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1.  Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital care: a qualitative study 
BMC Nursing  2014;13(1):39.
Background
Patient safety culture emerges from the shared assumptions, values and norms of members of a health care organization, unit, team or other group with regard to practices that directly or indirectly influence patient safety. It has been argued that organizational culture is an amalgamation of many cultures, and that subcultures should be studied to develop a deeper understanding of an organization’s culture. The aim of this study was to explore subcultures among registered nurses and nurse assistants in Sweden in terms of their assumptions, values and norms with regard to practices associated with patient safety.
Methods
The study employed an exploratory design using a qualitative method, and was conducted at two hospitals in southeast Sweden. Seven focus group interviews and two individual interviews were conducted with registered nurses and seven focus group interviews and one individual interview were conducted with nurse assistants. Manifest content analysis was used for the analysis.
Results
Seven patient safety culture domains (i.e. categories of assumptions, values and norms) that included practices associated with patient safety were found: responsibility, competence, cooperation, communication, work environment, management and routines. The domains corresponded with three system levels: individual, interpersonal and organizational levels. The seven domains consisted of 16 subcategories that expressed different aspects of the registered nurses and assistants nurses’ patient safety culture. Half of these subcategories were shared.
Conclusions
Registered nurses and nurse assistants in Sweden differ considerably with regard to patient safety subcultures. The results imply that, in order to improve patient safety culture, efforts must be tailored to both registered nurses’ and nurse assistants’ patient safety-related assumptions, values and norms. Such efforts must also take into account different system levels. The results of the present study could be useful to facilitate discussions about patient safety within and between different professional groups.
doi:10.1186/s12912-014-0039-5
PMCID: PMC4247876  PMID: 25435809
Nurses; Patient safety; Safety culture; Qualitative research
2.  Alcohol assessment and feedback by email for university students: main findings from a randomised controlled trial 
The British Journal of Psychiatry  2013;203(5):334-340.
Background
Brief interventions can be efficacious in changing alcohol consumption and increasingly take advantage of the internet to reach high-risk populations such as students.
Aims
To evaluate the effectiveness of a brief online intervention, controlling for the possible effects of the research process.
Method
A three-arm parallel groups design was used to explore the magnitude of the feedback and assessment component effects. The three groups were: alcohol assessment and feedback (group 1); alcohol assessment only without feedback (group 2); and no contact, and thus neither assessment nor feedback (group 3). Outcomes were evaluated after 3 months via an invitation to participate in a brief cross-sectional lifestyle survey. The study was undertaken in two universities randomising the email addresses of all 14 910 students (the AMADEUS-1 study, trial registration: ISRCTN28328154).
Results
Overall, 52% (n = 7809) of students completed follow-up, with small differences in attrition between the three groups. For each of the two primary outcomes, there was one statistically significant difference between groups, with group 1 having 3.7% fewer risky drinkers at follow-up than group 3 (P = 0.006) and group 2 scoring 0.16 points lower than group 3 on the three alcohol consumption questions from the Alcohol Use Disorders Identification Test (AUDIT-C) (P = 0.039).
Conclusions
This study provides some evidence of population-level benefit attained through intervening with individual students.
doi:10.1192/bjp.bp.113.128660
PMCID: PMC3814613  PMID: 24072758
3.  Facilitators and barriers influencing patient safety in Swedish hospitals: a qualitative study of nurses’ perceptions 
BMC Nursing  2014;13:23.
Background
Sweden has undertaken many national, regional, and local initiatives to improve patient safety since the mid-2000s, but solid evidence of effectiveness for many solutions is often lacking. Nurses play a vital role in patient safety, constituting 71% of the workforce in Swedish health care. This interview study aimed to explore perceived facilitators and barriers influencing patient safety among nurses involved in the direct provision of care. Considering the importance of nurses with regard to patient safety, this knowledge could facilitate the development and implementation of better solutions.
Methods
A qualitative study with semi-structured individual interviews was carried out. The study population consisted of 12 registered nurses at general hospitals in Sweden. Data were analyzed using qualitative content analysis.
Results
The nurses identified 22 factors that influenced patient safety within seven categories: ‘patient factors’, ‘individual staff factors’, ‘team factors’, ‘task and technology factors’, ‘work environment factors’, ‘organizational and management factors’, and ‘institutional context factors’. Twelve of the 22 factors functioned as both facilitators and barriers, six factors were perceived only as barriers, and four only as facilitators. There were no specific patterns showing that barriers or facilitators were more common in any category.
