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Purpose: To explore and describe patients' experiences and perceptions of rehabilitation according to the rehabilitation model 'Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain' (PREVSAM)., Method: A qualitative study was conducted, with individual semi-structured interviews analysed using qualitative content analysis. Fifteen patients from three primary care rehabilitation clinics in Sweden who had undergone rehabilitation based on the PREVSAM model participated., Results: Four categories were identified from the participants' experiences: Gratitude for the holistic view, Challenging but clarifying to create a health plan, Different needs for addressing work-related factors, and Difficulties and negative experiences. From these categories, an overarching theme was conceptualised: Grateful for being seen for who I am and given the care I need ., Conclusion: Participants were generally positive towards the PREVSAM model. The addition of occupational therapy and psychological treatment to physiotherapy was seen by many, albeit not all, as enriching the rehabilitation. Collaboration with the workplace was mainly considered 'good in theory'. The wide variation in the need for support underscore the importance of person-centredness.

Background: Consensus on priorities to optimize the sick leave and rehabilitation process (SRP) is lacking., Objective: To explore perspectives of stakeholders in the SRP on bridging the gap between desired process scope, and actual practice, from a multi-professional, multi-organizational, and interdisciplinary approach., Design and Setting: Focus group interviews were conducted with various SRP frontline professionals in Region Västra Götaland, Sweden, using purposive sampling to capture a range of experiences. Participants discussed their perceptions of critical changes and priorities needed to meet patients' SRP needs in a primary care context. All interviews were analyzed using systematic text condensation, as described by Malterud., Subjects: General practitioners ( n  = 6), rehabilitation coordinators and licensed healthcare professionals from primary healthcare ( n  = 13), administrators from the Social Insurance Agency, the Employment Agency and Social Services ( n  = 12)., Results: Through data analysis, the following themes emerged: 1) The need for rules and regulations to enable coherent process governance 2) Challenges and opportunities in person-centered SRP: Professional collaboration, organizational priorities, and the need for enhanced leadership, and 3) Balancing resources and patient needs in the SRP: How to improve care quality and accessibility. In summary, participants mainly discussed how to improve process efficiency and quality of care while balancing available resources and a heavy workload. A main goal was to prevent negative spirals of suboptimal decision-making in individual cases, which could lead to increased work, unfortunate outcomes, and patient suffering., Conclusions: This qualitative study indicated that gaps between a desired process scope and actual practice might be bridged by enabling coherent cross-organizational process governance, prioritizing person-centered ways of working, and balancing available resources and workload. The above changes were believed to improve process quality and overall efficiency., Trial Registration: The study project plan was pre-registered on September 21st, 2020, in the database FOU i VGR (researchweb.org), project number 274941.

Objectives: To describe changes in Swedish primary care physicians' use of, attitudes and intentions toward digital tools in patient care between 2019 and 2022., Design: A survey using a validated questionnaire measuring physician's intentions to use digital tools based on the theory of planned behavior., Setting: Sample of primary health care centers in southern Sweden., Subjects: Primary care physicians., Main Outcome Measures: Self-reported use and intentions to use, digital tools including digital consultations by text or video, chronic disease monitoring and artificial intelligence (AI) and the associations between attitudes, subjective norms, perceived behavioral control and behavioral intentions to use digital tools, in 2019 compared to 2022., Results: In both 2019 ( n  = 198) and 2022 ( n  = 93), physicians reported high intentions to use digital tools. Self-reported use of video was slightly higher in 2022 ( p  = .03). No other changes were seen in the self-reported use or behavioral intentions to use digital tools., Conclusion: The slow adoption of patient-related digital tools in Swedish primary health care does not seem to be explained by a low intention to use them among physicians. Future research on implementation of digital tools should include a focus on contextual factors such as organizational, technical and cultural barriers.

Background: Otomicroscopy and pneumatic methods are superior to otoscopy alone in diagnosing acute otitis media (AOM). There is a lack of knowledge regarding the use of different diagnostic methods for AOM in primary health care in Sweden and Norway., Methods: This cross-sectional study included a questionnaire completed by general practitioners (GPs) and specialist trainees (STs/residents/registrars) working in primary care in Sweden and Norway. Multivariable binary logistic regressions were performed to evaluate the use of diagnostic methods and written advice adjusted for educational level, sex and country., Results: Otoscopy was the most frequently used method. Sweden had greater access to the more accurate diagnostic methods. In Norway, the following methods were used to a lesser extent: pneumatic otoscopy, adjusted OR 0.15 (95% CI 0.10-0.23; p  < .001), otomicroscopy, adjusted OR 0.013 (95% CI 0.070-0.027; p  < .001), pneumatic otomicroscopy, adjusted OR 0.028 (95% CI 0.010-0.078; p  < .001) and tympanometry, adjusted OR 0.31 (95% CI 0.21-0.45; p  < .001). Written advice was used to a greater extent in Norway, adjusted OR 4.5 (95% CI 3.1-6.7; p  < .001). The STs used pneumatic otoscopy and pneumatic otomicroscopy to a lesser extent, adjusted OR 0.65 (95% CI 0.45-0.93; p  = .019) and 0.63 (95% CI 0.43-0.92; p  = .016)., Conclusions: Swedish physicians both used and had greater access to the significantly better diagnostic methods compared with Norwegian physicians while the opposite applied to the use of written information. The GPs used pneumatic otoscopy and pneumatic otomicroscopy to a greater extent than STs. Compared with 2012, the Swedish physicians now more frequently used pneumatic otoscopy.

