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Sjukvården i Sverige är i dag inte jämlik, har brister i tillgänglighet och erbjuds inte på likvärdiga villkor trots Hälso- och sjukvårdslagens mål om en god hälsa och en vård på lika villkor för hela befolkningen.

För att bryta den pågående trenden och öka jämlikheten gjordes en överenskommelse mellan regeringen och SKL om lärandeprojektet Vård på lika villkor (under åren 2011–2014). Syftet med projektets har varit att inom socioekonomiskt resurssvaga bostadsområden öka jämlikheten i första linjens vård. Detta genom att testa, utveckla och identifiera effektiva arbetssätt och metoder vid sju primärvårdsverksamheter från fem landsting i Sverige.

Mälardalens högskola, Akademin för hälsa, vård och välfärd, fick av SKL i uppdrag att svara för forskarstöd och att genomföra en utvärdering av de metoder och arbetssätt som utvecklades och testades i lärandeprojektet.

Resultatet från den genomförda utvärderingen som belyser den genomförda processen, mål- och resultat samt hälsoekonomiska aspekter beskrivs närmare i denna rapport.

Introduction: The Swedish Health Care Law requires the health system to provide good care on equal terms to all. However, several reports from different governmental agencies have revealed that health care is uneven in quality, lacking in accessibility, and not offered on equal terms to all people. Recent public health reports show that inequalities in health in the population have increased. To provide health care on equal terms has become a challenge for health care.

In order to apply methods for developing practice and policy in promoting health and equity the Swedish Association of Local Authorities and Regions developed and implemented a national project entitled Care on Equal Terms. The project began in 2011 and was completed in 2014 at seven Primary Health Care Units (PHCUs) in five regions. The aim of this study was to evaluate the outcomes of this project.

Methods: Based on a program theoretical approach an evaluation design was developed which included process, results and economical evaluation. In the data collection and analysis mixed methods were applied.

Results: According to the process evaluation, seven different strategies were applied in the process to develop primary health care on equal terms. One of the key observations was that in order to achieve health on more equal terms, health care needs to be provided on unequal terms, i. e. more needs to be done to reach those who need more assistance to access health services. Health promotion was one of the applied strategies and it was the most common strategy at some of the health care centers with the aim of developing patients' knowledge, awareness and understanding about health, care and self-care. The results evaluation showed that the PHCUs staff identified structural and organizational factors in health care as important factors for developing health promotion and equity in access. The health economic evaluation showed that the costs for implementing the activities for an improved equity were limited. Yet the majority of the PHCUs thought that the detailed regulation of their financing and reporting requirements were a limitation in their work for improved equity. Four of five county councils have recently introduced a primary care provider payment system (ACG) which may not be supportive of efforts to improve equity in access.

Conclusions: It is possible to develop and maintain practices that can contribute to more equitable care and increase health care personnel’s awareness about practice and policy in promoting health and equity.

Background: Digital development has caused rehabilitation services and rehabilitees to become increasingly interested in using technology as a part of rehabilitation. This study was based on a previously published study that categorized 4 groups of patients with cardiac disease based on different experiences and attitudes toward technology (e-usage groups): feeling outsider, being uninterested, reflecting benefit, and enthusiastic using. Objective: This study identifies differences in the biopsychosocial profiles of patients with cardiac disease in e-usage groups and deepen the understanding of these profiles in cardiac rehabilitation. Methods: Focus group interviews and measurements were conducted with 39 patients with coronary heart disease, and the mean age was 54.8 (SD 9.4, range 34-77) years. Quantitative data were gathered during a 12-month rehabilitation period. First, we used analysis of variance and Tukey honestly significant difference test, a t test, or nonparametric tests—Mann–Whitney and Kruskal–Wallis tests—to compare the 4 e-usage groups—feeling outsider, being uninterested, reflecting benefit, and enthusiastic using—in biopsychosocial variables. Second, we compared the results of the 4 e-groups in terms of recommended and reference values. This analysis contained 13 variables related to biomedical, psychological, and social functioning. Finally, we formed biopsychosocial profiles based on the integration of the findings by constant comparative analysis phases through classic grounded theory. Results: The biomedical variables were larger for waistline (mean difference [MD] 14.2; 95% CI 1.0-27.5; P=.03) and lower for physical fitness (MD −0.72; 95% CI −1.4 to −0.06; P=.03) in the being uninterested group than in the enthusiastic using group. The feeling outsider group had lower physical fitness (MD −55.8; 95% CI −110.7 to −0.92; P=.047) than the enthusiastic using group. For psychosocial variables, such as the degree of self-determination in exercise (MD −7.3; 95% CI −13.5 to −1.1; P=.02), the being uninterested group had lower values than the enthusiastic using group. Social variables such as performing guided tasks in the program (P=.03) and communicating via messages (P=.03) were lower in the feeling outsider group than in the enthusiastic using group. The feeling outsider and being uninterested groups had high-risk lifestyle behaviors, and adherence to the web-based program was low. In contrast, members of the being uninterested group were interested in tracking their physical activity. The reflecting benefit and enthusiastic using groups had low-risk lifestyle behavior and good adherence to web-based interventions; however, the enthusiastic using group had low self-efficacy in exercise. These profiles showed how individuals reflected their lifestyle risk factors differently. We renamed the 4 groups as building self-awareness, increasing engagement, maintaining a healthy lifestyle balance, and strengthening self-confidence. Conclusions: The results facilitate more effective and meaningful personalization guidance and inform the remote rehabilitation. Professionals can tailor individual web-based lifestyle risk interventions using these biopsychosocial profiles.

