Objectives Patients with type 2 diabetes are at much greater risk of developing cardiovascular diseases (CVD), including coronary heart disease (CHD), compared to non-diabetics. The lowering of glucose, blood pressure, and plasma lipid levels has been shown to reduce CHD risk, and treatment goals for these risk factors are now part of clinical practice guidelines. However, the incidence and outcome of CHD in diabetic patients does not show the same favourable trend as in the general population. Thus, the overall aim of the thesis was to investigate how the treatment goals for CVD risk factors contained in the national guidelines for diabetes care were reflected in clinical practice, and to explore factors that might influence the remaining high incidence of CHD in the type 2 diabetes population. Research designs and results I. The effectiveness of the introduction of treatment goals for dyslipidaemia was evaluated in a retrospective observational population-based cross-sectional study of 971 diabetic patients participating in the Västerbotten Intervention Programme (VIP) 1995–2004. There was a stronger trend of decrease in cholesterol levels among patients with diabetes compared to the non-diabetic population in 2000–2004. Increased use of lipid-lowering agents influenced the trend in diabetic patients, even though only 25.3% received lipid-lowering treatment after the introduction of the new guidelines. II. The experiences of general practitioners relating to treatment practice for type 2 diabetes with specific focus on the prevention of cardiovascular disease were explored in a focus group study. The overall theme was ‘dilemmas’ in GPs’ treatment practice for patients with type 2 diabetes. Five main dilemma categories were identified. First, GPs were hesitant about labelling a person who feels healthy as ill. Second, as regards communicating a diabetes diagnosis and its consequences, GPs were unsure as to whether patients should be frightened or comforted. Third, GPs experienced uncertainty in their role: should they take responsibility for the care or not? Fourth, GPs expressed concern over a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties when attempting to translate science into reality. III. Screening for microvascular and coronary heart disease according to national guidelines was evaluated in a cross-sectional study of 201 screening-detected patients with type 2 diabetes 1.5±0.7 years after diagnosis. A larger proportion of diabetic patients was screened for nephropathy and retinopathy than for CHD. Twenty-three percent of the patients had minor or major ECG abnormalities, but ECG findings seemed to have little or no impact on CHD prevention using lipid-lowering medication and ASA. A clinical history of CHD correlated with a larger proportion of patients receiving secondary prevention. IV. Time trends relating to the achievement of treatment goals and 10-year CHD risk at three years of diabetes duration were studied in 19,382 patients with type 2 diabetes without CHD, who were reported by primary health care sources in the National Diabetes Register in 2003–2008. National treatment goals for glycaemia, blood pressure, total cholesterol, and LDL cholesterol were achieved in 78.4%, 65.5%, 55.6%, and 61.0%, respectively, of the diabetic patients in 2008 following a trend of improved results in 2003–2008. Absolute 10-year risk of CHD increased between year of diagnosis and follow up in a studied subgroup while modifiable risk decreased. Conclusions The introduction of treatment goals for dyslipidemia in Swedish national guidelines in 1999 were reflected in lowered cholesterol levels in people with type 2 diabetes. Since the introduction of the guidelines, an increasing number of diabetic patients are treated in accordance with guidelines. A remaining microvascular focus on the patients together with the revealed dilemmas within the GP’s consultation with diabetic patients might negatively influence the remaining high incidence of CHD in the type 2 diabetes population. Lipid levels, blood pressure and smoking are targets for further improvements. / Kappa

