To Örebro University

Background: The study was conducted in Region Örebro County, Sweden, where taxes and governmental contributions are the main funding sources. The region has 28 primary healthcare centres and should work with systematic health promotion according to the overarching operational plan. We evaluated the uptake of a 12-month multifaceted implementation strategy based on a leading change model, using internal and external facilitators, reflections from patient representatives and a combined top-down and bottom-up approach to achieve a more health-promoting practice.

Methods: Five intervention centres and five matched control centres were included in a non-randomised parallel group study. An implementation intervention was provided for 12 months to the intervention centres. The clinical process included the use of lifestyle screening forms before patient visits at the healthcare centre, inviting the patient to talk about their habits and provide advice when called for; registering health-promotive activities in the respective medical record. The control centres did not receive any support. Registered lifestyle screening forms and health-promoting activities were collected monthly over the study period (6 months pre-implementation phase, 12 months intervention phase and 6 months post-implementation).

Results: During the 6-month baseline phase, the control centres sent out life-style screening forms to more patients (n = 194) compared to the intervention centres (n = 32). The mean uptake per 1000 visits for health-promotion activities was similar between intervention (39.7) and control centres (38.6) at baseline. The mean uptake per 1000 visits during the 12-month intervention period was 66 (intervention centres vs 38 (control centres). The improvements sustained during the 6-month post-implementation phase: mean uptakes per 1000 visits 136.5 (intervention centres) vs 73.2 (control centres). Data will be analysed further for relative effect.

Discussion and conclusion: While goal setting in operational plans – expecting all PHCCs to work health-promotive – provides direction, practical implementation support helps to achieve them.

Background: Healthy-lifestyle-promoting practices are recommended to reduce the prevalence of non-communicable diseases and increase health, but are underutilized in Swedish primary health care (PHC). As part of the Act in Time project, a 12-month multifaceted implementation intervention to support the uptake of a clinical intervention offering lifestyle-screening forms and counselling to patients with planned visits, was evaluated in a PHC setting. This study aimed to explore the experiences of PHC professionals, internal facilitators, and managers working with health promotion after receiving the 12-month implementation intervention.

Methods: A qualitative study was conducted at five PHC units in Sweden using interviews with managers (n = 9) and internal facilitators (n = 10) and focus group discussions (n = 5) with physicians, nurses, counsellors, and physiotherapists (n = 18). The data were analysed with qualitative content analysis, first inductively and then deductively by mapping the data against the 12 constructs of Normalization Process Theory.

Results: Implementation of the health-promoting practice was affected by contextual factors such as attitudes and available resources. The group dynamics at the PHC centres and the managers’ role as leaders were important for finding solutions to enact the health-promotion practice.

Health-promotion practice was seen as a natural development of PHC. A common focus and opportunity to influence created a sense of coherence. Feelings of autonomy enabled the professionals to collaborate and strengthened participation in the implementation intervention. The internal facilitators helped to guide the PHC centres forward in the implementation process and created strategies to integrate the health-promotion practice into existing clinical practice.

Uptake of the clinical intervention led to a more structural and holistic way of working with lifestyle habits, with patients taking an active part. The professionals’ competencies became more visible by working together, but frustration was also expressed due to different levels of engagement in the health-promotion practice.

Conclusions: Health-promotion practice can be normalized as routine work in PHC with targeted support but requires tailored strategies that rely on existing group dynamics and the manager’s role. To create motivation for providing health promotion, inter-professional collaboration is a key factor that ensures shared ownership of the implementation intervention.

BACKGROUND: The number of frail individuals is increasing, and the proportion of frail patients in hospital settings is high. Assessing patient frailty as a part of hospital care can guide clinicians in determining which interventions are needed and what to prioritise. Orthopaedic in-patients often experience both pain and mobility limitations, which, in combination with frailty, make these patients particularly vulnerable. There is limited knowledge regarding how staff working in orthopaedic acute care units understand frailty and how they adjust their clinical practices in response. The aim is to understand how healthcare professionals in an orthopaedic acute care unit perceive frailty and possibly adapt their clinical practices in response to it.

METHODS: The study adopted a qualitative design and included 16 healthcare professionals from two hospitals. Semi-structured individual face-to-face interviews were conducted, digitally recorded, transcribed verbatim, and subsequently analysed using thematic analysis with an inductive approach.

RESULTS: Two themes were developed during the analysis mirroring the healthcare professionals’ perceptions. The first is “Considering an individual frail” supported by the subthemes ”Describing frailty in different ways”, “Recognising vulnerability”, “Identifying the need for support”, and “Acknowledging frailty in different contexts”. The second is “Caring for the frail”, supported by the subthemes “Understanding the concept of frailty”, “Assessing frailty”, “Taking frailty into account”, “Being one step ahead”, and “Having resource awareness”.