The development of digital solutions is becoming increasingly important in facing global challenges. Therefore, research on this topic is important in taking into account cardiac patients’ experiences of the rehabilitation process for the design of digital counseling solutions. The aim of the present qualitative study was to explore the different meanings that patients give to the rehabilitation process using a Glaserian grounded theory (GT) approach. Qualitative interviews were conducted with 30 participants from a rehabilitation center in Finland. The findings indicated a “complex trust-building process” core category comprising five categories of trust-building in rehabilitation: feeling that one has hit rock bottom, facing and coping in a crosscurrent, understanding together as a peer group, moving toward a healthier lifestyle with technology, and finding self-awareness. The complex process of trust-building involved interactions among emotion, cognition, and acceptance and support processes. Therefore, digital rehabilitation should be incorporated into counseling based on patients’ psychosocial, physical and emotional needs to help patients become aware of their own feelings and thoughts during the rehabilitation process.

Objective: The aim of this investigation was to study the feasibility of a randomised controlled trial (RCT) based on a multicentre fall prevention intervention including exercise with or without motivational interviewing compared to standard care in community-living people 75. years and older. Method: The feasibility of a three-armed, randomised controlled trial was evaluated according to the following: process, resources, management by questionnaire, and treatment outcomes. The outcome measures were fall frequency, physical performance and falls self-efficacy evaluated after three months. Twelve physiotherapists conducted the measurements and treatments and responded to the questionnaire. The first 45 participants recruited to the ongoing RCT were included: 16 individuals in the Otago Exercise Program group (OEP), 16 individuals in the OEP combined with motivational interviewing group (MI), and 13 individuals in the control group. The study was conducted from November 2012 to December 2013. Results: The feasibility of the study process, resources and management reached the set goals in most aspects; however, the set goal regarding the MI guide and planned exercise for the participating older people was not completely reached. No significant differences were found between the groups regarding the outcome measures. Conclusion: This study confirmed the acceptable feasibility for the study protocol in the ongoing RCT.

Background: It is a challenge to promote exercise among older persons. Knowledge is needed regarding the maintenance of exercise aiming at preventing falls and promoting health and wellbeing in older persons.

Purpose: This descriptive study used a qualitative inductive approach to describe older persons’ experiences of a fall-preventive, home-based exercise programme with support for behavioural change.

Methods: Semi-structured interviews were conducted with twelve older persons aged 75 years or older, and a qualitative content analysis was performed.

Results: Four categories emerged: facilitators of performing exercise in everyday life, the importance of support, perceived gains from exercise, and the existential aspects of exercise.

Conclusion: With support from physiotherapists, home-based exercise can be adapted to individual circumstances in a meaningful way. By including exercises in everyday life and daily routines could support the experience of being stronger, result in better physical functioning and give hope for an extended active life in old age.

This study investigated if behavioral factors, treatment with behavioral support, readiness to change, fall self-efficacy, and activity habits could predict long-term adherence to an exercise program. Included in this study were 114 community-dwelling older adults who had participated in one of two home-based exercise interventions. Behavioral factors associated with adherence to the exercise program over 52 weeks were analyzed. The behavioral factors, specifically activity habits at baseline, significantly predicted adherence to the exercise program, with an odds ratio = 3.39, 95% confidence interval [1.38, 8.32], for exercise and an odds ratio = 6.11, 95% confidence interval [2.34, 15.94], for walks. Being allocated to a specific treatment including motivational interviewing was also significantly predictive: odds ratio = 2.47, 95% confidence interval [1.11, 5.49] for exercise adherence. In conclusion, activity habits and exercise in combination with motivational interviewing had a significant association with adherence to the exercise program at a 1-year follow-up.

Change-projects can be evaluated in different ways. One of the ways is to evaluate with process thinking, which means that evaluators are involved in the process from the very beginning. Involvement of evaluators already in the beginning of a project can mean several challenges for both the project itself and the evaluators. This study is about describing and analyzing how and with what results the perspective of process thinking on evaluation of the national learning project Care on equal terms was used. The results indicate, among other things, that it was a good choice to bring in evaluation perspective at the beginning of the project. Process thinking has, among other things, contributed to the activities throughout the project, and played a role in learning from and implementation of the project itself.

Background: In June 2011 the Swedish government signed an agreement with The Swedish Association of Local Authorities and Regions (SALAR), for a three year project to develop and implement “Health care on equal terms.” The project, which involved seven Primary Health Care Units (PHCU) from five county councils in different parts in Sweden, was completed in early 2014. The aim of the project was to develop methods and activities that could promote more equal health care provision in socio-economically disadvantaged areas.

Aim: To assess and compare health care providers’ experiences of and perceptions about equitable health care at the beginning and end of the national project “Health care on equal terms”.

Methods: A web survey was sent to all staff at the seven participating Primary Health Care Units (PHCU) at the beginning (2012) and the end (2013) of the project. Data were analyzed with descriptive statistics and the open issues with content analysis.

Results: In 2013, the percentage of health care providers who reported thinking patients’ ethnicity had no or very little impact on access to care increased, but the proportion of those who reported that they had “no idea” that patients’ gender, age, mental health and physical functioning were significant for access to care was lower in 2013 than in 2012. The results from analysis of the open-ended questions did not show meaningful changes in the respondents’ perceptions of the issues addressed in 2012-2013, but the analysis contributes to a deeper explanation of the answers.

Conclusion: The main conclusion is that it was possible to implement changes aiming for more equitable care through projects with a focus on learning.

The COVID-19 pandemic has caused radical changes in education, as in everything else, bringing many challenges. Despite all the difficulties, the COVID-19 pandemic has enormous opportunities for online teaching and the use of digital technologies. A comprehensive understanding of this period is needed to investigate these opportunities. Thus, this study aims to explore the academic staff's experiences of online teaching and the use of digital technologies in practical skills-based courses in health care education. This study was conducted at six universities from six countries (Türkiye, Sweden, Finland, Portugal, Latvia, Lithuania). Data were collected between June 17, 2021 and November 30, 2021 via a focus group with an in-depth interview technique. 22 focus group interviews were conducted with a total of 117 participants. Colaizzi's method was used to evaluate the data to discover, comprehend, and define the experiences of academic staff. The analysis of the interview data resulted in 6 themes, 25 subthemes and 56 categories that captured participants' experiences regarding online teaching of practical skills and using digital technologies in health care education. The findings of the study provide crucial information that will help online teaching and digital technology for practical skills be successfully integrated.