Conclusion
A broad range of factors are important for patient safety according to registered nurses working in general hospitals in Sweden. The nurses identified facilitators and barriers to improved patient safety at multiple system levels, indicating that complex multifaceted initiatives are required to address patient safety issues. This study encourages further research to achieve a more explicit understanding of the problems and solutions to patient safety.
doi:10.1186/1472-6955-13-23
PMCID: PMC4134467  PMID: 25132805
Patient safety; Nurse; Qualitative content analysis; Interview; Implementation; Intervention; Multifaceted
4.  Validation of the CPAP Habit Index-5: A Tool to Understand Adherence to CPAP Treatment in Patients with Obstructive Sleep Apnea 
Sleep Disorders  2014;2014:929057.
Long-term adherence to continuous positive airway pressure (CPAP) is low among patients with obstructive sleep apnea (OSA). The potential role of “habit” in sustaining adherence to CPAP use has not been studied. This study aimed to establish the relevance of habit to CPAP adherence, via validation of an adaptation of the Self-Report Habit Index (the CPAP Habit Index-5; CHI-5). Analyses focused on the homogeneity, reliability, and factor structure of the CHI-5 and, in line with theoretical predictions, its utility as a predictor of long-term CPAP adherence in middle-aged patients with OSA. A prospective longitudinal design was used. 117 patients with objectively verified OSA intended for CPAP treatment were recruited. Data was collected via clinical examinations, respiratory recordings, questionnaires, and CPAP devices at baseline, 2 weeks, 6 months, and 12 months. The CHI-5 showed satisfactory homogeneity interitem correlations (0.42–0.93), item-total correlations (0.58–0.91), and reliability (α = 0.92). CHI-5 data at 6 months showed a one-factor solution and predicted 63% of variance in total CPAP use hours after 12 months. Based on the satisfactory measurement properties and the high amount of CPAP use variance it explained, the CHI-5 can be seen as a useful tool in clinical practice.
doi:10.1155/2014/929057
PMCID: PMC4020158  PMID: 24876975
5.  Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial 
Background
Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden.
Methods
An implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson’s χ2 test and approximative z-test.
Results
168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes.
Conclusions
A tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.
doi:10.1186/1472-6963-14-105
PMCID: PMC3975873  PMID: 24589291
Implementation; Physical therapy; Evidence-based practice; Practice guidelines
6.  Acute Alcohol Consumption and Motivation to Reduce Drinking Among Injured Patients in a Swedish Emergency Department 
Journal of addictions nursing  2012;23(3):10.1097/JAN.0b013e31826f4bbd.
Background
Injuries constitute a major public health problem. Millions of people are injured each year and acute drinking is a well-known risk factor for injuries. Research suggests that acknowledgment of alcohol as a factor in an injury enhances willingness to change drinking behavior, possibly because the patient becomes aware of the negative consequences of their drinking.
Study Objectives
To investigate the prevalence of acute alcohol consumption (drinking prior to the event) among injury patients and to examine the importance of factors potentially associated with motivation to reduce alcohol consumption among these patients.
Methods
All patients aged 18–69 years were requested to answer alcohol-related questions on a touch-screen computer.
Results
Fifteen percent of injured patients were categorized as acute drinkers and, of these, 64% reported that their injury was connected to alcohol. There were significant differences for all sociodemographic and drinking characteristics between acute drinkers and non-acute drinkers. Acute drinkers were categorized as risky drinkers to a much higher extent than non-acute drinkers. Acute drinkers had a considerably higher average weekly alcohol consumption and engaged far more frequently in heavy episodic drinking than non-acute drinkers. Acute drinkers were motivated to reduce their alcohol intake to a greater extent than non-acute drinkers; 51% were in the action, preparation, and contemplation stages, compared with 19% of the non-acute drinkers.
Conclusion
Acute drinkers had considerably more detrimental alcohol consumption than non-acute drinkers and the acute drinkers were more motivated to reduce their drinking than the non-acute drinkers.
doi:10.1097/JAN.0b013e31826f4bbd
PMCID: PMC3868003  PMID: 24335731
alcohol consumption; acute drinking; motivation to change; injured patients; emergency department
7.  Prevalence of alcohol use before and during pregnancy and predictors of drinking during pregnancy: a cross sectional study in Sweden 
BMC Public Health  2013;13:780.
