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Children in need of special support in preschool (INS) often exhibit delayed time processing ability (TPA) which can significantly impact their everyday functioning (EDF).This study evaluates whether the MyTime intervention could improve TPA and EDF in preschool children aged five to six-year INS.A registered randomized controlled trial (ISRCTN85136134) using a waiting-list control group investigated the effectiveness of MyTime, an occupational therapy intervention program given to preschool children INS in their classrooms for 8 weeks. Data collection included KaTid-Child (R) for the assessment of TPA, the Time-Parent scale, the Adaptive Behavior Assessment System, and the Autonomy scale for assessing EDF. To evaluate between-group differences, data were analyzed using linear regression.The results show that both groups improved from baseline to post-intervention in TPA and everyday functioning but at the post-intervention, there were no between-group differences.To summarize, the MyTime intervention, indicated an increase in TPA and EDF but no between-group differences were found. Early cognitive levels of TPA in preschool children INS advocate for a longer intervention period. It is possible that long-term follow-up or additional measuring of the teacher's attitudes and the children's engagement in the preschool context could have yielded other results.

Children’s experiences of empowerment in relation to preschool peers and in child–adult interactions were studied, involving 25 four-to six-year-olds from four Swedish preschools. Group interviews using puppets comprised pre-constructed scenarios to examine preschools’ activities. Children took photos of indoor and outdoor preschool environments, followed by a photo-elicitation interview. Data were analysed by content analysis. Results showed that authority was expressed in relation to teachers and parents. Children negotiated about handling situations and described relations with teachers as uncomplicated; the contrary was the case with peers. Structure meant that children could choose between courses of action within set frames, describing empowerment as decision-making within limitations. Results indicated the importance of preschool teachers stimulating children to reflect on their own ability by discussing issues concerning children’s sense of empowerment, using methods similar to the ones in this study.

Recently, there has been a developing interest concerning children’s voices in for example decision-making and planning within different educational contexts, such as the preschool. Although children’s rights are emphasized, it is not clear how these rights are expressed in children’s everyday life. Further, children from a minority ethnic group risk marginalization in relation to other children as well as to significant adults and the society as a whole. The aim of this study was to analyze children’s perceptions of empowerment in a preschool context in a gender and ethnicity perspective. Data, collected in 2010, comprised of 25 children at 4 different preschools (aged 4-6, 13 girls, 7 children with other ethnicity than Swedish). Two different methods were used: (1) a group interview with 5-8 children at a time, using a puppet interview technique, playing different scenarios involving the children as co-actors, and (2) a photo walk where children took photos of their indoor and outdoor environment. The photos were used as stimulated recall in individual interviews with the children to let them express their empowerment in the everyday life at preschool. Children’s perceptions were in part related to environmental prerequisites such as the social and physical context of the preschool as well as more distal factors such as resources and values on the macro level. Therefore, to highlight the preschool as an influential micro environment in children’s exercising of empowerment, the interview analysis was based on an ecological systems perspective.The intersectional perspective was used to emphasize possible differences in the children’s perceptions of empowerment due to gender and ethnicity. The results indicate that children perceive the preschool teacher as an uncontested authority. In the preschool environment with least resources and most ethnic diversity among the children, there seem to be a tendency that children perceive the teachers as even stronger authorities, than in the more affluent preschool environments. The peer relations are, however, more complex and questioned by the children. If children have internalized parts of the social context, like rules, seem to vary due to their own experience of consequences of such rules. A salient prerequisite for empowerment is to increase children’s opportunities to understand and be understood. Therefore, preschool teachers need to elaborate on children’s experiences.

This study investigated patterns of interrelated positive subject and environmental factors related to participation in school activities of pupils with different kinds of disabilities. Questionnaires concerning participation were collected from 472 pupils with disabilities and their teachers, parents and special education consultants. A person-oriented approach with the aim to identify patterns of variables related to a high degree of participation of pupils with disabilities was used. Cluster-groups were formed based on scores for individual subjects on factors identified as important for participation. Groups with a high degree of participation were characterized by high scores in autonomy and perceived interaction with peers and teachers and an internal locus of control. Type and degree of disability did not predict cluster group membership. A conclusion is that the outcome participation is better predicted by patterns of interrelated positive subject and environmental factors than by type of disability or any other single factor. 