Background: Interventions promoting adherence to exercise-based cardiac rehabilitation (exCR) are important to achieve positive physical and psychological outcomes, but knowledge of the added value of behavioral medicine interventions for these measures is limited. The aim of the study was to investigate the added value of a behavioral medicine intervention in physical therapy (BMIP) in routine exCR on psychological outcomes and health-related quality of life (HRQoL) versus routine exCR alone (RC). Methods: A total of 170 patients with coronary artery disease (136 men), mean age 62.3 ± 7.9 years, were randomized at a Swedish university hospital to a BMIP plus routine exCR or to RC for four months. The outcome assessments included HRQoL (SF-36, EQ-5D), anxiety and depression (HADS), patient enablement and self-efficacy and was performed at baseline, four and 12 months. Between-group differences were tested with an independent samples t-test and, for comparisons within groups, a paired t-test was used. An intention-to-treat and a per-protocol analysis were performed. Results: No significant differences in outcomes between the groups were shown between baseline and four months or between four and 12 months. Both groups improved in most SF-36 domains, EQ-VAS and HADS anxiety at the four-month follow-up and sufficient enablement remained at the 12-months follow-up. Conclusion: A BMIP added to routine exCR care had no significant effect on psychological outcomes and HRQoL compared with RC, but significant improvements in several measures were shown in both groups at the four-month follow-up. Since recruited participants showed a better psychological profile than the general coronary artery disease population, further studies on BMIP in exCR, tailored to meet individual needs in broader patient groups, are needed. Trial registration number NCT02895451, 09/09/2016, retrospectively registered.

Background: To help patients with coronary artery disease (CAD) benefit from the positive health effects attained by exercise-based cardiac rehabilitation (CR), adherence to these programmes according to international guidelines is important. Strategies to increase adherence to exercise-based CR are mainly an unexplored area. The objective of this study is to investigate the effects of a behavioural medicine intervention in physiotherapy, containing goal-setting, self-monitoring and feedback, with the aim of improving rehabilitation outcomes for exercise-based CR, compared with usual care. Methods: This is a randomised, controlled trial. A total of 160 patients with CAD will be included consecutively at the Coronary Care Unit at a university hospital in Sweden. Patients are randomised 1:1 using sealed envelopes to usual care or a behavioural medicine intervention in physiotherapy, in addition to usual care for 4 months. Outcome assessment at baseline, 4 and 12 months includes submaximal aerobic capacity (primary outcome), exercise adherence, muscle endurance, level of physical activity, biomarkers, anxiety and depression, health-related quality of life, patient enablement and self-efficacy (secondary outcomes). Discussion: This is the first study to evaluate the role of an integrated behavioural medicine intervention in exercise-based CR in the effects of rehabilitation outcomes. The results of this study will provide valuable information about the effect of these interventions in exercise-based CR and it has the potential to inform and assist in further treatment in secondary prevention for patients with CAD. Trial registration: The study include all items from the World Health Organization Trial Registration Data Set. Trial registration number: NCT02895451, 2016-08-16, retrospectively registered. 

BACKGROUND:

There is a lack of knowledge regarding how individuals with acute whiplash-associated disorders (WAD) appraise and cope with situation-specific stressors.

PURPOSE:

The aim of the study was to describe the daily process of coping reported in a daily coping assessment by individuals with acute WAD within 1 month after the accident. More specifically, profiles of coping strategies were identified and patterns between stressors, primary and secondary appraisals, and coping strategy profiles were described in relation to reported level of activity, worries, depressed mood and pain intensity during the day.

METHOD:

A descriptive and exploratory design was applied. Two hundred and twenty-nine whiplash-associated disorders-daily coping assessment (WAD-DCA) collected during seven consecutive days from 51 participants with acute WAD in Sweden, were included. Cluster analysis was used to obtain coping strategy profiles and data were graphically visualised as patterns through the coping process.

RESULTS:

When measuring coping as a daily process relating to the specific stressful situation, different coping process patterns appeared. During days with a high degree of physical and mental well-being, high self-efficacy beliefs seemed to be working as an important secondary appraisal, whereas during days with a low degree of physical and mental well-being primary appraisals of the stressor as a threat and catastrophic thoughts were present in the coping process.

CONCLUSIONS:

Early identification of situational- and individual-specific stressors, appraisals and coping efforts as measured by the WAD-DCA may contribute to the understanding of the coping process in the acute stage of WAD and its possible impact on recovery and adjustment.

Purpose: Stressors in acute whiplash associated disorders (WAD), as reported on a daily basis, have hitherto been neglected in research. The primary aim of this study was to describe the most stressful daily situation or event reported by individuals with acute WAD within a month of a whiplash trauma. Another aim was to describe the meaning and significance of these daily stressors, i.e. primary appraisal. Method: A descriptive design with a content analysis approach was used. 260 WAD-daily coping assessments (WAD-DCA) generated during 1 week by 51 participants with acute WAD were included in the study. Stressors were analysed using qualitative content analysis. Results: The reported stressors generated 13 categories covering a wide range of stressful situations in daily life related to (i) work, (ii) physical symptoms, (iii) feelings and cognitions, (iv) family and home responsibilities and (v) recreation. The majority of the stressors were appraised as "expected" as well as "disabling". Most threatening stressors were related to work, driving and feelings/cognitions. Conclusions: The wide variety of stressors indicates that it is not only pain itself that influences daily life in acute WAD. Early identification of individual and situation-specific stressors gives new data regarding what bothers individuals suffering from WAD after a collision and may be helpful in understanding the coping process in relation to specific stressors and stressor appraisals

OBJECTIVE: To investigate the comparative effectiveness of current standard treatment, against an individually tailored behavioural programme delivered via the Internet or face-to-face for people with acute whiplash associated disorders.