CONCLUSIONS: This study revealed that healthcare professionals perceive frailty as a broad and multidimensional concept that requires clearer specification to guide appropriate interventions. Participants emphasised that care is shaped primarily by individual needs rather than by frailty assessment, reflecting a person-centred approach. They also expressed a strong sense of responsibility toward frail patients and viewed hospital admission as an opportunity to identify and address unmet needs at home. While tools such as the Clinical Frailty Scale were viewed as limited in terms of capturing the full complexity of frailty, they were described as helpful for drawing attention to frailty and prompting deeper reflection.

TRAIL REGISTRATION: https://researchweb.org/is/fourol/project/281574 Reg. no 28 15 74. 

BACKGROUND: Multiple sclerosis (MS) is a progressive disease that may affect respiratory muscle function. Pulmonary dysfunction may be subclinical, and posture changes can reduce lung volumes, especially in the presence of respiratory muscle weakness.

OBJECTIVE: To determine whether lung function differs between sitting and supine positions in individuals with moderate MS, and to explore associations with respiratory muscle strength and disability.

METHODS: Forty-eight participants with moderate MS (13 men, 35 women; median Expanded Disability Status Scale (EDSS) 4.5, range: 4.0-6.5) underwent spirometry (VC, FVC, FEV1, PEF) in sitting and supine positions. Respiratory muscle strength was assessed using maximal inspiratory (MIP) and expiratory pressures (MEP).

RESULTS: VC and FVC did not differ significantly between positions. FEV1 and PEF were slightly reduced in the supine position (p ≤ 0.001), with median relative decreases of -6% and -10%, respectively. These changes did not correlate with EDSS, MIP, or MEP. No sex-related differences were observed.

CONCLUSION: FEV1 and PEF are reduced in the supine position in individuals with moderate MS, indicating early positional respiratory changes. These alterations appear independent of disability level or respiratory muscle strength. However, it remains uncertain whether these changes differ from those of healthy individuals. Controlled studies are warranted to clarify their clinical significance.

Background: Patient involvement occurs at multiple levels of the healthcare system, at micro (patient consultations), meso (team-based collaboration within hospital departments), and macro (shaping policies and governance structures) levels, but research has predominantly focused on the micro level. In Sweden, patient involvement is a core component of the Swedish National System for Knowledge-driven management (NSK), a macro-level initiative. However, little is known about how patient involvement is enacted in practice at this level. This study aimed to explore patient involvement within the Swedish NSK in terms of motives, intentions and suggested progressions. To support the interpretation, we applied a theoretical framework to identify "work" as characterized in four different varieties; work as imagined; work as prescribed; work as disclosed and work as done.

Methods: A qualitative research design was used. Data sources included: (1) steering documents outlining formal policies and strategic goals; (2) interviews with key stakeholders to gather individual experiences and reflections; and (3) non-participant observations from two national working group meetings. Each dataset was first analyzed separately using content analysis and then interpreted through the lens of the Shorrock and Williams framework to enable cross-source synthesis.

Results: Data from documents, interviews, and observations aligned with three of the four varieties of work; Steering documents primarily reflected Work as Imagined, describing formal intentions and governance structures for patient involvement. Stakeholder narratives were largely categorized as Work as Disclosed, capturing personal interpretations, challenges, and enacted experiences. Work-as prescribed was related to the process of collaboration with patient organizations, which also contributed to the recruitment of two patient representatives. Observational data offered limited but insightful examples of Work as Done, revealing how patient involvement was performed in practice during meetings.

Conclusions: This study demonstrates the value of combining diverse data sources and applying structured theoretical lens for analyses to better understand how patient involvement is operationalized at the macro level, i.e. how policy intentions are turned into concrete actions, rules and structures. Analyzing observed activities provides essential insight into Work as Done, helping to bridge the gap between policy and practice and invites further exploration. Furthermore, the findings contribute to the refinement of the Shorrock and Williams framework by empirically illustrating its applicability in healthcare services research.

BACKGROUND: Poststroke fatigue (PSF) affects nearly half of all stroke survivors and significantly hinders rehabilitation and daily functioning. There is no established treatment. Low cardiorespiratory fitness may contribute to PSF, suggesting aerobic training as a potential intervention.

