Annual Rapport 2018

Annual Report
2017
Center for Primary Healthcare Research
Competence Center for Primary Healthcare in Skåne

Contents
Overview
04
The year in review 04
Organisation 06
Vision 07
Management & mission 08
Good rating in the National Board 09
of Health & Welfare appraisal
Competence Center
for Primary Healthcare
in Skåne
10
Primary care education unit:
Trainee physicians 12
Resident physicians 13
Workplace training, VFU 16
Diabetes coordinators 19
Family medicine consultants AKO 20
Knowledge Center for Migration and Health 28
Knowledge Center for Child Healthcare 32
Knowledge Center for Women’s Health 38

Center for Primary
Healthcare Research
40
Family medicine knowledge center, AKC 42
Short notices 44
Research (research leaders & research projects) 46
Doctoral students 62
PhD Thesis Defences 65
Database group 74
Analysis group 76
Molecular biology laboratory 80
International collaborations 82
The financial perspective 86
Published scientific articles 88

Summary
Summary
All research, competence development, education and ST/AT coordination
in Region Skåne’s primary healthcare are merged in two producing and
competitively operational divisions, the Center for Primary Healthcare
Research (CPF) and the Competence Center for Primary Healthcare in
Skåne (KCP), which serve as a cohesive knowledge platform for both the
private and public sectors.
4

Summary
VISION
Center for Primary Healthcare Research (CPF)
To counduct groundbreaking clinical research for primary care
of highest quality and help benefit a healthier population
as a result.
VISION
Competence Center
for Primary Care in
Skåne (KCP)
Equal health, equal treatment
and a highly competent staff.
5

Summary
Our annual report
from 2017 is
more extensive
than ever! We
show in detail
the activities
that happen at
both the Competence
Center for
Primary Care and
at the Center for
Primary Healthcare
research.
Everything would
not have been
possible were it
not for the efforts
and dedication of
our personnel.
A thriving network
6
The year 2017 was an
extraordinary and exciting
year for both the Center
for Primary Healthcare Research
(CPF) and the Competence Center
for Primary Care (KCP) as each
contributed to the development of
primary care in Skåne. Important
collaborations, both nationally
and internationally, began and
have been deepened.
In Skåne there was the ongoing
training of 380 resident physicians
in family medicine, ably
supported by 12 study directors at
the Primary Care Education Unit.
We have offered undergraduate
studies, in-service training, lectures,
seminars, interactive webinars
and video library.
The Knowledge Center for
migration and health, child health
care and women’s health care plays
a central role in the in-service
training within primary care – KC
for migration and health and also
for other specialist care – which
is included in its mission. All of
this and more you can read in this
yearbook.
We work closely together within
the Competence Center for Primary
Care and the Center for Primary
Healthcare Research, not only in
our joint management team but
also in different projects.
We also have a training course,
which is aimed at the whole
primary care, and comes out twice
per year. The cooperation creates
inspiration and innovation and
is necessary to implement new
research within primary care.
Anna Jarslund Broman, study
director for trainee physicians in
Helsingborg and Ängelholm, as
well as a district physician at Vårenscentralen
Husensjö, launched
a pilot project in cooperation with
Practicum Clinical Skills Centers
for trainee doctors in primary care
to be able to practise practical
skills. Today it is an established
method throughout Skåne. She
talks about this much appreciated
training in the yearbook.
Internationalisation is increasing
quickly. More and more want
to come here for exchanges in
undergraduate education and research,
which is important. There
have been several exchanges of
students, researchers and academic
teachers, especially in the
cooperation we have with Kyoto
Sangyo University and Shimane

Summary
University of Japan. In the same
vein, we have an exchange with
researchers at Virginia Commonwealth
University and German
Cancer Research Center in Heidelberg.
A large number of our employees
are clinically active and thus use
their scientific skills for the benefit
of primary care. At the same time,
researchers can seek stimulation
in the clinical soil where the best
research ideas are born.
In 2017 we received 19 million
Swedish kronor in external
allocations (Swedish Research
Council, NIH, Forte, Heart- Lung
Foundation) and 5.5 million
Swedish kronor in an ALF grant,
which enabled a large production
on a high scientific level: We published
a total of 135 scientific articles,
of which the majority were
about diseases that are common
in primary care. The articles were
published in reputable international
journals such as Gastroenterology
and the American Journal
of Psychiatry and Heart. Since the
Center for Primary Healthcare
research began in October 2008,
we have published about 1100
scientific articles!
Our collaboration with the
national research school in family
medicine intensified during the
year and several of the CPF’s
employees are now included in a
network of universities that are
actively supporting the administration.
This further strengthens
our research. District physician
Moa Wolff is our coordinator at
the research school.
A total of eight PhD students
held their defence in 2017. And
it was wonderful to witness. Let's
all congratulate Cecilia Lenander,
Karin Ranstad, Mia Tyrstrup, Marie
Köhler, Nermin Ghith, Marie
Nilsson, Sofie Persson, and Maria
Wemrell!
One of our platform’s missions
is to implement research within
primary care. In November 2017,
we sent out a survey regarding the
study of mindfulness treatment in
a group that we made. It turned
out that one third of healthcare
centers (33 out of 109 responders)
offer mindfulness in group form
to their patients. This is good and
the survey shows that we receive
information about our research
and that knowledge is applied in a
clinical setting.
Another important clinical
example is the FIRST project at
25 healthcare centers with Professor
Kristina Sundquist as research
leader. FIRST aimed to increase the
proportion of patients with atrial
fibrillation who received adequate
anticoagulant therapy, even high
up the ages; this is to reduce the
risk of stroke. The implementation
of the project led to many new
patients receiving treatment with
anticoagulants and that the level of
treatment increased by 76%.
Our annual report from 2017 is
more extensive than ever! We show
in detail the activities that happen
at both the Competence Center for
Primary Care and at the Center
for Primary Healthcare research.
Everything would not have been
possible were it not for the efforts
and dedication of our personnel.
Enjoy the fruits of our labour!
Jan Sundquist, Director, Professor and
Family Physician
Clinical support
group (from left)
Karolina Palmér,
Sanna Quirico
Rosenqvist,
Susanne Andrén,
Marie Mårtensson-
Ruscic and Jan
Sundquist. Missing
from the picture:
Emelie Stenman.
7

Summary
Management and Mission
The Center for Primary Healthcare Research (CPF) and
the Competence Center for Primary Healthcare in Skåne
are important resources for knowledge development
and clinical processes in both public and private primary
healthcare. Therefore, competition neutrality is of the
highest importance.
The role of operations manager for CPF falls under the remit of CPF’s board
while the job of operations manager of KCP falls under the management
division Primary Healthcare Sund within Region Skåne.
CPF and KCP have a joint management team to create an environment with
an emphasis on collaboration and synergies that make for an optimal use of
resources
The role of the board
The CPF is based on a collaboration between Region Skåne and Lund University.
The board members lead the work regarding strategic and comprehensive
planning. This means that it makes decisions about the direction
of the research that CPF intends to conduct and the board also draws up
an operational plan and is responsible for the required follow-up of CPF’s
operations and management of financial resources.
CPF’s and KCP’s Management Team
w Jan Sundquist, professor & director
w Kristina Sundquist, professor & research leader
w Patrik Midlöv, professor & research leader
w Eva Pulverer Marat, unit head (PUE)
w Marie Köhler, unit head (KC child healthcare &
KC women’s health)
w Jenny Malmsten, unit head (KC Migration & health)
w Sten Tyrberg, team leader (AKO)
w Emelie Stenman, team leader (AKC)
w Karin Hallstedt*, team leader (KC women’s health
*From 2018 Anna Kjellbom
w Kathy Falkenstein-Hagander, team leader
(KC child healthcare)
CPF’s Board
w Professor Jerzy Leppert, Uppsala University
w Professor Bodil Ohlsson, Lund University
w Senior Professor Lars H Lindholm, Umeå University
(Chairman)
w Professor Jan Sundquist, Director (Rapporteur)
w Professor Birgit Rasmussen, Lund University
w Professor and Vice Dean Lars B.Dahlin, Lund University
w Missing from picture: Stefan Bremberg, MD, PhD, Medical
specialist Capio
8

Summary
DECLARATION
"It’s important
recognition that
spurs us on"
”University Clinic Primary Care
Skåne is an extensive area for
research and education activities
without equal in Sweden and
can thus be a model for university
units within family medicine
in Sweden. It has advantages
in that there is one platform for
both research in primary care
as education (undergraduate,
trainee physician, resident physician
and continuing education)
and skills development
in a broad sense.”
Good rating in the National Board
of Health & Welfare appraisal
In 2017, the University Hospital Unit that consists of CPF,
KCP, AKO and AKC was reviewed during a visit by the National
Board of Health & Welfare.
All criteria for university health care were met and investigators
Lars Borgquist, Professor Emeritus, Linköping
University and Birgitta Hovelius, Professor Emeritus, Lund
University, wrote in the summary:
“University Clinic Primary Care Skåne is an extensive
area for research and education activities without equal in
Sweden and can thus be a model for university units within
family medicine in Sweden. It has advantages in that there is
one platform for both research in primary care as education
(undergraduate, trainee physician, resident physician and
continuing education) and skills development in a broad
sense.”
“This is important recognition that encourages us to
maintain a high level of research and education with the
ambition to create an even better primary care for staff and
patients at Skåne’s healthcare centers,” says Jan Sundquist,
Director.
CPF, KCP, AKO and AKC together form the
university healthcare unit since the beginning
of 2016-2017. The shared knowledge
platform is as follows:
w Continuously conduct research of a
high national and international quality.
w Provide high quality education.
w Follow international developments in
medical research, education and health
care.
w Contribute to evidence based health
and healthcare by transferring our own
and other research results to practical
care and continuously evaluate
established and new methods.
w Convey the message of the results to
the organisation and to other parts of
the healthcare network.
w Work with the business community and
patient organisations.
9

KCP
Competence
Center for
Primary
Healthcare in
Skåne
The Competence Center for Primary Healthcare in Skåne (KCP) provides
in-service training, AT (trainee physician) and ST (resident physician)
training, family medicine consultancy activities, further education, the
Knowledge Center for Child Healthcare, Women’s Healthcare Services
and Migration and Health Services. The common platform entails great
advantages of coordination at KCP, as well as between KCP and CPF.F.
Kompetenscentrums enheter och team:
10
The Competence Center’s units and teams:
Primary Healthcare Training Unit •
Skåne Family Medicine Consultancy, Region Skåne (AKO) •
• Knowledge Center, Migration and Health Services •
Knowledge Center for Child Healthcare Services •
Knowledge Center for Women’s Healthcare Services •

In-service training
Number of student enrolments
Training days
In Knowledge Center
for Migration & Health
Course participants
In education in knowledge center
KCP
4 363
1 560
22
Participants
In education at the knowledge center for women’s health
Live webinars
8
Resident
physician
activities
749
New AKO health guidelines
58
80
The Financial Perspective
Operations Revenue Costs Profit/Deficit
w Primary Care Training Unit
w Skåne Family Medicine Consultancy, (AKO)
w Knowledge Center, Child Healthcare
w Knowledge Center, Women’s Health
w Knowledge Center, Migration & Health
18 822 890
6 107 033
13 763 554
4 644 072
7 324 854
16 826 840
5 961 492
13 469 825
4 261 651
5 135 729
1 996 050
145 541
293 729
382 421
2 189 125
11

KCP Primary Healthcare Training Unit
Primary Healthcare
Training Units
The Primary Healthcare Training Unit is co-located within CPF. The
training unit is responsible for AT/ST training, coordination within
diabetes, further education issues and in-service training. Eva Pulverer-
Marat heads up the unit.
AT (Trainee Physicians)
During 2017, there were
141 trainee physicians that
were placed for six month
working stints in primary care in
Skåne. Five trainee physician study
directors worked with quality
control of the education sites. And
there were 88 seminars organised
locally for trainee physicians.
The number of AT services
has increased over the past year
within Region Skåne. More new
healthcare centers hosted a trainee
physician to manage the placements
and it worked well.
Primary care in Skåne received
good grades in SYLF’s trainee
physician ranking. Landskrona
was placed second in the whole
of Sweden with an overall rating
of 5.8, out of 1-6. The general
assessment for family medicine is
consistently good in Skåne with
Kristianstad, Ängelholm and
Malmö distinguishing itself with
excellent grades.
Trainee physician study directors
regularly visit trainee doctors
at the workplace to ensure that the
education environment and the
quality of education is optimal.
During the year, Skåne has
implemented training of practical
skills for trainee physicians who
are commencing their primary
care placement in collaboration
with Practicum Clinical Skills
Centers Region Skåne. The course
lasts1-2 days and consists of
practical elements within minor
surgery, spirometry/allergy test,
orthopaedic status, eye and ear
microscopy. The courses received
good evaluations and are scheduled
to continue.
In addition to these courses,
there were regular administrative
seminars organised with a total
of 88 elements for different areas.
Some examples of content in
the seminars were skin diseases,
assessment of dizziness and long
lasting pain. At the trainee physician
brunches, a total of 110 AT
physicians participated in lectures
and discussions regarding Scanian
primary care. These gatherings
aim to increase interest and boost
recruitment to resident physician
services in general medicine.
12
goals 2017
w Increase the quality of the supervision and the knowledge of skills
assessment methods in resident physician education
w Improve the information to administrative leaders and raise awareness of the
resident physician content services
w To ensure that the trainee physician is better prepared for primary care placement and gets optimal learning
w Improve diabetes care in Skåne and increase the number of certified units
w Good student satisfaction and well-educated future employees
w Support the development of methods that improve pedagogical meetings (peer learning)
w Produce four video tutorials and eight webinars
w Further develop our digital services

Primary Healthcare Training Unit KCP
ST (Resident Physicians)
Over the last four years, the number
of resident physicians has progressively
increased in Skåne and in 2017
amounted to 379 ST doctors that work
relatively proportionally in the private and
public sectors.
Our 12 study directors work within
four different areas of Skåne and each area
arranges their own ST meetings for ST doctors.
The study directors have continuous
contact and meetings with hospital clinics
as well as private clinics to ensure that
the required side programs are met. Upon
granting of ST education grants, the director
of studies conducts a quality control/ Pre-ST
assessment of the health center before it is
approved as a suitable training site. This is
to promote a good educational environment
and ensure clarity via a written ST agreement
between the director of studies, supervisor,
administrative leader and ST doctor.
The ST meetings were held once a month
with lectures and meetings in collegial socalled
FQ groups with 8-10 participants to
provide structured quality development and
in-service training.
In ST Forum, a digital portfolio, all ST
doctors plan and record their education,
monitor their educational activities against
the goal description and write a mandatory
annual report. The supervisor also writes an
annual report on skills development.
In August, the study directors had an internal
planning meeting at Skåne Tranås. At
the internal meeting they looked at working
methods and routines in Skåne’s various
areas in order to learn from each other.
SPUR process (a model for external review
produced by Swedish Medical Association
and the Swedish Society of Medicine foundation
for education quality) was also passed
with positive remarks for almost all healthcare
centers in Skåne that have conducted
ST education within the past five years and
participated in SPUR inspections or have
them planned. One of the goals for 2017
2017
vision
"We want to create an environment of equal
health, equal treatment and a highly competent
staff"
Primary Healthcare Training Units:
Number of employees:
11.3 full-time positions (25 staff)
ST-activities
28 in-service training days/courses
with 985 participants
30 ST-one day meetings with
1 527 participants
AT-activities
88 seminars
AT brunch with 111 participants
13 full-day practical skill sessions
(Practicum)
Further education for other employees
57 courses with 1 724 participants
Average grade for the courses –
VT 2017 4.3 and HT 4.1; scale 1-5
VFU, workplace training
1 560 student enrolments
2 supervisor courses with 40 participants
Diabetes coordinators
4 in-service training days with 270
participants
60 diabetes certified units
13

KCP Primary Care Training Unit
missive
gave results:
45 NEW
ST SERVICES
2018
was to increase the quality of supervision
and therefore three separate training days
were conducted for supervisor updates.
During the year the preparation group
for family medicine had three meetings
which led to a letter to the health and
welfare committee about the need for
extending ST services in general medicine.
This resulted, that in Skåne in 2018, there
will be an additional 45 ST services being
established in general medicine and 15 ST
services for double specialists.
Other activities during the year were
the ST physician day, supervisor meetings,
diplomacy events as well as start-up
meetings. An ST-day was held by the ST
Doctors in the North East of Sweden and
dealt with, among other things, sparsely
populated area medicine and dizziness.
Göran Stiernstedt, State investigator, and
regional director Alf Jönsson participated.
Autumn’s supervisor day was organised by
study directors in Malmö and attracted 120
participants and shone a light on competence
assessment methods as well as other
subjects. The ST unit planned and arranged
courses for ST doctors on consultations,
supervisor course, skin diseases, cognitive
diseases, orthopaedic manual therapy
(OMT), insurance medicine, injection
technique, pain management and in general
medical practice. There was also a course
for incoming FQ leaders.
Clinical
skills in
practice
14
Anna Jarslund Broman, AT-study director in Helsingborg and
Ängelholm, as well as a district physician at the Husensjö
healthcare center, launched a pilot project in collaboration
with Practicum so that resident physicians can practise their
skills in primary care. Today, the in-service training is
established throughout Skåne.

Primary Care Training Unit
KCP
During the last 18 months that the AT
service has been around it has since
established a practically designed
A&E course for AT physicians through
Practicum, where they train in emergency
situations in the hospital environment,” says
Anna Jarslund Broman. But Region Skåne
wants the AT training to be the same everywhere,
no matter what location you are
located in, so I was commissioned to start a
similar primary care education program.
Anna Jarslund Broman established the
training and recruited physicians, which
were specialised in different areas. In the
first year the training has already received
positive feedback from the AT doctors.
“We teach them what they need to
repeat, such as what was the basis in their
undergraduate education, and even things
they have not learned,” explains Anna. In
addition, this eases the burden on the AT
doctor’s supervisor.
The education goes by the name clinical
skills prior to primary care and comprises
at least one day. On the schedule there can
be orthopaedics, injection technics, eye and
ear microscopy as well as training on minor
surgical procedures.
“It's not just about techniques. We also
discuss how the medical investigations go,”
says Anna.
During the second year of education in
Helsingborg, Anna introduced teaching
into dermatoscopy, i.e. examination of skin
changes by means of a kind of magnifying
glass with a lamp; this is an area that primary
care in Helsingborg has good knowledge
and experience of.
“We learn how to use the instruments,
what to look for and how to interpret the
findings. When I'm planning the training, it
is important for me to know which colleagues
know who can do what and what they
are good at so they can learn,” says Anna.
In the practical education, which happens
about two to three weeks after the AT
doctor has begun working in primary care,
the AT doctors are divided into small groups
and then rotate between different stations
where they can practise practical skills. A
doctor should learn how to work with different
models of the medical instruments.
Today, the course is clinical skills prior
to primary care, which was established by
four other AT study directors in Skåne.
Practicum stands for the premises and the
compensation to the different clinics. In
Helsingborg, Gorthon’s central auditorium
in the hospital and adjacent small rooms for
group exercises are used.
In Helsingborg in 2017 approximately 30
AT doctors were educated while the figure
was 20 in Ängelholm. The program is now
entering its fourth year and remains popular.
The good results in course evaluations
continue.
We
learn
how the
instruments
will
be used,
what you
should
look after
and how
to interpret
the
findings.
15

KCP Primary Care Training Unit
Further Education
(VFU)
This unit covers all student categories in
addition to medical students. The VFU coordinator
represents the link between primary
care operations and Skåne’s three centres
of learning.
One of the roles of the coordinator is to harness
quality development and act as a support
for managers and employees relating to
VFU. Large demands have been placed on
the administration to offer further education
of high-quality as this comprises 30-50%
of time spent in several medical education
programs.
During 2017, the further education department
organised training events for approximately
1,560 students within all the primary
care administration as well as public and
private units.
Interactive
learning
The biggest advantage for
nursing students with Peer
Learning is that they dare
to ask more, thanks to the
confidence gained during
practice. Learning becomes
more simple,” says Karin
Werner Öhrnberg and Karin
Grottling, VFU coordinators,
who together with Malmö
University are spreading
Peer Learning in Skåne.
Two supervisor education courses for staff
working in primary care were conducted in
2017. One course was organised in Kristianstad
and another in Malmö. The total
number of participants was 40; Kristianstad
(15) Malmö (25).
In the spring of 2017, a pilot project was
started to introduce peer learning into primary
care. The project is described in the
article on the opposite page.
16