Objective: To investigate whether mental and work-related stress predicts a one-year incidence of sick leave in a cohort of middle-aged working women., Design: The 2016/17 survey was part of the Population Study of Women in Gothenburg, Sweden, with registry data information on sick leave during one year pre- and post-baseline., Subjects: A cohort of women aged 38 and 50 in 2016/17 ( n  = 573; 68% participation), of which 504 women were gainfully employed and not on sick leave ± 2 weeks around baseline examination; 493 women had complete data on stress exposure., Methods: We studied associations between self-assessed mental and work-related stress and incident sick leave of >14 days during the year following the baseline examination. We used multiple logistic regression, adjusting for age and previous sick leave, and additionally for sleep quality, well-being, and physical activity., Results: Overall, 75 women (16%) experienced at least one period of sick leave after baseline. Permanent stress during the last five years almost tripled the risk for incident sick leave, OR = 2.8 (95% CI 1.2-6.3), independent of previous sick leave, OR = 2.3 (95% CI 1.3-4.2). Among 21 specific work-related problems, conflicts at work, OR = 2.2 (95% CI 1.3-3.6), and low decision latitude, OR = 1.7 (95% CI 1.0-2.9), were associated with incident sick leave. The association with conflicts at work remained upon further covariate adjustment., Conclusion: Low decision latitude and conflicts at work are risk factors for incident sick leave among working women. The impact of conflicts at work, irrespective of own involvement, may indicate a specific vulnerability among women of interest for future interventions.

Methods: Measurement of HGS with Jamar dynamometers was added to annual check-ups for patients with T2DM by diabetes nurses in primary care with feedback about normal values for age and sex in the intervention group. The control group had standard check-ups. Change in self-reported PA level was measured with questionnaires., Results: Seven clinics and 334 patients participated. The intervention led to similar effects on PA in both groups. Patients with T2DM had comparable HGS to the general public. Regression analyses showed statistically significantly higher HGS in the intervention group than in the control group at follow-up and no improvement in PA, HbA1c, or waist circumference. Increased HGS was found for older people, men, and people with normal-to-high inclusion HGS, while patients with low inclusion HGS reduced their strength levels., Conclusions: Measuring HGS and giving feedback to patients with T2DM can lead to increased HGS but does not seem to affect general PA level, HbA1c, or waist circumference. People over 65 years, men, and people with normal-to-high HGS were influenced positively by the intervention. Patients with low HGS may need personalised support to increase physical activity and improve function. ClinicalTrials registration:  NCT03693521.

Objective: People with current or previous drug use (PCPDU) often lack long-term healthcare contacts in primary healthcare (PHC). While international research has shown negative attitudes toward PCPDU in healthcare, PHC professionals' attitudes toward PCPDU have not been assessed in Sweden. The aim of this study was to investigate PHC professionals' attitudes to PCPDU, and to compare attitudes toward people who actively use illicit drugs with those toward patients in opioid assisted treatment (OAT)., Design: In this survey study, respondents were asked for background data, and their attitudes toward patients using illicit drugs, OAT patients and patients with depression were assessed by using an adapted version of the Medical Condition Regard Scale (MCRS)., Setting and Subjects: Nurses and physicians at primary healthcare centers (PHCCs) in Skåne, Sweden., Main Outcome Measures: Mean MCRS scores, dichotomized responses to MCRS items, and associations between MCRS score and background covariates (age, sex, profession and duration of professional experience)., Results: Eighty-nine PHC professionals from 13 PHCCs responded (approximately 39% of relevant workforce). The median MCRS score was 44 for patients with illicit drug use and patients in OAT, and 51 for patients with depression. Drug use and OAT displayed similar minimum, maximum and interquartile range values as well, while scores regarding depression displayed a higher minimum value and smaller spread. No significant associations were found between background covariates and MCRS scores for either drug use or OAT., Conclusions: The results indicate widespread negative attitudes to PCPDU, with implications for health equity in the clinic. Further studies are needed to see if the results reflect attitudes in Swedish PHC in general.Key PointsPeople with current or previous drug use (PCPDU) often lack necessary primary healthcare (PHC) and are commonly subject to prejudice.Swedish PHC professionals held more negative attitudes toward PCPDU than toward patients with depression.Attitudes toward patients with active drug use and patients in opioid assisted treatment (OAT) were almost identical.Study findings have potential implications for the health of PCPDU as well as health equity in the clinic.Widespread negative attitudes to PCPDU in our sample indicate the need of larger-scale studies of attitudes toward PCPDU in Swedish PHC.