Background
There is a paucity of research on predictors for drinking during pregnancy among women in Sweden and reported prevalence rates differ considerably between studies conducted at different antenatal care centres. Since this knowledge is relevant for preventive work the aim of this study was to investigate these issues using a multicenter approach.
Methods
The study was conducted at 30 antenatal care centers across Sweden from November 2009 to December 2010. All women in pregnancy week 18 or more with a scheduled visit were asked to participate in the study. The questionnaire included questions on sociodemographic data, alcohol consumption prior to and during the pregnancy, tobacco use before and during pregnancy, and social support.
Results
Questionnaires from 1594 women were included in the study. A majority, 84%, of the women reported alcohol consumption the year prior to pregnancy; about 14% were categorized as having hazardous consumption, here defined as a weekly consumption of > 9 standard drinks containing 12 grams of pure alcohol or drinking more than 4 standard drinks at the same occasion. Approximately 6% of the women consumed alcohol at least once after pregnancy recognition, of which 92% never drank more than 1 standard drink at a time. Of the women who were hazardous drinkers before pregnancy, 19% reduced their alcohol consumption when planning their pregnancy compared with 33% of the women with moderate alcohol consumption prior to pregnancy. Factors predicting alcohol consumption during pregnancy were older age, living in a large city, using tobacco during pregnancy, lower score for social support, stronger alcohol habit before pregnancy and higher score for social drinking motives.
Conclusions
The prevalence of drinking during pregnancy is relatively low in Sweden. However, 84% of the women report drinking in the year preceding pregnancy and most of these women continue to drink until pregnancy recognition, which means that they might have consumed alcohol in early pregnancy. Six factors were found to predict alcohol consumption during pregnancy. These factors should be addressed in the work to prevent alcohol-exposed pregnancies.
doi:10.1186/1471-2458-13-780
PMCID: PMC3765772  PMID: 23981786
8.  MULTI-LEVEL ANALYSIS OF ALCOHOL-RELATED INJURY AND DRINKING PATTERN: EMERGENCY DEPARTMENT DATA FROM 19 COUNTRIES 
Addiction (Abingdon, England)  2012;107(7):1263-1272.
Aim
While drinking in the event is an important factor in injury occurrence, pattern of usual drinking may also be important in risk of injury. Explored here is the relationship of an alcohol-related injury with individual usual drinking pattern.
Design
Alcohol-related injury is examined using Hierarchical Linear models, taking into account individual usual volume of consumption over the past 12 months, as well as aggregate-level detrimental drinking pattern (DDP) and alcohol policy measures.
Setting
Data analyzed are from emergency departments (EDs) in 19 countries, comprising three collaborative studies on alcohol and injury, all of which used a similar methodology.
Participants
The sample consists of 14,132 injured drinkers across 46 ER studies.
Measurements
Alcohol-related injury was measured, separately, by any self-reported drinking prior to injury, a blood alcohol concentration (BAC) ≥ .08, and self-reported causal attribution of injury to drinking.
Findings
While individual usual volume strongly predicted an alcohol-related injury for all three measures, usual drinking pattern also predicted an alcohol-related injury (controlling for volume), with episodic heavy and frequent heavy drinking both more predictive of alcohol-related injury than other drinking patterns. When individual usual volume and drinking pattern were controlled, DDP was no longer a significant predictor of alcohol-related injury. Alcohol policy measures were predictive of both BAC and causal attribution (the stronger the policy the lower the rates of alcohol-related injury).
Conclusions
Volume of alcohol typically consumed and occurrence of heavy drinking episodes are independently associated with incidence of alcohol-related injury. The stronger the anti-alcohol policies in a country, the lower the rates of alcohol-related injury.
doi:10.1111/j.1360-0443.2012.03793.x
PMCID: PMC3330192  PMID: 22236278
9.  Never the twain shall meet? - a comparison of implementation science and policy implementation research 
Background
Many of society’s health problems require research-based knowledge acted on by healthcare practitioners together with implementation of political measures from governmental agencies. However, there has been limited knowledge exchange between implementation science and policy implementation research, which has been conducted since the early 1970s. Based on a narrative review of selective literature on implementation science and policy implementation research, the aim of this paper is to describe the characteristics of policy implementation research, analyze key similarities and differences between this field and implementation science, and discuss how knowledge assembled in policy implementation research could inform implementation science.