Health is today viewed as a multi-dimensional concept partly conceptualized independent from not being ill. The aim of this study was to gain knowledge of how young children perceive health. Interviews were conducted with 68 children (4-5 years), within their pre-school setting, with the help of a semi-structured interview guide. A multi-dimensional perspective represented by the health dimensions of the International Classificationof Functioning, Disability and Health (ICF) was used in a manifest deductive content analysis. The children's statements were categorized and placed under one of the four health dimensions, body, activity, participation and environment. A latent content analysis was applied to identify underlying themes in the manifest categories. The results revealed that young children perceive health as a multi-dimensional construct, largely related to being engaged, i.e. to be able to perform wanted activities and participate in a supportive every-day context. This implies that improvements of child engagement should be emphasized in health promotion and to a greater extent be the central focus of health interventions for young children.

The Swedish preschool curriculum stipulates that all children independent of support needs should attend mainstream preschool groups, with equal opportunities for learning and engagement. Preschool teachers are responsible for paying attention to children in need of special support to achieve this. How support is provided for children in need of special support due to behavior difficulties in Swedish preschools varies, however. Some children, often formally identified as in need of special support, are supported by preschool staff supervised by external services. Other children receive support initiated and implemented by preschool staff, without supervision from external services. A further number of children receive no support for behavior difficulties, on top of what is provided to all children. This study investigated associations between support format (i.e., supervised support, staff-initiated support, or no additional support), support content (i.e., implementation of support), behavior difficulties, socio-demographics and engagement. A mixed methods approach was used with a sample of 232 preschool children 15–71 months with assessed behavior difficulties. Preschool staff reported on the children's engagement, behavior difficulties, socio-demographics, and support provision. Logistic regression models were used to analyze the probability of children receiving either support format. Content analysis was used to categorize the support content, reported by preschool staff through open-ended questions. Point-biserial correlations were used to test associations between support content, behavior, socio-demographics and engagement. All children receiving supervised support for behavior difficulties were formally identified by external services as in need of special support. Supervised support was also more common if children disturbed the free play in the preschool group, with the most frequent support being collaboration with external teams. Staff-initiated support was most commonly given to children with high engagement, and for children who are not early second language learners. These children were most frequently supported by staff paying attention to negative behavior. Children who were not perceived as a burden to the group were less likely to receive any form of additional support. Ways of managing the preschool group seem to guide support strategies for children with behavior difficulties, rather than child-focused strategies emphasizing engagement in everyday activities.

Positive  functioning  relates  to  the  ability  to  live  a  good  and  healthy  life,  but  for  children  with  special  needs,  this  might  be  compromised  and therefore factors related to positive functioning should be explored. As their restrictions concern a variety of general life situations including issues such as peer group interaction, participation, autonomy and self-determination, the focus should be on the children’s capabilities when they act in their natural environments. Functional abilities and the creation of opportunities in a challenging environment are optimal for new learning to take place, leading the child towards a positive end point. This article analyses constructs of engagement, participation and flow, indicating their interrelatedness and association to positive functioning. Outcomes change and unfold over time, indicating that functioning should be considered dynamic, context-dependent, culturally and historically conditioned. The article concludes with a suggested model for intervention to enhance positive functioning of children with special needs.

AimThe aim of the study was to explore meaningful everyday life situations as perceived by six-year-old children born preterm. Materials and methodsThe study had a descriptive qualitative design with an inductive approach. Ten, six-year-old children born preterm, not diagnosed with any disabilities, participated. Data was collected by photo-elicitation interviews to stimulate and help the children to describe their meaningful everyday life situations. A qualitative content analysis according to Elo and Kyngas was applied. ResultsThe children's descriptions of meaningful everyday life situations can be understood as being in an active and dynamic process, representing the core category. The analysis resulted in three generic categories, as the children described the significance of having significant circumstances and doing things. The experiences the children gain when they do things create their desire for further development. DiscussionThe results reveal that children born preterm are able to reflect on and give detailed descriptions of situations of importance to them. The study suggests that if six-year-old children born preterm are given the opportunity to share their views they can take an active role e.g. in planning and carrying through of interventions by health care services.