Objective: To investigate whether the location and the number of nurse consultations have changed in response to the continuously decreasing number of GP consultations in the fourth-largest city in Finland. It has been suggested that nurse consultations are replacing GP consultations., Design: A retrospective register-based follow-up cohort study., Setting: Public primary health care in the City of Vantaa, Finland., Subjects: All documented face-to-face office-hour consultations with practical and registered nurses, and consultations with practical and registered nurse in the emergency department of Vantaa primary health care between 1 January 2009 and 31 December, 2014., Main Outcome Measures: Change in the number of consultations with practical and registered nurses between 2009 and 2014 in primary health care both during office-hours and in the emergency department., Results: Over the follow-up period, the monthly median number of practical nurse consultations in the emergency department per 1000 inhabitants increased from 1.6 (interquartile range [IQR] 1.3-1.7) to 10.5 (10.3-12.2) ( p  < 0.001) and registered nurse consultations from a median of 3.6 (3.0-4.0) to 14.5 (13.0-16.6) ( p  < 0.001). However, there was no significant change in the median monthly number of office-hour consultations with practical or registered nurses., Conclusions: It appears that in primary health care, medical consultations have shifted from GPs to nurses with lower education levels, and from care during office-hours to emergency care.

Background: Hypertension is an important cardiovascular risk factor with potentially harmful consequences. Home blood pressure monitoring is a promising method for following the effect of hypertension treatment. The use of technology-enabled care and increased patient involvement might contribute to more effective treatment methods. However, more knowledge is needed to explain the motivations and consequences of patients engaging in what has been called 'do-it-yourself healthcare'. Aim: This study aimed to investigate patients' experiences of home blood pressure monitoring through the theoretical frame of the Unified Theory of Acceptance and Use of Technology (UTAUT 2). Methods: The study had a qualitative design, with focus group interviews using the web-based platform Zoom. The data were analysed using qualitative deductive content analysis, inspired by Graneheim and Lundman. Results: The results are presented using the seven theoretical constructs of UTAUT 2: Performance Expectancy, Effort Expectancy, Social Influence, Facilitating Conditions, Hedonistic Motivation, Price Value and Habit. We found one overarching theme ‒ 'It's all about the feeling of security'. The patients were influenced by relatives or healthcare personnel and experienced the home monitoring process as being easy to conduct. The patients emphasised that the quality of the blood pressure monitor was more important than the price. Patients reported home monitoring of blood pressure as a feasible method to follow-up care of their hypertension. Discussion: This study indicates that among motivated patients, home blood pressure measurement entails minimal effort, increases security, and leads to better communication about blood pressure between healthcare personnel and patients.

Background: The aim of this study was to evaluate the effectiveness of the health screening procedure for home-dwelling older adults in reducing emergency department visits and associated costs., Methods: Data were derived from health screenings from 2020 to 2021 for 75-year-old home-dwelling residents of Western Finland. The study compared emergency department visits and associated costs between older adults who participated in the health screening (intervention group) and those who did not (non-intervention group). For each older adult, three non-intervention controls were matched according to age, sex, health screening year and wellbeing service county. Emergency department visits and International Classification of Diseases (ICD)-10 codes from one year before to two years after health screening were analyzed., Results: In the non-intervention group, a 19% increase in emergency visit rates was seen (457-564 per 1000 person-years), while the intervention group showed a 67% decrease (165-23). Annual costs for the non-intervention group increased from 148 euros (€) to €183, a mean ratio increase of 1.24 per person-year (range 1.08-1.40). In contrast, the intervention group's costs decreased from €53 to €8, a mean reduction ratio of 0.15 per person-year (range 0.10-0.71). The intervention group had lower frequency of visits for respiratory and circulatory diseases but higher for digestive and metabolic diseases, unlike the non-intervention group., Conclusions: The implementation of the health screening is an effective strategy for reducing both the frequency of emergency department visits and associated costs in home-dwelling older adults in good condition.