Primary Care Training Unit KCP
The model, where two students share
an internship and a supervisor, has
been used for a long time in psychiatric
education and even in somatics, but it’s
the first time peer learning has been used in
primary care in Skåne.
Since 2017, primary care has arranged
an education unit and Malmö University
the education model for staff at health care
centers, but also for teachers at colleges
with a nursing program.
"I contacted Malmö University in 2017.
There they have long taught and done
research about this model,” says Karin
Werner Öhrnberg, project manager.
Karin Werner Öhrnberg coordinates
the education together with her colleague
Karin Grottling in tandem with Malmö
University (which was a college until the
end of the year 2017). It started with a
workshop conducted over two full days,
followed by a two-day follow-up. In the
first round of education a total of three
healthcare centers from the Malmö area
participated.
“Now 10 units in Malmö have participated
in the education. Interest in the
supervisor model has spread among healthcare
centers,“ says Karin Grottling.
Peer learning is something which influences
everyone in the staff at the healthcare
centers, when the two nursing students
come out for their five-week practice and
will participate in the entire working day.
“They don’t need to be beside each
other all the time but they can reflect with
each other or together with the supervisor,”
says Karin Werner Öhrnberg. She adds,
“It demands more from the supervisor
initially and at the end of the period. But
at the same time, the students get to take
more responsibility; they get a better link
between theory and practice. They learn
both to perform tasks and to develop and
read about the healthcare guidelines that
apply in everyday practice.”
Peer Learning places the student's own
learning in focus – not the education from
the teacher.
Important concepts in the context are collaboration,
support, reflection, critical thinking
and feedback. In Swedish, Peer Learning
is sometimes called collegial learning.
“The discussions between the students or
together with the supervisor at the healthcare
center enable the learning to grow. They
learn more simply and the quality of the
pedagogic supervision will become
better,” remarks Karin Grottling.
At the end of the practical
service, the supervisor writes
separate reviews of the
nursing students. During the
education the supervisors
can themselves grasp the
new methodology as for their
part there is a lot to listen to
as well as asking open ended
questions to the students. The
supervisors use the learning activities
as educational aids, for example,
cards with descriptions of various practical
elements; this tool helps to bring the theory
closer to practice.
Both coordinators emphasise that there
are quality gains which are important to
peer learning. And for this to be created at
the same time as more internships
is just a bonus. Their
enthusiasm for the tutorial model
is supported by the participating
healthcare centers. An evaluation
of the scheme in 2017 gave an
overall positive result.
Karin Werner Öhrnberg is
now spreading the supervisor
model in Skåne. Starting in
Kristianstad in 2018, a course for 10 college
lecturers and staff from at least three
healthcare centers, so already in the spring
new student groups in this part of Skåne will
come to gain access to the new methodology.
“Soon I will have a meeting with Lund
University and their employees about their
nursing program. The hope is that we will
start an education program there in the
autumn,” concludes Karin Grottling.
From left:
Karin Grottling
and
Karin Werner
Öhrnberg.
"Learning
grows
with this
model"
17

KCP Primary Care Training Unit
In-service training unit
18
The unit has arranged, administered
and evaluated training for employees
within public and private
primary care. The need for continuous
professional competence
development is paramount within
primary care.
The contents are broad and there
are many professional categories.
Our courses are adapted to the
needs of the units and planned in
collaboration with the profession
specific reference groups. These
meetings occur 2-3 times a year.
Reference groups exist for counsellors,
psychologists, physiotherapists
and occupational therapists,
medical secretaries and dieticians
as well as nurses and district
nurses.
Examples of courses organised
during 2017 was the treatment
by therapy via telephone, triage
of which two different courses
were focused on triage of mental
diseases and symptoms. Other
courses were further education for
nurses/district nurses for elderly
care, prescription drugs and
dermatology education.
For counsellors and psychologists
there was online education on CBT,
PTSD, chronic stress and chronic
pain. Medical secretaries had two
courses in medical English and two
full days in the autumn on various
topics.
BOA course, dizziness, ergonomics,
pelvic floor problems during and
after pregnancy were other appreciated
full-day courses for physiotherapists
and occupational therapists.
In addition, another course was organised
on diet for dieticians about
dysphagia and two ECG courses for
assistant nurses.
Recurring for all employees are MI
education (motivational conversation)
and a mindfulness day. During
2017 two supervisor courses were
arranged over four days for employees
who supervise students
and new employees. Video library,
training directory as well as the
development of webinars were
conducted in close cooperation
with AKO. Four films and eight
webinars were produced.
In cooperation with the HR department
and some healthcare center
managers, there is a one-year
clinical function training for newly
employed nurses within primary
healthcare Sund being developed.
The purpose of functional training
is that nurses should be able to
perform their duties in a competent
manner.

Primary Care Training Unit KCP
Diabetes coordinators
Certification
During 2017, there were 60 of Region Skåne’s 154 healthcare
units that met the requirements for certification.
These units were awarded 20,000 kronor annually, received
a diploma to display in the waiting room and named in
1177 healthcare guide as a certified diabetes clinic. Skåne
continues to be first in Sweden and several county councils
plan to introduce certification for diabetes services. Information
about certification can be found at: www.vardgivare.
skane.se, click on health and healthcare, health center and
certification.
In 2017, 30 visits were made to the healthcare units that
requested a review of results in the National Diabetes
Registry (NDR) as well as support in routines and structure
regarding diabetes healthcare. Improvement projects were
started at four healthcare centers with the aim of improving
diabetes care.
Training
Two half-day training courses for diabetes team
about diabetes and feet were carried out in the
spring in both Malmö and Helsingborg. Two in-service
training days were carried out in the autumn in
Malmö and in Höör. The program for the whole day
was the same as in 2016, but with different lecturers.
All of the courses attracted many participants.
Diabetes
coordinators
(from left)
Katarina Klang
Larsson, Agneta
Lindberg and
Marianne
Lundberg.
19

KCP Skåne Family Medicine Consultancy, (AKO)
Family Medicine
Consultancy (AKO)
Family Medicine Consultancy in
Skåne (AKO) is a producer-neutral
player for the whole Hälsovalet
primary care working for Region
Skåne's vision towards our target
groups in collaborative issues between
Hälsovalet and specialised
care, knowledge management as
well as skills development for
doctors in Hälsovalet.
Fast Facts
10 personnel working at AKO’s central
operation.
44 family medicine consultants within 22
medical divisions distributed locally to
Skåne’s different hospitals.
91 local education responsible doctors.
41 continued education courses, 6 of which
are regional courses in Family Medicine Plus.
1,206 participants in AKO’s education.
To meet our stated goals for AKO Skåne
2017-2018 means the following:
w Collaborate with specialised care to
get well-functioning patient process
and referral system for maximum
patient benefit and patient safety.
w Highlight the role of general medicine
and the function of primary care
w Create and implement different forms
of adequate and attractive in-service
training for general practitioners.
w Create adequate and easily accessible
AKO care guidelines
17,933 visits to AKO’s
homepage www.skane/ako.
176 published AKO health guidelines; 80 of
which were new in 2017.
26 published SVFs, i.e. standardised care
processes in cancer and abridged versions of
regional care programs.
11,263 views of 18 self-produced videos since
their respective publication.
8 live webinars. 1,788 views afterwards on
the recorded webinars since 2017.
20

Skåne Family Medicine Consultancy, (AKO) KCP
Competence
development
Local in-service training
Local in-service training, half-day, has been organised
in the area:
w Lund on 9 occasions with a total of 206 participants.
w Malmö on 8 occasions with a total of 294
participants.
w Kristianstad on 9 occasions with a total of 140
participants.
w In-service training full day in Helsingborg on 8
occasions with a total of 403 participants.
Examples of subjects at the in-service training: interface
psychiatry, gynaecology, children and adolescents,
diabetes, gambling-medication-alcohol and drug addiction,
SVF (standardized care process within cancer
care) urinary tract infection in men, medication during
pregnancy as well as somatization and mental illness.
Regional in-service training
Regional in-service training, General Medicine Plus, full
day, has been arranged on six occasions with a total of
119 participants. Examples of subjects in the regional
education programs are dermatology for the general
practitioner, cardiovascular day, traffic medicine as well
as everyday jurisprudence.
AKO-day
The annual AKO Day included 44 participants from the
whole of Skåne and was arranged in Malmö. The
program for the day comprised training, national
clinical knowledge support in primary care, how a
subject group chairman works as well as time for
conversation amongst AKO.
Knowledge Management
During 2017, a lot was done within AKO’s knowledge
management and care guidelines. Abridged versions
have been made for SVF of all Region Skåne’s care
programs. Within Region Skåne's project Clinical
Knowledge Support, AKO been involved in the
development of new national knowledge support
for primary care. Four group chairman have been
appointed with their respective subject groups.
Questions & Answers
There are a total of 45 questions and
answers, of which 18 have been added
in 2017. The page is the fourth most
visited @ www.skane.se/AKO.
AKO Care Guidelines
A total of 176, of which 80 were published in
2017.
National Knowledge
Support Primary Care
National Knowledge Support Primary Care: 46 guidelines
during work in our four subject groups, of which 22 are
ready for national review.
Sten Tyrberg
coordinates
work at AKO.
21

KCP Skåne Family Medicine Consultancy, (AKO)
Collegial discussion
most important!
Learning is always ongoing. You cannot avoid learning new
things, but it is in the collegial discussions where learning
develops into deeper knowledge says Anders Lundqvist,
resident physician in Kristianstad and general medical consultant
since January 2017.
Anders Lundqvist,
resident physician in
Kristianstad
22

Skåne Family Medicine Consultancy, (AKO) KCP
Learning is always ongoing. You cannot
avoid learning new things, but it is in
the collegial discussions where learning
develops into deeper knowledge says Anders
Lundqvist, resident physician in Kristianstad
and general medical consultant since
January 2017.
Interest among general practitioners in
Skåne is in a slump at the moment. A survey
in 2017 showed a low participation for the
profession and the trend is declining.
“The reason for general practitioners
is time shortage. You choose short-term
patient work instead of long-term professional
development. This is a kind of survival
strategy to avoid a heavy backpack with a
backlog of work.”
What causes the lack of time is bureaucratic
processing – signing of sampling lists
in the present, unwieldy IT systems, just to
give an example.
“But as a GP we will maintain and renew
our knowledge, otherwise there is a risk of
stagnation and then we will be delivering a
poorer quality of health care.”
Many hope that a new SDV, Coherent
Digital Care Environment, will lead to a
smoother and smarter way of working and
that it will be easy to implement and thus
also able to create time for collegial dialogue
such as it frees up time for intercollegial
education in the workplace.
“You aren’t yet fully educated so one
should always be involved in an outside
world that is changing and get acquainted
with new knowledge. Through the collegiate
dialogue, using, among other things,
case descriptions, we cultivate propositional
knowledge to practical wisdom,” says
Anders.
To boost participation in further education
efforts for GPs, Anders draws inspiration
in his work as an AKO coordinator in
northeastern Skåne from another part of
Skåne, namely northwest. It’s there where
in-service training has a larger number of
participants, mainly thanks to so-called
duplicate full days. The same content is
conveyed at two adjacent occasions, which
allows participation for the entire
doctoral group at one healthcare
center.
“Yes, we are now following
the northwest Skåne model. The
whole day provides greater contact
between general practitioners; it becomes
an identity creation assembly,
unlike half-day courses, which do
not give the same social interaction.
“When more colleagues can go
to the same in-service training, they
go with each other. The conversation makes
them develop specialties in a better way and
it creates courage and power,” says Anders.
The participants prepare and plan their
education in a better way than when they
do half-day courses.
The venture also seems to have quickly
filled a need. Before 2018 it looks promising,
already at the beginning of the year
the number of registrations for duplicate
weekdays in the northeastern part of Skåne
exceeded those for the half days in 2017.
"Cultivate
propositional
knowledge
to practical
wisdom."
23

KCP Skåne Family Medicine Consultancy, (AKO)
Collaborative projects
Referral review
During the spring, five referral seminars were conducted in Helsingborg,
Kristianstad, Lund, Malmö and Ystad with 271 participants.
The background was the referral review report project,
which was carried out in Region Skåne in 2016, that showed deficiencies
in referral management. Routines for referral and referral
flow, examples of how to work to get good routines and remedy
management in Region Skåne, good clinical practice were points
taken up during the seminars. A report will be written during 2018;
it will be a part of AKO Skåne’s report series.
First national conference on clinical
knowledge support for primary care
On 13-14 December 2017 the first national conference was arranged
on clinical knowledge support for primary care. The conference
showed how a new national clinical knowledge support for primary
care could contribute to a more equal and safe healthcare in Sweden.
The conference turned to the interest in work on knowledge
support in primary care in county councils and regions.
"Good variety and different
angles. Impressive that so
many speak the same language
about national cooperation even
though knowledge about, and
the pictures of what knowledge
support is, varies.”
Over 140 participants from all over Sweden participated during
the two days. Organisers for the conference were General Medical
Consultants Skåne, Resource Group General Medicine Southern
Regional Care Authority, Swedish Association for General Medicine,
SFAM, together with the National Program Council Primary
Care and Project National Clinical Knowledge Support, Primary
care Sweden's municipalities and county councils, SKL.
Ulrika Elmroth, Primary Care Quality, SKL together with
Magnus Kåregård, General Practitioner referral management,
Region Skåne, were the conference’s moderators.
Incredibly good days in Malmö,
which gave a great exchange of
knowledge, networking, worldview,
practical and theory on both micro-,
meso- and macro level, mixed
in a nice way. Great fun to have
almost 150 people participating
with great interest in one joint
clinical knowledge support!
24

Skåne Family Medicine Consultancy, (AKO) KCP
Acute care, tests and
support for conversations
about tobacco on film
Lectures in
live broadcasts
In our webinars you can sit
in front of a computer and
follow live lectures and at
the same time be able to
ask questions.
During 2017 there were 8 live
webinars where there was an
opportunity to ask questions during
the lecture. Examples of topics that
were recorded, Dermatoscopy for
beginners, About IBS, Proctology as
well as PMS/PMDD.The recorded
webinars have had 1,788 visits.
There were also five webinars from
2016 that were shown during the
year with a total of 385 views.
Further
education
catalogue
Prior to each term, paper versions of the
training directory were distributed to all
units within Hälsovalet. In conjunction
with this there was also a published digital
version at www.skane.se/ako. The
training directory is for all employees
and sorted partly within the respective
professions, but also by topic.
There are a lot of instructional videos in the video
library on the treatment of various diseases
and disease issues – easy to view directly via
computer.
There are a lot of instructional videos in the video library on
the treatment of various diseases and disease issues - easy to
view directly via computer.
Since its inception in the spring of 2013, Videotek has produced
several self-produced films under the theme “Doctor
asks the doctor” where a specialist in general medicine talks
about a current subject with an organ specialist. Films taken
from other county councils are also published after quality
review in the video council. In 2017, Videoteket was the page
that was viewed the most times www.skane.se/ako.
During 2017, 3 self-produced films have been published
in subjects like acute care at the health care center, BBIC –
children’s needs in the center as well as cognitive testing when
investigating lasting cognitive failure.
Films from other county councils are about smoking cessation
– support for conversations about tobacco, routine
status, alcohol use, call assistance and depression treatment
for elderly.
Our self-produced films have since the start had 10,617
views, the three self-produced films in 2017 have had 646
views.
@ ? !
25

KCP Skåne Family Medicine Consultancy, (AKO)
More equal
with common
knowledge support
“The purpose of the national clinical knowledge support is to
create conditions for safe and equal care throughout the
country, it does not matter which care center you attend,”
says Gunilla Malm and Lisa Johansson, who both worked with
the knowledge documents in 2017. This comprehensive work
will continue in 2018.
26
Gunilla Malm, specialist in general
medicine and AKO coordinator
is subject group chairperson for
knowledge support in the field of kidneys,
urology and men’s health. Lisa Johansson is
coordinating project secretary
at AKO Skåne.
All over the country there
are 23 subject groups and in
the southern healthcare region
are four of these. Everyone
works to the same template so
that knowledge support gets
the same structure. Knowledge support will
be national but with the possibility of local
extras with what is specific to respective
counties and regions.
“Until today, each county council and
Region in Sweden had its own guidelines
and knowledge support which made them
all different,” says Gunilla Malm. Now we
are at the beginning of extensive work to draft
"Big challenge to
produce material
that is useful."
new knowledge support. An important part
of knowledge support is to highlight what is
primary care’s responsibility and what lies in
specialist care. It is good to clarify this.
In 2018, there will be 360 support provided
about treatment strategies
written within every healthcare
region. Of the 360, 46 are produced
in Skåne. When the texts
are ready after reviews and referral
rounds, then the knowledge
documents will be updated every
third year.
The development project started in 2015
within county councils and regions together
with SKL, Swedish municipalities and county
councils together created an organisation
with working groups responsible for national
diagnosis and treatment recommendations.
In addition, a technical platform was
built to edit, save, among other things and
distribute the content.

Skåne Family Medicine Consultancy, (AKO) KCP
For a long time, there was a wide range of
knowledge support; National Guidelines
from the National Board of Health & Welfare,
therapy guidelines from the Swedish
Agency For Health Technology Assessment
And Assessment of Social Services (SBU)
and the medical book that the Swedish
Medical Products Agency publishes. In addition,
there are also commercial websites
that have pharmaceutical products for the
common market. The need is largely for reliable
clinical knowledge support, which can
raise quality, equality and patient
safety in primary care.
“Though one should remember
that we do not have to make it the
same for it to be equal,” says Lisa Johansson.
But knowledge support will be an assurance
that everybody can receive good care.
The Southern Health Region areas of speciality
are: Pain and neurology (Catarina Canivet),
Kidneys, Urology and Men’s
Health (Gunilla Malm), Child and
adolescent health (Tina Runeke)
and eyes (Anders Lundqvist). Diligent work is
ongoing, but which one is the biggest challenge?
“It is to produce material that is useful to
all GPs,” says Anders Lundqvist.
He adds, “Material that is short and
concise that contains what is essential but
is sufficiently extensive. As chairman, my
approach is to focus and try to think of the
GPs’ perspective. Our starting point is previous
material but we would like to produce
something better!”
From left:
Lisa Johansson
and
Gunilla Malm.
27

KCP Knowledge Center, Migration and Health Services
Knowledge Center for
Migration & Health
The unit works with a long-term view regarding migration issues
within healthcare in Region Skåne. The mission includes asylum
seekers, new arrivals, people without papers and those that live in
hiding but also established migrant groups that have long been in
Sweden. The goal of the department is equal and safe care for
people from other countries, and to promote equal standards of
care across the whole region.
28

Knowledge Center, Migration and Health Services KCP
In-service
training
The Knowledge Center for Migration
& Health has organised
22 courses with nearly 1000
people involved. Participants
were comprised of different
professions in healthcare such
as psychologists, nurses, assistant
nurses, doctors, counsellors
and physiotherapists.
In addition, the participants
represented administrative
areas such as primary care,
psychiatry, emergency care
and others.
Via funding from SKL, the
Center conducted work on
student health in the autumn
of 2017 with over 120 people
from various schools around
Skåne participating in education
regarding mental health in
children and adolescents with
an experience of migration.
The Center has started a
special enterprise together with
ambulance care and SOS alert
regarding education in migration
and health where about
50 people were educated in
the autumn of 2017 and further
training courses are planned in
2018.
In addition to the above courses,
the Center has together
with the Knowledge Center
for dementia organised an
inspiration day about migration
and health with a further 160
participants.
Development
work
The Knowledge Center for
Migration and health carried out
a global analysis to take stock of
the knowledge situation within
migration and health and to
identify the focus to work on
during 2017/2018.
The overall analysis can downloaded
from www.skane.se/kcmigrationhalsa
under the heading
reports and analyses.
News
Nr 4: 2017
The Center has started a
newsletter to inform about
different education and activities
within migration and
health. The first newsletter
was released in November
2017 and can be found at
www.skane.com.se/kcmigration
under the heading newsletter
migration and health,
where you can subscribe to
the upcoming newsletter.
29

KCP Knowledge Center, Migration and Health Services
From left:
Mia Sandor,
Micaela Nilsson
and Jenny Malmsten
Increased investment
in targeted programs
30
“We noticed the need
to train in healthcare
about what they don’t
always know that they
need knowledge of,”
says Jenny Malmsten,
Head of Unit for Learning
Center migration
and health with a glint
in her eye.
She gets direct support
from her colleagues Mia
Sandor, training coordinator
and public health official and
Micaela Nilsson, care developer
and paediatric nurse:
“So the question is, how do
we attract people to training that
they do not know that they need?
It’s a challenge. We package our
education and now create more
targeted training,” says Mia
Sandor. General programs about
interpreting activities have not
made a breakthrough but the
program "Interpreting Conversation
Treatment" was well received
within health care. The direct link
to the healthcare staff work is
extremely important.
“We do not have a direct connection
to a specific administration
like many other knowledge
centers within Region Skåne,
clarifies Mia Sandor. She adds,
“For example, it is the Knowledge
Center for Women’s Health whose
target group is maternal health
care while we focus on the entire
healthcare. But we have noticed
that when we create education
concerning specific questions, then