Background/Aim Children born preterm are at risk of neonatal complications but the long-term consequences for everyday functioning is not well known. The study aimed to identify patterns of everyday functioning in preschool children born preterm and at term in relation to perinatal data, neonatal risk factors, behaviour, and socioeconomic status. Registry data and data from parent rated questionnaires were collected for 331 children. Method A person-oriented approach with a cluster analysis was used. Results A seven cluster solution explained 65.91% of the variance. Most children (n = 232) showed patterns of strong everyday functioning. A minority of the children (n = 99), showed diverse patterns of weak everyday functioning. Perinatal characteristics, neonatal risk factors and socio-economics did not predict cluster group membership. Children born preterm were represented in all clusters. Conclusion, implications Most preschool children are perceived by their parents with strong everyday functioning despite being born preterm. However small groups of children are, for various reasons, perceived with weak functioning, but preterm birth is not the sole contributor to patterns of weak everyday functioning. More critical for all children's everyday functioning is probably the interaction between individual factors, behavioural factors and contextual factors. To gain a broader understanding of children's everyday functioning. Child Health Services need to systematically consider aspects of body function, activity and in addition participation and environmental aspects.

 Early childhood intervention and habilitation services for children with disabilities operate on an interdisciplinary basis. It requires a common language between professionals, and a shared framework for intervention goals and intervention implementation. The International Classification of Functioning, Disability and Health (ICF) and the version for children and youth (ICF-CY) may serve as this common framework and language. This overview of studies implemented by our research group is based on three research questions: Do the ICF-CY conceptual model have a valid content and is it logically coherent when investigated empirically? Is the ICF-CY classification useful for documenting child characteristics in services? What difficulties and benefits are related to using ICF-CY model as a basis for intervention when it is implemented in services? A series of studies, undertaken by the CHILD researchers are analysed. The analysis is based on data sets from published studies or master theses. Results and conclusion show that the ICF-CY has a useful content and is logically coherent on model level. Professionals find it useful for documenting children's body functions and activities. Guidelines for separating activity and participation are needed. ICF-CY is a complex classification, implementing it in services is a long-term project

Children's experience of radiographic examinations remains largely unexplored, although most radiographers examine children on a daily basis. In order to provide the high quality care that meets the needs of patients it was considered important to undertake research focused upon the patients' experience of radiographic practice.The aim of the study was to investigate children's experiences undergoing a radiographic examination for a suspected fracture.Inclusion criteria were Swedish-speaking children between 3 and 15 years of age who were submitted for a radiographic examination with an acute condition of the upper or lower extremity. Patients were informed of the study and together with the escorting parent or relative asked for consent to participate.During the examination the child was videotaped and immediately after, the child was interviewed in a nearby facility. The interview contained open-ended questions and was conducted while watching the videotape together with the child and their parent or relative and the researcher.Qualitative content analysis was used in analyzing the collected data. The analysis resulted in two categories - " feeling uncomfortable" and " feeling confident" The subcategories contained in these categories were " pain in relation to injury and examination" , " the waiting time is strenuous" , " worries for the future and consequences of the injury" , " confidence in parental presence" , " confidence in radiographic staff and examination procedure" , and finally " recognition entails familiarity" .The results revealed that for the younger children, the experience of undergoing an acute radiographic examination was associated with pain and anxiety, but for the older children, the anxiety was more connected to whether the injury had caused a fracture and any anticipated future consequences or complications. © 2011 The College of Radiographers.

Child engagement has been defined as active participation in classroom routines, appropriate interactions with the environment and it also predicts academic achievement. Therefore, it is necessary to identify predictors of engagement over time. Moreover, cross-cultural data is needed to provide a global picture of the quality of Early Childhood Education and Care (ECEC) across countries. This study aims to describe the quality of Swedish preschool classrooms and its relationship with students' engagement over time. Data was collected from 165 preschool teachers in 55 preschool units in Sweden. Results show that all classroom-related variables (Emotional Support, Instructional Support and Classroom Organisation) have increased levels over time, while engagement remained stable. Three groups of preschool classroom units were identified with similar patterns of classroom quality over time (higher emotional support and lower instructional practice) and similar differences in level. Emotional Support was found to be the best predictor of student engagement over time.