Young adults experiencing unfamiliar symptoms commonly seek health information online. This study's aim was to explore how health information websites express and communicate health information about symptoms common among young adults and guide readers in regard to health, illness, and care. Symptoms commonly searched for by young adults were used as search terms. The resulting data comprised material from 24 web pages and was analyzed using content analysis. The foremost purpose of online health information is to try to narrow down the user's symptoms and then advise the user on what actions to take. This is done by first forming a foundation of knowledge through descriptions and explanations, then specifying the symptom's time, duration, and location, and finally giving advice on whether to self-manage symptoms or seek additional information about them. However, the uncertainty of the diagnosis may rule out self-care. For readers inexperienced with health care, forming a decisive conclusion about diffuse symptoms on the sole basis of online health information could be challenging. The necessity of numeracy skills and the ability to deal with uncertainty are highlighted. There is a discrepancy between health advice given online and readers' accessibility to health care that needs to be addressed in future policy and research.

Objective: To describe and compare contacts regarding self-injurious thoughts and behaviours to other contacts to emergency primary care., Design: Observational study., Setting: A sentinel network of seven emergency primary care centres throughout Norway., Subjects: Initial contacts regarding patients 10 years and older during 12 consecutive months (11/2021-10/2022)., Main Outcome Measures: Contacts due to self-injurious thoughts and behaviours., Results: Self-injurious thoughts and behaviours were the reason for contact for 0.6% ( n  = 478) of initial contacts for patients aged 10 years or older ( n  = 77 344). When compared to other contacts, self-injurious thoughts and behaviours were associated with female gender, younger age, occurrence during evening and nighttime, higher urgency, and more physician consultations and call-outs. Of contacts about self-injurious thoughts and behaviours, 58.2% were regarding thoughts and 41.8% about behaviours, and in 75.0% a history of similar contacts was recorded. Contacts regarding thoughts often concerned threats (30.6%) and were more often handled by telephone advice than contacts regarding behaviours. Contacts regarding behaviours with suicidal intent were associated with higher urgency and more physician call-outs than contacts regarding non-suicidal behaviours., Conclusion: Self-injurious thoughts and behaviours are rare reasons for contact to emergency primary care but are assessed as more urgent than other contact reasons and trigger more extensive medical help. Many of the patients are known to the service through a history of similar contacts., Implications: The infrequency and severity of these encounters might necessitate training, decision support and procedures to compensate for the health care personnel's limited exposure.

Objectives: To investigate whether intensified cooperation between general practitioner (GP), care manager and rehabilitation coordinator (RC) for patients sick-listed for stress-related mental disorder, combined with a person-centred dialogue meeting with employer, could reduce sick-leave days compared with usual care manager contact., Design: Pragmatic cluster-randomised controlled trial, randomisation at primary care centre (PCC) level., Setting: PCCs in Region Västra Götaland, Sweden, with care manager organisation., Participants: Of 30 invited PCCs, 28 (93%) accepted the invitation and recruited 258 patients newly sick-listed due to stress-related mental disorder ( n  = 142 intervention, n  = 116 control PCCs)., Intervention: Cooperation between GP, care manager and rehabilitation coordinator from start of illness notification plus a person-centred dialogue meeting between patient and employer within 3 months. Regular contact with care manager was continued at the control PCCs., Main Outcome Measures: 12-months net and gross number of sick-leave days. Secondary outcomes: Symptoms of stress, depression, anxiety; work ability and health related quality of life (EQ-5D) over 12 months., Results: There were no significant differences between intervention and control groups after 12 months: days on sick-leave (12-months net sick-leave days, intervention, mean = 110.7 days (95% confidence interval (CI) 82.6 - 138.8); control, mean = 99.1 days (95% CI 73.9 - 124.3)), stress, depression, or anxiety symptoms, work ability or EQ-5D. There were no significant differences between intervention and control groups concerning proportion on sick-leave after 3, 6, 12 months. At 3 months 64.8% were on sick-leave in intervention group vs 54.3% in control group; 6 months 38% vs 32.8%, and12 months 16.9% vs 15.5%., Conclusion: Increased cooperation at the PCC between GP, care manager and RC for stress-related mental disorder coupled with an early workplace contact in the form of a person-centred dialogue meeting does not reduce days of sick-leave or speed up rehabilitation. Trial registration: ClinicalTrials.gov Identifier: NCT03250026 https://clinicaltrials.gov/study/NCT03250026?tab=results#publicationsCO-WORK-CAREFirst Posted: August 15, 2017. Recruitment of PCCs: September 2017. Inclusion of patients from December 2017.

Background: There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years., Objective: To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors., Design and Setting: A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006-2014. The data were divided into three 3-year periods., Subjects: The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients' sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group., Main Outcome Measures: For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics., Results: The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days., Conclusion: Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship.

