflecting their parents’ expectations more than child behaviour requires further investiga

AIM: The aim of this study was to investigate mental health with respect to social-emotional problems among three-year-olds in relation to their gender, custody arrangements and place of residence. METHODS: A cross-sectional population-based design was used, encompassing 7,179 three-year-olds in northern Sweden during the period 2014-2017 from the regional Salut Register. Descriptive and comparative analyses were performed based on parents' responses on the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE), supplemented with items on gender, custody arrangement and place of residence. RESULTS: Parental-reported social-emotional problems were found in almost 10% of the children. Boys were reported to have more problems (12.3%) than girls (5.6%) (p<0.001). Parents were most concerned about children's eating habits and interactions at mealtimes. Parents not living together reported more problems among their children than those living together (p<0.001). When stratifying by custody arrangement, girls in rural areas living alternately with each parent had more problems compared to those in urban areas (p<0.008). CONCLUSION: Gender and custody arrangements appear to be important factors for social-emotional problems among three-year-olds. Thus, such conditions should receive attention during preschool age, preferably by a systematic preventive strategy within Child Health Care.

Det övergripande målet för svensk barnhälsovård är att främja barns hälsa, trygghet och utveckling samt ge stöd i föräldraskapet. Barn i Sverige är i hög grad fysiskt friska i internationell jämförelse, men det finns indikationer på att den psykiska ohälsan har ökat hos barn och ungdomar under de senaste decennierna. Kunskapen om förekomst av, och bakomliggande faktorer, till psykisk ohälsa hos förskolebarn är dock otillräcklig. Syftet med denna studie är därför att undersöka treåringars socioemotionella förmåga med avseende på könsskillnader och boende i stad eller på landsbygd i Västerbottens län. Förskolebarns psykiska hälsa undersöks systematiskt I denna studie har instrumentet Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) använts för att undersöka föräldrars rapporterade socioemotionella förmåga hos treåringar. ASQ:SE 36-månadersversion delas rutinmässigt ut till föräldrar inför treårsbesöket på barnavårdscentraler i Västerbottens län sedan 2013. ASQ:SE är ursprungligen utvecklat i USA och mäter barns socioemotionella förmåga inom sju domäner: självreglering, följsamhet, kommunikation, adaptiv förmåga, autonomi, affekt och social interaktion. Socioemotionell förmåga i treårsåldern är exempelvis förmåga till samspel med vuxna och jämnåriga samt förmåga att med stöd av förälder reglera egna känslor. Betydande avvikelser i den socioemotionella förmågan vid denna ålder kan tyda på att barnet har en sårbarhet som kan leda till fortsatta och ibland mer allvarliga socioemotionella problem. Generellt god psykisk hälsa men fler problem bland pojkar Svaren från majoriteten av föräldrarna indikerar god socioemotionell förmåga hos barnen, dock hade nästan en av tio treåringar föräldrarapporterade socioemotionella problem, med ASQ:SE-poäng över gränsvärdet 59. Problemen var dubbelt så vanliga bland pojkar (12 procent) som bland flickor (6 procent) (p <0,001). Det fanns inga signifikanta skillnader i socioemotionell förmåga mellan barn bosatta i städer i jämfö

BACKGROUND: The judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease. METHODS: A qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data. RESULTS: The guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: 'clinical knowledge and experience', 'potential guideline consequences' and 'needs of vulnerable groups'. The frequency of the use of various criteria in discussions varied over time. G

Aim The aim of this study is to investigate factors contributing to the failure of a randomized clinical trial designed to implement and test clinical practice guidelines for the treatment of depression in primary health care (PHC). BACKGROUND: Although the occurrence of depression is increasing globally, many patients with depression do not receive optimal treatment. Clinical practice guidelines for the treatment of depression, which aim to establish evidence-based clinical practice in health care, are often underused and in need of operationalization in and adaptation to clinical praxis. This study explores a failed clinical trial designed to implement and test treatment of depression in PHC in Sweden. METHOD: Qualitative case study methodology was used. Semi-structured interviews were conducted with eight participants from the clinical trial researcher group and 11 health care professionals at five PHC units. Additionally, archival data (ie, documents, email correspondence, reports on the clinical trial) from the years 2007-2010 were analysed. FINDINGS: The study identified barriers to the implementation of the clinical trial in the project characteristics, the medical professionals, the patients, and the social network, as well as in the organizational, economic and political context. The project increased staff workload and created tension as the PHC culture and the research activities clashed (eg, because of the systematic use of questionnaires and changes in scheduling and planning of patient visits). Furthermore, there was a perception that the PHC units' management did not sufficiently support the project and that the project lacked basic incentives for reaching a sustainable resolution. Despite efforts by the project managers to enhance and support implementation of the innovation, they were unable to overcome these barriers. The study illustrates the complexity and barriers of performing clinical trials in the PHC.