Knowledge Center, Migration and Health Services KCP
!FACTS
A quota refugee is a person who has fled
his/her home country and been selected
by the UN’s refugee agency, UNHCR, to be
resettled to a third country which offers
them protection. This process is called
resettlement. Refugees who are selected
for resettlement may be in refugee camps,
but they may also be in cities or rural areas.
Resettling in a third country may be the
only solution for people who can neither
remain in their first country of asylum nor
return home. Quota refugees are entitled to
the same type of health care as permanent
residents in Sweden.
interest increases among healthcare
professionals.”
When the Knowledge Center
for Migration and Health was inaugurated
in 2016 both education
activities began and surrounding
world analysis. The educational
activities continued in 2017 and
obtained support from the global
analysis that was completed last
year. The analysis works as a
guide for what questions the unit
focuses on.
An education that was planned
and was completed in 2017 was
on quota refugees’ rights.
“We observed in our global
analysis that refugees are a particularly
vulnerable group who need
more focus because during the
coming years there will be a greater
number of quota refugees to
Sweden’s municipalities,” explains
Jenny Malmsten.
Quota refugees (see below)
already have a decision on a
permanent residence permit when
they arrive in Sweden. One of the
reasons can be a health hazard. So
for healthcare and municipalities
it’s about understanding what they
need to prepare for the arrival.
“The planning work is done in
collaboration with Skåne’s County
Administrative Board and joint
representatives of Municipality Alliance
Skåne, Migration office, the
Tax Agency and various municipalities
to work out one foundation
for education,” explains Micaela
Nilsson.
The demand for education remains
large and a training day on
November 27th was very popular
with approximately 180 participants.
“We tried to make it visible
regarding the differences between
the authorities. This way, the
reception can be improved. Quota
refugees are entitled to subsidised
care on the same terms and conditions
as all registered persons. But
you can only get a social security
number through a personal visit
to the Tax Agency and then it can
take some time before the person
gets their number. For those who
have emergency care there may be
questions about payment liability
during this time,” says Jenny.
Micaela Nilsson adds, “During
the training day we could show
strategies for what one should do
when issues arise within health
care.”
“Our primary target group is
healthcare, but at the same time,
we also notice an increased interest
from other departments, e.g.
Skåne municipalities. Migration
issues are generally organisation
wide so we are many that cooperate
with both other authorities
and civil society,” says Mia
Sandor.
In 2017, SKL,
Sweden’s Municipalities
and County Council, provided
funds to a targeted
education to both
county councils
and municipalities
within the
framework of
the program Health in Sweden.
It gave the Knowledge Center for
Migration and Health the opportunity
to target education directly
towards student health. It concerned
mental ill-health in children
and adolescents with experience of
migration.
“We create forms of education
here at the unit. We build the
content internally but adapting it
depends on the prerequisites of the
department and the assignments,”
says Jenny.
The greatly appreciated training,
which continues during 2018,
addressed ambulatory care. It is
general education which increases
understanding for all aspects of the
ambulance staff working within
migration and health.
“The education takes up how
people with a migration background
can react in case of emergency
disposal and other situations,”
says Micaela Nilsson.
And another method is the unit
that specifically tests for primary
care is the concept of "Health on
Tour" where they attend the staff
meetings of healthcare centers and
listen to the needs and requests.
Much of the time is spent on the
needs not yet discovered.
During 2018 there will be training
for adult rehabilitation, more
training for ambulatory care in
Skåne, training aimed at children’s
clinic at SUS and an investment in
public psychiatry in Malmö.
“Something that feels
exciting is that for us, firsttime
training managers and
leaders in administration
of discrimination legislation,
the important area of
work is with equal standards
of care,” concludes
Jenny Malmsten.
31

KCP Knowledge Center for Child Healthcare Services
Child Healthcare
Knowledge Center
Our mission is to provide support to the child healthcare
services throughout the region particularly in the form of further
education for staff as well as counselling and working with
guidelines and care routines. An annual report on the preschool
children's health and access to Child Health Care was
presented and became the starting point for different ventures.
32
Goal
The goal is to create equal high
quality care throughout the
region in order to increase the
conditions for equal health for
children.
Introduction
In 2017, work has been ongoing
to introduce the national
child health care program in
Skåne. The focus has been on
the roll-out of two new visits,
partly an individual parental
conversation with parents that
did not give birth to the child
and one team visit when the
child is three-years-old.
Mission for
vulnerable
children
Three region-wide missions for
vulnerable children gives the
unit support for development
within Skåne healthcare. During
the annual in-service training,
support through cooperation
and support and analyses were
conducted. Commitments
refer to children as next of kin,
children who are ill and health
investigations according to
BBIC.
Other
w Six newsletters for em
ployees and others
interested parties were
given out.
w 4,363 people participated
in the knowledge center
in-service training in 2017
w Read more at: https://vard
givare.skane.se/kompe
tens-utveckling/sakkunnig
grupper/barnhalsovard/

Knowledge Center for Child Healthcare Services KCP
Inclusive conversation
The individual parental conversation is aimed at the parent who
did not give birth to the child. In practice, it usually means the
father. With the conversation, we want to promote a more inclusive
and gender equal responsibility between both parents, says
psychologist Lars Olsson, care developer at the Knowledge
Center for Child Health Care.
Another purpose with the individual
parenting conversation is that fathers
should feel that child health care has
a role to play for them and that the dads
should know themselves its significance for
the child’s well-being and development.
“A large group of dads do not feel
included in the paediatric health care, they
experience it as being more for mothers,”
says colleague Malin Skoog, district nurse
and healthcare developer.
Together, Malin Skoog and Lars Olsson
began the extensive development work throughout
Skåne about the individual parenting
conversation. Development work began
with planning work in spring 2016, also
involving psychologist Ida Ivarsson. The
first courses began in September the same
year and are ongoing from now till 2019
when all 350 nurses in child health care and
some of the psychologists have trained.
“In the past, child health care was often
one medical perspective on the child,” says
Malin Skoog. It did not matter so much
about security or a psychosocial approach.
Now we want to strengthen a family perspective.
Parental responsibility has many aspects
and most parents encounter obstacles in
some or a few parts – for both men and
women. The questions from nurses regarding
parental responsibility cover different
dimensions. There may be open questions
about the child, “tell me a little bit about
your child” and more specific like “what
are you and your child doing together?”
Other conversational issues are about how
it is to be a parent: “how has it been for
you to become a parent” but also questions
about how the parent is doing.
“We want to emphasise that the purpose
of the conversation is mainly that it makes a
health promotion effort, a parent
support, but we also try find
mental ill health so we can help
the dads who need it,” explains
Malin.
Since the late 1990s attention
within child health care has been
paid to the mental health of new
mothers. When the child is two
months old, a depression screening
is done and the mothers, if necessary,
are followed up with support calls or other
actions. The presence of mental ill-health
postpartum is about half as common with
dads as compared with mothers. Mental ill
health manifests in different ways in men
than in women so the education is also
about listening for other signals and in part
to set other questions than to mothers.
In mothers, common symptoms are in
the form of depression and sadness, while
dads, on the other hand, can suffer more
from irritability and anti-social behaviour.
In the individual parental interview, you ask
about the father’s well-being with help from
the so-called Whooley questions, originally
"A large group
of dads do not
feel included in
the paediatric
health care."
33

KCP Knowledge Center for Child Healthcare Services
34
formulated by Mary Whooley, Professor at
the University of California in San Francisco.
Another area to be noted are family relations.
An important issue is “How do you
handle conflicts within the family?” The
purpose of the question is to make conflicts
both as a normal part of family life, and to
give an opening to discover whether there is
potential violence in the family. As a pedagogical
method in the education is that Lars
and Malin recorded five role-playing films
that provide a concrete basis for the participants’
reflections. It can be about reading
body language and indirect answers, or to
talk about sensitive issues. The education
should help the nurse to follow and support
the parent through the conversation.
“The focus on education is a health
promoting conversation. What is a good
conversation? How does the nurse make it
a constructive call? The important thing is
to make sure that people are talking, giving
the parent the opportunity to formulate
while the nurse is listening. Saying things is
medicinal. If you do, you often need no advice
as things fall into place. A lot happens
regarding the nurses' understanding of what
they do,” says Lars.
Malin and Lars explain they are experiencing
that the education increases
self-confidence for nurses to handle these
kind of conversations, which may differ
from their other work. The conversation
increases understanding for how the whole
family feels and at the same time they can
also find dads that are not feeling so good.
Sometimes more talks are needed and then
others resources in the field of child welfare
are linked.
“The concerns the nurses have for
keeping these conversations is often about
thoughts about how to deal with mental
health illness. Nurses also have a crowded
situation,” says Malin. It can be difficult to
deal with the individual parental conversations.
But all dads should now be offered
the conversation.
All together it becomes a lot of information
from both parents that must be kept
apart, which is another possible problem
for the nurses.
“But information about the contents
of the conversation with the parents
are in separate records, not in the child's
journal. What the parents say comes in their
own records,” emphasises Lars.
Malin Skoog
and Lars Olsson

Knowledge Center for Child Healthcare Services
KCP
Team visit introduced
Major training efforts were made during the year to pave the way
for the introduction of team visits when the child is three years old.
The focus is to be emanated from the parents' questions where the
conversation may be an opportunity for empowerment and increase
parents' confidence in themselves.
In December 2017 we
trained, together with one
maternity and paediatric
health psychologist, 575
people from primary care
nursing care. The target
audience was doctors, nurses
and psychologists, who all
work within child health
care in Skåne. It was the climax of several
months preparing for the implementation of
the new team visit for child health when it
"This is part of
the national child
health care
program. "
was introduced for
three-year-olds says
Mariette Derwig,
paediatric physician
at the knowledge
center for child
health care.
Together with
colleagues Ylva
Thor, district nurse, and Micaela Nilsson,
child nurse, she has step by step informed
and anchored the new team visits health
From left:
Ylva Thor,
Micaela Nilsson
and Mariette
Derwig.
35

KCP Knowledge Center for Child Healthcare Services
strategy with other concerned units in
Skåne.
“This is part of the national child health
care program. Previously, it took place
during the last healthcare visit with a doctor
at 18 months but now it is a nurse visit
instead,” explains Micaela Nilsson.
From 2018, the children's health care
center will offer a team visit when the child
is four weeks, six months, 12 months and
three years. At the team visits, parents
and children will meet a doctor and nurse
together.
“It’s a lot about giving a health promotion
support for the parents. It is important
to strengthen and then confirm them during
parenthood,” says Ylva Thor.
“At the three-year visit, the child health
care center is primarily concerned with the
parents' questions, just like any other visit,
says Mariette Derwig. The team tries to
be open for what the parents want to talk
about.
This is done by entering an open conversation
with the parents. The conversation
should not focus only on single concerns,
without trying to catch the child’s development
and health in relation to many areas
based on the child’s current age, e.g. play,
communication, language, food, habits and
sleep. This way the child health care can be
done early via health-supportive efforts for
the children.
“The visit of the team can affirm the
parents. The conversation may be an opportunity
for empowerment and increase the
trust of parents in themselves,” emphasises
Micaela Nilsson.
At the forefront of the conversation is
mental health, language development and living
habits – with the visit children’s health
care wants, among other things to be able
to capture early signs of risk of obesity, so
that it can be prevented.
“We try to see the child as a whole and
if needed, we can provide more help,” says
Mariette Derwig.
“As far as language development is
concerned, child health care nowadays is
more focused on the child’s
understanding of the language
than on phonology; so on how
the sounds are pronounced,” says
Micaela Nilsson.
The visit also gives the team
the opportunity to see how the
child interacts and communicates
“But some screening of autism is not
done; there is no reliable screening tool yet,”
comments Ylva Thor. But with the new
three-year visit, child health care can still
pay attention to the needs of earlier work,
for example in cooperation with a maternity
and paediatric health psychologist, in good
time before the child starts school.
At the new three-year visit - first out in
Skåne will be all children born in 2015 - the
doctor and the nurse will thus put the child’s
development in context. The team looks to
factors such as everyday life, economics,
opportunity for excellence, temperament and
biological vulnerability, etc. These factors
can perhaps be reflected in the parents'
concerns, the child's medical history and life
history as well as the other observations in
the meeting with children and family.
“Child health care services see the child
over time. The staff has one long perspective
where the relationship with the family is
important,” says Micaela Nilsson.
“You should remember that good input
for the children in the long run gives good
results in adulthood,” says Mariette Derwig.
But one part of the health benefits may be
seen only after 25 years! A research study on
children's health in the 1930s showed that
they who had received child health care had
better conditions for good health as adults
compared with those who did not have
access to child health care, which could be
measured in reduced incidence of colon cancer.
The conclusion was that health promotion
work early in life has meaning.
“The three-year team visit has created a
further opportunity for children and parents
to meet the team in child health care to
maintain and achieve good health and development,”
concludes Ylva Thor.
Ö
36

Knowledge Center for Women’s Healthcare Services KCP
Knowledge Center
for Women’s Health
Its’ mission involves support for midwife units in issues such as
sexual and reproductive health, maternity care, contraception,
cervical cancer prevention and sexually transmitted diseases. The
support involves education, work with care networks and regional
guidelines as well as collaborative work and counselling.
vrigt
In-service training
w In-service training has during the year, among other things, treated foetal
diagnostics, mental illness during pregnancy, birth defects, cervical cancer
prevention, HPV screening and gender equality. As part of the national focus
on improving maternity care and women’s health there has been in-service
training regarding diabetes during pregnancy, maternity leave and breastfeeding.
A total of 749 people were trained.
Other
w Six newsletters were published. See https://vardgivare.skane.se/kompetensutveckling/
expert groups/knowledge center-Women's Health/
w A current situation analysis with information on sexual and reproductive
health in Skåne was produced during the year. This is the first time
that regional data within the area has been gathered in a report.
37

KCP Knowledge Center for Women’s Healthcare Services
Mental health
in focus
Our hope is that the midwives will be even better in
being able to support mental health but also provide
assistance to women with mental illness in connection
with pregnancy,” says Alexander von Schuppler,
psychologist and healthcare developer at the
Knowledge Center for Women's Health.
38
Together with healthcare
developer Mehrnoush
Rahmanian Kooshkaki,
co-ordinating midwife
as well as midwife of the BMM
family houses, Malmö, and Anna
Kjellbom, specialist in general
medicine at KC women's health
and at the health center Rosengården,
Alexander works at the
Knowledge Center for Women's
Health which organised training
days about mental illness and
pregnancy fears for all midwives
in Skåne in 2017, with a total of
320 participants in the various
programs.
“The midwives have a good
opportunity to spot early attention
signs of deficient psychosocial
support or psychological ill
health,” says Anna Kjellbom.
The recurring meetings enables
continuity which is significant -
both in terms of finding ill health,
initiate support and follow-up.
“The midwife has the opportunity
to assess if there is a need
for extra support call, with the
midwife or, for example, with a
psychologist, curator or others
in addition to support calls such
as a referral to a doctor,” says
Mehrnoush Rahmanian Kooshkaki.
The midwife looks after the
individual situation.
For maternal health care it’s
about increasing the security for
the pregnancy, the confidence to
talk about, for example, childbirth
fears which is an anxiety
that is more common than you
perhaps think.
“Our education is about how
to talk about the pregnancy and
about childbirth fears and how to
talk about it in a clear way. Then
you can see your midwife about
what kind of support is needed,”
says Alexander von Schuppler.
During 2018, the three healthcare
developers will publish guidelines
on mental ill health that
have been worked on in 2017.
“The midwives meet women
with fears that can be at the root
of different things,” says Mehrnoush
Rahmanian Kooshkaki.
It may be mothers that have
had a trauma from events during
earlier births or a first-time mother
who feels fear for different
reasons. First-time mothers can
feel an anxiety, which can sometimes
be relieved by visits to the
women's clinic, and feel more in
control of what will come.
There are many aspects that
care staff should take into account
and the support is assessed based
on the conversation. The focus of
the education was how with the
continuous conversation that we
can build trust, support and help.
In the health promotion work, we
look at living habits and women’s
social networks. Many initiatives
are a form of support during pregnancy.
Sometimes there is a need
for support post birth.
“It’s important that all different
participants become better at
interacting with each other,” says
Mehrnoush Rahmanian Kooshkaki.
Family Centers where child
health care, maternity care, open

Knowledge Center for Women’s Healthcare Services KCP
The team, which
among other things
is working to improve
support for
women with childbirth
fear. From left:
Alexander
von Schuppler,
Mehrnoush
Rahmanian
Kooshkaki och
Anna Kjellbom.
daycare and social services are
collected under one roof, facilitate
cooperation. But it also desirable
for better cooperation with other
therapists and parties such as
health care centers and psychiatry.
“Mental ill health is as common
among pregnant women as
in the population in general,”
says Anna Kjellbom. It has been
reported that stress-related mental
health generally increases.
But a group that does not get as
much help are those who are non-
European born. Less than half of
them receive help for childbirth
fears and mental ill health compared
to those born in Sweden.
“Still, there is a larger proportion
with mental ill health among
those who are non-European
born,” says Anna Kjellbom.
Communication is a common
denominator in the reason that
fewer in that group get support,
together with several other factors
such as social trust and the quality
of interpretation, which is often
done via phone.
It can be difficult to capture the
value of the words via an interpreter,”
says Alexander. Sometimes
it can be an advantage that the
interpretation is done via telephone
because then the midwife
and the pregnant woman are alone
together in the room but at other
times it can be a disadvantage - it
can be difficult for the interpreter
to hear all that is said and in particular
how it is said.
For midwife, it’s about if they
can adapt their questions to the
person in the meeting. It can be
difficult for the interpreters to
adapt the interpretation of words
and expressions from different
language usage.
“The nuances are extremely
important,” points out Alexander
von Schuppler. At the midwife unit
in Rosengård there is a waiting
room interpreter who speaks
Arabic.
“That she is in place makes it
much easier. Women who do not
speak Swedish can perhaps have
a hard time so have better accessibility
when they know the translator
is in place. It’s a way to try
to compensate for the differences
in health we know exist between
certain groups in the population.
To meet the same interpreter several
times can also feel secure and
facilitate the conversation around
more difficult topics.
For healthcare developers they
are now waiting on the work for
publishing guidelines and to plan
the in-service training for all new
midwife employees.
“Becoming a parent is a big
psychological event. For us it is
important to know how to talk
and meet prospective parents to
give support and talk so that we
can match the need and support
with what we can offer. It is important
to be able to go through
the pregnancy in a constructive
way,” says Alexander.
Anna Kjellbom adds, “We will
also work on how to ask further
questions; an approach that is
more hands on. As such there will
be a deepening in 2018 around
both parental support and groupbased
support to be offered at
midwife units.
And Mehrnoush Rahmanian
Kooshkaki concludes:
“As a healthcare developer we
work to find out how in reality it
looks and how we can improve it!”
39

cpf
Center for
Primary
Healthcare
Research
The Center for Primary Healthcare Research carries out, with primary care as its
base, world leading research through an active exchange of knowledge that is
comprised of basic research, epidemiology and patient-oriented research. The
administration also includes the Academic Knowledge Center, in-service training,
supervision, seminars and the Nordic region’s first experimental laboratory based
on primary health care.
Units of the Center for Primary Healthcare Research:
w Central Operations and Supporting Functions
w Academic Knowledge Centers (AKC)
w Mindfulness and Compassion Center for Research and Education
w Experimental laboratory
40

cpf
Research Leaders 17 Academic Knowledge Centers (aKC) 11
Resident Physician Courses
in Research Methods 4
Published Scientific Articles 135
PhD Thesis Defences 8
Contents
• AKC
• Short notices
• Research (Research leaders and research project)
• PhD students
• PhD thesis defences
• Database group
• Analysis group
• Molecular biology laboratory
• International collaborations
• The financial perspective
• Published scientific articles
41

cpf Academic Knowledge center (AKC)
AKC
The Academic Knowledge Center (AKC) is a network
of 10 healthcare centers across Skåne. At every AKC
there is a postdoctoral AKC coordinator. We attempt
to reach out to all who are interested in acquiring the
knowledge and scientific know-how to support with
scientific supervision, tips and contacts.
!
AKC
w Capio Citykliniken Helsingborg Söder
w Healthcare Center Sorgenfri, Malmö
w Healthcare Center Sorgenfri, Malmö
w Healthcare Center Sorgenfri, Malmö
w Healthcare Center Lomma
w Nova Clinic Rydsgård
w Healthcare Center Norra Fäladen, Lund
w Healthcare Center Måsen, Lund
w Healthcare Center Tåbelund, Eslöv
w Healthcare Center Fågelbacken, Malmö
w CPF
w Healthcare Center Laröd, Helsingborg
w Healthcare Center Löddeköpinge
w CPF
Coordinators
w Stefan Bremberg
w Beata Borgström Bolmsjö
w Annika Brorsson
w Louise Bennet
w Susanna Calling
w Rickard Ekesbo
w Ulf Jakobsson
w Tommy Jönsson
w Patrik Midlöv
w Anders Halling
w Bengt Zöller
w Veronica Milos Nymberg
w Moa Wolff
w Emelie Stenman
Orientation
w Medical Ethics
w Medications & the elderly
w Qualitative methodology
w Migration and health, diabetes
w Living habits, cardiovascular disease, epidemiology
w Cardiovascular disease, gastrointenstinal disease
w Elderly health
w Paleolithic diet
w Medications & the elderly
w Epidemiology, COPD, multimorbidity
w Cardiovascular disease, epidemiology
w Drugs and antibiotic resistance
w Yoga and hypertension
w Team Leader AKC
42