Objective: To explore in a primary care setting the associations between patients' daily self-measured blood pressure (BP) during eight weeks and concurrent self-reported values of wellbeing, lifestyle, symptoms, and medication intake. We also explore these associations for men and women separately., Design and Setting: The study is a secondary post-hoc analysis of the randomised controlled trial PERson-centeredness in Hypertension management using Information Technology (PERHIT). The trial was conducted in primary health care in four regions in Southern Sweden., Patients: Participants ( n  = 454) in the intervention group in the PERHIT-trial used an interactive web-based system for self-management of hypertension for eight consecutive weeks. Each evening, participants reported in the system their wellbeing, lifestyle, symptoms, and medication adherence as well as their self-measured BP and heart rate., Main Outcome Measures: Association between self-reported BP and 10 self-report lifestyle-related variables., Results: Self-reported less stress and higher wellbeing were similarly associated with BP, with 1.0 mmHg lower systolic BP and 0.6/0.4 mmHg lower diastolic BP ( p  < 0.001). Adherence to medication had the greatest impact on BP levels (5.2/2.6 mmHg, p  < 0.001). Restlessness and headache were also significantly associated with BP, but to a lesser extent. Physical activity was only significantly associated with BP levels for men, but not for women., Conclusion: In hypertension management, it may be important to identify patients with high-stress levels and low wellbeing. The association between medication intake and BP was obvious, thus stressing the importance of medication adherence for patients with hypertension.

Objective: Many countries experience challenges in recruiting and retaining general practitioners (GPs) as supervisors for medical students in clinical placements. We aimed to investigate the opportunities, capacities and limitations of Norwegian GPs to become supervisors., Design: Web-based cross-sectional questionnaire study., Setting: Norwegian general practice., Subjects: All GPs in Norway, including locums and those on leave, both active supervisors, and GPs who are not presently supervising medical students., Main Outcome Measures: GPs' terms of salary, office facilities, limiting factors, capacity and needs for becoming or continuing as supervisors., Results: Among 5145 GPs, 1466 responded (29%), of whom 498 (34%) were active supervisors. Lack of a dedicated student office was the most reported limitation for both active supervisors (75%) and other GPs (81%). A high proportion (67%) of active supervisors reported that they could host more students per year, given financial support for equipped offices and higher salaries. With this kind of support, 48% ( n  = 461) of the GPs who were not supervisors for medical students were positive about a future supervisor role. By adjusted regression analysis, female GPs had lower likelihood of being supervisors, OR (95% CI) 0.75 (0.59-0.95) than male colleagues. GPs in the North, Mid and West regions had higher odds (OR 3.89, 3.10 and 2.42, respectively) than those in the South-East region. Teaching experience also increased the odds (2.31 (1.74-3.05)., Conclusions: There seems to be capacity among both active and potential supervisors if increased salaries and financial support for office facilities are made available.

Objective: To investigate the prevalence of diabetes retinopathy and evaluate the factors influencing its occurrence both at the onset of type 2 diabetes (T2D) and three years into its duration., Design: Retrospective population-based study., Setting: Data was retrieved from Regional Healthcare Information Platform in Region Halland 2016-2020., Subjects: Patients 35-75 years old in Region Halland receiving first-time diabetes diagnosis according to ICD-code E11-14 in 2016-17. The total cohort consisted of 1659 patients., Main Outcome Measures: The main outcome measure of the study was the occurrence of diabetes retinopathy at onset and within three years from the diabetes diagnosis. Multivariate logistic regression analysis was conducted for diabetes retinopathy at onset and within three years, adjusted for age, gender, comorbidities, levels of HbA1c, cholesterol, kidney functional and blood pressure., Results: At onset, there were 12% with diabetes retinopathy and after three years, 32% of the patients had developed diabetes retinopathy. In the study cohort, 71 of patients who were examined with fundus photography within three years after onset, and 8% had had dietary recommendation without pharmacotherapy. High HbA1c levels, blood pressure values and impaired renal function already at onset were associated with development of diabetes retinopathy at onset and this association persisted after three years. The odds ratio for diabetes retinopathy was increased adjusted for HbA1c elevations, renal impairment, and increased blood pressure at index and when adjusted for these variables three years from index., Conclusion: These findings indicate that the risk of developing diabetes retinopathy is present early on at onset and within the first three years of diabetes diagnosis. This highlights the importance of promptly regulating glucose- and blood-pressure levels and follow up kidney dysfunction to mitigate the risk of diabetes retinopathy.

