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Objective: To explore women's experiences following polygenic risk score (PRS) testing for breast cancer risk and to assess the knowledge, attitudes, practices (KAP), and implementation perspectives of medical professionals and healthcare decision-makers in Sweden.

Methods: Convergent mixed-methods study combining quantitative survey data with qualitative thematic analysis of survey open-ended responses and focus group discussion (FGD) notes. Setting: Swedish healthcare context. Participants: 400 women receiving PRS results for a first Participants Feedback Survey; 289 women for the second Participants Feedback Survey, and 6 medical professionals/decision-makers for a KAP survey and FGD. Women completed two sequential online feedback surveys post-PRS result disclosure. Professionals completed a KAP survey and participated in an FGD. Quantitative survey data were analysed using descriptive statistics. Qualitative data from open-ended survey questions and FGD notes were analysed using thematic analysis.

Results: Participants valued participation in PRS testing and receiving PRS-test results, with 87% finding results interesting and 82% finding them valuable. Although most participants found the explanations understandable (approximately 75% in Survey 1 and 82% in Survey 2), qualitative comments indicated that some had difficulty interpreting probabilistic risk information, including participants who self-identified as highly educated or medically trained. Negative emotional impact was generally minimal (85% felt calm), though some women with high PRS risk experienced anxiety. Major unmet needs included clearer explanations, actionable guidance, and better access to follow-up support from healthcare. Professionals were cautiously positive: in the KAP survey, 5 of 6 were familiar with the concept of PRS, but confidence in the health system's readiness to integrate it was limited. The main barriers raised were the absence of clinical guidelines and the need for evidence of clinical utility.

Conclusions: Breast cancer PRS testing holds potential for enhancing risk assessment in Sweden. Key challenges for clinical integration include clinician readiness, the development of clear guidelines, and improved participant comprehension and communication. PRS tests should be accompanied with clinical decision support both for patients as well for medical professionals. Addressing these will require person-centered communication tools, robust evidence of clinical utility, well-defined clinical pathways, investments in provider education, and equitable implementation strategies within the Swedish healthcare system.Clinical trial number Not applicable.

Background: Children’s mental health is a critical public health priority, with approximately 8% of children aged 10 years or younger experiencing mental, behavioral, or emotional disorders. Despite evidence supporting early intervention, access to mental health services remains limited, particularly for socioeconomically disadvantaged populations. Art-based interventions have emerged as promising approaches to support mental health and socioemotional development. However, significant gaps persist in understanding their efficacy, scalability, and long-term impact.

Objective: This study aims to evaluate the effectiveness and cost-effectiveness of a community-based visual arts intervention on children’s self-concept, psychological adjustment, and health-related quality of life (HRQoL) in vulnerable communities.

Methods: This study is a cluster nonrandomized controlled trial with children from socioeconomically disadvantaged neighborhoods. Children aged 6 to 12 years (n=156; intervention: n=104, 66.7%; waitlist control: n=52, 33.3%) will be recruited through schools and community projects. Allocation to the intervention or waitlist control group will be based on neighborhood or cluster membership. The intervention consists of 1-hour weekly visual arts sessions over 9 months led by a professional artist, culminating in community art exhibitions. Assessments will be conducted at baseline (T1) and postintervention assessment (T2) using validated measures: the Strengths and Difficulties Questionnaire (SDQ) for psychological adjustment, the Self-Perception Profile for Children (SPPC) for self-concept, and the Child Health Utility 9D (CHU9D) for HRQoL, as well as societal resource use and related costs. Quantitative data will be analyzed using regression models and intention-to-treat principles.

Results: This study was funded in September 2023. Recruitment began in March 2024 and ended in July 2025. As of April 2024, a total of 179 participants had been enrolled. Data collection was completed in July 2025, and analysis is expected to begin in April 2026. Results are anticipated to be published in September 2026.

Conclusions: This project has the potential to enhance children’s self-concept, psychological adjustment, and HRQoL through participation in a community-based visual arts intervention. The study design, with assessments at preintervention and postintervention time points, will provide valuable insights into the trajectories of psychosocial and quality-of-life outcomes in this population. In addition, the combination of psychosocial assessment and economic evaluation will generate important evidence on the cost-effectiveness of art-based interventions, informing both educational and public health decision-making.

