1 Introduction

This focus group interview study explored how Targeted Health Dialogues (THDs; a Swedish cardiovascular disease and diabetes prevention program) was perceived among health dialogue coaches when used in a pilot project with 70-year-old participants. Most evidence for THDs so far comes from studies on middle-aged participants. To our knowledge, no studies have qualitatively examined how the method works in 70-year-olds.

1.1 Background

The implementation of THDs in Swedish regions has its background in the continuously high prevalence of cardiovascular risk factors. More than one-fifth of Swedes have hypertension (≥ 140/90 mmHg) [1], more than one in twenty have diabetes [2] and the prevalence of individuals being overweight or obese has increased steadily during recent decades and is currently above 50% [2]. In Sweden, like in most countries, cardiovascular diseases (CVDs) remain the dominating cause of death [3, 4]. However, a large part of the CVD cases is connected to potentially modifiable risk factors [5]. Via preventive measures, e.g., changing the way of living in a healthier direction, it may be possible to reduce the risk of getting ill with CVDs. Studies suggest that this is a valid approach also for older adults [6]. For example, smoking cessation at older ages has been shown to reduce the risk of CVD events and mortality [7].

Many different CVD prevention programs have been implemented and evaluated around the world [8]. The Swedish THD-model was developed for use in primary health care to encourage people to live healthier and thereby decrease the prevalence of CVD and diabetes. The method was introduced in two versions during the 1980s: Lifestyle health dialogues in Habo municipality [9] and Västerbotten Intervention Programme, VIP, in the county of West Bothnia [10]. The effectiveness of the method has been evaluated from different perspectives in several studies. A Swedish expert group compiled the main results in a systematic review and concluded that THDs can reduce all-cause [9, 11] and cardiovascular mortality [11] (moderate evidence level). There was also evidence for favorable effects on metabolic risk factors (cholesterol levels [12,13,14], fasting plasma glucose [15], systolic [12,13,14,15] and diastolic [12, 13, 15] blood pressure, BMI and waist circumference [12, 16]). Regarding health behaviors, there is so far evidence for a favorable effect on eating habits [12, 16]. Health economic evaluations have confirmed that THD can be a cost-effective method for the healthcare sector [17].

In the southernmost region, Scania, THDs were introduced in 2020 with the above-mentioned Lifestyle health dialogues from Habo as a model [9]. First in the form of a pilot project with 40-year-old participants at a few healthcare centers and later by a broad implementation at all, which was around 170, healthcare centers in the region.

The current intention is to invite all permanent residents in Scania to a THD during the years they turn 40 and 50 years old. In 2022, a political decision was made to include 70-year-olds in a pilot project comprising 14 healthcare centers. In total, 511 (54%) of the 952 invited 70-year-olds completed a THD.

The implementation of THDs in Scania was initiated by a team of lifestyle experts at the County Council. The Center for Primary Health Care Research, a collaboration between Region Scania and Lund University, was invited to evaluate the method scientifically.

1.2 Targeted health dialogues (THDs) in Scania, methodology 70-year-olds

Invitations to THDs were made via an information folder that was sent home followed by a phone call, in which two visits were booked for those who wanted to participate. At the first visit, blood samples were collected to assess plasma glucose and cholesterol levels. Blood pressure was measured, and BMI and waist-to-hip ratio were calculated. Before their next visit, participants filled in an extensive electronic questionnaire about health, lifestyle, heredity, and life situation. The results from the measurements and questionnaire were aggregated in a health profile with 13 categories: physical activity, diet, alcohol, tobacco, life situation, mental health, heredity diabetes, heredity CVD, body mass index (BMI), waist-hip ratio, blood pressure, cholesterol, and chronic diseases (Fig. 1). The categories were the same as for 40- and 50-year-olds. All results were stored in a specially designed database.