METHODS: In this 2-center, randomized, open-label, blinded end point trial, we evaluated a home-based, supervised cardiorespiratory interval training program (HS-CITP) in individuals with PSF (Swedish Fatigue Assessment Scale score ≥28) 1 to 7 months poststroke. Participants were randomized (1:1) to either HS-CITP or usual care with self-directed activity after early supported discharge. The intervention consisted of 35-minute cycling sessions performed 3 times per week at 70% to 80% of maximum heart rate for 8 weeks. The study was powered to detect a 9-point between-group difference on the Swedish Fatigue Assessment Scale. The primary outcome was self-reported fatigue (Swedish Fatigue Assessment Scale score) at 8 weeks (postintervention), and the secondary outcome was peak oxygen uptake (mL/kg per minute) at 8 weeks. Analyses were performed according to the intention-to-treat principle using adjusted between-group comparisons.

RESULTS: Forty-five participants were randomized; the mean age was 64 years, and 56% were women. Forty-three participants completed the postintervention assessment (HS-CITP: n=22; control: n=21). Adherence to HS-CITP was 92%, and no adverse events were reported. In adjusted analyses, compared with the control group, HS-CITP significantly reduced fatigue (between-group mean difference -5.35 Swedish Fatigue Assessment Scale score points [95% CI -9.03 to -3.67]; P<0.001) and improved cardiorespiratory fitness (+4.48 mL/kg per minute [95% CI, 3.41-5.54]; P<0.001). No significant group-by sex interaction was observed.

CONCLUSIONS: Supervised home-based interval training significantly reduced PSF and improved cardiorespiratory fitness, with good adherence and no safety concerns. These findings support integrating structured aerobic exercise into stroke rehabilitation. Larger, longer-term trials are needed to confirm durability, determine the optimal timing poststroke, and evaluate other exercise modalities.

REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03458884.

Introduction: Of individuals with mild-to-moderate multiple sclerosis (MS), 56% report falling at least once during a 3-month period. Several fall risk factors have been identified, but the issue is complex, with interactions between triggering factors and preceding activities and events. There is a lack of studies explicitly evaluating fall prevention strategies given as counselling over time.

Methods and analysis: The project includes (1) a two-armed randomised controlled internal pilot study with a nested qualitative study on participants' experiences and (2) a randomised controlled trial (RCT). The pilot study will evaluate feasibility in terms of recruitment, dropout, adverse events and battery of tests and will constitute a basis for recalculating the preliminary estimated sample size for a full-scale study. The RCT study will evaluate whether fall prevention strategies based on individual fall risk evaluation reduce fall frequency compared with general fall prevention information. Participants in the intervention group will have an extensive discussion with a physiotherapist regarding the impact of specific MS symptoms, environmental and personal factors, triggering factors and activities and/or circumstances that they perceive to precede fall situations; these discussions will then lead to the creation of individual strategies. In case of falling during follow-up, further discussions on strategies will be held by phone contact. The control group will receive general fall risk prevention recommendations. After completion of the study, the control group will be offered individual strategies based on reported falls. Participants in the pilot study allocated to the intervention group will after follow-up be invited to individual interviews focusing on experiences of taking part in the intervention and the study.

Adults diagnosed with MS, fall history and remaining walking ability will be recruited by physiotherapists from six sites in Sweden. The primary outcome will be self-reported falls for 6 months and secondary outcomes will be self-rating scales covering concern about falling, confidence in remaining balance during activities, walking limitations and ability to avoid falls. Descriptive measures of disease impact will be used.

Ethics and dissemination: The study was approved by the Swedish Ethical Review Authority, Stockholm Dept. 4 (ID: 2025-04486-1, date: 2025-08-12). All participants will provide written informed consent. Findings will be disseminated through peer-reviewed journals, conference presentations and relevant patient organisations.

Trial registration NCT07378566.

Background: In the "One fracture is enough!” project, we want to reduce recurrent fractures by implementing a tailored care process for elderly people with hip fractures. We will study both the implementation process and the effect of the clinical intervention (the care process). The overall project aim is to evaluate the uptake and effects of an implementation strategy for the introduction of a tailored care process based on the degree of frailty for older adults with fragility fractures. The specific aim of this study is to describe the internal facilitators’ experiences of taking part in the implementation strategy.

Methods: This study was performed in the orthopaedic units at one university hospital and one local hospital in one Swedish county. Both units are providing care for older adults with hip fractures. Each included unit appointed a multi-professional internal facilitator team to lead the implementation. The teams received a 1-year support programme including five workshops on frailty, osteoporosis and implementation, followed by monthly support from external facilitators. A qualitative descriptive approach was chosen, and data were collected by means of focus group discussions with the internal facilitator teams at the two units, internal facilitator logbooks and notes made by the researchers during the study period. Data will be analysed with qualitative content analysis.