Objective: To examine cardiovascular risk factors in 40-year-old participants in the health screening program targeted health dialogues (THDs)., Design: Cross-sectional study., Setting: 99 Swedish healthcare centers., Intervention: Metabolic risk factors and health behaviors were assessed. THDs were provided., Subjects: 1831 (62.3%) THD participants that consented to take part in the research project., Main Outcome Measures: (1) Prevalence of metabolic risk factors (blood pressure, LDL cholesterol, fasting plasma glucose, BMI, waist-hip ratio) and unhealthy behaviors (tobacco, alcohol, diet, physical activity) by sex, education, and place of birth. (2) Associations between different health behaviors and between the number of unhealthy behaviors and prevalence of metabolic risk factors. (3) THD participation by sociodemographics compared to age-matched controls., Results: Men had a higher prevalence of all metabolic risk factors, excessive alcohol use and tobacco use than women. Lower educated individuals had a higher prevalence of metabolic risk factors (except for LDL cholesterol) and tobacco use than highly educated. Participants born outside Sweden had a higher prevalence of obesity, high waist-hip ratio, and tobacco use. Participants with 3-4 unhealthy behaviors had significantly higher prevalence of each of the metabolic risk factors except BMI. Women, highly educated and Swedish-born participants were slightly over-represented in the THDs., Conclusion: Considering the associations between unhealthy behaviors and metabolic risk factors, the THD method, covering lifestyle as well as objective health measures, may be an appropriate method for early identification of individuals at risk for future non-communicable diseases in the whole population with a specific focus on certain groups., Clinicaltrials.gov: NCT04912739.

Objective: To investigate the experiences of healthcare staff in nursing homes during the COVID-19 pandemic., Design: Individual interviews. Latent qualitative content analysis., Setting: Ten nursing homes in Sweden., Subjects: Physicians, nurses and nurse assistants working in Swedish nursing homes., Main Outcome Measures: Participants' experiences of working in nursing homes during the COVID-19 pandemic., Results: Four manifest categories were found, namely: Balancing restrictions and allocation of scarce resources with care needs ; Prioritizing and acting against moral values in advance care planning ; Distrust in cooperation and Leadership and staff turnover - a factor for moral distress . The latent theme Experiences of handling ethical challenges caused by the COVID-19 pandemic gave a deeper meaning to the categories., Conclusion: During the pandemic, nursing home staff encountered ethical challenges that caused moral distress. Moral distress stemmed from not being given adequate conditions to perform their work properly, and thus not being able to give the residents adequate care. Another aspect of moral distress originated from feeling forced to act against their moral values when a course of action was considered to cause discomfort or harm to a resident. Alerting employers and policymakers to the harm and inequality experienced by staff and the difficulty in delivering appropriate care is essential. Making proposals for improvements and developing guidelines together with staff to recognize their role and to develop better guidance for good care is vital in order to support and sustain the nursing home workforce.

Objective: To compare management and documentation of vital signs, symptoms and infection severity in pneumonia patients seeking primary care and emergency care without referral., Design: Medical record review of vital signs, examination findings and severity of pneumonia., Setting: Primary and emergency care., Subjects: Two hundred and forty patients diagnosed with pneumonia., Main Outcome Measures: Vital signs, examination findings and severity of pneumonia. Assessments of pneumonia severity according to the reviewers, the traffic light score and CRB-65., Results: Respiratory rate, blood pressure, heart rate and oxygen saturation were less often documented in primary care ( p  < .001). Chest X-ray was performed in 5% of primary care patients vs. 88% of emergency care patients ( p  < .01). Primary care patients had longer symptom duration, higher oxygen saturation and lower respiratory rate. In total, the reviewers assessed 63% of all pneumonias as mild and 9% as severe. The traffic light scoring model identified 11 patients (9%) in primary care and 53 patients (44%) in emergency care at high risk of severe infection., Conclusions: Vital signs were documented less often in primary care than in emergency care. Patients in primary care appear to have a less severe pneumonia, indicating attendance to the correct care level. The traffic light scoring model identified more patients at risk of severe infection than CRB-65, where the parameters were documented to a limited extent.

Objective: To explore men's views on the causes and consequences of two common sexual dysfunctions - erectile dysfunction and premature ejaculation - and how this affects physical and mental health as well as social life and intimate or close relations., Design: A qualitative design with semi-structured interviews using open-ended questions was employed. Individual interviews were conducted, audio recorded and transcribed, and a qualitative content analysis of the text was performed., Setting: Informants were recruited from an outpatient primary care clinic in Sweden that offers consultation about sexual health to primarily younger men, age 20 years and above., Subjects: A total of 18 participants were included in the study, ten with erectile dysfunction and eight with premature ejaculation or both., Main Outcome Measures: Using the content analysis, different views and strategies of erectile dysfunction and premature ejaculation were presented to illustrate a range of perceptions., Results: The main theme emerged as 'Striving to understand and deal with the problem', which was divided into four categories: 'Reasons for seeking healthcare', 'Own perceptions/images about the problem and its cause', 'Experienced consequences on sex life' and 'Relationship qualities'.Participants experienced their problems in relation to a partner. Feelings of shame and fear of not being fit for desired sexual practices were common. They thought that underlying physical illness or previous sexual activities could have caused their problems. Decreased sexual desire and low self-esteem were seen as consequences, and participants wished for both medical treatment and counselling as support., Conclusion: Sexual dysfunction impairs general health and relationships with partners. While counselling is the basic treatment, those who are offered pharmaceutical treatment need follow-up concerning effectiveness and potential concerns.