Discussion
Following a brief overview of policy implementation research, several aspects of the two fields were described and compared: the purpose and origins of the research; the characteristics of the research; the development and use of theory; determinants of change (independent variables); and the impact of implementation (dependent variables). The comparative analysis showed that there are many similarities between the two fields, yet there are also profound differences. Still, important learning may be derived from several aspects of policy implementation research, including issues related to the influence of the context of implementation and the values and norms of the implementers (the healthcare practitioners) on implementation processes. Relevant research on various associated policy topics, including The Advocacy Coalition Framework, Governance Theory, and Institutional Theory, may also contribute to improved understanding of the difficulties of implementing evidence in healthcare. Implementation science is at a relatively early stage of development, and advancement of the field would benefit from accounting for knowledge beyond the parameters of the immediate implementation science literature.
Summary
There are many common issues in policy implementation research and implementation science. Research in both fields deals with the challenges of translating intentions into desired changes. Important learning may be derived from several aspects of policy implementation research.
doi:10.1186/1748-5908-8-63
PMCID: PMC3686664  PMID: 23758952
Policy; Implementation; Top-down; Bottom-up; Determinants; Context; Interdisciplinarity
10.  What supports physiotherapists’ use of research in clinical practice? A qualitative study in Sweden 
Background
Evidence-based practice has increasingly been recognized as a priority by professional physiotherapy organizations and influential researchers and clinicians in the field. Numerous studies in the past decade have documented that physiotherapists hold generally favorable attitudes to evidence-based practice and recognize the importance of using research to guide their clinical practice. Research has predominantly investigated barriers to research use. Less is known about the circumstances that actually support use of research by physiotherapists. This study explores the conditions at different system levels that physiotherapists in Sweden perceive to be supportive of their use of research in clinical practice.
Methods
Patients in Sweden do not need a referral from a physician to consult a physiotherapist and physiotherapists are entitled to choose and perform any assessment and treatment technique they find suitable for each patient. Eleven focus group interviews were conducted with 45 physiotherapists, each lasting between 90 and 110 minutes. An inductive approach was applied, using topics rather than questions to allow the participants to generate their own questions and pursue their own priorities within the framework of the aim. The data were analyzed using qualitative content analysis.
Results
Analysis of the data yielded nine favorable conditions at three system levels supporting the participant’s use of research in clinical practice: two at the individual level (attitudes and motivation concerning research use; research-related knowledge and skills), four at the workplace level (leadership support; organizational culture; research-related resources; knowledge exchange) and three at the extra-organizational level (evidence-based practice guidelines; external meetings, networks, and conferences; academic research and education).
Conclusions
Supportive conditions for physiotherapists’ use of research exist at multiple interdependent levels, including the individual, workplace, and extra-organizational levels. Research use in physiotherapy appears to be an interactive and interpretative social process that involves a great deal of interaction with various people, including colleagues and patients.
doi:10.1186/1748-5908-8-31
PMCID: PMC3610206  PMID: 23497502
Physical therapy; Evidence-based practice; Research use; System levels; Attitudes; Clinical practice
11.  Factors influencing patient safety in Sweden: perceptions of patient safety officers in the county councils 
Background
National, regional and local activities to improve patient safety in Sweden have increased over the last decade. There are high ambitions for improved patient safety in Sweden. This study surveyed health care professionals who held key positions in their county council’s patient safety work to investigate their perceptions of the conditions for this work, factors they believe have been most important in reaching the current level of patient safety and factors they believe would be most important for achieving improved patient safety in the future.
Methods
The study population consisted of 218 health care professionals holding strategic positions in patient safety work in Swedish county councils. Using a questionnaire, the following topics were analysed in this study: profession/occupation; number of years involved in a designated task on patient safety issues; knowledge/overview of the county council’s patient safety work; ability to influence this work; conditions for this work; and the importance of various factors for current and future levels of patient safety.
Results
The response rate to the questionnaire was 79%. The conditions that had the highest number of responses in complete agreement were “patients’ involvement is important for patient safety” and “patient safety work has good support from the county council’s management”. Factors that were considered most important for achieving the current level of patient safety were root cause and risk analyses, incident reporting and the Swedish Patient Safety Law. An organizational culture that encourages reporting and avoids blame was considered most important for improved patient safety in the future, closely followed by improved communication between health care practitioners and patients.