Academic Knowledge center (AKC)
cpf
The AKC coordinators have
had a year with great focus
on the ST doctors' scientific
work. As many as 55 ST projects
have been overseen during the
year, which is an “all time high”.
The desire after scientific
supervision likely depends on the
increased number of ST doctors
in family medicine and thus also
the need for scientific support in
the mandatory essay writing. We
hope of course that what we see is
also a general interest in research
among Skåne’s future GPs’ to get
statistics on publications and dissertations
over time.
The idea of AKC is, however,
that we will supervise all researchers
in occupational groups in
primary care, not just ST doctors,
and during 2018 Professor Ulf
Jakobsson will begin a research
school within health and health
sciences for nurses, physiotherapists
and occupational therapists.
The training, which was fully
booked immediately after the autumn
advertisement, includes eight
meetings.
Another forum that exists
for all interested researchers in
primary care is our open-ended
AKC seminars (Group supervision
sometimes with theme). In 2017
we held 32 AKC seminars around
Skåne. The seminar series continues
in 2018 - take a look at AKC's
website and in Region Skåne's
education catalogue.
In May we had a themed
seminar about evidence-based
medicine (EBM) together with Ulf
Eriksson, district physician and
EBM teacher in Karlskrona.
EBM is something
that AKC also continues to
invest in.
Did you know that you
can book an AKC coordinator?
On our website there is a list
with seminars in areas like
cardiovascular disease, stomach
concerns and descriptive statistics
explains Emelie Stenman, AKC
team leader. The seminars are free
and can be ordered, for example,
at a workplace meeting or an FQ
group. We had several bookings
during 2017, among other journal
clubs, which were appreciated.
In addition to the ST supervision,
the AKC coordinators have
been main supervisor to 17 and
co-supervisor to 19 PhD students
in 2017. We have also overseen
medical and nursing students as
well as several other projects in
primary care.
10 Academic Knowledge
Centers
AKC offers:
w Free seminars for primary
care staff.
w Scientific supervision -
individually or in groups.
w Scientific workshops.
w Introductory course in medical
science and quality work.
w Toolbox.
Academic Knowledge Centers
(AKC) are health care centers
with clinically active researchers,
AKC coordinators, who supervise
primary care staff in scientific
queries and projects.
The AKC coordinators are a
group with high scientific competence.
During 2017 we had
three professors, five associate
professor and six did their PhD
thesis defence. AKC coordinators
participated in 50 of CPF's
publications in 2017 plus miscellaneous
book chapters (General
Practitioner, Elderly, Pharmaceutical
Handbook, Provincial doctors
in Skåne during the 1800s).
Contact
You are welcome to reach out
to an AKC coordinator or AKC
team leader Emelie Stenman
(emelie.stenman@med.lu.se).
Check out our website or
in-service training catalogue
– our meetings are great opportunities
to discuss project
ideas and meet scientific
supervisors.
43

cpf short notices
30 Course
Jubilee!
By the end of 2017/2018, CPF has held a
total of 27 introductory courses in medical
science and quality control for ST doctors
since the start 2011. In 2018 there will be a
30th course celebration!
ST doctors from all over the country and all
specialties have learned the basics of scientific
theory, study design, evidence-based
medicine and qualitative methods. The course
participants often have different levels of
previous knowledge and the idea is that the
education should be able to give something
to everyone, which of course is a challenge –
but in a fun way.
The course falls into a project plan for a
compulsory scientific essay. During the year
90 participants completed the course, half
of them ST doctors from Skåne Health Care
Centers. To provide further support to the
participants' essay project, we tested in 2017
four half day “Open statistics house” where
CPF's statisticians worked with participants
who needed individual help. It worked well
and the concept will continue in 2018.
Published
in renowned
journals
During 2017 we have published 135 scientific
articles in international journals of very high class.
Since November 2008 we have published 1100
scientific articles; it makes us one of the most scientifically
active research units in Skåne.
This year’s research has resulted in a number of
important publications focusing on primary care
psychiatry and addiction, health economics, gastroenterology,
mindfulness, heart disease, thrombotic
diseases, diabetes and other common diseases
in primary care. The articles have been published
in: Gastroenterology, American Journal of Psychiatry,
Molecular Psychiatry. American Journal
of Epidemiology, European Journal of Psychiatry,
Journal of Health Economy, American Journal of
Cardiology, Heart, Annals of Medicine, Diabetologia
and other high ranked journals.
44

short notices cpf
Raining
gold by the end
of the year
External funding is very important for the administration
because they provide funds for
top quality research and at the same time is
an endorsement for the high scientific competence
of CPF.
A new type of
newsletter!
CPF started a new concept after a request
from Region Skåne: newsletter in the form of
short slide shows that are sent to all health care
centers for display in, for example, in workplace
meetings. The slide shows are inspired by the
already established "Green Cross" and are a
part in the implementation of new findings and
dissemination of important knowledge.
Some of the largest were:
In mid-December 2017 several large grants were announced.
Associate Professor Jianguang Ji at the CPF was awarded
1.8 million kronor from Cancerfonden for the project
“National study on health risks in children of cancer survivors.”
The project covers the period 2018-21.
Shortly afterwards, Professor Patrik Midlöv and his colleagues
received a large grant of 10 million kronor from the
Kamprad Family Foundation and half a million kronor from
the Heart-Lung Foundation for a study on e-health. In the
patient study, using a mobile phone as a support for blood
pressure treatment is evaluated. A total of 800 patients with
high blood pressure will be included in the study.
Call for research
CPF sends out a monthly email with current announcements of
research funding for all primary care professionals who report interest.
More information can be found at www.cpf.se.
45

cpf Research
Research leaders
These are the research leaders at the CPF in 2017.
Read more about their research and teaching at www.cpf.se.
w Anders Beckman, Associate Professorw Healthcare Center Lunden
w Medical care research and pedagogic research
w Anders Halling, Professor
w Healthcare Center Fågelbacken
w Epidemiology, COPD, multimorbidity
w Ashfaque Memon, Associate Professor w CPF
w Experimental research
w Bengt Zöller, Associate Professor
w Henrik Ohlsson, Associate Professor
w Jan Sundquist, Professor
w Jianguang Ji, Associate Professor
w Juan Merlo, Professor
w Kristina Sundquist, Professor
w Louise Bennet, Associate Professor
w Margareta Troein, Professor Emeritus
w Martin Lindström, Professor
w Patrik Midlöv, Professor
w Ulf Gerdtham, Professor
w Ulf Jakobsson, Professor
w Xinjun Li, Associate Professor
w Xiao Wang, MD, PhD
w Healthcare Center Granen
w CPF
w Healthcare Center Sorgenfri
w CPF
w Social epidemiology
w Healthcare Center
w Healthcare Center Limhamn
w Healthcare Center Södervärn
w Social epidemiology
w Healthcare Center Tåbelund
w Health Economics
w Healthcare Center Norra Fäladen
w CPF
w CPF
w Cardiovascular disease
w Epidemiology, genetically and environmentally oriented application
w Mental disease and substance abuse in primary healthcare
w Alcohol and the family environment, epidemiology
w Social epidemiology
w Social and physical environment and cardiovascular disease
w Diabetes and cardiovascular disease
w Professional development
w Social capital and health
w Medications and the elderly
w Health Economics
w Elderly health
w Molecular epidemiology, cardiovascular disease and cancer
w Experimental research
46

Research cpf
Economic
terms and
mortality
There is a great interest in the connection between economic conditions and
mortality in the population. Some studies show mortality is pro-cyclical, i.e.
mortality increases when the business cycle turns upwards, while other studies
show the opposite effect.
A new study (van den Berg et al. 2017) used data at the individual and
regional level from the same data source, on a sample of 20-64-year-old men,
during the period 1993-2007.
“Our results show that the relationship between economics and mortality
is not dependent on aggregation,” says Professor Ulf Gerdtham. The direction
and the size of the taxed coefficient on unemployment (as a measure of economic
activity) mortality rates are similar when taxed on an individual level and
regional level (county council). In both cases mortality is pro-cyclical.
“We can also show that this relationship is driven by the younger part of
the labour force (20-44 years), i.e. there is no relationship in the age group 45-
64 years. We could also see that the results are driven by the younger part of
the labour force in the poorest income quartile.”
Grain protein
controls satiation
District physician Tommy
Jönsson is an AKC coordinator
at Måsen Health Care Center in Lund.
His research is about the palaeolithic diet
and its effects on common diseases such as
diabetes, cardiovascular disease and obesity.
Above all, it is the qualitative difference
between the palaeolithic diet and a regular
diet that interests him.
Together with Professor Sara Linse at the
Kemicentrum in Lund, the research group
found that the grain protein disturbs the
bond between the saturation hormone leptin
and receptors in the brain. The disturbance
means that if you eat bread, for example,
leptin is blocked and hence our sense of
saturation. Tommy is a supervisor of two PhD
students in the project, Pedro Carrera-Bastos
and Maelán Fontes-Villalba, and a further
PhD student is on the way. In the autumn,
the research group organised a conference
in Lisbon in memory of Tommy’s friend and
former supervisor Staffan Lindeberg.
In addition, there is a research collaboration
with Professor Yvonne Granfeldt on food
technology, Kemicentrum. Together with
Professor Ulf Jakobsson at AKC Norra Fäladen
in Lund, Tommy hosts open seminars
a couple of times each semester. A tip for
those who need scientific supervision (see
times on AKC's website).
On the agenda:
drugs, elderly and
blood pressure
Professor Patrik Midlöv's research is about different
risk factors for drug side effects in elderly
people with multiple illnesses, e.g. the meaning
of malnutrition or decreased kidney function in
order for the patient to be hospitalised or risk of
disease. The research group has also studied
the effects of different interventions to optimise
drug treatment in the elderly and individuals with
developmental disorder. Cardiovascular diseases
in primary care is another area the group
is researching. Some examples are yoga's effect
on high blood pressure and also an interactive
web system that uses a mobile phone to be an
effective tool for better blood pressure control.
47

cpf Research
The risk of being
sick with type 2
diabetes is twice
as high for Malmö
residents born in
Iraq as for Swedishborn.
Several risk
factors stand out
but a new culturally
suited program has
been found to be a
good support for a
healthier lifestyle.
Meet Louise Bennet
- a fighter for a more
equal diabetes care.
"More global focus
when we give
advice about habits"
48
As district physician in an immigration
heavy area with many patients with
type 2 diabetes or in the danger zone,
Louise Bennet thought about why she did
not reach out to her Iraqi-born patients in
an attempt to find healthier lifestyles. Did
it depend on their own actions? Were there
hereditary, cultural or genetic factors, or
obstacles in the patients’ everyday life?
The questions were the genesis of the
MEDIM study (Migration and Ethnicity for
Diabetes Development in Malmö) which
has been ongoing since 2010.
“The project aims to even out differences
in health,” says Louise Bennet, professor
of general medicine and project manager
for MEDIM.
The background for Louise to monitor
diabetes risk among Swedes that immigrated
from Iraq is that the Middle East is a
high risk area for diabetes, and that Iraqis
are the largest non-European group in
Sweden. In the first phase of the study, almost
1400 Malmö residents with the roots
in Iraq were compared with just over 700
Swedish-born residents that participated

Research cpf
It is important
that health and
clinical personnel
are aware of
the limitations
available in a
part of the questionnaire
which
exists to gauge
the patients’
lifestyle habits.
in health surveys. The differences between
the groups were great. Diabetes was twice
as common in the Iraqi group. Among the
Iraqis aged over 60, almost every third
person had type 2 diabetes. A partial study
showed that they also had a higher incidence
of diabetes than among Iraqis in their
home country. In addition, the Iraqi-born
were on average seven years younger.
“It’s valuable knowledge for the sooner
you get diabetes then the sooner you can
also have complications in the cardiovascular
system, kidneys and eyes” says Louise.
The results also show that every other
person with an Iraqi background had a
parent, sibling or child with type 2 diabetes.
The immigrant Iraqis also had worse insulin
sensitivity than the Swedish patient group.
It was concerning that many were obese or
had obesity.
“There may be a migration effect linked
to more physical inactivity in connection
with migration, as other studies showed.
Other explanations may be that the traditional
Iraqi food contains a lot fat and sugar
and fruit that is sugar coated,” says Louise
Bennet.
Additional examples of obstacles and
cultural differences that the researchers met
were that some Muslim women, due to cultural
traditions, could not train in premises
where men were present. Many were also
anxious about exercising: “Then the heart
beats faster and then you get a heart attack”
or a notion that diabetes was unavoidable:
“When you reach 40, you get a bit more
round in stomach and you get diabetes.”
According to Louise, it was unethical to
not try to do something about the situation.
One culturally-adapted program to promote
healthy living habits was started. What
“culturally adapted” means here is that all
information and communication took place
in the participants' native language (Arabic)
and that gender-specific health and fitness
groups were offered.
In addition, financial support was provided
with exercise clothes, gym cards and
coaches. Cooking courses were especially
popular.
“Participants were allowed to bring their
own favourite recipes where they were
supported by a chef, who had diabetes
herself, who modified the recipe with less
fat and sugar,” says Louise.
The concept was effective. Those
who attended got better insulin sensitivity,
decreased fat intake, increased
motivation and physical activity and
improved mental health. Louise believes
the positive results depend on several
factors. In part because the health
coach, who led the group activity, had
a good knowledge of the existing culture,
traditions and social norms that can affect
living habits. There was a close cooperation
with local associations, such as the Iraqi
women's association, ABF, Skåneidrotten
and Hälsans Hus.
“The study was also adapted to be applied
based on existing resources in primary
care or municipality in cooperation with
local associations, which means that the
measures are relatively easy to introduce
too for others,” says Louise.
In the third phase of MEDIM, which
is currently under investigation, is cardiovascular
changes in which they try to put
them in relation to ethnicity and insulin
resistance.
Louise calls on her colleagues in primary
care to be more vigilant on diabetes risk
among Iraqi born Swedes through more regular
follow-up and more plentiful glucose/
HbA1c controls associated with doctor
visits, even for other reasons than diabetes.
She also calls for cultural competence in
care and in healthcare programs.
“We have a very western European focus
when we give diet and exercise advice to
our patients,” says Louise.
In MEDIM it was reported that more
than 60% of Iraqi born Swedes had estimated
their health badly.
“In future studies I am interested to
know more about what is behind the numbers
because mental ill health is often one
barrier to get started with lifestyle change,”
concludes Louise.
49

cpf Research
E-health services are becoming more common. But what does
the growing and older section of the population think about these
services? Important and good, but unsure how to use it according
to a scientific study involving elderly patients’ experiences
and views about how eHealth services are charted.
Older patients liking
e-health services
50
The use of digital
information and
digital tools as a
tool for administrative
development and equal
care has increased rapidly.
It can, for example, be
used to book time for a
care visit, renew prescriptions
or read personal care
information. A growing
group of older people, many with limited
internet experience, are expected to use
these services.
But what do they think about
the services themselves and are
they tailored to their needs?
“The elderly's ability to use
digital technology and e-health
services is a fundamental one
for security, self-determination
and participation in health
care. Their experience is therefore
important when e-health
initiatives are introduced in
primary care,” says Dr Moa Wolff, Coordinator
at Löddeköpinge AKC.
She is part of a research group called

Research cpf
High Five that focuses on evaluating and
developing e-health services. In addition to
Moa are Dr Veronica Milos Nymberg, coordinator
at Laröd's AKC, Dr Beata Borgström
Bolmsjö, Coordinator at Sorgenfri
AKC, Susanna Calling, Associate Professor
and coordinator at Lomma AKC and Dr
Magnus Sandberg at the Faculty of Medicine
at Lund University.
In the study, 15 patients were recruited
aged 65-80 from three health care centers.
To chart the needs of the elderly, experiences,
ideas and suggestions were observed
in three focus groups. The result showed
that for many, digital communication and
technology are a natural part of everyday
life, while for others they are new areas
to conquer. Most people thought that e-
health services are important and good, but
expressed an uncertainty at the same time
with the practical use and demanded more
technical support and courses in e-health
services.
“The main demand was for knowledge
about e-health services that are available
today? Many did not even know you could
read your medical notes online,” says Susanna
Calling.
The focus groups also found that some felt
a fear of the physical meetings with the
healthcare staff will reduce in favour of e-
health services.
The research group
is involved in more
health projects. Namely
evaluating online medical
visits increases prescription
of antibiotics;
evaluate a tool where
patients can fill in their
own names digitally
before the doctor's visit,
as well as a program with lifestyle advice
via SMS to reduce cardiovascular problems
and promote healthy habits.
“Interest in e-health concepts is large
both among patients and health care
providers. So far, however, there are few
scientific evaluations of the medical benefit
and effect. New smart solutions adapted
for primary care are also needed, as well as
more knowledge of patients' and the staff's
experience and perception,” says Veronica
Milos Nymberg.
"The demand
was mainly for
which e-services
existed."
From left: Moa
Wolff, Veronica
Milos Nymberg
and Susanna
Calling, who
want more done
about scientific
evaluations of
e-health services
being
introduced.
51

cpf Research
Can a text with
health advice lower
blood pressure?
Simple regular text messages sent via
mobile that encourage healthy behaviour
can motivate people to improve
their health, lower blood pressure and
prevent cardiovascular disease. That’s
the hope of the research group HighFive
in the brand new e-health project PUSH
52
High blood pressure is one of the
biggest risk factors for myocardial
infarction and stroke. Even though
there is effective treatment with lifestyle
changes that can be combined with drugs
there are some patients with high blood
pressure that can reach their own goal
value.
In a new project, a research team is
investigating the effects of lifestyle advice
delivered via sms
“Preventive work is a major task for us
in primary care. But sometimes it is hard
to reach our patients and increase their
motivation to healthier behaviours. A complementary
addition is needed,” says one of
the project managers, Moa Wolff.
The first pilot study, called PUSH ME, includes
60 hypertension patients between 40
and 80 years of age. They will be recruited
from three health centers located in areas of
different socioeconomic status. The participants
are divided between a treatment
group and a control group. The treatment
group may try one program consisting of
a total of 104 text messages with lifestyle
advice as the participants get on the phone
four times a week.
“All questions and advice are based on
different Swedish recommendations on
healthy living habits,” says Veronica Milos
Nymberg.
At the start and after six months, the
participants do a health survey where they
check their health, check blood pressure,
take blood samples and measure waist
circumference and weight.
The text messages consist of both reminders
and lifestyle advice to quit smoking
increase physical activity, drink less alcohol,
eat healthier and stress less. A few examples
are: “Do not forget that physical activity is
good for you.” “A walk 30 minutes every
day can reduce the risk of cardiovascular

Research cpf
The treatment group
can try a program
that consists
of a total of 104
text messages with
lifestyle advice as
participants get via
mobile four times a
week. All questions
and advice are
based on different
Swedish recommendations
about
healthy lifestyles.
disease.” “Studies show that stress, anxiety
and loneliness can increase the risk of heart
disease. Contact your healthcare center if
you need help.”
The purpose is to strengthen the patients
themselves to take command of their health.
And the mobile phone is an excellent and
easy tool. Most people in Sweden own one
and carry it around.
Information can be personalised
and delivered
fast without a login to a
website and at a low cost
for primary care,” says
Susanna Calling.
“The group hopes
the concept, which was
inspired by an Australian
research team, can give a
hint about the outcome
of PUSH ME.
“One of their studies
"The purpose is
to strengthen
patients to
take command
over their
health."
showed that the study participants who received
lifestyle texts had better cholesterol,
blood pressure and BMI as well being more
physically active and smoked less, compared
with the control group. They also thought
the text was motivating to change their
lifestyle habits,” said Moa Wolff.
With a successful conclusion of the Swedish
PUSH ME study, the
researchers see opportunities
for ripples in the water:
“Then perhaps we can
in the primary care services
offer this as a part of the
treatment and advice for
patients with high blood
pressure. There are many diseases
and illnesses where a
similar setup can be interesting.
An example is diabetes
and COPD,” says Veronica
Milos Nymberg.
53

cpf Research
In a new study from CPF, researchers investigated
the risk factors for blood clots, i.e. venous thromboembolism
(VTE). The results show a strong
correlation between height and VTE risk for both
women and men. The risk increases with height.
Correlation
between
height and
risk of
thrombosis
54

Research cpf
"It’s more
difficult for
blood to flow
back to the
heart. "
Tall people have a higher hydrostatic
pressure in the body, i.e. pressure
from blood and other fluids, compared
to shorter people, which could explain
the findings.
“We used several Swedish registers in the
largest and hitherto only countrywide study.
We are therefore sure that our findings are
of high statistical significance”, emphasises
associate professor Bengt Zöller of Lund
University and CPF.
The research program investigated risk
factors for venous thromboembolism (VTE)
for better risk assessment, prophylaxis and
treatment. VTE is the third most common
cardiovascular disorder after heart attacks
and strokes. A correlation between height
and VTE has been described before, but the
possible causal link was not established.
The correlation was also not previously
consistent among women.
In the current study, the researchers
found a strong correlation between height
and VTE risk in both women and men. The
correlation is attributed to the fact that the
longer a person’s legs are, the longer their
blood vessels need to be. This makes it
more difficult for blood to flow back to the
heart. This slow blood flow is likely what
increases the risk of thrombosis.
By analysing the correlation between
height and risk of VTE in sibling pairs as
well, the researchers could adjust their
results for other genetic similarities and
familial environmental factors. The correlation
was nevertheless equally strong among
sibling pairs, indicating that there could
be a causal connection, i.e. that the height
in itself, and not another factor linked to
height, causes the correlation.
For women aged
around 60 with a
height of around 155
cm, the risk of VTE
is 3 per cent, whereas
it increases to 6 per
cent for women of
the same age who are
over 185 cm tall. For men aged around 60
and under 160 cm tall, the risk is 2 per cent,
whereas for men of the same age over 190
cm the risk rises to 7 per cent.
“We used several national registers that
are, of course, anonymised, but invaluable
for epidemiological research, such as the
military register, the medical register of
births, the patients register and the multigenerational
register”, explains Zöller.
But how do we benefit from the results?
That the length cannot influence.
“We hope that height will come to be
included in risk assessments for VTE. In
addition, if you are very tall it is extra important
to think of influential risk factors,
such as inactivity, overweight, smoking,
contraceptive pills and preventive treatment
at e.g. pregnancy, especially if at the same
time there is heredity in the family, says
Bengt Zöller.
Another question which needs to be
answered is whether compression hose is
effective in tall individuals to counteract the
increased hydrostatic pressure.
“The new findings give rise to more in
depth research,” concludes associate
professor Bengt Zöller.
Study title: “Body Height and Incident
Risk of Venous Thromboembolism:
A Co-sibling Design”.
Circulation: Cardiovascular Genetics.
Author: Bengt Zöller, associate
professor, Jianguang Ji, associate
professor, Jan Sundquist, professor
and Kristina Sundquist, professor.
55

cpf Research
Anxiety increases
among young people
Anxiety is increasing in the population especially
among young women aged 16-23 years in Sweden.
Self-reported anxiety has increased threefold
in young women between 1980 and 2005.
56
Studies over time on the presence of anxiety
are rare and may be affected by population
age and generation distribution.
The current study examined the self-reported
anxiety every eight years between 1980 and
2005 through personal interviews with more
than 5000 Swedes aged 16-71 years.
“By following different age groups and generations
we analysed the trend of anxiety over
time, which has never been done before,”
says Susanna Calling, associate professor
at Lund University and researcher
at CPF.
The analyses were checked for
differences in education, place of
residence (i.e. larger/smaller city or
rural area), marital status, smoking,
physical activity and BMI.
Between 1980 and 2005 the total
occurrence of self-reported anxiety increased
from 8% to 12.4% in men and from
17.8% to 23.6% percent women. The increasing
trend was seen in all age groups except in the
oldest age groups, and the biggest increase was
seen in young people 16-23 years, with more
than a threefold increase in women and a 2.5-
fold increase in men.
“A possible explanation for the results can be
that the entrance to the labour market is delayed
to a higher age, due to increased education requirements
in the labour market and increased
"Special
efforts
for young
women
needed."
unemployment among young people. There may
also be other factors, such as the appearance requirements,
which many young women say they
experience,” says Susanna Calling.
The researchers suggest that the increased
reporting of anxiety may to some extent be affected
by reduced stigmatisation and increased
awareness about mental illness although this is
likely not the whole explanation. In the older age
groups, they did not find any increased incidence
of anxiety, and in women 64-71 years it dropped
in occurrence between 1980 and 2005.
Possible causes behind this may be better
treatment of chronic diseases in this group,
but also safer social circumstances.
“Increased anxiety has increased suffering
for a large part of the population
and is likely to increase the burden on
healthcare. Many patients seek primary care
because of mental health problem, even if they
do not get a psychiatric diagnosis. The results indicate
a dark number of mental ill-health, which
is not visible in the statistics of psychiatric diagnoses,”
said Susanna Calling.
“Clinical efforts should focus particularly on
young women aged 16 to 23, where the increase
in anxiety over time was greatest. Increased access
to psychosocial efforts can be valuable. Because
anxiety often occurs at young age it is possible
to focus on early efforts within school and
high school,” she says.