Background – People with functional impairments have unmet needs and they are not given the support and service they are entitled to. According to international studies, early measures and treatment may slow down the outbreak of mental illness and relieve its course. Aims - To elucidate and compare both somatic poor health and social needs of people with either physical or mental functional impairments in a rural district, and to explore and compare how different personnel in the primary health care service and psychiatric services are able to detect early signs of psychosis. Moreover, to find out how early signs of psychosis are detected in primary health services, and to explore the patients’ pathways to the GPs. Methods – In studies I and II, people with severe functional impairments were offered a screening health examination followed by an interview. Three vignettes were presented to personnel in the primary health care service and the psychiatric services in study III. The participants were asked to detect any signs and symptoms of psychosis in the vignettes. In studies IV and V, notes in primary health care records were studied during a period of two years and six months, respectively, before a diagnosis of psychosis was made by the general psychiatric services. Results – People with severe functional impairments had poorer health and more problems with their ADL (Activities of Daily Life), economy/work and Quality of Life than people in general. Among the groups studied, people with mental impairments had the poorest living conditions. There were no differences between the participants in study III regarding sex, age and occupation; and the participants detected the signs and symptoms in the vignettes to a high degree (75% of all signs and symptoms). In all, 152 patients (22 with schizophrenia/ schizoaffective disorders, 41 with schizophrenia preceded by other psychotic disorders and 89 with persisting psychiatric disorders) with the diagnosis of psychosis made by the general psychiatric services were included in study IV and V. There were notes in 77% of the primary health records during the two-year study period, and 70% of these notes were about psychiatric signs and symptoms, which means that the GPs detected signs and symptoms of psychosis in 2/3 of the cases. The analysis of the patients’ visiting patterns to GPs showed that many patients did not visit their “own” primary health care centre or their “own” GP. Furthermore, many patients had no contact with the primary health care service at all, and the subgroup with schizophrenia/schizoaffective disorders visited the primary health care service less frequently than the other groups. Main conclusion – People with severe functional impairments must be granted regular contacts with a GP, whose role must be: to identify and motivate the patients; to detect when there are needs for care and social needs; to function as a representative for the patients; to inform the patients about their rights and to guide them to other social or health authorities. The GPs detected early signs and symptoms of an emerging psychosis to a high degree, which would make early intervention possible. The more visits to the GPs, the more symptoms were detected, and out of all signs and symptoms with psychiatric content noted, the GPs would have suspected an emerging psychosis in almost every second patient who visited them. To detect early signs and symptoms of psychosis is difficult, and whenever in doubt, primary health care personnel must be able to consult psychiatric professionals. Otherwise we may miss the opportunity to intervene in an early phase of the illness. Additional training could also mean better understanding and earlier detection of people at risk of an emerging psychosis.

The general aim of this thesis was to evaluate different aspects of patient education for people with type 2 diabetes in Swedish primary health care. The evaluation was conducted in a primary health care setting in central Sweden and in Swedish primary health care in its entirety. Seven centres in central Sweden had implemented the empowerment programme for patients with type 2 diabetes. Data on 16 care providers’ views on implementing the programme were collected in focus-group interviews. The effect and the patients’ experiences of the programme were evaluated in a randomized controlled trial (RCT) (n=101) and in individual interviews (n=28). In the RCT, 50 patients were assigned to the programme and 51 patients to routine diabetes care. The patients answered a 27-item questionnaire and BMI and HbA1c were measured, before the intervention and at one-year follow-up. Further, data from 485 primary health care centres with 91,637 diabetic patients were collected to evaluate patient education in Swedish primary health care in its entirety. The care providers experienced conflicting roles in changing from expert to facilitator in the empowerment programme. The programme improved patients’ confidence in diabetes knowledge and contributed to their experience of self-control, while patients in the routine diabetes care experienced external control. Of the 485 centres, 50% reported having checklist-driven individual counselling and 8% that they individualized the counselling based upon patients’ needs. Most centres (>90%) set individual goals, but only one-third involved patients in the final decisions regarding their goals. Setting individual goals was found to have an impact on patients’ possibilities to reach national treatment targets. In conclusion, the implementation of empowerment in patient education demands support to care providers in order to influence patients’ self-care. Furthermore, patients need to reflect upon necessary self-care changes and also set individual goals to facilitate the reaching of national treatment targets.

The purpose of this study was to describe how nurses, working in primary health care and responsible for diabetes care, reflected on patient information and education, its’ content and experiences of providing it. The study had a descriptive design and seven nurses from seven health care units in the middle of Sweden participated in the study. Data were analyzed with qualitative content analysis. The results are presented in two main categories; “The information” and “The procedure”. The two subcategories; Adjusting information and Bring about knowledge and to live with the disease emerged from “The information”. The five subcategories; Specific situation information, Increased insight about lifestyle changes, Developed dialogues, Nurses’ and patients’ perspective of responsibility and Supporting and follow ups were formulated from “The procedure”. Individual adjusted information within dialogues was highlighted. The motivational interview technique was considered as contributing to possibilities for more successful treatment and lifestyle changes. The main result showed that nurses responsible for diabetes care in primary health care empathized the need of individual adjusted information and the procedure providing it, in order to support the patients’ daily life.