DESIGN: A multicentre, randomized, three-group design, with concealed allocation.

SUBJECTS AND SETTINGS: A total of 55 participants (37 female), age 18-65, with acute Whiplash Associated Disorder (Grade I-II), recruited at two emergency clinics in Sweden.

INTERVENTIONS: Before randomization all participants received standard self-care instructions. The Internet and face-to-face groups followed a seven-week behavioural programme involving individual tailoring, via email (Internet group), or in sessions at a physical therapy unit (face-to-face group). The control group only received the self-care instructions.

MAIN MEASURES: Pain-related disability, pain intensity, self-efficacy in daily activities, catastrophizing and fear of movement/(re)injury. Assessments were performed at baseline (2-4 weeks postinjury) and at three, six and 12 months postintervention.

RESULTS: Both the Internet (n = 16) and face-to-face (n = 14) group showed a larger decrease in pain-related disability than the control group (n = 16); -12 and -11, respectively, compared with -5 in the control group at 12-months follow-up. Significant differences between the groups in overall treatment effect were shown in all outcomes except pain intensity. All groups improved significantly over time in all outcomes, except for fear of movement/(re)injury and catastrophizing in the control group.

CONCLUSION: An individually tailored behavioural programme improved biopsychosocial factors in patients with whiplash associated disorders up to 12 months after treatment. Internet-delivered intervention was as effective as clinic-based face-to-face therapy sessions.

Background: To be an older woman, live alone, have chronic pain, and be dependent on support are all factors that may have an impact on daily life. One way to promote ability in everyday activities in people with pain-related conditions is to use individualized, integrated behavioral medicine in physical therapy interventions. How this kind of intervention works for older women living alone at home, with chronic pain, and dependent on formal care to manage their everyday lives has not been studied. The aim was to explore the feasibility of a study and to evaluate an individually tailored integrated behavioral medicine in physical therapy intervention for the target group of women. Materials and methods: The study was a 12-week randomized trial with two-group design. Primary effect outcomes were pain-related disability and morale. Secondary effect outcomes focused on pain-related beliefs, self-efficacy for exercise, concerns of falling, physical activity, and physical performance. Results: In total, 23 women agreed to participate in the study and 16 women completed the intervention. The results showed that the behavioral medicine in physical therapy intervention was feasible. No effects were seen on the primary effect outcomes. The experimental intervention seemed to improve the level of physical activity and self-efficacy for exercise. Some of the participants in both groups perceived that they could manage their everyday life in a better way after participation in the study. Conclusion: Results from this study are encouraging, but the study procedure and interventions have to be refined and tested in a larger feasibility study to be able to evaluate the effects of these kinds of interventions on pain-related disability, pain-related beliefs, self-efficacy in everyday activities, and morale in the target group. Further research is also needed to refine and evaluate effects from individualized reminder routines, support to collect self-report data, safety procedures for balance training, and training of personnel to enhance self-efficacy.

Purpose: To investigate 1)how older women who are living alone perceive chronic musculoskeletal pain,Activities of Daily Living (ADL), physical activity, affective distress,pain-related beliefs, pain management, and rate pain-related disability andmorale,  2) the relationships betweendemographic variables, ADL, physical activity, affective distress, pain-relatedbeliefs, and pain management with pain-related disability and morale.Method: The study had across-sectional and correlational design. Sixty women, living alone with chronicpain and community support aged ≥65 years were included.Results: The women were on average 81 years old and had lived with pain forabout 21.5 years. They reported low scores of affective distress,catastrophizing thoughts and self-efficacy, high scores of fear of movement,low degrees of pain-related disability, and low levels of  morale. The multiple regression analysisshowed that only catastrophizing thoughts significantlyexplained the variation in pain-related disability, and both affective distress and catastrophizing thoughtssignificantly explained the variation in morale. Conclusion: These older women livingalone with chronic pain reported similar prevalence ofchronic pain and pain-related disability but lower morale when comparingthe results with similar studies about older people in the same age group orolder people who are in need of help to manage their daily life. The only variable that was independely associated to bothpain-related disability and morale was catastrophizing. Further researchshould focus on identifying catastrophizing thougts,and also on developing a rehabilitation program based on a biopsychosocialperspective with the goal to decrease catastrophizing, pain-relateddisability, and increase morale for this target group

The study aimed to explore how home help service staff described their role in improving the abilities of older people, in particular, older women with chronic pain who are dependent on formal care, to perform everyday activities. Three focus group interviews were conducted, and a qualitative inductive thematic content analysis was used. The analysis resulted in one theme: struggling to improve the care recipients' opportunities for independence but being inhibited by complex environmental factors. By encouraging the care recipients to perform everyday activities, the staff perceived themselves to both maintain and improve their care recipients' independence and quality of life. An important goal for society and health care professionals is to improve older people's abilities to "age in place" and to enable them to age independently while maintaining their quality of life. A key resource is home help service staff, and this resource should be utilized in the best possible way.

Purpose: The aim of this study was to explore how older women living alone with chronic musculoskeletal pain, describe their ability in performing activities in everyday life and what could promote their ability in activities in everyday life as well as their perceived meaning of a changed ability to perform activities in everyday life. Method: Qualitative interviews were conducted with 12 women, and an inductive content analysis was used. Results: The results showed the importance of a daily rhythm of activities. Activities included in the daily rhythm were socializing with family and friends, physical activities, doing own activities as well as activities supported by relatives and the community. The activities described by the women also promoted their ability in activities in everyday life. Other findings were the women's perceived meaning of being independent and maintaining that independency, along with the meaning of accepting and adapting to a changed life situation. Conclusion: This paper concludes that it is important to be sensitive of individual needs regarding the daily rhythm of activities when health-care professionals intervene in the activities in everyday life of older women living alone, promote the women's independency, and enable them to participate in the community. 