Research cpf
Poor health in youth
can increase risk for
illnesses further on
In his dissertation, Gabriel Högström showed that poor physical
health increases the risk of various diseases and premature death.
In the next step, he will investigate together with Kristina Sundquist,
at the CPF, about the risk that cancer sufferers can be linked to poor
health early in life.
Gabriel Högström is affiliated with IKE,
department of clinical and experimental
medicine at Linköping university.
In February 2017, he defended his dissertation
“Cardiovascular disease and death: Impact
of fitness, overweight and genetic factors” at
Umeå University. The dissertation was about
how fitness and overweight are associated with
cardiovascular disease as well as the risk of
dying prematurely. Now, Gabriel investigates
the link between fitness and the respective risk
of death and cancer.
“I contacted Kristina Sundquist and sent my
dissertation to her because she did studies in
the same areas. We met and discussed the research
project and how my work in Linköping
could then be adapted to my research together
with CPF,” says Gabriel.
In his dissertation, Högström noted that
many with poor health died due to trauma,
suicide and abuse, which was unexpected.
Certainly, there was poor
health associated with an increased
risk of cardiovascular disease, but
most strongly was the connection to
death caused by addiction.
“Through a twin study in my
doctoral dissertation, we could see
that heredity played a very important
role in the link
between fitness
and the risk of
sickness and
death,” says
Gabriel, and
adds that this
kind of data
is considered
to be controversial
in the
research community.
During
2018, Gabriel’s research will comprise a
new six-week research period during the
summer months and then three months’
full-time research during spring 2019.
“The hope is that I can explore the connection
between fitness, overweight and the
risk of cancer in further studies.
“I enjoy writing and analysing. Here
at CPF, I analyse the data together with
Henrik Ohlsson, lecturer and statistician. I
want to understand my own data to be able
to translate in a good way for them to have
scientific reasoning. That way, I can tell a
story from outside the numbers,” concludes
Gabriel.
57

cpf Research
Neighbourhood area
affects our health
Where we live matters for our health says Professor Kristina
Sundquist, one of the pioneers in the country on research on the
neighbourhood area’s effect on our health.
Her own experience of
living in a Stockholm
suburb with low status
has spurred Kristina in her
research which has carried a
theme in her entire research
career: The impact of the residential
area on our health and
differences in health between
socioeconomic vulnerable
areas and more wealthy areas.
Kristina Sundquist, who
was born in Bulgaria's capital
Sofia, moved to Sweden as a
child and grew up in Västerås.
After medical education and
a few years of clinical work
she began work at Karolinska
University Hospital and
settled in Skärholmen, which
is an immigrant suburb with
high unemployment and low
middle income but that was
nothing she reflected on when
she moved there. But several
of her colleagues did.
“There was a patronising attitude among
some,” says Kristina.
These experiences of being lower in rank
because of the area she lived in led further
to the question of how neighbourhood
socioeconomic status is also important for
our health. In her doctoral dissertation, she
examined whether there was a connection
between what kind of residential area a person
lives in and the risk of cardiovascular
disease. The result surprised her.
“For example, cardiovascular disease
was more than twice as common among
people living in socioeconomically disadvantaged
areas compared with those living
in more affluent areas,” she says.
After her defense in 2003, things took off
fast. She became an associate professor in
2005 and a professor at Karolinska Institutet
in 2007. In 2010 she came to Malmö as
a professor at the newly established CPF. In
addition, Kristina had a 3-year guest professorship
at Stanford University and is currently
a guest professor at the Icahn School
of Medicine at Mount Sinai in New York
and at Shimane University in Japan.
58

Research cpf
She has received a number of large external
grants, including from the National Institutes
of Health in the United States and is
an often engaged lecturer. In addition, she
has further developed the Care Need Index
(CNI – one system for defining care needs)
that is today used in large parts of Sweden
for distribution of primary care resources.
One day a week she works as a GP at
Granen’s health care center in Malmö.
“The research is needed in healthcare
and the patient perspective is needed in the
research. Working clinically is extremely
important to me because the work makes
a direct difference to patients and it is in
the meeting with the patients where many
People in vulnerable
neighbour-
of the best scientific ideas are born,” says
hoods suffer Kristina.
more often, During her career, she has continued to
for example,
investigate the link between neighbourhood
environment and health. She has been
cardiovascular
disease, diabetes
and mental responsible and participated in a number
illness and have of projects concerning diabetes, psychiatric
increased
risk of
diseases and premature birth. One problem
premature over the years has been to find out whether
death than it is the residential area itself or characteristics
of the people who live there which leads
people
in more
affluent to ill-health. With more refined technology
areas.! and analytical methods, the different factors
today are measured more efficiently than
before, e.g. the importance of heredity.
“It’s not surprising that both the environment
and heredity are important and
genetic vulnerability seems to play a role
in how one responds to the environment.
We could imagine that earlier. Now we are
more sure,” says Kristina.
That the inequalities in health are so clearly
dependent on where you live concerns her.
“I would like to see more primary care
resources invested in vulnerable areas to
help those people who need more help to
achieve good health. But it does not solve
all problems. People must also get meaningful
employment and many residential areas
need to be improved and made safer to live
in. And those are issues outside healthcare’s
responsibility,” she says.
In addition to research on neighbourhood
environment, Kristina is leading the
clinical project about atrial fibrillation
called FIRST. The aim was to improve the
knowledge of atrial fibrillation at the health
care centers in Skåne as well as ensure that
more patients got anticoagulant therapy and
thus reduce stroke risk.
“Patients with atrial fibrillation have a
greatly increased risk of stroke. Yet only
42% of them have the correct kind of blood
thinning medication for a few years before,”
Kristina says.
She adds,” After an in-service training
session, journal review as well as other
parallel efforts in Region Skåne, 76% of
patients at the 25 health care centers that
participated in the project today get proper
treatment. It is still 4% from the national
target but we are still quite satisfied.
The project was costeffective.
Four out of five
"Four out of
five doctors
gained valuable
knowledge."
doctors who participated
in FIRST also considered
that they gained valuable
knowledge and could
imagine participating in
more similar studies.
After all her years in the research community,
Kristina still thinks her work is
stimulating, developing and important. And
for students and staff in primary care who
are considering doing research she advises:
“Do not hesitate! You will be developing
as a person at the same time as your results
can come to improve human health.”
59

cpf Research
In depth
with cancer
An email from Sweden became crucial to the Chinese
doctor Jianguang Ji and an important puzzle piece for his
future occupational choice. Today he is a prominent cancer
researcher and believes the ideas of what can be explored
are just getting more interesting over the years.
"Cancer is the
primary individual
cause of death
in the world"
60
He grew up in the small Hebei province
outside of Beijing and trained
to become a doctor. But not the
doctor he thought he would be. Interest in
air pollution and its various health effects
affected Ji and his continued focus.
“For a Swede it is difficult to
understand how the situation
can be in Beijing or other big
Chinese cities when the smog is
at its worst. I wanted to know
more about the connection to
diseases like cancer and asthma
and began work in an organisation
that worked with these
issues. But I understood that I had to start
researching to get more clarity,” he says.
That Jianguang Ji eventually ended up in
Sweden was a conscious choice. He read in
a magazine that there were unique conditions
in the Nordic region for epidemiological
research due to the long tradition
with social security number, many different
registers, and sample collections in biobanks
that brought opportunities to implement
large population studies. He sent an email
to cancer researcher Kari Hemminki at Karolinska
Institutet. Two days later he got a
response and an invitation to become a PhD
student in Stockholm.
And on that road he continues. Fourteen
years later, Jianguang Ji is a teacher and
leads a research group at CPF that helps
large-scale epidemiological studies in attempting
to identify new ways to predict
and treat various diseases and disorders. An
important part of the research is understanding
the cause of some cancers and the keys
to new methods to detect and treat.
“Much research progress has contributed
to increased knowledge, better treatment
and more survivors but more knowledge is
needed. Cancer is still the primary individual
cause of death in the world according
to the WHO,” says Ji.
Colon cancer is the third most common
cancer form in Sweden. Just why some suffer
and others seem to have a protection is
still not fully clear but we know that other
factors play a role.
In a recent study, the researchers at
CPF have been able to show that cholera

Research cpf
In an exciting
project, researcher
Jianguang
Ji will study how
the health of
children whose
parent survived
cancer is affected.
vaccine, in addition to protecting against
cholera, also seems to protect against colon
cancer.
“To vaccinate against cholera in order to
prevent tourist diarrhoea for a trip abroad
may in other words have more advantages.
We still do not know what mechanisms
make the vaccine appear to have anticancer
properties. But it raises interesting
questions and demands further research
with clinical studies,” he says.
In another exciting project, funded by
the Swedish Research Council, Ji and his
research group are studying how health in
children whose parents or parents survived
cancer is affected.
“We know that more and more survive
cancer. But at the same time, we do not
know that much about the consequences
for the children that come
after.”
With the help of the Cancer Registry,
The Death Cause Register
and the Multi-generation Register,
the researchers have access to
approximately 30,000 individuals
with a parent who had a cancer diagnosis
before the birth of the children. They will
investigate if parents post chemotherapy
have an increased risk of having children
with, for example, congenital injuries, mental
illness, cancer diseases or other health
risks. A child’s health prognosis will be
compared to corresponding children with
previously healthy parents. Comparisons
will be made with any siblings born before
the parents’ cancer.
“We hope to receive valuable information
from both healthcare and people who
previously had cancer and considering becoming
a parent,” says Jianguang Ji.
What distinguishes a good researcher is
clear to Jianguang Ji.
“You must be able to ask the right questions
and interpret the results. But additionally
you have to be very driven, that it is
hard work that is involved,” he says.
Jianguang Ji himself has no plans to slow
down the pace.
“In fact, the ideas are just getting greater
with the years and the CPF is an exciting and
inspiring environment to work in,” he says.
61

cpf PhD students
Newly Enrolled
PhD Students
2017
Artin Entezarjou,
Trainee physician.
Digital triage and digital
visits to the health care
center. Supervisor:
Patrik Midlöv.
Maria Glans,
Pharmacist.
Risk factors for the
readmittance of elderly
hospital patients.
Supervisor:
Patrik Midlöv.
Christopher
Nilsson, Trainee
physician.
Regulating blood pressure
mechanisms and
renal function within
different ethnicities.
Supervisor:
Louise Bennet.
62
Karin Westerlund
Effectiveness, cost effectiveness
and health
inequality of a strategic
dementia care plan
Supervisor:
Ulf Gerdtham.

Earlier Enrolled
PhD Students
PhD students cpf
Abrar Ahmad, msc.
Risk prediction of cardiovascular
diseases;
a multibiomarker approach.
Main supervisor:
Ashfaque Memon.
Delshad Akrawi,
specialist physician in
family medicine.
An epidemiological
study of the importance
of hereditary and nonhereditary
factors for
chronic kidney disease
in Sweden. Main supervisor:
Bengt Zöller.
Carl Antonson,
resident physician.
Mindfulness as a method
for increasing mental
well-being and cognitive
performance and reducing
stress among high
school students: A prospective,
controlled pilot
study. Main supervisor:
Kristina Sundquist.
Helén Arvehammar,
social scientist.
Municipal differences in
elderly care. Main supervisor:
Martin Lindström.
Henrik Axelson, msc
Essays on the impact of
targeted social health
insurance: evidence from
Vietnam. Main supervisor:
Ulf Gerdtham.
Jakob Axelsson,
msc.
Essays on the impact of
targeted social health
insurance: evidence
from Vietnam. Main supervisor:
Ulf Gerdtham.
Pedro Carrera
Bastos,
The role of western diet
on intestinal permeability
measured by zonulin,
including possible associations
with the metabolic
syndrome and
autoimmune diseases.
Main supervisor:
Jan Sundquist.
Sixten Borg,
statistician.
Disaggregation and
indirect estimation
methods on data for
health economic models
and economic evaluation,
with applications
to inflammatory bowel
disease and diabetes.
Main supervisor: Ulf
Gerdtham.
Gabriella Caleres,
specialist physician.
Elderly drug treatment
- information transfer
and follow-up in primary
healthcare. Main supervisor:
Patrik Midlöv.
Lina Ejlertsson
Recovery in work: An
intervention project for
better health among coworkers
in primary healthcare.
Main supervisor:
Annika Brorsson.
Sten Axelsson Fisk,
Trainee physician.
Social theoretical and
epidemiological perspectives
on Chronic
Obstructive Pulmonary
Disease in Sweden.
Main supervisor:
Juan Merlo.
Per Ola Forsberg,
specialist physician
Neighbourhood influence
on cardiovascular
health. Main supervisor:
Kristina Sundquist.
Maria Fridh,
specialist physician
Determinants of mental
illness among adolescents
and young adults
with a special focus on
exposure on violence
and bullying. Main
supervisor: Maria
Rosvall.
Henrik Grelz,
district physician
Group therapy for physical
inactivity in primary
healthcare. Main supervisor:
Patrik Midlöv.
Gawain Heckley, msc.
Essays on the demand
for and the effect of
alcohol. Main supervisor:
Ulf Gerdtham.
Helena Isberg
Kornfält, specialist
physician.Urinary tract
infections in primary
healthcare. Main supervisor:
Anders Beckman.
Elzbieta Kaszuba
Studies of social and
administrative contexts
impact on health.
Main supervisor:
Anders Halling.
Magnus Lindgren,
specialist physician
Epidemiological studies
on heart failure
Main supervisor:Bengt
Zöller.
Christine Lindström,
specialist physician
Studies on social and
administrative contexts
influencing health
Main supervisor:
Martin Lindström.
Ensieh Memarian,
specialist physician
Obesity surgery in
Sweden: The effect of
socioeconomics
Main supervisor:
Xinjun Li.
63

cpf PhD students
Sofia Nilsson,
speech therapist.
Language development
disorders in childhood
and adolescence and
health and healthcare
utilisation later in life: A
multilevel and life-course
approach. Main
supervisor: Juan Merlo.
Peter Nymberg,
specialist nurse.
Opportunistic screening
and intervention,
cardiovascular disease.
Main supervisor:
Bengt Zöller.
Sara Olofsson,
msc. Methodological
studies on willingness
to pay for risk reduction
Main supervisor:
Ulf Gerdtham.
Jon Pallon,
specialist physician.
Throat pain among
children and young
adults. Main supervisor:
Katarina Hedin.
Sofie Schön
Persson,
public health scientist.
Working relationships
and interaction with
the workplace. Main
supervisor: Ingemar
Andersson.
Jesper Alex
Petersen,
Materialistic/postmaterialistic
values and
health as well as longitudinal
studies on health
effects of the introduction
of school lunches in
Sweden in 1946 – 1973.
Main supervisor:
Martin Lindström.
Ferdinando Petrazzuoli,
Dementia management
in European primary
healthcare. Main supervisor:
Hans Thulesius.
Miriam Pikkemaat,
specialist physician.
The prognosis with
Type 2 diabetes. Some
biochemical markers significance
for metabolic
disorders and cardiovascular
complications.
Main supervisor: Kristina
Bengtsson Boström.
Per Rosengren,
trainee physician.
An epidemiological
study of supraventricular
tachycardia. Main supervisor:
Bengt Zöller.
Faiza Siddiqui,
Prevention of type 2
diabetes & poor mental
health amongst immigrants
from the Middle-
East to Sweden.
Main supervisor:
Louise Bennet.
Cecilia Sjöstedt,
specialist physician.
Individual, family and
neighbourhood factors
and mental illness
Main supervisor:
Xinjun Li.
Kristine Thorell,
Improving pharmacological
care in the elderly
population. Main supervisor:
Anders Halling.
Carin Tillman,
specialist physician.
Pharmaceutical continuity
during treatment of
diabetes. Main supervisor:
Anders Beckman.
Frida Thorsén,
specialist physician.
Stress related poor
health among young
people. Main supervisor:
Kristina Sundquist.
Madelaine Agosti
Törnquist,
public health planner.
Salutogenic factors for
a health-promoting life
rhythm. Main supervisor:
Ingemar Andersson.
Rasmus Waehrens,
specialist physician.
An epidemiological
study on the importance
of hereditary and nonhereditary
factors in
irritable bowel syndrome
(IBS). Main supervisor:
Bengt Zöller.
Leila Waleij,
pharmaceutical chemist.
Drug treatment and drug
related problems in frail,
elderly patients. Main
supervisor: Patrik Midlöv.
Katharina
Verheijen,
specialist physician.
Osteoporosis in women
based on wrist fractures
and how the fear of
falling again can affect
life quality. Main
supervisor: Kristina
Bengtsson Boström.
Hanna Wickström,
specialist physician.
TeleUlcer: Telemedicine
and RiksSår (Swedish
quality register for treatment
resistant sores):
Modern sore treatment
for patients and staff.
Main supervisor:
Patrik Midlöv.
Maelán Fontes
Villalba,
Food and metabolic syndrome
in Western and
non–Western populations.
Focus on adipokines
and glucagon.
Main supervisor:Jan
Sundquist.
Sofia Zettermark,
gender studies.
Use of hormonal anticonceptives
and psychical
health in young women:
An intersectional
approach. Main
supervisor: Juan Merlo
Ye Zhang, msc.
Economic evaluations of
kidney transplants.
Main supervisor:
Ulf Gerdtham.
64

PhD thesis defences cpf
PhD Thesis
Defences
2017
Public health with
focus on social
paediatrics
Marie Köhler
Vulnerable children. A
social perspective on
health and healthcare.
Main supervisor:
professor Maria Rosvall.
Public Health
Sciences
Public health with
focus on health
economics
Clinical medicine
with focus on experimental
medicine
Cecilia Lenander
Interventions to improve
medication use in elderly
primary care patients.
Main supervisor:
Patrik Midlöv.
Clinical medicine
with focus on
family medicine
Karin Ranstad
Importance of relationships
with primary care.
Implications for patients
and health care. Main
supervisor: Anders
Halling.
Mia Tyrstrup
Quality in antibiotic prescribing
in primary care.
Current practice, relation
to guidelines and antimicrobial
resistance.
Main supervisor:
Katarina Hedin.
Nermin Ghith
Multilevel analysis of
individual heterogeneity
to investigate hospital
quality of care with a
focus on clinical patient
indicators. The case
of patients with heart
failure and diabetes
Main supervisor:
Juan Merlo and
Anne Frølich.
Marie Nilsson
Salutogenic Resources
in the Everyday Lives
of Teachers. Promoting
workplace learning and
well-being.
Main supervisor:
Kerstin Blomqvist.
Sofie Persson
Socioeconomic Consequences
of Childhood
Onset Type 1 Diabetes
– a case study of the
impact of an early life
health shock.
Main supervisor:
professor Ulf Gerdtham.
Public health with
focus on health
anthropology
Maria Wemrell
An intersectional approach
in social epidemiology:
Understanding
health heterogeneity.
Main supervisor:
professor Juan Merlo.
65

cpf PhD thesis defences
"Dare to ask more
about a child’s
life situation"
66
With an already strong focus on child health care as a new
doctor in the mid-80s and a lifelong desire to get more
knowledge, Marie Köhler defended her thesis on June 1, 2017
in public health sciences with a focus on social paediatrics
with her dissertation about especially vulnerable children.
Marie works everyday as unit manager with 25 employees at
the Knowledge Center for Child Care and Knowledge
Center for Women's Health.