<p>According to the United Nations, more than half a billion people (about 650 million) worldwide are disabled. Disability can have a vast impact on both the individual and the family. Rehabilitation is therefore a fundamental need for the persons with disability to achieve functional independence and have an improved quality of life. To enhance the effectiveness of rehabilitation, it is important to seek clients&rsquo / perspectives of the rehabilitation services and to incorporate these perspectives into the planning and delivery of rehabilitation services. In areas where rehabilitation services are available in South Africa, minimal research has been done to explore the clients&rsquo / experiences regarding provision of these services. The aim of this study&nbsp / therefore was to explore the persons with physical disabilities&rsquo / experiences of the rehabilitation services they received at community health centres (CHCs) in the Cape Town Metro Health&nbsp / District. Data was collected using a mixed methods design in the form of a sequential exploratory strategy. Qualitative data collection was done using in-depth interviews and this was followed&nbsp / by administration of an interview questionnaire. The questionnaire was developed using results from the in-depth interviews together with information from literature. Ten persons with physical&nbsp / isabilities, who had received rehabilitation services at participated in the in-depth interviews and 95 responded to the interview questionnaire. The interviews were tape-recorded and&nbsp / transcribed verbatim and they were analysed using predetermined themes. The SPSS version 16.0 was used to analyse the quantitative data which was presented in frequencies, medians, quartiles and percentages. The results&nbsp / of the study revealed that the participants experienced problems with getting transport to travel to the community health centres and getting adequate information from the service providers,&nbsp / &nbsp / particularly information regarding disability and support services available for them. Experiences regarding participants&rsquo / involvement in their rehabilitation were generally positive. Generally, the&nbsp / participants reported positive experiences regarding their interaction with service providers and family support and involvement and this study recommends the staff to maintain their standards&nbsp / &nbsp / regarding these two dimensions of rehabilitation. However most of the participants were not concerned about whether the service providers gave them an opportunity to express their preferences or not. The results indicate the need to improve transport services for persons with physical disabilities and to give them more information regarding support services. The service providers&nbsp / should also give the clients more opportunities to get involved in their rehabilitation and educate them about the benefits of them getting involved.</p>

Bakgrund/syfte: Många patienter, varav unga vuxna(18-25 år) utgör en stor grupp, använder akutmottagningar [AM] av obefogade skäl. Problemet med icke-akuta patienter på AM har varit ett diskussionsämne sedan 80-talet i västvärlden. De långa väntetiderna och ökade patienttrycket på AM är associerat till en försämrad upplevelse av vården ur ett patientperspektiv. Primärvården har en nyckelroll i att styra flödet av patienter som söker vård. Föreliggande studie syftar till att undersöka hur unga vuxna (18-25 år) söker vård relaterat till kön, ålder, symptom och lämplig vårdnivå, AM kontra Närakuten [NA]. Metod: En deskriptiv konsekutiv enkätinsamling genomfördes på akutmottagningen på Akademiska sjukhuset och på närakuten (Cityakuten) i Uppsala. Resultat: Kvinnor sökte mer vård i undersökningsgruppen och den vanligaste orsaken till besök på AM var buksymptom och på NA var det allmänna influensasymptom. Inget samband mellan tidigare kontakt med sjukvården och huruvida undersökningsgruppen sökte rätt vårdnivå kunde påvisas. En av fem patienter bedömdes initialt ha sökt fel vårdnivå på båda verksamheterna. Slutsats: Primärvården kan spela en nyckelroll i styrning av patientflödet men även andra instanser som kuratorstöd och psykologstöd kan bidra. Mer forskning behövs för att fastställa bakomliggande orsaker och prevalens. / Background/aim: Many patients seek emergency departments [ED] based on inappropriate causes, a considerable amount of which are young adults (aged 18-25). In the western society, the problem with non-acute patients seeking ED care, have been a topic of debate since the 80´s. The long waiting times and the increasing flow of patients at the ED are associated to a lower level of satisfaction amongst patients. The primary health care plays a key role in controlling the flow of patients seeking care. The aim of this study is to describe health care seeking behaviors, based on sex, age, symptoms and appropriate level of care, ED versus the out-of-hospital ED. Method: A descriptive consecutive questionnaire collection was conducted at the ED in Uppsala University Hospital and at the out-of-hospital ED (Cityakuten) in Uppsala. Result: Female patients were most represented seeking care in the study group, and the most common reason for seeking ED care was abdominal symptoms. At the out-of-hospital ED the most common reason was general flu symptoms. No correlation between previous health care contact and whether the study group used the appropriate health care level was found. At the first assessment one in five patients sought the wrong care level at hospital based ED and at the out-of-hospital ED. Conclusion: The primary health care should play a key role in controlling the patient flow. Other agencies such as counselor support and psychiatrists should contribute as well. Further research should focus on establishing underlying causes and the prevalence.