Objective: Inconsistent reporting of outcomes in clinical trials of treatments for Whiplash-associated Disorders (WAD) hinders effective data pooling and conclusions that can be drawn about the effectiveness of tested treatments. The aim of this study was to provide recommendations for core outcome domains that should be included in clinical trials of WAD. Materials and Methods: A 3-step process was used: (1) A list of potential core outcome domains were identified from the published literature. (2) Researchers, health care providers, patients, and insurance personnel participated and rated the importance of each domain via a 3-round Delphi survey. A priori criteria for consensus were established. (3) Experts comprising researchers, health care providers, and a consumer representative participated in a multidisciplinary consensus meeting that made final decisions on the recommended core outcome domains. Results: The literature search identified 63 potential core domains. A total of 223 participants were invited to partake in the Delphi surveys, with 41.7% completing round 1, 45.3% round 2, and 51.4% round 3. Eleven core domains met the criteria for inclusion across the entire sample. After the expert consensus meeting, 6 core domains were recommended: Physical Functioning, Perceived Recovery, Work and Social Functioning, Psychological Functioning, Quality of Life, and Pain. Discussion: A 3-step process was used to recommend core outcome domains for clinical trials in WAD. Six core domains were recommended: Physical Functioning, Perceived Recovery, Work and Social Functioning, Psychological Functioning, Quality of Life, and Pain. The next step is to determine the outcome measurement instruments for each of these domains.

Although the physical therapist profession is the leading established, largely nonpharmacological health profession in the world and is committed to health promotion and noncommunicable disease (NCD) prevention, these have yet to be designated as core physical therapist competencies. Based on findings of 3 Physical Therapy Summits on Global Health, addressing NCDs (heart disease, cancer, hypertension, stroke, diabetes, obesity, and chronic lung disease) has been declared an urgent professional priority. The Third Summit established the status of health competencies in physical therapist practice across the 5 World Confederation for Physical Therapy (WCPT) regions with a view to establish health competency standards, this article's focus. Three general principles related to health-focused practice emerged, along with 3 recommendations for its inclusion. Participants acknowledged that specific competencies are needed to ensure that health promotion and NCD prevention are practiced consistently by physical therapists within and across WCPT regions (ie, effective counseling for smoking cessation, basic nutrition, weight control, and reduced sitting and increased activity/exercise in patients and clients, irrespective of their presenting complaints/diagnoses). Minimum accreditable health competency standards within the profession, including use of the WCPT-supported Health Improvement Card, were recommended for inclusion into practice, entry-to-practice education, and research. Such standards are highly consistent with the mission of the WCPT and the World Health Organization. The physical therapist profession needs to assume a leadership role vis-à-vis eliminating the gap between what we know unequivocally about the causes of and contributors to NCDs and the long-term benefits of effective, sustained, nonpharmacological lifestyle behavior change, which no drug nor many surgical procedures have been reported to match.

Background: Other than activity and exercise, lifestyle practices such as not smoking and healthy nutrition, well established for preventing and managing lifestyle-related non-communicable diseases (i.e., heart disease, cancer, hypertension, stroke, obstructive lung disease, diabetes, and obesity), are less emphasized in the physical therapy guidelines for addressing chronic pain, e.g., back pain. This state-of-the-art review examines the relationships between lifestyle behaviours and musculoskeletal health, with special reference to chronic pain, and their clinical and research implications. Discussion: A state-of-the-art review was conducted to synthesize evidence related to lifestyle factors (not smoking, healthy diet, healthy weight, optimal sleep and manageable stress, as well as physical activity) and musculoskeletal health, with special reference to chronic pain. The findings support that health behaviour change competencies (examination/assessment and intervention/treatment) may warrant being included in first-line management of chronic pain, either independently or in conjunction with conventional physical therapy interventions. To address knowledge gaps in the literature however three lines of clinical trial research are indicated: 1) to establish the degree to which traditional physical therapy interventions prescribed for chronic pain augment the benefits of lifestyle behaviour change; 2) to establish the degree to which adopting healthier lifestyle practices, avoids or reduces the need for conventional physical therapy; and 3) to establish whether patients/clients with healthier lifestyles and who have chronic pain, respond more favourably to conventional physical therapy interventions than those who have less healthy lifestyles. Summary: Lifestyle behaviour change is well accepted in addressing lifestyle-related non-communicable diseases. Compelling evidence exists however supporting the need for elucidation of the role of negative lifestyle behaviours on the incidence of chronic pain, and the role of positive lifestyle behaviours on its incidence and effective management. Addressing lifestyle behaviour change in patients/clients with chronic pain, e.g., back pain, as a first-line intervention might not only constitute a novel approach, but also reduce the socioeconomic burden related to chronic pain as well as non-communicable diseases.

Background: To increase the global impact of health promotion related to non-communicable diseases, health professionals need evidence-based core competencies in health assessment and lifestyle behavior change. Assessment of health promotion curricula by health professional programs is a first step. Such program assessment is a means of 1. demonstrating collective commitment across health professionals to prevent non-communicable diseases; 2. addressing the knowledge translation gap between what is known about non-communicable diseases and their risk factors consistent with 'best' practice; and, 3. establishing core health-based competencies in the entry-level curricula of established health professions. Discussion: Consistent with the World Health Organization's definition of health (i.e., physical, emotional and social wellbeing) and the Ottawa Charter, health promotion competencies are those that support health rather than reduce signs and symptoms primarily. A process algorithm to guide the implementation of health promotion competencies by health professionals is described. The algorithm outlines steps from the initial assessment of a patient's/client's health and the indications for health behavior change, to the determination of whether that health professional assumes primary responsibility for implementing health behavior change interventions or refers the patient/client to others. An evidence-based template for assessment of the health promotion curriculum content of health professional education programs is outlined. It includes clinically-relevant behavior change theory; health assessment/examination tools; and health behavior change strategies/interventions that can be readily integrated into health professionals' practices. Summary: Assessment of the curricula in health professional education programs with respect to health promotion competencies is a compelling and potentially cost-effective initial means of preventing and reversing non-communicable diseases. Learning evidence-based health promotion competencies within an inter-professional context would help students maximize use of non-pharmacologic/non-surgical approaches and the contribution of each member of the health team. Such a unified approach would lead patients/clients to expect their health professionals to assess their health and lifestyle practices, and empower and support them in achieving lifelong health. Benefits of such curriculum assessment include a basis for reflection and discussion within and across health professional programs that could impact the epidemic of non-communicable diseases globally, through inter-professional education and evidence-based practice related to health promotion.