Conclusion
Health care professionals with important positions in the Swedish county councils’ patient safety work believe that conditions for this work are somewhat constrained. They attribute the current levels of patient safety to a broad range of factors and believe that many different solutions can contribute to enhanced patient safety in the future, suggesting that this work must be multifactorial.
doi:10.1186/1472-6963-13-52
PMCID: PMC3579677  PMID: 23391301
Patient safety; Patient involvement; Communication; Safety culture; Root cause analysis; Risk analysis; Incident reporting
13.  Effectiveness of a Proactive Mail-Based Alcohol Internet Intervention for University Students: Dismantling the Assessment and Feedback Components in a Randomized Controlled Trial 
Background
University students in Sweden routinely receive proactive mail-based alcohol Internet interventions sent from student health services. This intervention provides personalized normative feedback on alcohol consumption with suggestions on how to decrease drinking. Earlier feasibility trials by our group and others have examined effectiveness in simple parallel-groups designs.
Objective
To evaluate the effectiveness of electronic screening and brief intervention, using a randomized controlled trial design that takes account of baseline assessment reactivity (and other possible effects of the research process) due to the similarity between the intervention and assessment content. The design of the study allowed for exploration of the magnitude of the assessment effects per se.
Methods
This trial used a dismantling design and randomly assigned 5227 students to 3 groups: (1) routine practice assessment and feedback, (2) assessment-only without feedback, and (3) neither assessment nor feedback. At baseline all participants were blinded to study participation, with no contact being made with group 3. We approached students 2 months later to participate in a cross-sectional alcohol survey. All interventions were fully automated and did not have any human involvement. All data used in the analysis were based on self-assessment using questionnaires. The participants were unaware that they were participating in a trial and thus were also blinded to which group they were randomly assigned.
Results
Overall, 44.69% (n = 2336) of those targeted for study completed follow-up. Attrition was similar in groups 1 (697/1742, 40.01%) and 2 (737/1742, 42.31% retained) and lower in group 3 (902/1743, 51.75% retained). Intention-to-treat analyses among all participants regardless of their baseline drinking status revealed no differences between groups in all alcohol parameters at the 2-month follow-up. Per-protocol analyses of groups 1 and 2 among those who accepted the email intervention (36.2% of the students who were offered the intervention in group 1 and 37.3% of the students in group2 ) and who were risky drinkers at baseline (60.7% follow-up rate in group 1 and 63.5% in group 2) suggested possible small beneficial effects on weekly consumption attributable to feedback.
Conclusions
This approach to outcome evaluation is highly conservative, and small benefits may follow the actual uptake of feedback intervention in students who are risky drinkers, the precise target group.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 24735383; http://www.controlled-trials.com/ISRCTN24735383 (Archived by WebCite at http://www.webcitation.org/6Awq7gjXG)
doi:10.2196/jmir.2062
PMCID: PMC3510746  PMID: 23113955
Alcohol drinking; Web-based intervention; proactive intervention; university students
14.  Alcohol email assessment and feedback study dismantling effectiveness for university students (AMADEUS-1): study protocol for a randomized controlled trial 
Trials  2012;13:49.
Background
Alcohol causes huge problems for population health and for society, which require interventions with individuals as well as populations to prevent and reduce harms. Brief interventions can be effective and increasingly take advantage of the internet to reach high-risk groups such as students. The research literature on the effectiveness of online interventions is developing rapidly and is confronted by methodological challenges common to other areas of e-health including attrition and assessment reactivity and in the design of control conditions.
Methods/design
The study aim is to evaluate the effectiveness of a brief online intervention, employing a randomized controlled trial (RCT) design that takes account of baseline assessment reactivity, and other possible effects of the research process. Outcomes will be evaluated after 3 months both among student populations as a whole including for a randomized no contact control group and among those who are risky drinkers randomized to brief assessment and feedback (routine practice) or to brief assessment only. A three-arm parallel groups trial will also allow exploration of the magnitude of the feedback and assessment component effects. The trial will be undertaken simultaneously in 2 universities randomizing approximately 15,300 students who will all be blinded to trial participation. All participants will be offered routine practice intervention at the end of the study.
Discussion
This trial informs the development of routine service delivery in Swedish universities and more broadly contributes a new approach to the study of the effectiveness of online interventions in student populations, with relevance to behaviors other than alcohol consumption. The use of blinding and deception in this study raise ethical issues that warrant further attention.