Adolescents need support from family, friends, and teachers to increase their involvement in everyday life. Their environment and their own characteristics also influence their ability to participate in an everyday supportive environment. Aim The aim of the study was to investigate patterns of support from parents, teachers, and very important persons such as peers to the ability of adolescents to participate in everyday life, as well as the importance of interpersonal relations as experienced by the adolescents. Method The study has a cross-sectional design. The data compiled and analysed in this study are part of a longitudinal study of adolescents and their development into adults-LoRDIA (Longitudinal Research on Development In Adolescence). A combination of person- and variable-oriented design was used to capture patterns of support. Results Adolescents with a complicated home situation and low economic prerequisites who received little support from parents and friends participated to a lower degree in home activities. A substantial number of these adolescents had self-reported neurodevelopmental disorders and, as a group, were more often exposed to harassment. However, these adolescents participated to a higher extent in school activities, although they received little support from the teachers. The adolescents who received most support from parents and teachers were those with a country of origin other than Sweden and those who lived with both of their parents and had more siblings than average. However, this did not mean that they participated to a higher extent in home and school activities.

Across countries, there are important differences related to the goals, organization, and educational philosophies of care provided to young children prior to formal schooling. Those differences are likely reflected in the classroom practices and teacher-child interactions within a country's early childhood education and care (ECEC) classrooms. This study aims to evaluate the within-country relevance of two classroom observation measures primarily based on a behavioral count approach focused on teacher and child behaviors; and to examine preschool practices in Sweden, Portugal, and the U.S., as they reflect each country's ECEC goals, organization, and educational philosophies. Participants are 78 preschool settings in Sweden, 42 in Portugal, and 168 in the U.S. Results show that the measures targeted culturally-relevant behaviors and provided inter-rater reliability for the behavior count variables in the three countries. Future collaborations may address additional culturally-specific variables. The behavioral descriptions yielded by combining behavioral counts of the measures are analyzed by researchers from the relevant country for insights to the country's values related to early childhood as well as current debates regarding care for children. Measures that provide comprehensive descriptions of classroom settings and apply minimal external or comparative value judgments on the behaviors observed are of practical utility for collaborative international work.

To review the longitudinal trajectories – and the factors influencing their development – of mental health problems in children with neurodevelopmental disabilities. Systematic review methods were employed. Searches of six databases used keywords and MeSH terms related to children with neurodevelopmental disabilities, mental health problems, and longitudinal research. After the removal of duplicates, reviewers independently screened records for inclusion, extracted data (outcomes and influencing factors), and evaluated the risk of bias. Findings were tabulated and synthesized using graphs and a narrative. Searches identified 94,662 unique records, from which 49 publications were included. The median publication year was 2015. Children with attention deficit hyperactivity disorder were the most commonly included population in retrieved studies. In almost 50% of studies, trajectories of mental health problems changed by < 10% between the first and last time point. Despite multiple studies reporting longitudinal trajectories of mental health problems, greater conceptual clarity and consideration of the measures included in research is needed, along with the inclusion of a more diverse range of populations of children with neurodevelopmental disabilities. 

Preschool staff in general face challenging work conditions, contributing to high turnover and sick leave. This issue may be more complex for staff working in groups with high proportions of early second language learners (L2-groups), compared to those working in groups with a majority of first language learners (L1-groups). Yet, studies focusing on this issue are scarce. This study aimed to explore and describe the organizational and psychosocial work conditions experienced by staff in L2-groups. Through interviews with individual staff and workgroups, followed by content analysis, three themes emerged: perceiving organizational conditions, establishing professional relationships, and using competence. Staff in L2-groups experienced a context that was more complicated and demanding compared to those in L1-groups. This was primarily due to insufficient organizational resources, challenges in establishing professional relationships, and limited ability to use their education and experience effectively. These challenges compromised their professional well-being, and by extension, their psychological and physiological well-being. Addressing these issues necessitates additional resources and a nuanced understanding by policymakers of the unique challenges faced by staff in L2-groups. 

Research on childrenofethnicminoritiesin Swedish preschoolsand theirengagementhas beena mainfocus area for research, eventhoughEuropeis facinga migration crisis. Child engagement predicts, amongotheroutcomes, futureacademicperformanceand mental well-being. Child engagementshouldbe promotedby the staff accordingto the curriculum for preschool. More research on ethnicity, engagementand staffingis needed.