Trial Registration: ClinicalTrials.gov NCT07165704; https://clinicaltrials.gov/study/NCT07165704

Background

Breast cancer (BC) remains the most common type of cancer and the leading cause of cancer-related deaths in women despite the widespread screening programs and personalized treatment options. Current age-based screening programs are suboptimal missing high-risk young women. The “Be RIGHT with breast cancer risk management” (BRIGHT) study evaluated a genetic risk-based personalized BC screening service model in real-world healthcare settings, focusing on younger women excluded from standard screening.

Methods

The BRIGHT study included 800 healthy Estonian women aged 35 to 49 using telemedicine and home-based testing. Participants underwent polygenic risk score (PRS) testing and based on the questionnaire those meeting the monogenic pathogenic variant (MPV) testing criteria were referred to clinical geneticists. All women received personalized genetic risk-based clinical recommendations, and if needed, referral to BC screening. Participants’ and healthcare professionals’ feedback was collected.

Results

330 (41.3%) women with elevated polygenic risk received recommendations to start screening earlier than the current standard. 124 (15.5%) women were advised to begin BC screening immediately, among whom one was diagnosed with stage 0 cancer and one with a precancerous lesion. Of the 90 participants completing MPV testing, four (4.4%) were MPV-positive. Feedback indicated high satisfaction with the digital approach and a clear understanding of results and recommendations.

Conclusions

The study demonstrated the feasibility and acceptability of a personalized genetic risk-based BC screening model. It has the potential to enhance BC screening programs, particularly for younger women and those at higher genetic risk, while avoiding unnecessary interventions for low-risk individuals.

Background: Digital health technologies (DHTs) are increasingly integrated into clinical practice, yet economic evaluations remain scarce, particularly in the early development stages. Within the NICE (National Institute for Health and Care Excellence) Evidence Standards Framework, Tier C DHTs comprise technologies with direct clinical implications and measurable health outcomes, for which robust economic evidence is essential. Early-stage assessments are particularly important to inform subsequent development, refinement, and adoption decisions across the digital health lifecycle.

Objective: This study aims to explore the feasibility of integrating a full trial-based economic evaluation within an early-stage pilot comparing a chatbot-supported remote patient monitoring (RPM) solution for anticoagulation management with the standard of care (SOC).

Methods: A cost-effectiveness analysis was performed alongside a pilot crossover trial among adult cardiac surgery patients receiving vitamin K antagonists. Participants were allocated to two 6-month sequences (SOC→RPM or RPM→SOC). The intervention consisted of a rule-based chatbot integrated with home-based international normalized ratio self-testing using portable coagulometers to support communication and therapy management. Effectiveness was measured as time in therapeutic range (TTR), and costs were estimated from the Portuguese National Health Service and a limited societal perspective over a 1-year horizon. The analysis 1 applied a within-patient cost-effectiveness approach to estimate incremental costs, incremental TTR, and incremental cost-effectiveness ratios. Uncertainty was explored through nonparametric bootstrapping (5000 replications) and deterministic sensitivity analyses. Complementary comparisons examined differences between sequences (analysis 2), between periods (analysis 3), and within each sequence (analysis 4).

Results: A total of 19 patients were included in the analyses. In analysis 1, RPM improved anticoagulation control, with a mean within-patient increase of 10.43 percentage points in time in TTR. The mean incremental costs were €198.61 (€1=US $1.08) from the Serviço Nacional de Saúde perspective and €270.05 from the limited societal perspective. The corresponding incremental cost-effectiveness ratios were €19.03 and €25.88 per additional percentage point of TTR gained. Sensitivity analyses produced consistent estimates across parameter variations. Complementary analyses (2-4) suggested that RPM tended to be more cost-effective when implemented after the initial 6-month postoperative period.

Conclusions: This proof-of-concept study demonstrates that a full trial-based economic evaluation can feasibly be embedded within an early-stage Tier C DHT. The intervention showed improved anticoagulation control alongside higher costs, providing initial insights into its cost-effectiveness profile. Positioned within the digital health evidence continuum, such assessments can function as a learning stage within the lifecycle. To address the persistent adoption-evidence gap, tier- and stage-aligned frameworks are needed to guide the economic evaluation of DHTs. This study contributes to that goal by providing a set of recommendations specifically for Tier C DHTs.