Trial registration
ISRCTN28328154
doi:10.1186/1745-6215-13-49
PMCID: PMC3390901  PMID: 22540638
15.  Creatures of habit: accounting for the role of habit in implementation research on clinical behaviour change 
Background
Social cognitive theories on behaviour change are increasingly being used to understand and predict healthcare professionals’ intentions and clinical behaviours. Although these theories offer important insights into how new behaviours are initiated, they provide an incomplete account of how changes in clinical practice occur by failing to consider the role of cue-contingent habits. This article contributes to better understanding of the role of habits in clinical practice and how improved effectiveness of behavioural strategies in implementation research might be achieved.
Discussion
Habit is behaviour that has been repeated until it has become more or less automatic, enacted without purposeful thinking, largely without any sense of awareness. The process of forming habits occurs through a gradual shift in cognitive control from intentional to automatic processes. As behaviour is repeated in the same context, the control of behaviour gradually shifts from being internally guided (e.g., beliefs, attitudes, and intention) to being triggered by situational or contextual cues. Much clinical practice occurs in stable healthcare contexts and can be assumed to be habitual. Empirical findings in various fields suggest that behaviours that are repeated in constant contexts are difficult to change. Hence, interventions that focus on changing the context that maintains those habits have a greater probability of success. Some sort of contextual disturbance provides a window of opportunity in which a behaviour is more likely to be deliberately considered. Forming desired habits requires behaviour to be carried out repeatedly in the presence of the same contextual cues.
Summary
Social cognitive theories provide insight into how humans analytically process information and carefully plan actions, but their utility is more limited when it comes to explaining repeated behaviours that do not require such an ongoing contemplative decisional process. However, despite a growing interest in applying behavioural theory in interventions to change clinical practice, the potential importance of habit has not been explored in implementation research.
doi:10.1186/1748-5908-7-53
PMCID: PMC3464791  PMID: 22682656
Habits; Social cognitive theories; Clinical behaviour; Interventions
16.  Predictors of Drinking During Pregnancy: A Systematic Review 
Journal of Women's Health  2011;20(6):901-913.
Abstract
Background
Many pregnant women continue to drink alcohol despite clinical recommendations and public health campaigns about the risks associated with alcohol use during pregnancy. This review examines the predictors of prenatal alcohol use, with the long-term goal of developing more effective preventive efforts.
Methods
A literature search of several databases for relevant articles was undertaken. Studies were included if they occurred in the context of antenatal care, collected data during the woman's pregnancy (between 1999 and 2009), investigated predictors of any drinking, had a population-based orientation (e.g., did not focus only on high-risk drinkers), and were published in English in a scientific peer-reviewed journal between 1999 and 2009.
Results
Fourteen studies published between 2002 and 2009 fulfilled the inclusion criteria (United States, 4; Europe, 4; Australia and New Zealand, 3; Japan, 2; and Uganda, 1). The predictors of prenatal alcohol use most consistently identified were prepregnancy alcohol consumption and having been abused or exposed to violence. Less consistent predictors of drinking during pregnancy were high income/social class and positive dependence screen. Unemployment, marital status, and education level were examined in many studies but found to be predictive only infrequently.
Conclusions
Women's prepregnancy alcohol consumption (i.e., quantity and frequency of typical drinking) and exposure to abuse or violence were consistently associated with drinking during pregnancy. Antenatal care providers should assess these factors for improved detection of women at risk for alcohol-exposed pregnancies.
doi:10.1089/jwh.2010.2216
PMCID: PMC3159119  PMID: 21671775
17.  Parent and Patient Satisfaction after Treatment for Supracondylar Humerus Fractures in 139 Children: No Difference between Skeletal Traction and Crossed Pin Fixation at Long-Term Followup 
Advances in Orthopedics  2012;2012:958487.
Aim. The aim of this study was to see whether the benefits of crossed wire fixation over skeletal traction in the treatment of pediatric supracondylar humerus fractures (SCHF) were mirrored in the children's or their caregivers' rating of the experience. Methods. As part of a study of the clinical outcome of SCHF, all the patients and the parents were asked to rate their experience of the treatment on a visual analogue scale (VAS). Results. There was no difference in the patients' or the parents' experience between the treatment groups. However there was a difference between the parents with children who experienced a neurovascular complication (mean VAS 6.1) and those that did not (mean VAS 4.3, P = 0.03). The boys rated the experience as less negative (mean VAS 3.6) than the girls (mean VAS 4.7, P = 0.02). Conclusion. In the long term, avoiding complications was more important to the parents than the choice of treatment for SCHF in the children.
doi:10.1155/2012/958487
PMCID: PMC3290814  PMID: 22454774
21.  Adverse events in spine surgery in Sweden 
Acta Orthopaedica  2011;82(6):727-731.