Background. Studies that examined community samples have reported several risk factors for the development of depressive episodes. The few studies that have been performed on primary care samples were mostly cross-sectional. Most samples had originated from highly developed industrial countries. This is the first study that prospectively investigates the risk factors of depressive episodes in an international primary care sample. Methods. A stratified primary care sample of initially non-depressed subjects (N = 2445) from 15 centres from all over the world was examined for the presence or absence of a depressive episode (ICD-10) at the 12 month follow-up assessment. The initial measures addressed sociodemographic variables, psychological/psychiatric problems and social disability. Logistic regression analysis was carried out to determine their relationship with the development of new depressive episodes. Results. At the 12-month follow-up, 4·4% of primary care patients met ICD-10 criteria for a depressive episode. Logistic regression analysis revealed that the recognition by the general practitioner as a psychiatric case, repeated suicidal thoughts, previous depressive episodes, the number of chronic organic diseases, poor general health, and a full or subthreshold ICD-10 disorder were related to the development of new depressive episodes. Conclusions. Psychological/psychiatric problems were found to play the most important role in the prediction of depressive episodes while sociodemographic variables were of lower importance. Differences compared with other studies might be due to our prospective design and possibly also to our culturally different sample. Applied stratification procedures, which resulted in a sample at high risk of developing depression, might be a limitation of our study.

Högt blodtryck (hypertoni), en riskfaktor för hjärt-kärlsjukdomar, ökar. Studiens syfte var att undersöka hur patienter med högt blodtryck upplever samtal med personal i primärvården. En kvalitativ intervjustudie med 10 deltagare där semistrukturerade frågor ställdes resulterade i tre kategorier: ”känsla av trygghet- otrygghet”, ”förståelse av information” och ”drivkrafter och hinder till förändring”. Samtal med personal i primärvården upplevdes positivt. I de fall där upplevelsen av samtal angående levnadsvanor inte upplevdes som positivt var anledningen att informanterna kände att de var tvungna att engagera sig. De flesta intervjuade upplevde att de fått frågor om levnadsvanor i början, när hypertoni konstaterades, men sedan togs det upp mer sällan. Det var oftast läkaren som samtalade med patienten om levnadsvanor. Samtliga hade fått frågor om kostvanor, motionsvanor och tobaksvanor men frågor om alkoholvanor ställdes inte i samma omfattning. Alla informanter hade förändrat sina motionsvanor och majoriteten hade även gjort förändringar i kostvanor. Flera informanter ansåg att de visste för lite om samband mellan levnadsvanor och högt blodtryck. I de fall uppföljning skedde avtog intensiteten med tiden. Önskemål om samtal där orsaken till hypertonin, samband mellan levnadsvanor och hypertoni och vad den enskilda individen kan göra för att förbättra sitt blodtryck framkom. / High blood pressure (hypertension), a risk factor for cardiovascular diseases is increasing. The aim of this study was to investigate how patients with high blood pressure perceive talks with primary care personnel. A qualitative study by means of interviewing ten participants was conducted. Semi-structured questions were asked which resulted in three categories of perception: "sense of security versus insecurity", "understanding information" and "incentive versus unwillingness to change ones lifestyle". Talks with primary care personnel were perceived in a positive manner. In those cases where the perception of talks regarding ways of everyday life and daily living habits however, was not as positive, it was mainly because the informants felt they had to get involved on a personal level. A majority of those interviewed pointed to the fact, that they had been asked questions about their living habits at the beginning, when diagnosed with hypertension, but as time progressed these were addressed more infrequently. Most often it was the physician who spoke to the patient about his or her living habits. All participants were asked questions pertaining to their habits regarding diet, exercise and tobacco. Questions about alcohol were not asked to the same extent. All informants had changed their exercise habits and the majority had also changed their eating habits. A number of informants felt they knew too little about the connection between living habits and hypertension. In those cases where a follow-up was done the intensity of the follow-ups decreased with time. Requests for talks emerged, where not only reasons for hypertension but also the connection between living habits and hypertension could be explained, as well as how the individual himself could improve his blood pressure.