Inequality in society has increased in succession
since 1980, says Marie Köhler. It
shows. Many people in Sweden live poor
and crowded lives. And today more children
live that way than 40 years ago – their
health is affected by living conditions.
In her work as a paediatrician, Marie
Köhler is particularly interested in vulnerable
children and especially those who have
migrated, homeless children and children
who feel bad in different ways.
“Even though we have come a long way
in Sweden with laws and
rights, so we must all the
time work to develop society.
Over the years I have
wondered, what’s making
children feel bad?”
A couple of years ago
Marie was given the opportunity
to participate in a
research group in a project
concerning children in family homes. Even
Malmö City got engaged in the research
project. It resulted in two published research
articles and several articles on the
theme of vulnerable children that eventually
led to the dissertation “Vulnerable children:
A social perspective on health and healthcare.”
“That family-home reared children have
worse health is not surprising, but child
welfare centers are not fully delivering for
this group. Child health care is simply not
available to them. There are many factors
that are the reason for this, but many links
are constantly broken for these particularly
vulnerable children during their upbringing,”
says Marie.
The work of all the articles was instructive
says Marie:
“It’s almost invisible work – the research
process is more extensive than what
"Health is
influenced by
much more than
biological
factors."
you think before you start! But you learn
a lot, for example, critically reviewing
and reading other people’s articles. I am
very happy for all this as I can use it in my
regular job.”
A partial study examined the health
situation for four year olds in Skåne. The
odds were higher for the children having a
stomach ache if the parents had bad health,
were anxious about finances or if there
was violence in the family. That knowledge
became a eureka experience for Marie.
“Health is affected by
so many other factors
than just biological. The
social situation can also
lead to ill-health. As a
doctor that meets children
we must dare to ask
more to get more knowledge
of the child’s life
situation. And that basic
knowledge about how the situation is can
help us make efforts.
“I want us in health care to work more
with the social determinants,” emphasises
Marie Köhler. The World Health
Organization report “Closing the gap in a
generation” is extremely important in this
context,” says Marie.
To transform research into practical
measures is central
to Marie and
her colleagues
at the Knowledge
Center
for Child Health
and Women’s
Health. “It is
one perfect work.
We make a difference in
a scientific way!”
PhD thesis defences cpf
67

cpf PhD thesis defences
Variation in
antibiotic
prescribing
What led to my PhD student work was actually that I wanted to
immerse myself in the topic of antibiotic resistance. I wanted a
parallel track for my work as a district physician,” says Mia Tyrstrup,
who in October defended her thesis at Lund University with the
dissertation Quality in antibiotic prescribing in primary care.
68
Ihad during my medical education the idea
of becoming an infections physician, says
Mia. “When my resident physician work
on antibiotic resistance finished, I felt that I
wanted to do something more so I contacted
Sigvard Mölstad, who has just become a
professor at IKVM Malmö and had a connection
with CPF.”
Sigvard Mölstad is one of the pioneers
that founded STRAMA in 1995, the strategy
group for rational antibiotic use and
reduced antibiotic resistance.
In her thesis, Mia Tyrstrup examines
various aspects of antibiotic deprivation,
partly by charting the current prescriptions
in Swedish primary care and partly how
you can compare the antibiotic deprivation
between countries as well as the resistance
situation among children with respiratory
tract infection.
The studies show, among other things,
increased compliance to the diagnosis and
treatment guidelines for ear infections, throat
and respiratory tract, but that the antibiotic
deprivation varies considerably between different
health centers. In the case of respiratory
infections among children, the studies
support a careful selection of primary care
patients who benefit from treatment with
antibiotics. The thesis also analyses different
obstacles that GPs’ follow-up to the national
guidelines for antibiotic deprivation.
“It is important to know how best we
reach the doctors. We need to give the doctors
a good evidence-based basis for supervision
in their prescription work. Within
STRAMA, you will find various tools, such
as information sheets and explanatory
leaflets as support in communication with
patients,” says Mia.

PhD thesis defences cpf
"It is important that
primary care develops
its own research base."
STRAMA, which is a national organisation,
collaborates with the Public Health Agency,
in the design of national guidelines and also
with other authorities in the task to take an
overall approach to the antibiotic issue.
Regional STRAMA groups work with
education aimed at both physicians and
nurses as well as having regular contact with
follow-up centers regarding current antibiotic
deprivation.
To change the antibiotic deprivation,
documentary evidence is needed for different
action. Mia Tyrstrup emphasises that it is
equally important to clarify what medical
care is doing right as well as what it is does
wrong.
“In Sweden, nurses have a key role in
the success of this relatively low antibiotic
deprivation compared to other countries.
Their triage of which patients that need to
meet doctors keeps the unnecessary antibiotic
deprivation down.”
It was hectic weeks before her dissertation
on October 20th. She is now finishing
some remaining parts as well as starting new
projects.
“It was a bonus to get an insight into
the academic world, and not least get to
know all international contacts. The time
in Australia through the National Research
School helped me incredibly much,” says
Mia.
According to Mia, it is very evolving to be
a part of primary care research.
“It is important that primary care develops
its own research base also in order to
increase the status of general medicine as a
medical specialty,” she says.
69

cpf PhD thesis defences
Fewer die
from heart
valve
disease
“We have found that mortality
for patients with aortic stenosis
seems to go down, most
likely due to improved surgical
techniques and post-operative
care, but also because the
care for other cardiovascular
cohabitation, such as a
heart attack and heart failure,
has improved, says Andreas
Martinsson, who received his
doctorate with his thesis “Epidemiological
aspects of aortic
stenosis” in May. His supervisors
come from both the the
cardiology clinic in Lund and
CPF in Malmö.
70

PhD thesis defences cpf
The dissertation also shows that patients
with aortic stenosis have a double
risk of both bleeding, recurrent
disease in infarction and death after a first
myocardial infarction. This calls for aortic
patients to be a high-risk group that should
be monitored and evaluated carefully.
The findings indicate that aortic stenosis
is a disease that is affected by risk factors
that are similar to atherosclerosis, but there
is currently no medical treatment for aortic
stenosis.
“Perhaps you can, if you treat these risk
factors early in the process, prevent that
some of the patients develop an equally
severe disease. There seems to be a clear
genetic component when siblings have a
clear increased risk of aortic stenosis,” says
Andreas.
“More research is needed to clarify
which genes and mechanisms contribute to
its development.”
A collaboration between cardiology in
Lund (IKVL, Department of Clinical Sciences,
Lund) and the CPF (IKVM, Department
of clinical sciences, Malmö) has emerged in
recent years.
“It is a collaboration between the end
and primary care that allows us to take
advantage of each other’s skills, explains
Andreas Martinsson. There have been clear
synergies when we have had the opportunity
to work with different angles that
primary and outpatient care works from the
outside. There is a great deal of expertise
and experience with CPF when it comes to
using and working with the major national
health records. Together we have been able
to identify and answer most of the questions
during the period we have collaborated,
which has resulted in my dissertation.”
Cooperation began with work concerning
epidemiological time trends for aortic
stenosis, which is an area where there was
an information deficit; something to be explored
further at cardiology in Lund along
with the CPF.
“I started researching in cardiology in
connection with my master’s degree in
2013. That same year, I became a PhD
student. I am also a doctor and my last
workplace was a thoracic surgery in Gothenburg,”
says Andreas.
Interest in research
arose early during his
medical education but it
was really only in term six
when he started studying
about heart disease that
he got attached to the
subject. He was doing his
master’s degree in cardiology
and then continued
further with heart valve
illnesses during his doctoral
studies.
“It was hardest during
my doctoral studies where I was limited
to keep focus on the issues just for the
project that you are currently working on.
One thinks easily about nearby issues and
unfortunately there isn’t enough time for
them, but it is also what makes me think it
is enjoyable to research,” he says.
He has a tip for anyone who is thinking
about starting research studies:
“If you find something that you are
interested in, it’s best to contact someone
you think you are can agree with - try and
see if it’s as interesting as it seems and you
can always change. Because you work close
to their supervisors and colleagues, find a
group that you like as well. It is almost as
important as the subject itself, but how it
works cannot be known before you have
tried it.
"There have been
clear synergies
when we have had
the opportunity
to work with
different angles."
71

cpf PhD thesis defences
Drug reviews
make a difference
72
Longer life spans and a larger proportion of older people
in Sweden and other countries has led to increased use of
drugs. A new dissertation from Lund University is highlighting
for the first time in a more comprehensive way, the benefit of
existing primary care work structured with elderly drug intake.

PhD thesis defences cpf
Despite various initiatives to reduce
incorrect and unnecessary prescription
of medicines for older people in
Sweden, total consumption has increased
among persons older than 75.
One way to improve the situation may
be, to a greater extent than today, get started
with personal drug reviews and other
interventions already in primary care and
outpatient care.
“A better dispensation of medication benefits
both our elderly and society at large.
Previous surveys have shown that as much
as 30-40 percent of the emergency hospitalisations
of elderly in hospital depends on
drug-related problems
and that the majority
of these are possible to
prevent,” says Cecilia
Lenander, pharmacist
at Näset’s medical
team in Höllviken/Skanör
who held her defence
on May 5, 2017
at Lund University.
In her doctoral
dissertation, she
evaluated two different
methods with
the aim of minimising
unnecessary or inappropriate medication
of elderly in primary care: A drug review
where a doctor and nurse together with
pharmacists goes through the individual’s
different drugs. Based on a single picture
the prescription can then if necessary be
corrected. And secondly, SÄKLÄK (safe
use of medicinal products in primary care)
where the management team at the health
center do their own evaluation of their way
of working. The method is cross-professional
and also includes one external review,
feedback and agreement about action.
Research on drug reviews included data
from about 1,700 drug reviews in Skåne.
Briefings have been done within primary
care and with patients in special accommodation.
The research showed that eight out of
ten had at least one
drug-related problem.
The studies also showed
that the median
age of patients was
87.5 years old and
the patients had on
average 11.3 drugs
(variation between 1
and 35) and that 61%
had at least 10 drugs.
“Thanks to the
drug reviews, there
was a decrease in
varying degrees of use
of potentially inappropriate drugs, neuroleptics
as well as parallel use of psychiatric
medications,” said Cecilia.
"Better dispensation
of medication
benefits both our
elderly and society
at large."
73

CPF DATABASE GROUP
Database Group:
New data directive
and spatial studies
The database group includes database
administrators Helene Brandt and Mats-Åke Persson
as well Klas Cederin, GIS Engineer.
Primary Care Data
CPF conducts register studies with data from authorities such as
the National Board of Health & Welfare and Statistics Sweden.
In connection with the latest project database, data is also collected
from county councils and regions around Sweden. That
has involved extensive contact with the 21 healthcare authorities
from Luleå in the north to Malmö in the south. The National
Board of Health & Welfare has access to individual-based data
from outpatient care and obstetrics while county councils and
regions have access to primary care records. CPF has good national
coverage in primary care data and has already done studies
based on diagnoses of mental health in primary care.
74

DATABASE GROUP CPF
Spatial studies
The database group prepares data that is bound to
location for spatial storage in database server SQL
server 2008. Tables with coordinate data such as
neighbourhood and workplace points can be converted
to point databases with SQL Server Spatial tools.
Similarly, business data can be made searchable in
the SQL server. Studies that requires distance calculations
between individuals or between individuals
and points of interest are easy to perform with the
database content spatially stored. Neighbourhood
areas of different kinds are also easy to store in the
database and can then be used in issues that concern
whether the individual is in the area or outside, for
example, to assess the degree of exposure of any
social factors.
Social capital
Cooperation with Japan involves epidemiological issues
around social capital that is a central concept for
the state of a population. In CPF’s studies voter turnout
in general elections is used as an indirect measure
of social capital. It is the participation in mainly
the municipal elections that is considered as social
responsibility indicator. Data regarding voting exists
for most modern elections despite that the conditions
change at each election, by means that the geography
should be the design of the constituencies change.
Modernisation
of server
environment
In the autumn, the first virtual server was put
in service for evaluation. The result shows
significant better performance when analysing
large data amounts, which means the remaining
researchers at CRC in Malmö discuss
switching to the new machine in the spring. In
addition, two new servers will be purchased
shortly to increase capacity and decrease the
risk of interruption.
GDPR – The new
data directive
The Personal Data Act is replaced by new EU
legislation on May 25, 2018, General Data
Protection Regulation (GDPR), which means
higher demands on the handling of our
personal data and consent. In addition, the
participants in our research studies are entitled
to find out what is saved about them and right
to request correction of errors in our databases
as well as the right to be removed from the database.
Documentation requirements have also
increased and CPF must be able to account for
how and where data is stored, the purpose of
this and how data is protected against unauthorised
access. Currently in progress is an
impact assessment of the new personal data act
and we are waiting for the e-course on GDPR
at Lund University will launch in spring.
75

cpf Analysis group
Analytical
team players
The analysis group, which consists of statisticians and
database managers, collaborates on planning studies, building
databases and analyses. Whether small or large amounts of
data, there is close collaboration between the analysis group
and the clinical researchers.
From left, back row: Xinjun Li, researcher, associate professor; Mats-Åke
Persson, database administrator; Helene Brandt, datatbase administrator.
Front row from left Klas Cederin, GIS-engineer; Karolina Palmér,
statistician; MirNabi PirouziFard, statistician, PhD; Henrik Ohlsson,
statistician, associate professor; Sara Larsson Lönn, statistician, PhD;
Jianguang Ji, researcher, associate professor. All are employed in CPF’s
analysis group to provide support for researchers.
76

Analysis group cpf
"It demands great
cooperative ability
to communicate
statistical
questions."
In most projects, an analyst is involved
from beginning to end and involved in
study design, data processing, statistical
analysis, interpretation of results as well as
writing of scientific article. In other projects,
the analyst is only involved in a part of the
process.
For example, Mir Nabi Pirouzi Fard
(Statistician, PhD) works together with
Bengt Zöller (Associate Professor of General
Medicine) in studies about heredity and risk
factors for venous thromboembolism.
“A large part of our work as a statistician
is to be a sounding
board and coach for research
clinics. It demands
great cooperative ability
and that you can communicate
statistical questions
in an educational way,”
says Mir Nabi.
Much of the research at
the CPF is registry based
and the group has during
the years built a unique combined expertise
on how these records can be used in the
best way.
Our Swedish registers are a gold mine
for research which resulted in that in addition
to local projects. CPF also has several
common collaborations with international
research groups. The analyses are then
performed by the analysis group in Sweden,
however, always in close cooperation with
the researcher.
However, some scientific issues cannot
be answered using registers and one significant
part of medical research is therefore
based on analysis of collected data from
clinical trials. One example is the ongoing
mindfulness project where survey data is
collected annually from school students in
grade F-9.
In order to analyse collected material
and draw conclusions requires good planning
of the study with close cooperation
with project coordinators, research nurses
and other employees.
“It's important that statistics are provided
as early as possible in one such big one
project,” says statistician Karolina Palmér.
Careful planning is crucial to get a good
study design and the right number of study
participants to answer survey question.
During 2017 more schools were recruited
to mindfulness project and approximately
940 students have now taken the
opportunity to participate in the study and
began to fill in surveys.
In addition to supporting researchers
in the scientific department, the statisticians
are active in teaching for doctors and
graduate students, where knowledge of statistical
methods is a necessary tool in order
to plan, analyse and evaluate quantitative
studies.
77

cpf Analysis group
Important to put the
numbers in context
The vast amount of data and materials that the researchers at
CPF are producing must be interpreted in the right way. Sara
works with different statistical models and methods for
analysing the material, a task that is vital for obtaining
relevant research results.
78
"The statistical
analyses
themselves
!
rarely
tell
the
whole
story."
Working as a statistician is an exciting
blend of the abstract in the
form of applicable mathematics
and the concrete task of getting the numbers
in context clearly linked to people’s health
and the society in which we live. It appeals
to me! That's what Sara Larsson Lönn, a
statistician at CPF since 2011, says after
working within the pharmaceutical industry
for some years.
The statisticians at CPF contribute
to study designs, make
calculations and interpret results
from studies as well as teach. Sara
holds a PhD – in mathematical
statistics since 2007 – and is coauthor
of most studies that she is
involved in.
At CPF, it is essential for she
and her three team colleagues to
be able to handle large amounts
of information, which places
great requirements for method
competence, wide subject knowledge and
modern technology. And not least to be
able to present it all in an understandable
manner.
“Many people have a very narrow picture
of what statistics and a statistician are. But
it works to be both theoretical and at the
same time be educational and flexible. But
sure, sometimes I go deep and theorise,”
she says and smiles.
Sara is careful to point out that the
statistical analyses themselves rarely tell the
whole story. At their zenith they can give
an indicator to what extent the truth lies.
The second half of the job is to substantiate
the conclusions with facts from several
sources and conclusions that can be tested.
“It can be both about the method
selection and different ethical and medical
considerations that need to be weighed in,”
says Sara.
Having these discussions with the researchers
is among the most stimulating parts
of her work thinks Sara.
“To build trustworthy relationships,
where you can both be creative and dare to
have a healthy scepticism, when someone
presents a figure and you can discuss different
aspects of the results, high as low, is
both important and enjoyable and a regular
eye opener,” Sara says.

Analysis group cpf
Discussions with researchers
thinks Sara Larsson
Lönn (statistician, PhD) are
among the most stimulating
parts of her work.
At the moment she is involved in two such
major research projects.
In one, working with Professor Kenneth
S. Kendler at Virginia Commonwealth
University and CPF’s researchers at the
CPF, about alcohol abuse, among other
things, the protective effect of marriage. A
new study investigates if it is an additional
protective factor to have children.
In the second project, led by Professor
Kristina Sundquist, it focuses on the
importance of the neighbourhood area’s
socioeconomics for our health. For the
first time, the length of time in different
neighbourhood areas affecting the risk of
cardiovascular disease has been studied.
Both projects use longitudinal exposure;
people are followed-up for a long time and
on several occasions.
“To distinguish individual changes over
time from differences between individuals
in a cross-sectional study is most valuable
with the studies and makes them unique,”
says Sara.
With many distinguished researchers
associated with CPF, Sara is often involved
in results that get widely shared in Sweden
and beyond.
“It’s a kick for me as a statistician that
results about public welfare get out there,”
she says.
79

cpf Molecular biology laboratory
Broad mix
I was a little worried in May 2011 when I learned that I was
starting laboratory research in a lab that consisted of empty
spaces! But after six months we were operating with high
performance machines and a rewarding collaboration with
several researchers,” says associate professor Ashfaque
Memon, who leads the CPF molecular laboratory.
80
CPF is the only family medicine
institution in Sweden that has its own
molecular medicine laboratory. We also
have our own biobanks department.
The lab is open to clinically effective
researchers and molecular medicine/
translational researchers.