Background and purpose
Our knowledge of complications and adverse events in spinal surgery is limited, especially concerning incidence and consequences. We therefore investigated adverse events in spine surgery in Sweden by comparing patient claims data from the County Councils' Mutual Insurance Company register with data from the National Swedish Spine Register (Swespine).
Methods
We analyzed patient claims (n = 182) to the insurance company after spine surgery performed between 2003 and 2005. The medical records of the patients filing these claims were reviewed and compared with Swespine data for the same period.
Results
Two-thirds (119/182, 65%) of patients who claimed economic compensation from the insurance company were registered in Swespine. Of the 210 complications associated with these 182 claims, only 74 were listed in Swespine. The most common causes of compensated injuries (n = 139) were dural lesions (n = 40) and wound infections (n = 30). Clinical outcome based on global assessment, leg pain, disability, and quality of health was worse for patients who claimed economic compensation than for the total group of Swespine patients.
Interpretation
We found considerable under-reporting of complications in Swespine. Dural lesions and infections were not well recorded, although they were important reasons for problems and contributed to high levels of disability. By analyzing data from more than one source, we obtained a better understanding of the patterns of adverse events and outcomes after spine surgery.
doi:10.3109/17453674.2011.636673
PMCID: PMC3247893  PMID: 22066564
22.  Who is not adhering to physical activity referrals, and why? 
Objective
To analyse patients’ self-reported reasons for not adhering to physical activity referrals (PARs).
Design and setting
Data on 1358 patients who did not adhere to PARs were collected at 38 primary health care (PHC) centres in Sweden.
Intervention
PHC providers issued formal physical activity prescriptions for home-based activities or referrals for facility-based activities.
Subjects
Ordinary PHC patients whom regular staff believed would benefit from increased physical activity.
Main outcome measure
Reasons for non-adherence to PARs: “sickness”, “pain”, “low motivation”, “no time”, “economic factors”, and “other”.
Results
Sickness and pain were the most common motives for non-adherence among older patients. The youngest patients blamed economic factors and lack of time more frequently than those in the oldest age group. Economic factors was a more common reason for non-adherence among those referred for facility-based activities compared with those prescribed home-based activities. Low motivation was a more frequent cause of non-adherence among those prescribed home-based activities compared with those referred for facility-based activities. Furthermore, lack of time was a more common reason for non-adherence among patients issued with PARs due to high blood pressure than other patients, while low motivation was a more common reason among patients issued with PARs because of a BMI of > 25.
Conclusion
The reasons for non-adherence differ between patients prescribed home-based activities and referred for facility-based activities, as well as between patients with different specific characteristics. The information obtained may be valuable not only for the professionals working in PHC, but also for those who work to develop PARs for use in different contexts.
doi:10.3109/02813432.2011.628238
PMCID: PMC3308466  PMID: 22126223
Adherence; exercise; lifestyle; health promotion; prescription; primary prevention
23.  Improvement of Physical Activity by a Kiosk-based Electronic Screening and Brief Intervention in Routine Primary Health Care: Patient-Initiated Versus Staff-Referred 
Background
Interactive behavior change technology (eg, computer programs, Internet websites, and mobile phones) may facilitate the implementation of lifestyle behavior interventions in routine primary health care. Effective, fully automated solutions not involving primary health care staff may offer low-cost support for behavior change.
Objectives
We explored the effectiveness of an electronic screening and brief intervention (e-SBI) deployed through a stand-alone information kiosk for promoting physical activity among sedentary patients in routine primary health care. We further tested whether its effectiveness differed between patients performing the e-SBI on their own initiative and those referred to it by primary health care staff.
Methods
The e-SBI screens for the physical activity level, motivation to change, attitudes toward performing the test, and physical characteristics and provides tailored feedback supporting behavior change. A total of 7863 patients performed the e-SBI from 2007 through 2009 in routine primary health care in Östergötland County, Sweden. Of these, 2509 were considered not sufficiently physically active, and 311 of these 2509 patients agreed to participate in an optional 3-month follow-up. These 311 patients were included in the analysis and were further divided into two groups based on whether the e-SBI was performed on the patient´s own initiative (informed by posters in the waiting room) or if the patient was referred to it by staff. A physical activity score representing the number of days being physically active was compared between baseline e-SBI and the 3-month follow-up. Based on physical activity recommendations, a score of 5 was considered the cutoff for being sufficiently physically active.