PurposeUsing COR theory to study developments of health and other key resources in self-employed workers in Sweden over 6 years, this study: (1) explored whether the heterogenous group of self-employed workers contained subgroups with different health trajectories, (2) investigated whether these were more typical for certain individuals (with respect to age, gender, sector, education, employment status), and (3) compared the different health trajectories regarding resource development in mental well-being, business resources, employment status, work ability.

MethodThe study used data from the Swedish longitudinal occupational survey of health (SLOSH) and included participants working as self-employed or combiner (N = 2642).

ResultFive trajectories were identified with latent class growth curve model analysis (LCGM). Two health trajectories with (1) very good, respective (2) good stable health (together comprising 78.5% of the participants), (3) one with moderate stable health (14.8%), (4) one with a U-shaped form (1.9%), and (5) one with low, slightly increasing health (4.7%). The first two trajectories flourish: they maintained or increased in all key resources and were more likely to remain self-employed. Trajectories three and five consist of those who fight to maintain or increase their resources. Workers in the U-shaped health trajectory show signs of fight and flight after loss in health and other key resources.

ConclusionsStudying subgroups with different resource developments over time was suitable to understand heterogeneity in self-employed workers. It also helped to identify vulnerable groups that may benefit from interventions to preserve their resources.

BACKGROUND: A behavioural medicine approach in physiotherapy has shown positive effects on increased and sustained activities and participation, including reduced sick leave for patients with persistent musculoskeletal pain. The aim of this study was to explore the health outcomes of patients with persistent musculoskeletal pain treated by physiotherapists who had received active compared with passive support when implementing a behavioural medicine approach.

METHODS: An explorative and comparative pre-/post-test trial was conducted. A total of 155 patients with musculoskeletal pain ≥4 weeks were consecutively recruited by physiotherapists in primary healthcare who had received active or passive support when implementing a behavioural medicine approach. Data concerning health outcomes for patients were collected using questionnaires before and after the physiotherapy treatment and at half-, one- and two-year follow-ups. Descriptive, non-parametric and parametric bi- and multivariate statistics were used.

RESULTS: There were no differences over time between the patients treated by physiotherapists who had received active compared to passive implementation support regarding pain-related disability, pain intensity, self-rated health, self-efficacy in performing daily activities, catastrophic thinking related to pain, and fear of movement. Significant improvements over time were identified in both groups regarding all variables and the effect sizes were large. The percentage of patients on sick leave significantly decreased in the patient group treated by physiotherapists who had received active implementation support.

CONCLUSION: It is very important to include patient outcomes when evaluating the implementation of multicomponent interventions. It seems that the implementation method did not play a major role for the patients' outcomes in this study. Most of the patients' health outcomes improved regardless of whether they were treated by physiotherapists who had received active or passive support when implementing a behavioural medicine approach. This was likely because the active implementation support was not extensive enough to enable the physiotherapists to sustain the behavioural medicine approach.

TRIAL REGISTRATION: The study protocol was retrospectively registered in ClinicalTrials.gov . ID NCT03118453 , March 20, 2017.

Background: A behavioural medicine approach in physiotherapy for patients with persistent musculoskeletal pain is recommended based on evidence. The approach aims at an individually tailored treatment targeting motor behaviour, cognition, disability and active patient involvement. The behavioural medicine approach is complex and it is challenging in implementation to achieve clinically relevant behaviours in physiotherapy. Process evaluation is an essential part of designing and testing implementation interventions to improve the quality of the implementation. However, studies evaluating the implementation process of a behavioural medicine approach in physiotherapy are sparse.

Purpose: To explore the implementation process of a behavioural medicine approach in physiotherapy.

Methods: Qualitative and quantitative methods were used. 15 physiotherapists working in six primary health care units were consecutively included. A theory based implementation intervention was tailored to the participating individual physiotherapists. Active and multifaceted implementation strategies were used during a total of seven days spread over a six months implementation period. The main implementation strategies were external facilitation and peer-learning. Ten two-hours outreach sessions were offered to each unit. The physiotherapists were encouraged to use individual goal setting and video recordings of treatment sessions to facilitate feedback and reflection during the sessions with the external facilitator. Process data were collected using semi-structured interviews, self-reports of time allocation for different implementation strategies and documented individual goals. Qualitative content analysis and quantitative frequency scorings were used for data analyses.