Trial Registration: ClinicalTrials.gov NCT06423521; https://clinicaltrials.gov/study/NCT06423521

Background: Mental health problems in preschool children are rising in Sweden, yet their economic impact on the health sector remains poorly quantified. This study estimated the incremental healthcare utilization and costs associated with early mental health problems to inform resource allocation and early intervention.

Methods: We analyzed an exact matched sample of 1206 drawn from a cohort of 6957 children aged 3-5 from Uppsala Region, Sweden. Early mental health problems were identified using the Strengths and Difficulties Questionnaire reported by mothers, fathers and teachers. Data were linked to national registers to estimate cumulative healthcare utilization and costs over four years from a health sector perspective. Hurdle models, generalized linear models, and two-part models compared utilization and costs between children with and without early symptoms. Sub-group analyses by sex, symptoms, and raters were performed.

Results: Children with early mental health problems consumed three additional units of medication with an incremental cost of US$ 299, one additional specialized outpatient visit with an incremental cost of US$ 622, and five additional primary care visits with an incremental cost of US$ 376 compared to their healthy peers. Healthcare utilization and costs were higher for boys with externalizing and internalizing symptoms. Findings were consistent across all rater groups.

Conclusions: Early childhood mental health problems represent a substantial economic impact to the healthcare sector. The findings suggest that early identification and intervention in the preschool years may offer significant opportunities for cost-offsetting and improved long-term system efficiency.

Introduction:

Polygenic risk scores (PRS) offer a novel means of stratifying breast cancer risk, with the potential to personalize screening protocols and measures, and thus improve early detection. However, their implementation in real-world settings remains poorly understood. This study, as part of the BRIGHT project, investigates how PRS-based breast cancer screening is being piloted, adapted, and resisted across five European countries, Estonia, Portugal, Spain, Sweden, and France, drawing on a combination of implementation science and business model theory.

Methods:

We employed a multiple-case study approach, conducting 94 semi-structured interviews with stakeholders across healthcare, policy, industry, and civil society. Analysis was guided by the Value-Information-Process (VIP) framework and complemented by selected constructs from the Consolidated Framework for Implementation Research (CFIR). Data were coded thematically and triangulated with national policy documents, pilot evaluations, and stakeholder workshops.

Results:

Implementation trajectories varied significantly across contexts. Estonia demonstrated advanced policy-driven integration enabled by digital infrastructure and centralized governance. Sweden and Spain followed pilot-to-policy models, with strong regional autonomy but slower national uptake. Portugal exhibited market-led adoption driven by private sector innovation, while France pursued a trial-first logic centered on MyPeBS. Common barriers included limited clinical guidelines, low genetic literacy among frontline providers, fragmented IT systems, and slow and unclear Health Technology Assessment (HTA) cycles. Key facilitators included strong institutional alignment, biobank-linked infrastructures, and public trust in preventive care.

Discussion:

Successful PRS implementation requires more than scientific validation; it depends on systemic readiness across value narratives, information systems, and governance processes. PRS-based screening thus serves as a test case for the broader challenge of integrating personalized genomics into public health. Findings offer strategic guidance for policymakers, clinicians, and researchers designing future-ready prevention pathways.

OBJECTIVES: Digital health technologies (DHTs) are reshaping healthcare delivery; yet, their diverse functionalities, dynamic nature, and nontraditional impact pathways challenge conventional economic evaluation methods. This scoping review aimed to systematically map existing frameworks for the economic evaluation of DHTs, assess their methodological components, and identify gaps to inform more robust, standardized approaches.

METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines, we conducted a comprehensive literature search across academic databases (PubMed, Scopus, Web of Science, and Business Source Complete) and gray literature. Records published since 2015 were included if they described frameworks incorporating economic evaluation methods for DHTs. Data were extracted across the following key methodological dimensions: evaluation type, study design, comparator, time horizon, perspective, effectiveness measures, cost components, and uncertainty analysis.