BACKGROUND: Evidence has come to play a central role in health policymaking. However, policymakers tend to use other types of information besides research evidence. Most prior studies on evidence-informed policy have focused on the policy formulation phase without a systematic analysis of its implementation. It has been suggested that in order to fully understand the policy process, the analysis should include both policy formulation and implementation. The purpose of the study was to explore and compare two policies aiming to improve health and social care in Sweden and to empirically test a new conceptual model for evidence-informed policy formulation and implementation. METHODS: Two concurrent national policies were studied during the entire policy process using a longitudinal, comparative case study approach. Data was collected through interviews, observations, and documents. A Conceptual Model for Evidence-Informed Policy Formulation and Implementation was developed based on prior frameworks for evidence-informed policymaking and policy dissemination and implementation. The conceptual model was used to organize and analyze the data. RESULTS: The policies differed regarding the use of evidence in the policy formulation and the extent to which the policy formulation and implementation phases overlapped. Similarities between the cases were an emphasis on capacity assessment, modified activities based on the assessment, and a highly active implementation approach relying on networks of stakeholders. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was empirically useful to organize the data. CONCLUSIONS: The policy actors' roles and functions were found to have a great influence on the choices of strategies and collaborators in all policy phases. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was found to be useful. However, it provided insufficient guidance for analyzing actors involved in the polic

BackgroundMany of the world¿s life threatening diseases (e.g. cancer, heart disease, stroke) could be prevented by eliminating life-style habits such as tobacco use, unhealthy diet, physical inactivity and excessive alcohol use. Incorporating evidence-based research on methods to change unhealthy lifestyle habits in clinical practice would be equally valuable. However gaps between guideline development and implementation are well documented, with implications for health care quality, safety and effectiveness. The development phase of guidelines has been shown to be important both for the quality in guideline content and for the success of implementation. There are, however, indications that guidelines related to general disease prevention methods encounter specific barriers compared to guidelines that are diagnosis-specific. In 2011 the Swedish National board for Health and Welfare launched guidelines with a preventive scope. The aim of this study was to investigate how implementation challenges were addressed during the development process of these disease preventive guidelines.MethodsSeven semi-structured interviews were conducted with members of the guideline development management group. Archival data detailing the guideline development process were also collected and used in the analysis. Qualitative data were analysed using content analysis as the analytical framework.ResultsThe study identified several strategies and approaches that were used to address implementation challenges during guideline development. Four themes emerged from the analysis: broad agreements and consensus about scope and purpose; a formalized and structured development procedure; systematic and active involvement of stakeholders; and openness and transparency in the specific guideline development procedure. Additional factors concerning the scope of prevention and the work environment of guideline developers were perceived to influence the possibilities to address implementation issues.C

Background: The judgment and decision-making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on four decision-criteria: research evidence; severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives is assigned the task of ranking condition–intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision-making process during the two-year development of national guidelines for methods of preventing disease. Methods: A qualitative longitudinal case study approach was used to investigate the decision-making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Results: The guideline development model was adapted ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs low adoptability of recommendation; insufficient evidence vs high urgency to act; and incoherence in vertical and horizontal judgments. Decision-criteria added by the group were ‘clinical knowledge and experience’, ‘potential guideline consequences’ and ‘needs of vulnerable groups’. Gender, professional status, and interpersonal skills were perceived to affect individuals’ relative influence on group discussions. Decision criteria changed over time in the group discussions. Conclusions: The study shows that guideline-development groups make compromises between rigour and pragmatism. The formal guideline-development model incorporated multiple aspects, but