Fig. 1
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The health profile

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The health profile was used as a basis for the second counselling meeting offered by specially trained health dialogue coaches, i.e., registered nurses, dieticians, physiotherapists, occupational therapists or physicians with a two-day education in the THD method and three-day education in motivational interviewing. Health dialogue coaches in the pilot project with 70-year-olds attended an additional one-day course about THDs for this group. The counselling meeting was estimated to take one hour plus 30 min of administration. The healthcare centers received financial compensation of 1000 Swedish kronor (around €85) per participant. When needed, follow-up visits were booked, and referrals could be sent to other specialists, either in the healthcare center or in other clinics. The participants could also get tips about activities in their municipality or at companies, e.g., pensioner associations, local walking groups or gyms. A central THD organization including medical and IT specialists was available daily to support the health dialogue coaches. They also received a written method support folder for THDs with 70-year-olds, which provides evidence-based advice about all health profile categories.

1.3 Aim

It is of great importance to evaluate THDs in 70-year-olds from the health dialogue coaches’ perspective, since a lot of healthcare resources are invested in the initiative, possibly not only in Scania, but also in other Swedish regions. The evaluation may be of interest to other countries as well where similar methods are used. Follow-up questionnaires to quantitatively examine the perceived effects of THDs on health behaviors are planned but before that, we wanted to conduct an in-depth study on how the health dialogue coaches experienced THDs with 70-year-olds. Thus, the aim was to identify what worked well, but also possible needs for improvement from the coaches’ perspective. The results can contribute to the design of a future broad implementation of THDs for 70-year-olds.

2 Methods

2.1 Design

This study had a qualitative design with focus group interviews, suitable to catch the experiences of the health dialogue coaches.

2.2 Participants

All health dialogue coaches in the pilot study with THDs for 70-year-olds were invited by e-mail with two additional reminders. Data were collected through three focus group interviews and two individual interviews. All registered health dialogue coaches that were recruiting 70-year-olds in the pilot project were invited. Some had completed very few or no dialogues and thus declined participation and some declined for other reasons. Sixteen of 22 health dialogue coaches participated, 14 in one of three focus groups and two in individual interviews. The participants worked at 12 of the 14 healthcare centers that recruited 70-year-olds. Among the participants, there were 14 nurses, one physiotherapist and one dietician.

2.3 Data collection

A semi-structured guide was used to ensure that all relevant topics were covered. The first topic was wide and open. Ideally, the participants reported their experiences spontaneously, if needed the guide served as a checklist. The focus groups lasted between 60 and 90 min and the individual interviews between 35 and 50 min. They were all audio-recorded and transcribed verbatim by a professional secretary.

2.4 Analysis

The analysis was inspired by systematic text condensation [18]. First, the recordings were compared to the transcripts and possible errors or unclarities were attended to. Then, the transcripts were read repeatedly to obtain an overview. In the next step, broad preliminary themes were identified; thereafter meaning units were defined and labelled with codes. The codes were merged into broader and more abstract categories. The researchers primarily conducted the analysis separately, differences were discussed until consensus was reached.

3 Results

Two main themes were identified: Implementation and Relevance. The theme Implementation dealt with the THD model’s application at the healthcare centers and methodological issues. The theme Relevance dealt with whether the THDs were a purposive approach to address the most important health problems in 70-year-olds and the challenge of prioritizing health dialogues with limited resources in primary health care. The two main themes were then divided into five subcategories (Fig. 2).

Fig. 2
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Themes and subcategories

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3.1 Implementation

3.1.1 Introduction at the healthcare centers

To become health dialogue coaches, the coaches had to attend certain courses (see “Introduction”). The coaches expressed that they much appreciated the courses beforehand, and the meetings/workshops that were provided during the project by the method support group. To further facilitate the implementation of THDs with 70-year-olds, the coaches suggested that some kind of support for immediate reflection after each health dialogue could improve the learning and quality of the forthcoming health dialogues. It could be in the form of a few questions for the coach to answer after the dialogue.

The introduction of THDs was carried out differently at different healthcare centers. At some centers, the pilot project with 70-year-olds was presented at workplace meetings with all occupational groups. This was valued and seemed to facilitate collaboration with e.g., the physicians. At other healthcare centers, the decision came more “from above” and information was given directly to the health dialogue coaches. Insufficient information to the rest of the staff was believed to imply a risk of misunderstandings.