Results: The implementation support programme, as well as the internal facilitator role, was experienced as complex by some internal facilitators. Other internal facilitators understood their role and mission and wanted to know even more about implementation. They used the achieved knowledge to implement the new care process and could also see that they could also use this knowledge in other implementation projects. When the internal facilitator teams shifted focus from being task-oriented to becoming process-oriented, the implementation moved forward. Also, the first-line managers seem to play a central role in implementation.

Discussion and conclusion: Both the internal facilitator role and the implementation support programme were experienced as complex. Still, focus on the implementation process and managerial support are beneficial for successful implementation.

Background: Despite the importance of promoting healthy lifestyles in primary healthcare (PHC) to prevent non-communicable diseases, implementing and sustaining evidence-based health-promotion lifestyle practices remains challenging. This study aimed to evaluate the sustainability of uptake of a health-promoting practice using a 12-month multifaceted implementation intervention in a Swedish PHC setting.

Methods: A non-randomized parallel group design was used to compare five PHC intervention centers and five matched control centers with respect to health-promotion activities registered in medical records at: 6 months pre-implementation, during a 12-month implementation phase, and a follow-up at 18 months (sustainability). The intervention centers received a multifaceted implementation intervention based on a leadership change model using internal and external facilitators. Uptake was analysed using negative binomial mixed-effects models with a log link, modelling monthly uptake rates with an offset for the number of visits. Time since intervention initiation and time since the post-implementation phase were modelled using restricted cubic splines, allowing intervention effects to vary over time. Models were adjusted for seasonality, secular trends, patient sex, and site pair, with site included as a random effect. Intervention effects were estimated as ratios of rate ratios with simultaneous 95% confidence intervals.

Results: The intervention centers successfully adopted and sustained the clinical intervention. At the 18-month follow-up, intervention centers sent out 7.2 times as many lifestyle screening forms compared with the control centers. The mean crude uptake difference was 43.6 and the relative rate was estimated at 2.23, indicating that patients at the intervention centers were more often asked about their lifestyle and more often received advice or consultative conversations about lifestyle changes.

Conclusions: This multifaceted implementation intervention, focusing on leading change and facilitation in a routine clinical setting, increased the uptake of a health-promoting practice at the PHC intervention centers that was sustained over time. Health-promoting activities reached a larger proportion of patients in the intervention centers, indicating that the clinical intervention may work under routine conditions. These results are promising but need to be verified in larger randomized studies. In addition, differences between the intervention centers emphasize the need to explore the mechanisms of impact.

Trial registration: This study was registered at ClinicalTrials.gov on 4 March 2021 (ref: NCT04799860).

BACKGROUND: Evidence-based healthcare recommendations exist for tobacco use, harmful alcohol consumption, low physical activity, and poor diet. However, the uptake of these recommendations in Swedish primary healthcare is poor, and the potential benefits for patients are not fully realized. Our aim was to evaluate the effect (i.e. the uptake) of a 12-month multifaceted implementation strategy to achieve a more health-promoting practice. We hypothesized that primary healthcare centers receiving this strategy would increase and sustain their health-promotion practices to a significantly greater extent than control centers, from baseline to the 6-month follow-up.

METHODS: In a non-randomized parallel group study, 5 intervention centers and 5 matched control centers were compared regarding health-promotion activities delivered in relation to visits to each center. The intervention centers received a multifaceted implementation strategy over at least 12 months based on established strategies, the Astrakan model of leading change, and findings from pre-implementation studies. The main strategies were: using external and internal facilitators to combine bottom-up and top-down perspectives, and emphasizing leadership responsibility for change. Medical record data on health-promotion activities, including prescribed physical activity and use of lifestyle screening forms, were collected monthly for 2 years: 6 months before and after implementation, and during the implementation phase. The implementation strategy effect was estimated using generalized linear mixed models.

RESULTS: During the 12-month implementation phase, the intervention and control sites had 135 002 and 160 987 healthcare visits, respectively; conducted 8839 and 6171 health-promotion activities, respectively; and administered 2423 and 282 lifestyle screening forms, respectively. A statistically significant higher relative uptake rate of health-promotion activities was found in intervention sites compared to control sites after the implementation period compared to before. The effect increased during the active phase, with the intervention sites having on average 1.07 and 2.0 times the uptake rate of the control sites at 1 and 12 months, respectively; this effect was largely maintained during the 6-month post-intervention phase. A significant absolute effect, in terms of difference in predicted uptake per 1000 visits, was evident 7 months into the implementation phase.

CONCLUSION: This multi-faceted implementation strategy was successful in achieving a more health-promoting practice.