Nonnative English-speaking scholars and trainees are increasingly submitting their work to English journals. The study’s aim was to describe their experiences regarding scientific writing in English using a qualitative phenomenographic approach. Two focus groups (5 doctoral supervisors and 13 students) were conducted. Participants were nonnative English-speakers in a Swedish health sciences faculty. Group discussion focused on scientific writing in English, specifically, rewards, challenges, facilitators, and barriers. Participants were asked about their needs for related educational supports. Inductive phenomenographic analysis included extraction of referential (phenomenon as a whole) and structural (phenomenon parts) aspects of the transcription data. Doctoral supervisors and students viewed English scientific writing as challenging but worthwhile. Both groups viewed mastering English scientific writing as necessary but each struggles with the process differently. Supervisors viewed it as a long-term professional responsibility (generating knowledge, networking, and promotion eligibility). Alternatively, doctoral students viewed its importance in the short term (learning publication skills). Both groups acknowledged they would benefit from personalized feedback on writing style/format, but in distinct ways. Nonnative English-speaking doctoral supervisors and students in Sweden may benefit from on-going writing educational supports. Editors/reviewers need to increase awareness of the challenges of international contributors and maximize the formative constructiveness of their reviews.

As SARS-CoV-2, the virus responsible for COVID-19, spread globally, the most severely affected sub-populations were the elderly and those with multi-morbidity largely related to noncommunicable diseases (NCDs), e.g., heart disease, hypertension, type 2 diabetes, obesity. NCDs are largely preventable with healthy nutrition, regular activity, and not smoking. This perspective outlines the rationale for health professionals' including physical therapists' role in reducing COVID-19 susceptibility. Evidence is synthesized supporting the pro-inflammatory effects of the western diet, increasingly consumed globally, inactivity, and smoking; and the immune-boosting, anti-inflammatory effects of a whole food plant-based diet, regular physical activity, and not smoking. An increased background of chronic low-grade systemic inflammation associated with unhealthy lifestyle practices appears implicated in an individual's susceptibility to SARS-CoV-2. It is timely to re-double efforts across healthcare sectors to reduce the global prevalence of NCDs on two fronts: one, to reduce SARS-CoV-2 susceptibility; and two, to reduce the impact of subsequent waves given high blood pressure and blood sugar, common in people with multi-morbidity, can be improved within days/weeks with anti-inflammatory healthy lifestyle practices, and weight loss and atherosclerosis reduction/reversal, within months/years. With re-doubled efforts to control NCD risk factors, subsequent waves could be less severe. Health professionals including physical therapists have a primary role in actively leading this initiative.

Lifestyle-related non-communicable diseases (NCDs) and their risk factors are unequivocally associated with SARS-CoV-2 susceptibility and COVID-19 severity. NCD manifestations and their lifestyle risks are associated with chronic low-grade systemic inflammation (CLGSI). This review supports that immuno-modulation with positive lifestyle change aimed at reducing SARS-CoV-2 susceptibility and COVID-19 severity, is a goal consistent with contemporary physiotherapy practice. Physiotherapists have a long tradition of managing a , thus, managing CLGSI is a logical extension. Improving patients' lifestyle practices also reduces their NCD risks and increases activity/exercise capacity, health and wellbeing - all principal goals of contemporary physiotherapy. The COVID-19 pandemic lends further support for prioritising health and lifestyle competencies including smoking cessation; whole food plant-based nutrition; healthy weight; healthy sleep practices; and stress management; in conjunction with reducing sedentariness and increasing physical activity/exercise, to augment immunity as well as function and overall health and wellbeing. To support patients' lifestyle change efforts, physiotherapists may refer patients to other health professionals. The authors conclude that immuno-modulation with lifestyle behaviour change to reduce susceptibility to viruses including SARS-CoV-2, is consistent with contemporary physiotherapy practice. Immuno-modulation needs to be reflected in health competencies taught in physiotherapy professional education curricula and taught at standards comparable to other established interventions.(c) 2021 The Author(s).

Aim: To describe the systematic development of an evidence-based, tailored, interactive web application for self-management of work-related stress, and to test usability issues regarding how to proceed through the programme. Methods: Evidence from the fields of stress management, behaviour change and web-based interventions was the foundation for the theoretical framework and content. The next step was the development process of the web application and validation among experts and one possible end user. Last, a usability test with 14 possible end users was conducted. Results: The web-application, My Stress Control (MSC), was built on a solid theoretical framework. It consists of 12 modules including: introduction, psychoeducation, ambivalence, stress management strategies, lifestyle change, and maintenance. Self-monitoring, goal-setting, re-evaluating goals, feedback, and prompting formulation of intention to change are central techniques supporting behaviour change. The usability test revealed difficulties in understanding how to proceed through the programme. Conclusion: The development contributes to filling a gap in the literature regarding development of complex web-based interventions. MSC is dissimilar to existing programs in the field, considering the tailoring and multi-tracked opportunities. Although developed from the evidence in multiple fields, the web application would benefit from further development to support users in reaching the end module.