I think it's really important that you see [the THDs] as a mission for the whole organization. That it is not just the health dialogue coach who has to carry them through, because it doesn’t really work then.

The crux of the matter seemed to be time. Some coaches, but not all, felt that an hour was too short for THDs with 70-year-olds, especially when the participants had not managed to fill in the questionnaire by themselves before. What was perceived as especially important was time for planning before, and reflection after the THDs, but many coaches reported stress. In addition, the physicians at some of the healthcare centers had limited time to take care of new medical problems that were found as of the result of the THDs. Support from co-workers was considered a success factor. For example, at some healthcare centers, medical secretaries handled the invitations to the THDs, and assistant nurses could often help with blood sampling and anthropometric measures. Most healthcare centers had physiotherapists, occupational therapists, diabetes nurses, dieticians, and social workers in-house who could take care of health problems that were identified. Some healthcare centers had continuous medical rounds where patient cases from the THDs could be discussed. The county council of Scania also has special lifestyle reception units for help with smoking cessation and excessive alcohol consumption.

External resources that the health dialogue coaches could recommend as needed included pensioner associations, activities by the municipalities, the church, sport schools at the Swedish Sports Confederation-the Sports Trainers (RF-SISU), the “Leisure-time bank” (a library for free borrowing of sports and leisure items), and local gyms. One healthcare center had recently established contact with a nearby grocery store to collaborate in a project called “The dietician recommends”, in which healthy products are highlighted in the store.

3.1.2 Method support and health profile

The health dialogue coaches were, in general, satisfied with the method support (technical, written, and personal). The specially designed electronic platform for THDs worked well, but some wished that the different electronic platforms used in primary care (e.g., the THD platform and patient records) could interact automatically. Another issue, although not frequent, was that some 70-year-olds did not have access to computers. They had to fill in the questionnaire on paper or together with the coach, which was time-consuming.

Several health dialogue coaches thought that the THD questionnaire was unnecessarily extensive for 70-year-olds. Even though this population has more spare time than their 40- and 50-year-old counterparts do, for some 70-year-olds, it took a couple of hours to complete the questionnaire. In some cases, this may even have been a reason for interrupting participation, as they had started to fill in the questionnaire but did not complete it and then did not show up at the counselling meeting. Suggestions were to reduce the number of questions that had no immediate connection with the health profile, especially some questions regarding physical activity and diet.

The questionnaire is the part that I would like to see adjusted for our 70-year-olds, to make it easier to answer and handle. That would also make it a simpler tool for us coaches to work with.

The opinions regarding the different health profile categories were similar in all groups. Four categories were found to cause trouble in 70-year-olds: physical activity, alcohol, waist-hip ratio, and chronic diseases.

Some physical activity questions were, as mentioned above, perceived as being difficult to fill in. Participants that were rather active (e.g., taking 1-h daily walks) still ended up in high-risk categories due to low intensity and became disappointed. A question concerning transport to work and back was considered irrelevant for most 70-year-olds (some coaches solved this by filling in other everyday activities, which sometimes made the category on the profile turn green).

Regarding physical activity, many people were...felt like a little disappointed, “I walk so much, but it doesn’t show”.

The health dialogue coaches were surprised that many 70-year-olds reported that they drank quite a lot of alcohol, sometimes daily. Many participants were not interested in changing this habit but believed that some alcohol consumption is good for the body. A suggestion that was discussed in one group was to add a PEth test to the blood sampling to further motivate reduced drinking.

Waist-hip ratio was mentioned as a problem by almost all health dialogue coaches, especially for female participants. 70-year-olds that were thin and had low BMI often had a high waist-hip ratio due to a body composition with narrow hips. Some coaches found this hard to discuss or even tried to ignore it during the THDs.

Almost everyone fails at the waist-hip ratio....you wonder if it is correct. There I had to explain, when they said “how can this...how can this be true...I who train so much” You have too small a butt, we had to say.