Molecular biology laboratory cpf
At the beginning Ashfaque Memon
and his laboratory colleagues
focused on cardiac and vascular
diseases, but quite soon switched focus to
early cancer diagnosis.
“For this, very sensitive equipment is
needed as otherwise you cannot observe the
early changes in the patient. We are constantly
working on developing methods and
investing continuously in modern equipment,”
says Ashfaque.
Over the years the lab has in studies,
together with the researchers at the CPF,
gathered in large quantities of samples via
health centers in Skåne and thus built up its
own biobank section.
The laboratory cooperates with university
researchers and also with several clinics
within the SUS in Malmö. The latest of
these collaborations is a research project
with Anders Gottsäter, adjunct professor at
clinical vascular disease research at Lund
University.
“Together we study aortic aneurysm in
men aged 65, or aortic hernia, as it is also
called. We study different biomarkers, for
example proteins, in order to be able to find
the early markers that indicate a serious
development for the person. This is for
healthcare to be able to provide the best
care to patients as possible.
The lab is today oriented towards molecular
level research on chronic diseases so
that the diseases can be detected before they
can be displayed clinically.
“For example, we hope to study the resistance
of various cancers against different
kinds of medicines, so healthcare can more
quickly make the right choice of medication.
We are looking for the molecular
changes that exist prior to the clinical
results, which are sometimes seen only
several years after changes at molecular
level. That way we can predict both disease
response and treatment,” says Memon.
During 2017, the lab group, as well as
Professor Ashfaque Memon, consists of
researcher Xiao Wang (MD, PhD), Anna
Hedelius, biomedical analyst, Hamideh
Rastkhani, laboratory engineer and Abrar
Ahmad, PhD student, published 8 articles.
Among the articles was the following:
“Quantification of mitochondrial DNA
copy number in suspected cancer patients
by a well optimized ddPCR method” by
Ashfaque Memon, Bengt Zöller, Anna
Hedelius, Xiao Wang, Emelie Stenman, Jan
Sundquist and Kristina Sundquist, that was
published in Biomolecular Detection and
Quantification, August 2017.
“The article describes a molecular medicine
laboratory method developed to be
more accurately able to quantify circulating
DNA,” says Anna Hedelius, biomedical
analyst at the lab. Circulating DNA is a potential
non-invasive biomarker for cancer
and other chronic diseases.
In the CPF study where mindfulness like
therapy for patients with depression and
anxiety was compared with cognitive behaviour
therapy (CBT), they investigated the
underlying molecular mechanisms coupled
to the response of the respective treatment.
The study was published in Psychiatry
Research in August 2017 entitled “Role
of IL-8, CRP and epidermal growth factor
in depression and anxiety patients treated
with mindfulness-based therapy or
cognitive behavioural therapy in primary
health care.” Article authors were Ashfaque
Memon, Kristina Sundquist, Abrar Ahmad,
Xiao Wang, Anna Hedelius and Jan
Sundquist.
81

cpf International collaborations
Esteemed researcher
analyses addiction
from different angles
"The unique Swedish national registers make me feel like
a kid in a candy store," says Kenneth Kendler, professor of
psychiatry at Virginia Commonwealth University.
82
I
n one such research collaboration, the
American professor has been casting the
spotlight on the various underlying aspects
of drug and alcohol abuse in order to see
the problem from different angles.
"Yes, we need to look at several factors
when investigating these types of addictions,"
he says.
Kendler adds, “And at the same time, we
need to take a multidisciplinary approach
and see the drug and alcohol problems
through different lenses.”
This methodology is central to Professor
Kendler's research; he repeatedly emphasises
that it is not possible to see the
problem solely from a single angle.
"But with the help of the Swedish registers,
we can be rigorous in our research,
although one must keep in mind that the
paths our research follows are complex!
The Swedish registers are of extraordinary
importance to elucidate scientific issues
from several perspectives.”
At the same time, is it important to ask
the right questions?
"Absolutely, that's what it's all about,"

International collaborations cpf
Kenneth Kendler
is one of
the most cited
and award winning
researchers
in the
world within
psychiatry and
drug abuse.
For the past 7
years he has
collaborated
with Professor
Jan Sundquist
and Professor
Kristina Sundquist
at CPF on
research projects
with an
international
perspective.
says Kendler, who has a broad field of
research within psychiatry.
In addition to the studies together with
Professor Jan Sundquist and Professor
Kristina Sundquist on alcohol and drug
abuse, his research interests include molecular
genetics of schizophrenia, depression
and addiction, as well as twin studies on
addiction in Norway and the Netherlands.
In addition, Kendler studies philosophy and
the history of psychiatry.
"It's another very interesting area," says
the professor, who seems to have a limitless,
calm and energy-oriented approach to all
that he's doing.
"During the last decades the focus of
psychiatry has shifted - largely - from interest
around the brain to the human mind as
such, and now back to focus on the brain.
Many researchers emphasise their own
discipline in answer to all questions, but I
think the grounds are various. Behind the
abuse, many factors hide,” he says.
In the research collaboration at the CPF,
the skilled analysts are of vital importance.
Together with Professor Henrik Ohlsson,
statistician at CPF, Kendler has worked on
several studies on harmful and protective
factors in relation to addiction, i.e. factors
that can stop or reduce addiction and factors
that can start or increase an addiction.
"Alcohol abuse is generally two to four
times more common in men than women
who, on the other hand, suffer much more
from depression - another of my research
areas," says Kendler.
Together with Sara Larsson Lönn, statistician
and PhD, Kendler is collaborating on
a register study that is investigating women
suffering from both alcohol problems and
depression. The question is what leads to
which? Do alcohol problems lead to depression
or is it reversed?
Professor Kendler and his colleagues
at CPF never only ask a single question
when they seek to highlight a problem;
they always return to scientific issues with
new questions. The relationship between
heredity and the environment is now being
investigated by studying differences in relation
to addiction for siblings and the effects
of older siblings' impact on younger siblings
in families with parents with addiction problem.
They have also conducted adoptive
studies.
"Our adoption studies show that it's not
just about genes. If you have a parent who
is an addict but gets adopted and ends up in
an addiction environment, you get a double
dose of risk factors. It's naive to believe that
it's just about the genes. The interaction
between inheritance and the environment is
a very important factor in the development
of addiction.
One thing is certain, we can expect many
interesting research articles from Kenneth
Kendler and his colleagues at the Center for
Primary Health Care Research in the future.
83

cpf International collaborations
Cooperative care
and medical
organization
“Primary care is at the heart of everything we do. It is what's most
important of all,” emphasises Michael Fischetti, a physician in California
with many years of involvement at Kaiser Permanente, the leading
physician-controlled health care organisation in the Golden State.
84
The non-profit organisation Kaiser
Permanente includes, which is
somewhat unusual for the United
States, insurance companies for employees,
hospitals and medical teams. Everything is
done on a cooperative basis with the organisation
controlled by a doctor.
“But none of the management staff leave
their clinical work. All of them still see patients,
usually two days a week,” says Fischetti
who graduated from medical school in
1970 with a specialisation in oncology and
began working at Kaiser Permanente in
1977 in northern California.
Today, Kaiser Permanente provides care
in many regions of the US. In many respects,
the healthcare organisation differs
from others in the industry.
“Out of our budget, five percent goes
to wages, administration and advertising.
In profit-making health organisations, the
corresponding figure is 80 percent,” says
Fischetti.
The road to a fully functioning organisation
that serves 10.2 million patients, of
which 4.5 million are in California, has
been built by many components. Such building
blocks began to be introduced about
15 years ago:
“Step by step, Kaiser Permanente began
implementing user-friendly IT technology
to support our staff,” explains Fischetti.
“We started successively with one application
at a time, listened to the staff and
gave education,” he recalls.
The initiatives began under the leadership
of Robert Pearl, who joined the organisation
in 1999. A major success story
was the implementation of the digital panel
management system for primary care
staff, which was introduced in 2003.
Everything that a doctor needs both
before and after seeing a patient is
available in a single smart view - it
saves a lot of clicks.
“And time!” says Michael enthusiastically.
He adds, “Naturally, there
were some teething problems and
complaints at the outset. Going
from a paper-based journal
system to a digital alternative
wasn't easy for everybody,”
Another early improvement

International collaborations cpf
Michael Fischetti,
doctor at Kaiser
Permanente, a
non-profit organisation
that has a
big commitment
to vulnerable
patient groups in
the United States;
he was invited
to CPF where he
held an appreciated
lecture.
was E-Phones, which were distributed to all
specialists. Via these mobile phones, other
physicians could contact specialists for
consultations at any time regarding different
assessments. Today, the system has been
expanded so all staff have iPhones.
But is there not a risk that you can never
switch off from work?
“The job is going to be done, many
people work on the commuter train to work
and gain time that way. IT support is no
burden, it's a zero sum game!” says Michael
enthusiastically.
Different support features have been
introduced for several years now. Every
change is allocated time in order to be implemented
properly.
One of the latest major support features
is called PROMPT (Prevention Reminder
Outreach Manager and Population Tracker).
In a clear and concise manner, staff
can follow each patient's status, with all
data being updated every night. Everything
pertaining to, e.g. an ongoing treatment or
examination is available via PROMPT.
“This has led to doctors having better
contact with patients; primarily all IT support
is about what is best for the patients in
primary care,” says Michael.
Fischetti worked at Kaiser Permanents
until he retired but the energetic doctor has
not relinquished his commitments to health
care. He continues to work within hospital
care in Santa Clara County (roughly
equivalent to counties) with a focus on
assistance to the poor, and he also works at
the Mayview Community Clinic, especially
with health care for immigrants.
“The downturn in the 2008 economy
brought a good thing with it; namely that
Santa Clara's healthcare service began to
operate more efficiently and with better
cost control. In this way, we can today give
people better help,” concludes Michael
Fischetti.
85

cpf The financial perspective
The Financial Perspective
External Council Grants
grants 2017
STATE BUDGET
grants 2017
Forte FAS
w Jan Sundquist
1 023 000
w Jan Sundquist
1 030 000
w Ulf Jakobsson
576 000
w Ulf Gerdtham
1 100 000
w Patrik Midlöv
768 000
w Ulf Gerdtham
735 000
VR
w Juan Merlo
214 000
w Jan Sundquist
2 304 000
Total
3 316 000
w Kristina Sundquist
1 000 000
w Juan Merlo
1 825 000
w Martin Lindström
700 000
ALF-medel
grants 2017
w Bengt Zöller
700 000
w Jan Sundquist
1 292 000
w Jianguang Ji
700 000
w Kristina Sundquist
1 064 000
w Bengt Zöller
434 000
NIH
w Martin Lindström
485 000
w Jan Sundquist
1 700 000
w Louise Bennet
445 000
w Kristina Sundquist
6 700 000
w Patrik Midlöv
500 000
w Ji Jianguang
460 000
HLF
w Ulf Gerdtham
822 000
w Bengt Zöller
400 000
Total
5 502 000
OTHERS
w Jan Sundquist
500 000
w Ulf Jakobsson
150 000
w Patrik Midlöv
200 000
TOTAL EXTERNAL
19 009 000
86

The financial perspective cpf
REGIONAL GRANTS
REVENUE
budget 2017
result 2017
Regional grant CPF
Funding for salaries
Regional research funds
Total revenues Region Skåne
12 558
5 320
17 878
12 558
5 183
180
17 921
Other revenues
– Compensation for temporary personnel
– In-service training sales
– Other
TOTAL REVENUES
2 735
2 375
0
0
20 613
3 238
2 306
170
762
21 159
EXPENSES
Personnel expenses
Combined services
Cost for AKC private
Cost for AKC public
Research time public/private
OPERATING COSTS
IT costs, LU and RS & telephony
Travel costs, costs and accommodation
Postage, printing, office supplies, advertising
Lab material
TOTAL COSTS
18 950
3 191
524
1 627
1 339
765
546
50
129
40
19 715
18 871
3 127
517
1 465
1 384
965
499
47
125
175
19 836
Rent for premises
Overheads costs
TOTAL COSTS
300
598
20 613
414
477
20 727
SURPLUS/DEFICIT
0
432
87

cpf Published scientific articles
Family Medicine
1. Ahmad A, Sundquist K, Zöller B, Dahlbäck B, Elf J, Svensson PJ, Strandberg K, Sundquist J, Memon AA.
Evaluation of Expression Level of Apolipoprotein M as a Diagnostic Marker for Primary Venous Thromboembolism.
Clin Appl Thromb Hemost. 2017 Jan 1:1076029617730639.
2. Ahmad A, Sundquist K, Zöller B, Svensson PJ, Sundquist J, Memon AA. Association between TLR9 rs5743836
poly morphism and risk of recurrent venous thromboembolism. J Thromb Thrombolysis. 2017 Mar 20.
3. Ahmad A, Sundquist K, Zöller B, Svensson PJ, Sundquist J, Memon AA. Identification of Genetic Aberrations in
Thrombomodulin Gene in Patients With Recurrent Venous Thromboembolism. Clin Appl Thromb Hemost. 2017 Jan
1:1076029616686716.
4. Akrawi DS, PirouziFard M, Fjellstedt E, Sundquist J, Sundquist K, Zöller B. Heritability of End-Stage Renal Disease: A
Swedish Adoption Study. Nephron. 2017 Nov 9
5. Al-Majdoub M, Geidenstam N, Ali A, Ridderstråle M, Storm P, Groop L, Bennet L, Spégel P. Branched-chain amino
acids are associated with odd-chain fatty acids in normoglycaemic individuals. Diabetes Metab. 2017 Oct;43(5):475-47
6. Andell P, Li X, Martinsson A, Andersson C, Stagmo M, Zöller B, Sundquist K, Smith JG. Epidemiology of valvular heart
disease in a Swedish nationwide hospital-based register study. Heart. 2017 Apr 21. pii: heartjnl-2016-310894.
7. Andersson S, Karlsson V, Bennet L, Fellbrandt K, Hellgren M. Attitudes Regarding Participation in a Diabetes
Screening Test Among an Assyrian Immigrant Population in Sweden. Nurs Res Pract. 2016: 2016
8. Antonson C, Thorsén F, Sundquist J, Sundquist K. Upper secondary school students' compliance with two Internetbased
self-help programmes: a randomised controlled trial. Eur Child Adolesc Psychiatry. 2017 Aug 3.
9. Axmon A, Kristensson J, Ahlström G, Midlöv P. Use of antipsychotics, benzodiazepine derivatives, and dementia
medication among older people with intellectual disability and/or autism spectrum disorder and dementia. Res Dev
Disabil. 2017 Mar;62:50-57.
10. Axmon A, Sandberg M, Ahlström G, Midlöv P. Prescription of potentially inappropriate medications among older
people with intellectual disability: a register study. BMC Pharmacol Toxicol. 2017 Oct 25;18(1):68.
11. Beckman A, Midlöv P. Correlation of Seminar Attendance and Written Examinations in Medical Education. J Medic
Educ Training 2017; 1:020.
12. Bennet L, Franks PW, Zöller B, Groop L. Family history of diabetes and its relationship with insulin secretion and
insulin sensitivity in Iraqi immigrants and native Swedes: a population-based cohort study. Acta Diabetol. 2017 Dec
22. doi: 10.1007/s00592-017-1088-5. [Epub ahead of print]
13. Bennet L, Lindström M. Self-rated health and social capital in Iraqi immigrants to Sweden: The MEDIM populationbased
study. Scand J Public Health. 2017 Sep 1
14. Bennet L, Stenkula K, Cushman S, Brismar K. Obesity cutoffs for insulin sensitivity in Middle Eastern immigrants and
native Swedish population – the MEDIM study. BMC Public Health. Aug 15th 2016 (ej med i Årsbok 2016)
15. Borgström Bolmsjö B, Chalmers J, Mölstad S, Gallagher M, Östgren CJ, and Midlöv P. Risk factors and consequences
of decreased kidney function in nursing home residents -a longitudinal study. Geriatr Gerontol Int. 2017 May;17(5):791-797
16. Bruun Larsen L, Soendergaard J, Halling A, Thilsing T, Thomsen JL. A novel approach to population-based risk
stratification, comprising individualized lifestyle intervention in Danish general practice to prevent chronic diseases:
Results from a feasibility study. Health Informatics J. 2017 Dec;23(4):249-259.
17. Calling S, Midlöv P, Johansson SE, Sundquist K, Sundquist J. Longitudinal trends in self-reported anxiety. Effects of
age and birth cohort during 25 years. BMC Psychiatry. 2017 Apr 26;17(1):119. doi: 10.1186/s12888-017-1277-3.
18. Carlsson AC, Li X, Holzmann MJ, Ärnlöv J, Wändell P, Gasevic D, Sundquist J, Sundquist K. Neighborhood socioeconomic
status at the age of 40 years and ischemic stroke before the age of 50 years: A nationwide cohort study
from Sweden. Int J Stroke. 2017 Jan 1:1747493017702663.
19. Chen T, Brenner H, Fallah M, Jansen L, Castro FA, Geiss K, Holleczek B, Katalinic A, Luttmann S, Sundquist K,
Ressing M, Xu L, Hemminki K; GEKID Cancer Survival Working Group. Response: Methods for second primary
cancers evaluation have to be standardized (IJC-17-2354). Int J Cancer. 2017 Nov 14. doi: 10.1002/ijc.31151.
88

Published scientific articles cpf
20. Chen T, Brenner H, Fallah M, Jansen L, Castro FA, Geiss K, Holleczek B, Katalinic A, Luttmann S, Sundquist K,
Ressing M, Xu L, Hemminki K; GEKID Cancer Survival Working Group+. Risk of second primary cancers in women
diagnosed with endometrial cancer in German and Swedish cancer registries. Int J Cancer. 2017 Aug 17.
21. Crump C, Sundquist J, Winkleby MA, Sundquist K. Aerobic fitness, muscular strength and obesity in relation to risk of
heart failure. Heart. 2017 May 12.
22. Crump C, Sundquist J, Winkleby MA, Sundquist K. Height, weight, and aerobic fitness in relation to risk of atrial
fibrillation. Am J Epidemiol. 2017 Jun 21.
23. Crump C, Sundquist J, Winkleby MA, Sundquist K. Interactive Effects of Aerobic Fitness, Strength, and Obesity on
Mortality in Men. Am J Prev Med. 2017 Mar;52(3):353-361.
24. Crump C, Sundquist J, Winkleby MA, Sundquist K. Interactive effects of obesity and physical fitness on risk of i
schemic heart disease. Int J Obes (Lond). 2017 Feb;41(2):255-261.
25. Delling FN, Li X, Li S, Yang Q, Xanthakis V, Martinsson A, Andell P, Lehman BT, Osypiuk EW, Stantchev P, Zöller B,
Benjamin EJ, Sundquist K, Vasan RS, Smith JG. Heritability of Mitral Regurgitation: Observations From the
Framingham Heart Study and Swedish Population.Circ Cardiovasc Genet. 2017 Oct;10(5). pii: e001736.
26. Edwards AC, Larsson Lönn S, Sundquist J, Kendler KS, Sundquist K. Associations Between Divorce and Onset of
Drug Abuse in a Swedish National Sample. Am J Epidemiol. 2017 Nov 16.
27. Edwards AC, Lönn SL, Karriker-Jaffe KJ, Sundquist J, Kendler KS, Sundquist K. Time-specific and cumulative effects
of exposure to parental externalizing behavior on risk for young adult alcohol use disorder. Addict Behav. 2017 Mar
8;72:8-13.
28. Frank C, Sundquist J, Hemminki A, Hemminki K. Risk of other Cancers in Families with Melanoma: Novel Familial
Links. Sci Rep. 2017 Feb 15;7:42601.
29. Frank C, Sundquist J, Yu H, Hemminki A, Hemminki K. Concordant and discordant familial cancer: Familial risks,
proportions and population impact. Int J Cancer. 2017 Apr 1;140(7):1510-1516.
30. Garmy, P. Berg, A. Clausson, E. Hagell, P. Jakobsson, U. Psychometric analysis of the Salutogenic Health Indicator
Scale (SHIS) in adolescents. Scandinavian Journal of Public Health. 2017; 45 (3): 253-259.
31. Hamano T, Li X, Sundquist J, Sundquist K. Association between Childhood Obesity and Neighbourhood Accessibility
to Fast-Food Outlets: A Nationwide 6-Year Follow-Up Study of 944,487 Children. Obes Facts.
2017 Nov 22;10(6):559-568. doi: 10.1159/000481352.
32. Hamano T, Shiotani Y, Takeda M, Abe T, Sundquist K, Nabika T. Is the Effect of Body Mass Index on Hypertension
Modified by the Elevation? A Cross-Sectional Study of Rural Areas in Japan. Int J Environ Res Public Health.
2017 Sep 7;14(9). pii: E1022.
33. Hamano T, Takeda M, Tominaga K, Sundquist K, Nabika T. Is Accessibility to Dental Care Facilities in Rural Areas
Associated with Number of Teeth in Elderly Residents? Int J Environ Res Public Health. 2017 Mar 21;14(3). pii: E327.
34. Hellgren M, Steiner K, Bennet L. HbA1c as a diagnostic tool for diabetes and prediabetes in populations of Swedish
and Middle-East ancestry. Prim Care Diabetes. 2017 Aug;11(4):337-343.
35. Hemminki K, Försti A, Sundquist K, Sundquist J, Li X. Familial associations of lymphoma and myeloma with
autoimmune diseases. Blood Cancer J. 2017 Jan 6;7(1):e515.
36. Hemminki K, Hemminki A, Försti A, Sundquist K, Li X. Genetics of gallbladder cancer. Lancet Oncol. 2017
Jun;18(6):e296.
37. Hemminki K, Hemminki O, Försti A, Sundquist K, Sundquist J, Li X. Familial risks in urolithiasis in the population of
sweden. BJU Int. mple Urolithiasis. Sci Rep. 2017 Aug 14;7(1):8073.
39. Hemminki K, Liu H, Hemminki A, Sundquist J. Power and limits of modern cancer diagnostics: cancer of unknown
primary. Ann Oncol. 2017 Mar 27. IF=6.578.
40. Jakobsson, U. Measuring frailty among older people: evaluation of a brief self-report frailty index. Journal of Frailty
and Aging. 2017: 6 (4): 224-227.
41. Ji J, Dimitrijevic I, Sundquist J, Sundquist K, Zöller B. Risk of ocular manifestations in patients with giant cell arteritis:
a nationwide study in Sweden. Scand J Rheumatol. 2017 Feb 22:1-6. IF=2.307.
89

cpf Published scientific articles
42. Ji J, Sundquist J, Sundquist K. Cholera Vaccine Use Is Associated with a Reduced Risk of Death in Patients with
Colorectal Cancer: A Population-based Study. Gastroenterology. 2017 Sep 15. pii: S0016-5085(17)36149-8.
43. Ji J, Sundquist J, Sundquist K. Use of hormone replacement therapy improves the prognosis in patients with
colorectal cancer: A population-based study in Sweden. Int J Cancer. 2017 Dec 22.
44. Karlsson S, Rahm Hallberg I, Midlöv P, Fagerström C. Trends in treatment with antipsychotic medication in relation to
national directives, in people with dementia - a review of the Swedish context. BMC Psychiatry. 2017 Jul 14;17(1):251.
45. Karriker-Jaffe KJ, Ji J, Sundquist J, Kendler KS, Sundquist K. Disparities in Pharmacotherapy for Alcohol Use Disorder
in the Context of Universal Healthcare: A Swedish Register Study. Addiction. 2017 Apr 12.
46. Kendler KS, Lönn SL, Salvatore J, Sundquist J, Sundquist K. Divorce and the Onset of Alcohol Use Disorder:
A Swedish Population-Based Longitudinal Cohort and Co-Relative Study. Am J Psychiatry.
2017 Jan 20:appiajp201616050589.
47. Kendler KS, Lönn SL, Sundquist J, Sundquist K. The role of marriage in criminal recidivism: a longitudinal and
co-relative analysis. Epidemiol Psychiatr Sci. 2017 Jan 18:1-9.
48. Kendler KS, Ohlsson H, Edwards A, Sundquist J, Sundquist K. The clinical features of alcohol use disorders in
biological and step-fathers that predict risk for alcohol use disorders in offspring. Am J Med Genet B Neuropsychiatr
Genet. 2017 Aug 29.
49. Kendler KS, Ohlsson H, Edwards AC, Sundquist J, Sundquist K. A developmental etiological model for drug abuse in
men. Drug Alcohol Depend. 2017 Oct 1;179:220-228.
50. Kendler KS, Ohlsson H, Karriker-Jaffe KJ, Sundquist J, Sundquist K. Social and economic consequences of alcohol
use disorder: a longitudinal cohort and co-relative analysis. Psychol Med. 2017 Apr;47(5):925-935.
51. Kendler KS, Ohlsson H, Keefe RSE, Sundquist K, Sundquist J. The joint impact of cognitive performance in
adolescence and familial cognitive aptitude on risk for major psychiatric disorders: a delineation of four potential
pathways to illness. Mol Psychiatry. 2017 Apr 18.
52. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. Familial transmission of externalizing syndromes in extended
Swedish families. Am J Med Genet B Neuropsychiatr Genet. 2017 Dec 15.
53. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. School Achievement, IQ, and Risk of Alcohol Use Disorder:
A Prospective, Co-Relative Analysis in a Swedish National Cohort. J Stud Alcohol Drugs. 2017 Mar;78(2):186-194.
54. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. Transmission of alcohol use disorder across three generations: a
Swedish National Study. Psychol Med. 2017 Sep 28:1-10.
55. Kendler KS, Ohlsson H, Sundquist K, Sundquist J. Drug abuse-associated mortality across the lifespan: a populationbased
longitudinal cohort and co-relative analysis. Soc Psychiatry Psychiatr Epidemiol. 2017 Jul;52(7):877-886.
56. Kendler KS, Ohlsson H, Sundquist K, Sundquist J. Prediction of drug abuse recurrence: a Swedish National Study.
Psychol Med. 2017 Oct 10:1-10.
57. Kendler KS, Ohlsson H, Sundquist K, Sundquist J. Sources of Parent-Child Transmission of Drug Abuse: Path
Analyses of Not-Lived-With Parental, Stepparental, Triparental, and Adoptive Families. J Nerv Ment Dis. 2017 Dec 15.
58. Kendler KS, Ohlsson H, Sundquist K, Sundquist J. Sources of Parent-Offspring Resemblance for Major Depression in
a National Swedish Extended Adoption Study. JAMA Psychiatry. 2017 Dec 13.
59. Kendler KS, Ohlsson H, Svikis DS, Sundquist K, Sundquist J. The Protective Effect of Pregnancy on Risk for
Drug Abuse: A Population, Co-Relative, Co-Spouse, and Within-Individual Analysis. Am J Psychiatry. 2017 Oct
1;174(10):954-962. . .
60. Larsson C, Ekvall Hansson E, Sundquist K, Jakobsson U. Chronic pain in older adults: prevalence, incidence, and risk
factors. Scandinavian Journal of Rheumatology. 2017; 46 (4): 317-325.
61. Lenander C, Bondesson Å, Viberg N, Jakobsson U, Beckman A, Midlöv P. Effects of an intervention (SÄKLÄK) on
prescription of potentially inappropriate medication in elderly patients. Fam Pract. 2017 Apr 1;34(2):213-218.
90