The aim of the current study was to investigate the feasibility of a Web-based program that promotes behavior change for stress-related problems in terms of the program’s acceptability, practicability, and any possible effects. In addition, the aim was also to study how appropriate and realistic the study’s process and resource management would be for conducting a randomized controlled trial. A convenience sample consisting of 14 individuals was recruited from a university in Sweden. The participants had access to the program for a duration of 9 weeks. Questionnaires were answered before accessing, during use of, and after completing the program. Both qualitative and quantitative data were collected and analyzed. The program was considered acceptable and practically feasible, though small adjustments have to be made. The program was considered time-consuming, extensive, and in need of some clarifications. Regarding process and resource management, the study participants required minimum support. It was difficult to identify the time point when to send out the process measures because the participants worked at their own pace. Also, one of the process measurements, the motivation to change, remained stable. With some adjustments to the instructions to the study participants and minor changes in the program, the intervention and study’s procedure were considered as feasible and can be carried out in a randomized controlled trial.

Objectives: To explore users’ experiences of a tailored, interactive web application that supports behaviour change in stress management and to identify if and in that case what in the web-based programme that needed further development or adjustment to be feasible in a randomised controlled trial.

Method: The design of this study was explorative with a qualitative approach. Nine individuals were recruited among the staff at a university. Semi-structured individual interviews were conducted and analysed using qualitative content analysis, after the participants had completed the web-based stress management programme.

Results: One theme was identified, Struggling with what I need when stress management is about me, describing the paradox in having a programme that is perceived as supporting stress management while also being perceived as extensive and time consuming. The theme was divided in two categories: Defining the needs, where the users expressed what they needed from the programme and their everyday environment, to be able to use the programme, and It is about me, where the programme was described as helping the users understand their own stress.

Conclusion: The participants expressed acceptance of using a web-based programme for stress related problems. The perceived extensiveness of the programme must be considered in further development.

Context: Stress preventive interventions should support behaviour change. Web-based programs are less resource demanding than face-to-face solutions. For the purpose of supporting behaviour change in persons with work related stress, the web-based program My Stress Control (MSC) was developed. The aim of this study was to evaluate the feasibility and effect of MSC.

Methods: MSC’s feasibility was tested with 14 end-users before evaluating its effect in a two-armed RCT with 95 persons. The same procedure as for the RCT was used in the feasibility study. Questionnaires were used as data collection method. The primary outcome was perceived stress.

Intervention: MSC was built on evidence regarding theoretical frame, content and informational design. MSC is tailored to each individual by Stages of Change and with a functional behaviour analysis (FBA) conducted by the users in interactive assignments, steering the user to stress-management strategies. Techniques supporting behavioural change are integrated throughout the program.

Results: The feasibility of MSC reached above the pre-set cut-off score. The results of the RCT revealed no significant differences between groups in the primary outcome, but a small effect size was shown between intervention and wait-list group. Adherence was low with 25% of the participants in the intervention group responding to post assessment. 

Conclusions: It is still uncertain if MSC is an effective method for supporting behaviour change in persons with work related stress. Further development must be conducted regarding adherence before next evaluation study. Nevertheless, the small effect size encourages further development and evaluation of MSC.

Objective

Sedentary behavior (SB) is defined as a mean of >6 hours of daytime sitting or lying down. SB has been shown to increase with older age and is a risk factor for disease. During the transition from working life to retirement, changes in daily life activities occur, risking increased SB. The aim of the present study was to gain a deeper understanding of SB in relation to the transition from working life to retirement as experienced by persons in retirement.

Methods

The study was grounded in a phenomenological life-world perspective. Fourteen semi-structured interviews were conducted with participants aged 64–75. Data were analyzed using the empirical phenomenological psychological method.

Results

The participants described that voluntary sedentary time was positively related to general health and well-being, while involuntary sedentary time was negatively related to health. Increased sedentary time was described as natural when aging. Retirement was expressed as a time for rest after hard work and the ability to choose a slower pace in life. Internal and external demands and daily routines interrupted SB, whereas loneliness was perceived to increase SB. Participants strived to find a balance between physical activity and sedentary time. The variations in the participants’ descriptions formed three typologies: in light of meaningful sedentary behavior, in the shadow of involuntary sedentary behavior, and a dual process – postponing sedentary behavior with physical activity.

Conclusions

Increased SB was perceived as natural when aging, but something that may be postponed by conscious choices. SB was perceived as associated with health, rest and recovery but also with the risk of deteriorating health.

Impact

This knowledge of the experienced meaning of SB could guide the design of health promotion interventions and may be helpful in targeting those in need of support and individualizing interventions to decrease SB in retirement.Lay SummaryThis study reveals how persons in retirement describe sedentary behavior as something healthy but also as unhealthy and that sedentary behavior is natural in aging and can be postponed by physical activity.

Background: Stress is one of the most common reasons for sick leave. Web-based interventions have the potential to reach an unlimited number of users at a low cost and have been shown to be effective in addressing several health-related problems. Handling stress on an individual level is related to behavior change. To support behavioral changes in stress management, My Stress Control (MSC) was developed. The development of MSC was based on several health psychology theories and models; however, central in the development were Social Cognitive Theory, Theory of Reasoned Action, Theory of Planned Behavior, Transactional Theory of Stress and Coping, and the Transtheoretical Model and Stages of Change. MSC is a fully automated program. The program is tailored to the user’s specific needs for stress management and behavior change.

Objective: In this study, we aim to conduct a randomized controlled trial to evaluate the extent to which MSC affects perceived stress in persons experiencing work-related stress.

Methods: This was a randomized controlled trial with 2 arms. Study participants were recruited by visiting the worksites and workplace meetings. Participants were assigned to the intervention or wait-list group. Web-based questionnaires were used before and after the intervention to collect data. Perceived stress measured using the Perceived Stress Scale-14 was the primary outcome measurement. Analyses were conducted for both between-group and within-group changes.