Regarding chronic diseases, the health dialogue coaches should fill in and rank those as a part of the health profile. This was perceived as tricky, and some coaches even skipped this category in the beginning, which resulted in an incomplete health profile.

Categories in the health profile that were highlighted as being particularly important were life situation and mental health. They provided a base for fruitful discussions about life and relations and if needed, referrals could be sent for meetings with social workers.

Two categories that have given a lot were life situation and mental health. They got to tell a little about their lives. You have lived for 70 years, what is it that makes you have a good life situation? That you have friends perhaps, friends and family and so on. They got the opportunity to tell us this, without feeling stressed.

3.2 Relevance

3.2.1 Equal participation

Many health dialogue coaches had a feeling that the participants belonged to the healthier part of the 70-year-old population.

One has the impression that those who feel quite well and are doing fine agree to these dialogues, but perhaps not those who have a lot of health behaviors that need to be fixed.

It was noticed that language difficulties could be a barrier to both participation and filling in the questionnaire among foreign-born 70-year-olds. The county council of Scania provides interpreters with special education in the THD-method, which was appreciated, but some coaches still saw challenges for foreign-born participants. For example, they expressed the need for invitations in more languages (invitation folders were available in the five most common languages; Swedish, English, Somali, Arabic and Dari).

It is, I think, a general weakness of health dialogues that the written information is not available in [more] foreign languages. It enhances this filtering [of participants] even more regarding who actually comes to the health dialogues.

Another common barrier to participation was that some invitees declined participation and referred to being abroad during the winter.

3.2.2 Cardiovascular disease prevention and/or quality of life?

Some health dialogue coaches expressed a feeling that 70-year-olds may not be the optimal group for the THD-model with its strict focus on CVD prevention. Many of the 70-year-olds were already under treatment for CVD risk factors/diagnoses. However, the coaches tried to keep the focus on CVD prevention and health behaviors. Since living conditions, stress, sleep, anxiety, and depression were also considered relevant in this regard, they were included in the health profile and health dialogues as well. The participants were frequently genuinely interested in these topics. Beyond this, the participants had a lot of other issues to discuss connected with life in general, and aging in particular, such as other diseases, motor skills and balance, incontinence, sexual problems, and loneliness. These extra topics took a lot of time to discuss, but some coaches considered them essential and would like to add such categories to the method support for 70-year-olds.

The method support and health profile are oriented towards cardiovascular health, but one can miss a focus on elderlies’ health in a wider perspective, for example on incontinence, osteoporosis, and strength training, yes, a slightly different focus.

Regardless of the purpose of the dialogues, the 70-year-olds seemed to value the THDs highly. They appreciated that someone listened to them for a whole hour, and they could be referred to different specialists (e.g., social workers, physiotherapists, physicians) as needed.

One could see that they really appreciated that we paid attention to them and took our time, and that we could help them in many ways.

Some participants seemed truly interested in the health profile and in making lifestyle changes. There was, however, a feeling among the coaches that many 70-year-olds were reluctant to change their way of living (this needs to be further examined, though. It is possible that the participants were inspired to change their health behaviors later).

It was a bit hard…to make them realize that it is time for a change, they thought that they felt pretty good, so they said “I mean why should I lose weight, it doesn’t matter”. And yes, maybe you should be able to enjoy good food and drink in old age...

3.2.3 Prioritization with limited resources

Some coaches expressed doubts about the preventive effects of THDs. They believed that most health problems among 70-year-olds were already known and treated. They also found it hard to prioritize healthy people with risk factors above patients with an actual disease.

...we haven’t found much disease, no....we haven’t felt that we have done much good.

Occasionally, the dialogues were seen as an opportunity to catch up with unmet care needs that, for example, emerged after the Covid-19 pandemic.

I worked for a unit that had been a little understaffed for quite a long time with quite a backlog regarding follow-ups and annual checks. I’m a diabetes nurse and I’ve had a lot of use from that, and I’ve answered a lot of questions that may not have been one hundred and ten percent related to the very reason why they were there.

However, it was pointed out that when encountering people without known diagnoses, you were encouraged and felt that this was true health promotion.