Results: In median the physiotherapists participated in 9 (3-10) out of 10 sessions with the external facilitator. Discussing clinical experiences of the behavioural medicine approach together with the external facilitator was perceived as valuable. These discussions stimulated reflection and problem solving, and was also experienced as a reminder for practicing skills in behavioural medicine. Video recordings of treatment sessions were used by ten of the physiotherapists at 17 out of 57 possible sessions. Video recordings were experienced as too complicated to use in relation to the gains. Lack of time was also considered as a barrier for using video recordings. Individual goal-setting from one session to the next with the external facilitator was frequently used by all the participants. Relevant skills for the goals were practiced in between the sessions. However, goal setting was not considered important by the physiotherapists. In median the physiotherapists spent 3.25 (0-9.5) hours for peer discussions. Peer discussions were a strategy that the physiotherapists wanted to continue with, even after the implementation intervention period. Even though the physiotherapists had permission from the manager to spend time on the implementation intervention, it was challenging for the physiotherapists to prioritize the implementation intervention before patient care.

Conclusion(s): External facilitation and peer discussions were perceived as important strategies for stimulating practice of behavioural medicine skills in physiotherapy. Further, peer discussions could stimulate sustainability of the implementation. The physiotherapists needed support to use the designated time for the implementation.

Implications: Quantitative and qualitative analyses of the implementation process is useful for understanding the mechanisms of impact for the implementation intervention, how outcomes were achieved and for future replications.

Background: In a quasi-experimental study, facilitation was used to support implementation of the behavioral medicine approach in physiotherapy. The facilitation consisted of an individually tailored multifaceted intervention including outreach visits, peer coaching, educational materials, individual goal-setting, video feedback, self-monitoring in a diary, manager support, and information leaflets to patients. A behavioral medicine approach implies a focus on health related behavior change. Clinical behavioral change was initiated but not maintained among the participating physiotherapists. To explain these findings, a deeper understanding of the implementation process is necessary. The aim was therefore to explore the impact mechanisms in the implementation of a behavioral medicine approach in physiotherapy by examining dose, reach, and participant experiences. Methods: An explorative mixed-methods design was used as a part of a quasi-experimental trial. Twenty four physiotherapists working in primary health care were included in the quasi-experimental trial, and all physiotherapists in the experimental group (n = 15) were included in the current study. A facilitation intervention based mainly on social cognitive theory was tested during a 6-month period. Data were collected during and after the implementation period by self-reports of time allocation regarding participation in different implementation methods, documentation of individual goals, ranking of the most important implementation methods, and semi-structured interviews. Descriptive statistical methods and inductive content analysis were used. Results: The physiotherapists participated most frequently in the following implementation methods: outreach visits, peer coaching, educational materials, and individual goal-setting. They also considered these methods to be the most important for implementation, contributing to support for learning, practice, memory, emotions, self-management, and time management. However, time management support from the manager was lacking. Conclusions: The findings indicate that different mechanisms govern the initiation and maintenance of clinical behavior change. The impact mechanisms for initiation of clinical behavior change refers to the use of externally initiated multiple methods, such as feedback on practice, time management, and extrinsic motivation. The lack of self-regulation capability, intrinsic motivation, and continued support after the implementation intervention period were interpreted as possible mechanisms for the failure of maintaining the behavioral change over time. 

Purpose: To explore the effects on and sustainability of physiotherapists’ clinical behavior when using facilitation to support the implementation of a behavioral medicine approach in primary health care for patients with persistent musculoskeletal pain. Methods: A quasi-experimental pre-/post-test trial was conducted. Fifteen physiotherapists were included in the experimental group, and nine in the control group. Based on social cognitive theory and the Promoting Action on Research Implementation in Health Services framework, facilitation with multifaceted implementation methods was used during a six-month period. Clinical behaviors were investigated with a study-specific questionnaire, structured observations, self-reports and patient records. Descriptive and non-parametric statistical methods were used for analyzing differences over time and effect size. Results: A sustained increase in self-efficacy for applying the behavioral medicine approach was found. Clinical actions and verbal expressions changed significantly, and the effect size was large; however, changes were not sustained at follow-ups. The behavioral changes were mainly related to the goal setting, self-monitoring and functional behavioral analysis components. No changes in clinical behavior were found in the control group. Conclusion: Tailored multifaceted facilitation can support the implementation of a behavioral medicine approach in physiotherapy in primary health care, but more comprehensive actions targeting sustainability are needed.