Published scientific articles cpf
62. Lenander C, Midlöv P, Viberg N, Chalmers J, Rogers K, Bondesson Å. Use of Antipsychotic Drugs by Elderly Primary
Care Patients and the Effects of Medication Reviews: A Cross-Sectional Study in Sweden. Drugs Real World
Outcomes. 2017 Jun 16.
63. Lionis C, Midlöv P. Prevention in the elderly: A necessary priority for general practitioners.
Eur J Gen Pract. 2017 Dec;23(1):202-207.
64. Liu X, Chen Y, Wang Y, Dong X, Wang J, Tang J, Sundquist K, Sundquist J, Ji J. Cancer risk in patients with hepatitis C
virus infection: a population-based study in Sweden. Cancer Med. 2017 Apr 4.
65. Long EC, Lönn SL, Ji J, Lichtenstein P, Sundquist J, Sundquist K, Kendler KS. Resilience and Risk for Alcohol Use
Disorders: A Swedish Twin Study. Alcohol Clin Exp Res. 2017 Jan;41(1):149-155.
66. Long EC, Lönn SL, Sundquist J, Sundquist K, Kendler KS. A National Swedish Longitudinal Twin-Sibling Study of
Alcohol Use Disorders among Males. Addiction. 2017 Mar 26.
67. Martinsson A, Li X, Zöller B, Andell P, Andersson C, Sundquist K, Smith JG. Familial Aggregation of Aortic Valvular
Stenosis: A Nationwide Study of Sibling Risk. Circ Cardiovasc Genet. 2017 Dec;10(6). pii: e001742.
68. Memon AA, Sundquist K, Ahmad A, Wang X, Hedelius A, Sundquist J. Role of IL-8, CRP and epidermal growth factor
in depression and anxiety patients treated with mindfulness-based therapy or cognitive behavioral therapy in primary
health care. Psychiatry Res. 2017 Aug;254:311-316.
69. Memon AA, Zöller B, Hedelius A, Wang X, Stenman E, Sundquist J, Sundquist K. Quantification of mitochondrial DNA
copy number in suspected cancer patients by a well optimized ddPCR method. Biomol Detect Quantif.
2017 Aug 31;13:32-39.
70. Mölstad S, Löfmark S, Carlin K, Erntell M, Aspevall O, Blad L, Hanberger H, Hedin K, Hellman J, Norman C, Skoog G,
Stålsby-Lundborg C, Tegmark Wisell K, Åhrén C, Cars O. Lessons learnt during 20 years of the Swedish strategic
programme against antibiotic resistance. Bull World Health Organ. 2017 Nov 1;95(11):764-773.
71. Nasser S, Ahmadi N, Bennet L, Larsson CA, Andersson S, Månsson J, Lindblad U. Clinical characteristics of
asymptomatic left ventricular diastolic dysfunction and its association with self-rated health and N-terminal B-type
natriuretic peptide: a cross-sectional study. ESC Heart Failure 2016 Sep; 3(3) (ej med i Årsbok 2016)
72. Nikberg M, Ji J, Leppert J, Sundquist K, Chabok A. Socioeconomic characteristics and comorbidities of diverticular
disease in Sweden 1997-2012. Int J Colorectal Dis. 2017 Aug 7.
73. Nilsson C, Christensson A, Nilsson PM, Bennet L. Renal function and its association with blood pressure in Middle
Eastern immigrants and native Swedes. J Hypertens. 2017 Dec;35(12):2493-2500.
74. Nilsson P, Bennet L. Diabetes: the cost of globalization. Heart Metab. (2017) 73: 4-8
75. Ohlsson H, Kendler KS, Lichtenstein P, Sundquist J, Sundquist K. The Decomposition of Shared Environmental
Influences on Externalizing Syndromes in the Swedish Population: A Multivariate Study. Twin Res Hum Genet. 2017
Aug;20(4):298-309.
76. Oudin A, Forsberg B, Lind N, Nordin S, Oudin Åström D, Sundström A, Nordin M. Is Long-term Exposure to Air
Pollution Associated with Episodic Memory? A Longitudinal Study from Northern Sweden. Sci Rep. 2017 Oct 6;7(1)
77. Packness A, Waldorff FB, Christensen RD, Hastrup LH, Simonsen E, Vestergaard M, Halling A. Impact of
socioeconomic position and distance on mental health care utilization: a nationwide Danish follow-up study. Soc
Psychiatry Psychiatr Epidemiol. 2017 Nov;52(11):1405-1413.
78. Ranstad K, Midlöv P, Halling A. Socioeconomic status and geographical factors associated with active listing in
primary care: a cross-sectional population study accounting for multimorbidity, age, sex and primary care. BMJ Open.
2017 Jun 9;7(6):e014984.
79. Reilev M, Lykkegaard J, Halling A, Vestbo J, Søndergaard J, Pottegård A. Stability of the frequent COPD exacerbator
in the general population: A Danish nationwide register-based study. NPJ Prim Care Respir Med. 2017 Apr 17;27(1):25.
91

cpf Published scientific articles
80. Rudnicki, M. Majida, M Claes Magnusson, C. Katarina.von Bothmer-Ostling, K. Holstad, A. Merkel, C. Prien, J.
Jakobsson, U. Teleman, P. Adjustable mini-sling compared to conventional mid-urethral slings in women with urinary
incontinence. A randomized controlled study. Acta Obstetricia et Gynecologica Scandinavica.
2017; 96 (11): 1347-1356.
81. Salvatore JE, Larsson Lönn S, Sundquist J, Lichtenstein P, Sundquist K, Kendler KS. Alcohol use disorder and divorce:
evidence for a genetic correlation in a population-based Swedish sample. Addiction. 2017 Apr;112(4):586-593.
82. Selan, D. Jakobsson, U. Condelius, A. The Swedish P-CAT: Modification and exploration of psychometric properties of
two different versions. Scandinavian Journal of Caring Sciences. 2017; 31 (3):527-535.
83. Siddiqui F, Kurbasic A, Lindblad U, Nilsson P, Bennet L. Effects of a culturally adapted lifestyle intervention on
cardio-metabolic outcomes: a randomised controlled trial in Iraqi immigrants to Sweden at high risk of type
2 diabetes. Metabolism. 2017 Jan;66:1-13 (ej med i Årsbok 2016)
84. Siddiqui F, Winther V, Kurbasic A, Sonestedt E, Lundgren KB, Lindeberg S, Nilsson PM, Bennet L. Changes in dietary
intake following a culturally adapted lifestyle intervention among Iraqi immigrants to Sweden at high risk of type 2
diabetes: a randomised trial. Public Health Nutr. 2017 Oct;20(15):2827-2838.
85. Sivberg, B. Jakobsson, U. Lundqvist, P. Parent infant interactions looking for instances of volitional social gaze versus
reflexive gaze: an observational study. Early Child Development and Care. 2017 DOI: 10.1080/03004430.2017.1410479.
86. Sjöstedt C, Ohlsson H, Li X, Sundquist K. Socio-demographic factors and long-term use of benzodiazepines in
patients with depression, anxiety or insomnia. Psychiatry Res. 2017 Mar;249:221-225.
87. Sud A, Thomsen H, Sundquist K, Houlston RS, Hemminki K. Risk of Second Cancer in Hodgkin Lymphoma Survivors
and Influence of Family History. J Clin Oncol. 2017 Mar 13:JCO2016709709.
88. Sundquist J, Ohlsson H, Sundquist K, Kendler KS. Common adult psychiatric disorders in Swedish primary care where
most mental health patients are treated. BMC Psychiatry. 2017 Jun 30;17(1):235.
89. Sundquist J, Palmér K, Johansson LM, Sundquist K. The effect of mindfulness group therapy on a broad range of
psychiatric symptoms: A randomised controlled trial in primary health care. Eur Psychiatry. 2017 Feb 8;43:19-27.
90. Taj T, Malmqvist E, Stroh E, Oudin Åström D, Jakobsson K, Oudin A. Short-Term Associations between Air Pollution
Concentrations and Respiratory Health-Comparing Primary Health Care Visits, Hospital Admissions, and Emergency
Department Visits in a Multi-Municipality Study. Int J Environ Res Public Health. 2017 May 31;14(6).
91. Taube E, Kristensson J, Midlöv P, Jakobsson U. The use of case management for community-dwelling older people:
the effects on loneliness, symptoms of depression and life satisfaction in a randomised controlled trial. Scand J
Caring Sci. 2017 Sep 12.
92. Tyrstrup M, Melander E, Hedin K, Beckman A, Mölstad S. Children with respiratory tract infections in Swedish primary
care; prevalence of antibiotic resistance in common respiratory tract pathogens and relation to antibiotic
consumption. BMC Infect Dis. 2017 Sep 4;17(1):603.
93. Van den Berg GJ, Gerdtham UG, von Hinke S, Lindeboom M, Lissdaniels J, Sundquist J, Sundquist K. Mortality and
the business cycle: Evidence from individual and aggregated data. J Health Econ. 2017 Sep 14;56:61-70.
94. Waehrens R, Li X, Sundquist J, Sundquist K, Zöller B. Perinatal and familial risk factors for irritable bowel syndrome in
a Swedish national cohort. Scand J Gastroenterol. 2017 Nov 10:1-8.
95. Waehrens R, Zöller B, Sundquist J, Sundquist K, Pirouzifard M. A Swedish national adoption study of risk of irritable
bowel syndrome (IBS). BMJ Open Gastroenterol. 2017 Oct 21;4(1):e000156.
96. Wändell P, Carlsson AC, Holzmann M, Ärnlöv J, Johansson SE, Sundquist J, Sundquist K. Association between
antithrombotic treatment and hemorrhagic stroke in patients with atrial fibrillation-a cohort study in primary care. Eur J
Clin Pharmacol. 2017 Feb;73(2):215-221.
97. Wändell P, Carlsson AC, Holzmann MJ, Ärnlöv J, Sundquist J, Sundquist K. Comparison of Mortality and Nonfatal
Cardiovascular Events in Adults With Atrial Fibrillation With Versus Without Levothyroxine Treatment. Am J Cardiol.
2017 Aug 30.
92

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98. Wändell P, Carlsson AC, Holzmann MJ, Ärnlöv J, Sundquist J, Sundquist K. Mortality in patients with atrial fibrillation
and common co-morbidities - a cohort study in primary care. Ann Med. 2017 Nov 27:1-8.
99. Wändell P, Carlsson AC, Li X, Gasevic D, Ärnlöv J, Holzmann MJ, Sundquist J, Sundquist K. Atrial fibrillation in
immigrant groups: a cohort study of all adults 45 years of age and older in Sweden. Eur J Epidemiol. 2017 Jul 12.
100. Wändell P, Carlsson AC, Li X, Gasevic D, Ärnlöv J, Holzmann MJ, Sundquist J, Sundquist K. Gout in immigrant
groups: a cohort study in Sweden. Clin Rheumatol. 2017 Jan 13.
101. Wang X, Sundquist K, Hedelius A, Palmér K, Memon AA, Sundquist J. Leukocyte telomere length and depression,
anxiety and stress and adjustment disorders in primary health care patients. BMC Psychiatry. 2017 Apr 24;17(1):148.
102. Wang X, Sundquist K, Rastkhani H, Palmér K, Memon AA, Sundquist J. Association of mitochondrial DNA in
peripheral blood with depression, anxiety and stress- and adjustment disorders in primary health care patients.
Eur Neuropsychopharmacol. 2017 Aug;27(8):751-758.
103. Wolff M, Brorsson A, Midlöv P, Sundquist K, Strandberg EL. Yoga - a laborious way to well-being: patients'
experiences of yoga as a treatment for hypertension in primary care. Scand J Prim Health Care. 2017 Nov 10:1-9.
104. Yu H, Frank C, Hemminki A, Sundquist K, Hemminki K. Other cancers in lung cancer families are overwhelmingly
smoking-related cancers. ERJ Open Res. 2017 Jun 27;3(2). pii: 00006-2017.
105. Yu H, Hemminki A, Sundquist K, Hemminki K. Familial Associations of Colorectal Cancer with Other Cancers. Sci
Rep. 2017 Jul 12;7(1):5243.
106. Zheng G, Yu H, Hemminki A, Försti A, Sundquist K, Hemminki K. Familial associations of female breast cancer with
other cancers. Int J Cancer. 2017 Aug 12.
107. Zheng G, Yu H, Hemminki A, Försti A, Sundquist K, Hemminki K. Familial associations of male breast cancer with
other cancers. Breast Cancer Res Treat. 2017 Aug 23.
108. Zöller B, Ji J, Sundquist J, Sundquist K. Body Height and Incident Risk of Venous Thromboembolism: A Cosibling
Design. Circ Cardiovasc Genet. 2017 Oct;10(5).
109. Zöller B, Li X, Ohlsson H, Sundquist J, Sundquist K. Seasonal variation of pulmonary embolism and age dependence.
Thromb Res. 2017 Feb;150:76-77.
110. Zöller B, Ohlsson H, Sundquist J, Sundquist K. A sibling based design to quantify genetic and shared environmental
effects of venous thromboembolism in Sweden. Thromb Res. 2017 Jan;149:82-87.
111. Zöller B, Ohlsson H, Sundquist J, Sundquist K. Cardiovascular fitness in young males and risk of unprovoked venous
thromboembolism in adulthood. Ann Med. 2017 Mar;49(2):176-184.
112. Zöller B, Pirouzifard M, Memon AA, Sundquist J, Sundquist K. Risk of pulmonary embolism and deep venous
thrombosis in patients with asthma: a nationwide case-control study from Sweden. Eur Respir J. 2017 Feb 15;49(2).
pii: 1601014.
93

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113. Austin PC, Merlo J. Intermediate and advanced topics in multilevel logistic regression analysis. Stat Med. 2017 Sep
10;36(20):3257-3277.
114. Austin PC, Stryhn H, Leckie G, Merlo J. Measures of clustering and heterogeneity in multilevel Poisson regression analyses
of rates/count data. Stat Med. 2017 Nov 8.
115. Austin PC, Wagner P, Merlo J. The median hazard ratio: a useful measure of variance and general contextual effects in
multilevel survival analysis. Stat Med. 2017 Mar 15;36(6):928-938.
116. Axelsson Fisk S, Merlo J. Absolute rather than relative income is a better socioeconomic predictor of chronic obstructive
pulmonary disease in Swedish adults. Int J Equity Health. 2017 May 4;16(1):70.
117. Bjerkeli PJ, Mulinari S, Zettermark S, Merlo J. Sociodemographic patterns in pharmacy dispensing of medications for
erectile dysfunction in Sweden. Eur J Clin Pharmacol. 2017 Nov 3.
118. Fridh M, Köhler M, Modén B, Lindström M, Rosvall M. Subjective health complaints and exposure to peer
victimization among disabled and non-disabled adolescents: A population-based study in Sweden. Scand J Public Health.
2017 Jul 1:1403494817705558.
119. Ghith N, Frølich A, Merlo J. The role of the clinical departments for understanding patient heterogeneity in one-year mortality
after a diagnosis of heart failure: A multilevel analysis of individual heterogeneity for profiling provider outcomes. PLoS One.
2017 Dec 6;12(12):e0189050
120. Giordano GN, Lindström M. Trust and health: testing the reverse causality hypothesis. J Epidemiol Community Health 2016;
70: 10-16., pii: jech-2015-205822. doi: 10.1136/jech-2015-205822 (ej med i Årsbok 2016)
121. Ivert AK, Merlo J, Gracia E. Country of residence, gender equality and victim blaming attitudes about partner violence: a
multilevel analysis in EU. Eur J Public Health. 2017 Sep 27.
122. Jarl, J, Desatnik, P, Peetz Hansson, U, Prütz, KG, Gerdtham, U-G. Do kidney transplantations save money? – A study using
a before–after design and multiple register-based data from Sweden. Clinical Kidney Journal 2017, 1-6.
doi: 10.1093/ckj/sfx088.
123. Lindström M, Rosvall M. Parental separation in childhood and self-reported psychological health: A population-based study.
Psychiatry Research 2016; 246: 783-788. doi: 10.1016/j.psychres.2016.10.049 (ej med i Årsbok 2016)
124. Lindström M. Commentary on Wang et al. (2017): Differing patterns of short-term transitions of nondaily smokers for
different indicators of socioeconomic status (SES). Addiction. 2017 May;112(5):873-874.
125. Merlo J, Mulinari S, Wemrell M, Subramanian S V, Hedblad B. The tyranny of the averages and the indiscriminate use of risk
factors in Public Health: The case of coronary heart disease. SSM - Population Health. 2017;3:684-9
126. Mulinari S, Wemrell M, Rönnerstrand B, Subramanian SV, Merlo J. Categorical and anti-categorical approaches to US racial/
ethnic groupings: revisiting the National 2009 H1N1 Flu Survey (NHFS). Critical Public Health. 2017:1-13
127. Olofsson S, Gerdtham UG, Hultkrantz L, Persson U. Measuring the end-of-life premium in cancer using individual ex ante
willingness to pay. Eur J Health Econ. 2017 Aug 12.
128. Persson S, Dahlquist G, Gerdtham UG, Steen Carlsson K; Swedish Childhood Diabetes Study Group. Why childhood-onset
type 1 diabetes impacts labour market outcomes: a mediation analysis. Diabetologia. 2017 Nov 23.
129. Rodriguez-Lopez M, Wagner P, Perez-Vicente R, Crispi F, Merlo J. Revisiting the discriminatory accuracy of traditional risk
factors in preeclampsia screening. PLoS One. 2017 May 25;12(5):e0178528.
130. Traulsen LK, Baelum J, Halling A, Thomsen G, Thilsing T, Sherson D, Sigsgaard T, Omland Ø, Malling T, Skadhauge LR. Risk
factors for incident asthma and COPD in a cohort of young adults. Clin Respir J. 2017 Mar 7.
131. Tremmel M, Gerdtham UG, Nilsson PM, Saha S. Economic Burden of Obesity: A Systematic Literature Review. Int J Environ
Res Public Health. 2017 Apr 19;14(4).
132. Wemrell M, Merlo J, Mulinari S, Hornborg AC. Two-Thirds of Survey Respondents in Southern Sweden Used Complementary
or Alternative Medicine in 2015. Complement Med Res. 2017;24(5):302-309.
133. Wemrell M, Mulinari S, Merlo J. An intersectional approach to multilevel analysis of individual heterogeneity (MAIH) and
discriminatory accuracy. Soc Sci Med. 2017 Apr;178:217-219.
134. Wemrell M, Mulinari S, Merlo J. Intersectionality and risk for ischemic heart disease in Sweden: Categorical and
anti-categorical approaches. Soc Sci Med. 2017 Mar;177:213-222.
135. Zhang Y, Jarl J, Gerdtham UG. Are There Inequities in Treatment of End-Stage Renal Disease in Sweden? A Longitudinal
Register-Based Study on Socioeconomic Status-Related Access to Kidney Transplantation. Int J Environ Res Public Health.
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94

Print: Eo Grafiska, 2018
Translation: Patrick Reilly
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