Objective : When organising healthcare and planning for research to improve healthcare, it is important to include the patients' own perceptions. Therefore, the aim was to explore older patients' views on what is important concerning their current care and possible future interventions in a primary care setting. Design : A qualitative design with individual interviews was used. Analysis through latent content analysis. Setting : Seven Swedish primary care centres. Subjects : Patients (n 30) aged >75 years, connected to elder care teams in primary healthcare. Results : Three categories, consisting of 14 sub-categories in total, were found, namely: Care characterised by easy access, continuity and engaged staff builds security; Everyday life and Plans in late life. The overarching latent theme Person-centred care with easy access, continuity and engaged staff gave a deeper meaning to the content of the categories and sub-categories. Conclusion : It is important to organise primary care for older people through conditions which meet up with their specific needs. Our study highlights the importance of elder care teams facilitating the contact with healthcare, ensuring continuity and creating conditions for a person-centred care. There were variations regarding preferences about training and different views on conversations about end-of-life, which strengthens the need for individualisation and personal knowledge. This study also exemplifies qualitative individual interviews as an approach to reach older people to be part of a study design and give input to an upcoming research intervention, as the interviews contribute with important information of value in the planning of the Swedish intervention trial Secure and Focused Primary Care for Older pEople (SAFE).

Background: Antibiotic resistance is an increasing global threat, accelerated by both misuse and overuse of antibiotics. Most antibiotics to humans are prescribed in primary care, commonly for respiratory symptoms, and there is a need for research on the usage of and outcomes after antibiotic treatment to counteract antibiotic resistance., Objective: To evaluate symptom duration, treatment length, and adverse events of antibiotic treatment in children., Design and Setting: Observational study at four out-of-hours services and one paediatric emergency clinic in Norwegian emergency primary care., Subjects: 266 children aged 0 to 6 years with fever or respiratory symptoms., Main Outcome Measures: Duration of symptoms and absenteeism from kindergarten/school, treatment length, and reported adverse events., Results: There were no differences in duration of symptoms, fever or absenteeism when comparing the groups prescribed (30.8%) and not prescribed (69.2%) antibiotics. This lack of difference remained when analysing the subgroup with otitis media.In the group prescribed antibiotics, 84.5% of parents reported giving antibiotics for 5-7 days, and 50.7% reported no difficulties. Adverse events of antibiotics were reported in 42.3% of the cases, the vast majority being gastrointestinal disturbances., Conclusion: Children with fever or respiratory symptoms experience similar duration of symptoms and absenteeism regardless of antibiotic treatment. A substantial number of parents reported adverse events when the child received antibiotics. Several parents experienced additional difficulties with the treatment, some ending treatment within day 4., Trial Registration Number: NCT02496559; Results.

Objective: A pilot study to evaluate a staff training intervention implementing a nurse-led hypertension care model., Design and Setting: Clinical and laboratory data from all primary care centres (PCCs) in the Swedish region Västra Götaland (VGR), retrieved from regional registers. Intervention started 2018 in 11 PCCs. A total of 190 PCCs served as controls. Change from baseline was assessed 2 years after start of intervention., Intervention: Training of selected personnel, primarily in drug choice, team-based care, measurement techniques, and use of standardized medical treatment protocols., Patients: Hypertensive patients without diabetes or ischemic heart disease were included. The intervention and control groups contained approximately 10,000 and 145,000 individuals, respectively., Main Outcome Measures: Blood pressure (BP) <140/90 mmHg, LDL-cholesterol (LDL-C) <3.0 mmol/L, BP ending on -0 mmHg (digit preference, an indirect sign of manual measuring technique), choice of antihypertensive drugs, cholesterol lowering therapy and attendance patterns were measured., Results: In the intervention group, the percentage of patients reaching the BP target did not change significantly, 56%-61% (control 50%-52%), non-significant. However, the percentage of patients with LDL- C  < 3.0 mmol/L increased from 34%-40% (control 36%-36%), p = .043, and digit preference decreased, 39%-27% (control 41%-35%), p  = 0.000. The number of antihypertensive drugs was constant, 1.63 - 1.64 (control 1.62 - 1.62), non-significant, but drug choice changed in line with recommendations., Conclusion: Although this primary care intervention based on staff training failed to improve BP control, it resulted in improved cardiovascular control by improved cholesterol lowering treatment.