RESULTS: We identified 26 frameworks, and the analysis revealed pronounced heterogeneity across methodological domains. Although 50% (n = 13) included both full and partial evaluations, core components were often missing: 81% (n = 21) did not define a time horizon, and in 73% (n = 19) the evaluation perspective was absent. Cost-utility analysis and budget impact analysis were the most frequently cited methods; yet, few frameworks justified their choice or linked it to the maturity of the technology. Some addressed adaptive study designs or aligned evaluation strategies with DHTs lifecycle stages. Cost inclusions varied substantially, with limited attention to productivity losses costs.

CONCLUSIONS: Current frameworks lack standardization and are not fully adapted to the characteristics of DHTs. Future development should prioritize flexible, lifecycle-aligned evaluation models and standardized guidance to support evidence-based digital health decision making.

Introduction Mental health conditions are prevalent during adolescence, but access to early evidence-based treatments remains limited. Scalable, online, theory-based transdiagnostic interventions delivered in primary care have the potential to reduce this treatment gap, but the effectiveness remains unknown. The objective is to investigate whether an online transdiagnostic emotion regulation treatment for adolescents with mental health conditions is superior to an active control treatment.

Methods and analysis This single-blind, randomised clinical superiority trial will evaluate the effectiveness and cost-effectiveness of an online transdiagnostic emotion regulation treatment for adolescents with mental health conditions within primary care in Sweden. We aim to include 388 participants (adolescents aged 12–17 years with mental health conditions and their parents), recruited through primary care and self-referral. Patients will be randomised to either an online transdiagnostic emotion regulation treatment or an active control treatment. Participants will receive 6 weeks of therapist-guided online transdiagnostic emotion regulation treatment or an active control treatment consisting of 6 weeks of online supportive treatment. Parents will participate in parallel with their adolescents in both conditions and will receive an online parent course. The primary outcome, assessed by blinded assessors, will be clinical global symptom severity measured with the Clinical Global Impressions-Severity scale. Treatment effectiveness will be evaluated through blinded assessment and self-assessment at primary endpoint (immediately after treatment) and 3 months after treatment. In addition, a health economic evaluation will be conducted. The study will be undertaken between October 2023 and July 2026.

Ethics and dissemination The study has obtained ethical approval from the Swedish Ethical Review Authority. Findings will be disseminated in peer-reviewed publications and presented at scientific conferences.

Trial registration number NCT06067165.

Background 

Sweden allocated SEK 354.5 million (approximately EUR 31.5 million) between 2018 and 2022 to extend home visiting services for families in socioeconomically disadvantaged areas. This initiative operationalises proportionate universalism within a decentralised welfare system where 21 regional governments hold authority over healthcare delivery. We examined whether program resources reached areas of greatest need and how targeting varied across regions and over time. 

Methods 

We analysed Swedish administrative register data aggregated to 12,258 small statistical area-year observations across four implementing regions during each region's post-rollout period. Program dosage was measured as probability-weighted exposure based on patient registration patterns between areas and child health centres. Socioeconomic need was measured using the Care Need Index (CNI). We estimated targeting associations using linear regressions with year fixed effects and standard errors clustered at the area level. We assessed equity using the Concentration Index and a proportional allocation benchmark, and evaluated within-area heterogeneity in household vulnerability. 

Results 

Program resources were positively associated with area-level need (beta = 0.101, 95% CI: 0.091-0.111, p < 0.001). Where the program operated, targeting exceeded proportional benchmarks (proportionality ratio = 1.33) and the Concentration Index was positive (CI = 0.074), indicating pro-poor allocation. However, only 47% of high-need areas had any program presence, and regional variation was substantial: Stockholm's targeting association was over three times stronger than Sk & aring;ne's (beta = 0.145 vs. 0.043). Within-area analysis revealed that more heterogeneous areas received slightly lower dosage, suggesting area-based allocation partially misses within-neighbourhood inequalities. 

Conclusions 

Sweden directed resources toward higher-need areas, with targeting that exceeded proportional benchmarks where the program was implemented. The primary equity challenge was not targeting accuracy but coverage: more than half of high-need areas lacked any program presence. Achieving equitable outcomes through proportionate universalism requires both accurate allocation formulas and sufficient implementation capacity to reach all areas of need.