Results: A total of 92 participants were included in this study: 48 (52%) in the intervention group and 44 (48%) in the wait-list group. Overall, 25% (12/48) of participants in the intervention group and 43% (19/44) of participants in the wait-list group completed the postintervention assessment. There were no significant effects on perceived stress between the intervention and wait-list groups or within the groups. A small effect size (Cohen d=0.25) was found when comparing mean change over time on the primary outcome measure between the intervention and wait-list groups. In addition, a small effect size was found between pre- and postintervention assessments within the intervention group (Cohen d=0.38) as well as within the wait-list group (Cohen d=0.25).

Conclusions: The effect of MSC on perceived stress remains uncertain. As adherence was low in the intervention group, elements or features that facilitate adherence and engagement must be further developed before firmer conclusions regarding the effect of MSC can be made.

Background: Knowledge regarding the impact of curricula with behavioral medicine content and competencies (BMCC) on physical therapy (PT) students’ clinical reasoning skills is lacking. Objectives: The primary objective was to compare the clinical reasoning skills, focusing on clients’ behavioral change, of entry-level PT students with or without BMCC in their curricula. The second-ary objective was to compare students’ attitudes and beliefs in a biomedical and biopsychosocial practice orientation.Methods: Swedish final-semester PT students (n = 151) completed the Reasoning 4 Change (R4C) instrument and the Pain Attitudes and Beliefs Scale for Physiotherapists. A blueprint was used for curricular categorization. The independent t-test was used.Results: Students attending programs with BMCC curricula (n = 61) had superior scores compared with students without BMCC curricula (n = 90) in the following R4C variables, all of which were related to clinical reasoning focused on behavioral change: Knowledge, Cognition, Self-efficacy, Input from the client, Functional behavioral analysis, and Strategies for behavioral change. Students who did not receive BMCC curricula scored higher in the R4C contextual factors and reported a greater biomedical practice orientation than students receiving BMCC curricula. There was no difference in the biopsychosocial practice orientation between groups.Conclusions: Our findings support the benefit of structured entry-level PT curricula with BMCC on final-semester students’ clinical reasoning skills focused on behavioral change and their level of biomedical practice orientation. Further, our findings elucidated educational opportunities to augment students’ self-efficacy and strengthen their behavioral competencies in clinical reasoning. For the generalizability of the results further research in other contexts is needed.

Background and purpose: A biopsychosocial approach and behaviour change strategies have long been proposed to serve as a basis for addressing current multifaceted health problems. This emphasis has implications for clinical reasoning of health professionals. This study's aim was to develop and validate a conceptual model to guide physiotherapists' clinical reasoning focused on clients' behaviour change. Methods: Phase 1 consisted of the exploration of existing research and the research team's experiences and knowledge. Phases 2a and 2b consisted of validation and refinement of the model based on input from physiotherapy students in two focus groups (n=5 per group) and from experts in behavioural medicine (n=9). Results: Phase 1 generated theoretical and evidence bases for the first version of a model. Phases 2a and 2b established the validity and value of the model. The final model described clinical reasoning focused on clients' behaviour change as a cognitive, reflective, collaborative and iterative process with multiple interrelated levels that included input from the client and physiotherapist, a functional behavioural analysis of the activity-related target behaviour and the selection of strategies for behaviour change. Conclusions: This unique model, theory- and evidence-informed, has been developed to help physiotherapists to apply clinical reasoning systematically in the process of behaviour change with their clients.

Background and Aim: A systematically developed and evaluated instrument is needed to support investigations of physiotherapists' clinical reasoning integrated with the process of clients' behavior change. This study's aim was to develop an instrument to assess physiotherapy students' and physiotherapists' clinical reasoning focused on clients' activity-related behavior and behavior change, and initiate its evaluation, including feasibility and content validity. Methods: The study was conducted in three phases: 1) determination of instrument structure and item generation, based on a model, guidelines for assessing clinical reasoning, and existing measures; 2) cognitive interviews with five physiotherapy students to evaluate item understanding and feasibility; and 3) a Delphi process with 18 experts to evaluate content relevance. Results: Phase 1 resulted in an instrument with four domains: Physiotherapist; Input from client; Functional behavioral analysis; and Strategies for behavior change. The instrument consists of case scenarios followed by items in which key features are identified, prioritized, or interpreted. Phase 2 resulted in revisions of problems and approval of feasibility. Phase 3 demonstrated high level of consensus regarding the instrument's content relevance. Conclusions: This feasible and content-validated instrument shows potential for use in investigations of physiotherapy students' and physiotherapists' clinical reasoning, however continued development and testing are needed.

Background and aim: 'Reasoning 4 Change' (R4C) is a newly developed instrument, including four domains (D1-D4), to assess clinical practitioners' and students' clinical reasoning with a focus on clients' behaviour change in a physiotherapy context. To establish its use in education and research, its psychometric properties needed to be evaluated. The aim of the study was to generate criterion scores and evaluate the reliability and construct validity of a web-based version of the R4C instrument. Methods: Fourteen physiotherapy experts and 39 final-year physiotherapy students completed the R4C instrument and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT). Twelve experts and 17 students completed the R4C instrument on a second occasion. The R4C instrument was evaluated with regard to: internal consistency (five subscales of D1); test-retest reliability (D1-D4); inter-rater reliability (D2-D4); and construct validity in terms of convergent validity (D1.4, D2, D4). Criterion scores were generated based on the experts' responses to identify the scores of qualified practitioners' clinical reasoning abilities. Results: For the expert and student samples, the analyses demonstrated satisfactory internal consistency (alpha range: 0.67-0.91), satisfactory test-retest reliability (ICC range: 0.46-0.94) except for D3 for the experts and D4 for the students. The inter-rater reliability demonstrated excellent agreement within the expert group (ICC range: 0.94-1.0). The correlations between the R4C instrument and PABS-PT (r range: 0.06-0.76) supported acceptable construct validity. Conclusions: The web-based R4C instrument shows satisfactory psychometric properties and could be useful in education and research. The use of the instrument may contribute to a deeper understanding of physiotherapists' and students' clinical reasoning, valuable for curriculum development and improvements of competencies in clinical reasoning related to clients' behavioural change.