Syfte: Att utreda om primärvårdssjuksköterskor i Uppsala län upplevde att det fanns faktorer sompåverkade deras möjligheter att skriva ut fysisk aktivitet på recept. Metod: Deskriptiv kvalitativ intervjustudie. Sju primärvårdssjuksköterskor inom Uppsala län harintervjuats med semistrukturerad metod. En kvalitativ innehållsanalys enligt Granheim ochLundman (2003) utfördes på manifest nivå. Resultat: Primärvårdssjuksköterskor i Uppsala län upplevde att det fanns faktorer som påverkadederas möjligheter att förskriva FaR. Det uppgavs nödvändigt att ha kunskap om hur man arbetarmed förskrivning av FaR och att uppleva sig kunna motivera patienter som har mindre mottaglighetför FaR. Att ha tillräckligt med tid avsatt upplevdes som en förutsättning för förskrivningen. Arbetetmed FaR ansågs underlättas om det fanns tillgång till direktiv som implementerade FaRförskrivning vid patientkontakt. Samarbetet med andra yrkesgrupper nämndes underlättaförskrivningen av FaR. Slutsats: Primärvårdssjuksköterskors förskrivning av FaR i Uppsala län skulle kunna underlättasav:  Ytterligare information om metoden, där underlaget FYSS introduceras, men ocksåutbildning i motiverande samtalsteknik.  Att det finns utrymme för primärvårdssjuksköterskan att avsätta nödvändig tid.  Att möjligheter till ett tvärprofessionellt samarbete upprätthålls.  Att i det fortsatta arbetet med metoden i Uppsala läns primärvård utforma gemensammadirektiv som implementerar FaR vid patientkontakt. / Aim: To investigate whether nurses in the primary health care within the county of Uppsalaexperiences that there are elements which influences their possibilities to prescribe FaR, a methodfor prescribing physical activity in a recipe. Method: Descriptive qualitative interview study. Seven nurses in the primary health care within thecounty of Uppsala have been interviewed with a semi structured approach. A qualitative contentanalysis according to Granheim and Lundman (2003) where conducted on a manifest level. Result: There were factors which was experienced to have an impact on the prescription of FaRmade by the nurses of the primary health care in Uppsala county. It was seen necessary to have theknowledge about how to work with the prescription of FaR. It was also necessary to experience anability to motivate patients with low susceptibility to FaR. Enough time given was said to bee arequirement to prescribe FaR. Directives, which was implementing FaR, made it easier to prescribe.The collaboration with other occupational groups was experienced to benefit the prescription ofFaR. Conclusion: The prescription of FaR, made by nurses within the primary health care in Uppsalacounty, would benefit from:  Further information about FaR, where FYSS (a script containing facts about FaR) isincluded in the education as well as a motivational conversation technique.  Making sure that the nurses of the primary health care has the ability to make enough timeto prescribe a recipe.  Seeing to the possibilities of the different occupational groups collaborating.  Continuously developing common directives that implements FaR in primary health care.

Bakgrund: Plötsligt hjärtstopp är en av de vanligaste orsakerna till för tidig död i vårt samhälle och den största dödsorsaken runt om i världen. Syfte: Syftet med studien var att studera vilken kunskap, utbildning och beredskap i hjärt-lungräddning (HLR), som medarbetarna i primärvården anser sig ha och om det fanns skillnader i detta mellan yrkesprofessioner och mellan vårdcentraler i stad respektive landsort. Metod: Designen är en deskriptiv och jämförande tvärsnittsstudie. En enkät användes för att få med så många respondenter som möjligt. Resultat: Resultatet baseras på svar från 144 respondenter. Av samtliga medarbetare hade 87 ­% gen­omgått en HLR utbildning det senaste året. Detta till trots ansåg sig endast 66 % ha tillräckliga kunskaper i HLR. Någon signifikant skillnad mellan yrkesprofessioner gällande kunskap i HLR gick inte att signifikant säkerställa (p = 0,107). Endast 80 % av medarbetarna visste hur ambulans larmas. I en jämförelse mellan stad och landsort fanns dock ingen signifikant skillnad i den kunskapen (p = 0,12). Slutsats: Det är viktigt att skapa förutsättningar för fortlöpande utbildningar till medarbetarna för att öka kunskap, utbildning och beredskap i HLR, vilket även kan ses som ett kvalitetssäkringsarbete i vården. / Background: Sudden cardiac arrest is one of the most common causes of premature death in our society and the largest cause of death worldwide. Purpose: The purpose of this study was to investigate primary health care employee’s knowledge, training and preparedness they consider themselves to have in cardiopulmonary resuscitation (CPR) and to study whether there are differences between professional roles as well as differences in urban and rural health centers. Method: The design of this study is a descriptive and comparative cross-sectional study.  To capture as many respondents as possible a questionnaire was used. Result: The result in this study is based on responses from 144 respondents. Eighty-seven percent of employees have been training CPR the last year. Despite that only 66 % felt they have sufficient know­­ledge. There was no significant differences indicated in knowledge in CPR between professions roles (p = 0,107). Only 80 % knew how to alert the ambulance. In a comparison between urban and rural no significant difference in knowledge can be seen (p = 0, 12). Conclusion: The conclusion of the study is that it´s important to create competence for the employees, education for members of the CPR in order to improve the skills which can also be seen as a quality work in health care centers.