Many of them had several diagnoses, of course, but I found a few who didn’t and that is amusing, it becomes health promotion then.

There was indeed consensus among the health dialogue coaches that they themselves enjoyed the THDs with 70-year-olds. They felt that they had a lot to give and that it was rewarding.

Thus, even if they sometimes thought that it was stressful and that they doubted their own knowledge, the health dialogue coaches were, in general, positive to continue THDs with 70-year-olds.

I wrote down some words that I think sum up the health dialogues with the 70-year-olds, and they are appreciation, positivism, laughter, tears, and interesting meetings.

4 Discussion

Focus group interviews with health dialogue coaches who met 70-year-olds in THDs showed rather consistent opinions about the method and its application in primary health care. The central method support that was provided before and during the project was appreciated. However, some needs for improvement regarding the extent and content of the questionnaire and health profile were identified. The participants were perceived to be relatively healthy and reluctant to change their lifestyle in a healthier direction. On the other hand, both 70-year-olds and health dialogue coaches appreciated the opportunity to talk about different health issues and life in general for a whole hour. The coaches believed that they could help many participants and that what they did was true health promotion. The possible value of such an intervention in primary health care—for public health and working environment—should not be underestimated, though the overall focus of targeted health dialogues for 70-year-olds might be discussed.

The way of introducing THDs for 70-year-olds differed between healthcare centers. At some centers, the entire workplace was informed at common meetings, whereas other managers chose to inform the health dialogue coaches exclusively. Since health dialogues generate extra work, not only for the coaches, but also for co-workers from different professions, it may be advantageous to inform all personnel early in the process. Support from co-workers at the healthcare center was pointed out as a success factor—but lack of time, especially among physicians, was mentioned as a problem. Many health dialogue coaches also felt stressed themselves and pointed out the importance of time for planning before, and reflection after, the health dialogue, preferably with some sort of short questionnaire as support. The importance of organizational space and support has also been emphasized by healthcare professionals working with THDs in other populations [19, 20]. Clear information to all co-workers and reasonable time frames may improve the so-called work-related sense of coherence (SoC). This is a three-factor construct consisting of perceived comprehensibility (i.e., structured, consistent, and clear work assignments), manageability and meaningfulness [21], which has been shown to be associated with reduced emotional exhaustion and improved work engagement [22]. Thus, transparency, involvement of all personnel, and careful scheduling may be success factors for implementing THDs at primary healthcare centers in the future.

The 70-year-olds in the pilot project filled in the same questionnaire as the 40- and 50-year-old THD participants. This questionnaire may, however, be too extensive for 70-year-olds. It was even suspected that some 70-year-olds did not show up at the health dialogue after giving up filling in the questionnaire. Considering probable differences in health literacy, it is important not to preclude certain groups, e.g., with language difficulties, by using a complicated questionnaire. The concept of health literacy refers to the individual’s ability to access, understand, appraise, and apply health-related information. This in turn influences the contacts with the health care system as well as the attitude towards disease prevention and health promotion. A Danish study indicated that inadequate health literacy is often linked to lower socioeconomic status as well as self-assessed health and physical inactivity [23]. There was indeed a feeling among the health dialogue coaches that they did not always reach 70-year-olds in most need of health advice. The THD participants were perceived to be relatively healthy. This was also seen in a previous evaluation of 33–42-year-old men invited to THDs in Habo municipality, which showed that non-participants had a higher healthcare consumption, were more often smokers, living alone, unemployed, and registered at the social welfare office or temperance board compared to participants [24]. Even though the populations are slightly different, both findings point toward a risk of unequal participation in health screening programs.

It is reasonable to believe that participation in THDs could per se improve health literacy. For that reason, it seems important to counteract barriers against participation, e.g., to provide information in different languages and offer assistance with online questionnaires. A careful review with age-adjustment of the questionnaire may also improve the method and increase participation.