Results
In all, 137 of 311 patients (44%) were sufficiently physically active at the 3-month follow-up. The proportion becoming sufficiently physically active was 16/55 (29%), 40/101 (40%), and 81/155 (52%) for patients with a physical activity score at baseline of 0, 1 to 2, and 3 to 4, respectively. The patient-initiated group and staff-referred group had similar mean physical activity scores at baseline (2.1, 95% confidence interval [CI] 1.8-2.3, versus 2.3, 95% CI 2.1-2.5) and at follow-up, (4.1, 95% CI 3.4-4.7, vs 4.2, 95% CI 3.7-4.8).
Conclusions
Among the sedentary patients in primary health care who participated in the follow-up, the e-SBI appeared effective at promoting short-term improvement of physical activity for about half of them. The results were similar when the e-SBI was patient-initiated or staff-referred. The e-SBI may be a low-cost complement to lifestyle behavior interventions in routine primary health care and could work as a stand-alone technique not requiring the involvment of primary health care staff.
doi:10.2196/jmir.1745
PMCID: PMC3236669  PMID: 22107702
Computer-tailored; eHealth; lifestyle behavior; exercise; automated
24.  Deformity and functional outcome after treatment for supracondylar humerus fractures in children: a 5- to 10-year follow-up of 139 supracondylar humerus fractures treated by plaster cast, skeletal traction or crossed wire fixation 
Purpose
At Haukeland University Hospital (HUH), we used overhead skeletal traction for displaced supracondylar humerus fractures (SCHF) in children until closed reduction and crossed wire fixation was introduced in the early 1990s. Though there are obvious and well-documented benefits of wire fixation, the aim of this study was to document and compare the results and complication rates for both methods.
Patients and methods
One hundred and thirty-nine patients treated for SCHF between 1988 and 1998 were available for follow-up. Of these, 40 children were treated with a plaster cast, 46 with overhead skeletal traction and 45 with crossed wire fixation. Eight children were treated with open reduction and crossed wires. The mean time to follow-up was 7.1 years [standard deviation (SD) 3.2].
Results
The length of hospital stay was 2 days for those treated with crossed wire fixation compared to 11 days for traction (P < 0.001). The rate of nerve injury in Gartland type 3 fractures was 19%. There was no significant difference in the number of complications or in the functional outcome after skeletal traction or wire fixation, but there were more reoperations in the traction group (P = 0.04). Patients treated solely with a plaster cast had a mean of 4° increased extension of the affected elbow compared to 1° in the crossed pin fixation group (P = 0.02). Though this has little clinical relevance, it does indicate improved reduction in the operated patients, as one would expect.
Conclusions
The introduction of crossed wire fixation has significantly reduced the number of days for which patients are hospitalised for SCHF. The rate of nerve injuries in Gartland type 3 fractures is high. Despite the fact that this study includes the first patients to be treated with crossed wire fixation at our institution, no significant increase in the risk of complications could be found compared to skeletal traction.
doi:10.1007/s11832-010-0274-6
PMCID: PMC2946525  PMID: 21966309
Paediatric fracture; Supracondylar humerus fracture; Skeletal traction; Crossed wire fixation; Complications; Outcome
25.  Implementing Brief Interventions in Health Care: Lessons Learned from the Swedish Risk Drinking Project 
The Risk Drinking Project was a national implementation endeavour in Sweden, carried out from 2004 to 2010, based on a government initiative to give alcohol issues a more prominent place in routine primary, child, maternity and occupational health care. The article describes and analyses the project. Critical factors that were important for the results are identified. The magnitude of the project contributed to its reach and impact in terms of providers’ awareness of the project goals and key messages. The timing of the project was appropriate. The increase in alcohol consumption in Sweden and diminished opportunities for primary prevention strategies since entry to the European Union in 1995 have led to increased expectations for health care providers to become more actively involved in alcohol prevention. This awareness provided favourable conditions for this project. A multifaceted approach was used in the project. Most educational courses were held in workshops and seminars to encourage learning-by-doing. Motivational interviewing was an integral aspect. The concept of risk drinking was promoted in all the activities. Subprojects were tailored to the specific conditions of each respective setting, building on the skills the providers already had to modify existing work practices. Nurses were afforded a key role in the project.
doi:10.3390/ijerph8093609
PMCID: PMC3194107  PMID: 22016706
alcohol; brief intervention; secondary prevention; public health; risk drinking; implementation; continuing professional education

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