Regarding the different categories in the health profile, the physical activity category caused disappointment in some 70-year-olds. They believed that they were active, e.g., taking daily walks, but due to low intensity, this was not enough according to the health profile. According to the WHO, adults > 65 years benefit from doing moderately intense aerobic physical activity for at least 150–300 min (or vigorous-intensity aerobic activity for at least 75–150 min) per week, and in addition to this, muscle-strengthening activity. It is also pointed out that some physical activity is better than none [25]. Swedish guidelines have suggested that a reasonable recommendation for healthy older adults may be 7000 steps per day [26]. A recent meta-analysis showed a non-linear dose–response association between number of steps and cardiovascular and all-cause mortality where “more was more”, irrespective of age, and a reduced risk of cardiovascular mortality was seen already at 2337 steps [27]. Thus, encouraging physical activity in this group should be beneficial, but the design of the questionnaire section could be better adapted to older adults with age-appropriate activities, e.g., by removing the question about transport to work.

It was relatively common with risk consumption of alcohol among the 70-year-olds, and the coaches suggested that a PEth test may be used to motivate reduced consumption. Another way to motivate reduced alcohol consumption may be to highlight not only cardiovascular risks but additional consequences, such as increased risk of fall injuries, liver damage and cancers [28].

Almost all health dialogue coaches mentioned waist-hip ratio as a problem, especially in women. Perfectly lean 70-year-olds with low BMI often still ended up in the high-risk level. Discussing this in the THDs often became uncomfortable for the 70-year-olds as well as for the coaches. Individuals with central obesity have an increased health risk [29], but the question is what health advice you should give to them if their BMI is normal. If you lose weight on your waist, you will probably also lose weight on your hips and the ratio will remain high. In a Swedish evaluation of THDs in different age groups, the prevalence of high waist-hip ratio increased in 70-year-olds during five years follow-up despite improved dietary habits and increased physical activity [30]. Considering the high genetic influence on body constitution, we suggest that waist-hip ratio should be considered a risk indicator rather than a risk factor in this case and thus better be removed from the health profile. An individual’s waist can still be measured, but for research purposes only. An alternative could be to use waist-height ratio instead where the waist should not exceed half of the length. This has been shown to be useful in different ages in a systematic review [31].

THDs with younger citizens aim at preventing cardiovascular disease and diabetes later in life. But for 70-year-olds, one can ask if the THDs primarily provide primary or secondary prevention. The health dialogue coaches said that many 70-year-olds were already diagnosed and treated. On the other hand, THDs for older adults may have other important implications in addition to disease prevention. They got an opportunity to catch up with unmet care needs and to identify other crucial problems among the elderly, such as loneliness. In addition, interventions to improve health behaviors have not only long-term physical benefits, but they can also promote general well-being in older adults [32]. Despite limited resources in primary care, general health and quality of life among older adults may be something that is really worth prioritizing.

4.1 Strengths and limitations

There was no sampling or selection process, which means that all coaches were invited. Focus groups were held on three occasions and those who still couldn’t participate were offered an individual interview. Sixteen out of 22 coaches chose to participate. Some declined because of changed workplace or lack of time. Most of those who participated had conducted a substantial number of dialogues, often between 15 and 50. Furthermore, the dialogues were rather recent in time, between a few weeks and a few months, which may have decreased the risk of time distorting their memories.

The focus groups and interviews were initially planned to be conducted face-to-face, but for time and logistic reasons, they were held online. This can have affected the group dynamics in the focus groups and thus possibly also made the data material somewhat thinner.

The experiences of the 70-year-old individuals participating in the project are merely indirectly reported. Their experiences and possible lifestyle changes will be further explored, primarily with a questionnaire, and possibly also with a qualitative approach.

The authors have different professional backgrounds as an occupational therapist and as primary care physicians. The authors have also conducted different kinds of research. This may have decreased the influence of preconception.

5 Conclusions

The health dialogue coaches valued THDs with 70-year-olds highly. They had a feeling that the 70-year-olds appreciated them as well and that they, in many cases, were helped by the advice given at the counselling meetings. The personal and technical method support during the pilot project was appreciated, but minor adaptations of the information given, questionnaire and health profile were suggested to increase participation and facilitate the dialogues with this age group.