Objective: Describe a method in a real-world setting to identify persons with undiagnosed prediabetes and type 2 diabetes through an interprofessional collaboration between Public Dental Services and Primary Health Care in Regions Stockholm., Design: A descriptive observational study., Setting: The study was conducted at seven sites in the region of Stockholm, Sweden. Each collaborating site consisted of a primary health clinic and dental clinic., Subjects: Study participants included adults over 18 years of age who visited the Public Dental Services and did not have a medical history of prediabetes or type 2 diabetes., Main Outcome Measures: Selective screening is conducted in accordance with a risk assessment protocol at the Public Dental Services. In the investigated method, DentDi (Dental and Diabetes), adults diagnosed with caries and/or periodontitis over a cut-off value are referred to the Primary Health Care clinic for screening of prediabetes and type 2 diabetes., Results: DentDi, introduced at seven sites, between the years 2017 and 2020, all of which continue to use the method today. A total of 863 participants from the Public Dental Services were referred to the Primary Health Care. Of those 396 accepted the invitation to undergo screening at the primary health care centre. Twenty-four individuals did not meet the inclusion criteria, resulting in a total of 372 persons being included in the study. Among the 372 participants, 27% (101) had elevated glucose levels, of which 12 were diagnosed with type 2 diabetes and 89 with prediabetes according to the study classification., Conclusions: DentDi is a feasible method of interprofessional collaboration where each profession contributes with the competence included in everyday clinical practice for early identification of persons with prediabetes and type 2 diabetes with a complete chain of care. The goal is to disseminate this method throughout Stockholm County and even other regions in Sweden.

Objective: To explore the experiences and views of Norwegian Municipality Chief Medical Officers (MCMOs) on preparedness, collaboration, and organization during the COVID-19 pandemic to gain insight into local crisis management of value for future pandemic responses., Design: Longitudinal qualitative interview study. We conducted semi-structured digital interviews with nine MCMOs working in different municipalities in Norway from September to December 2020. Five MCMOs were re-interviewed from January to April 2021. We used thematic analysis to analyze the data., Results: Through the analysis, three major themes were identified in the material; 1) The view of preparedness changed from being low-priority and dormant to the desire to strengthen preparedness as a permanent measure; 2) The nature of the pandemic forced a change in internal and external communication and collaboration for the MCMOs towards direct dialogue, teamwork and digital networking; 3) The pandemic changed the role and position of the MCMO within the municipal organization. Although most MCMOs were given a leading role in the municipal pandemic response, some MCMOs experienced that they were not positioned to fully exercise their intended role. In our material, de-authorization of the MCMO role seemed to coincide with the increasing size and organizational complexity of the municipality., Conclusions: The Norwegian pandemic response and outcome have been regarded as successful internationally. Although the MCMOs managed to implement flexible and quick responses facilitated by teamwork, dialogue, and joint sensemaking, they also identified several challenges and shortcomings of the Norwegian pandemic preparedness requiring organizational and financial changes to sustain future health system resilience.

Objective: Optimizing care at home, or home health care (HHC), is necessary as the population of care-dependent older people receiving care at home steadily increases. The COVID-19 pandemic tested Swedish primary care professionals as they provided HHC for a population of very frail older homebound people, but a better understanding of what healthcare workers did to manage the crisis may be useful for the further development of HHC. In this study, we aimed to understand how HHC physicians solved the problems of providing home healthcare during the pandemic to learn lessons on how to improve future HHC., Methods: This is a qualitative study of individual interviews with 11 primary care physicians working in HHC (8 women) from 7 primary care practices in Region Stockholm, Sweden. Interviews were conducted between 1 December 2020, and 11 March 2021. The data were analyzed using inductive thematic analysis., Results: We generated an overarching theme in our analysis: Physicians focus on core tasks and professional values in response to crisis. This theme incorporated three underlying subthemes describing this response: physicians prioritize and resolve ethically challenging situations in new ways, cultivate the patient perspective, and build on existing teams., Conclusion: This study indicates that a healthcare system that gives HHC physicians agency to focus on core tasks and professional values could promote person-centered care.

Objective: Document the impact of an outbreak of gastroenteritis on local primary health care services, compared to a control period., Design: Controlled observational study with data from the outbreak and a control period. Data obtained from electronic medical records (EMR) of general practitioners (GPs) and the out-of-hours (OOH) service. Telephone data from the OOH service's telephone records., Setting: Campylobacteriosis outbreak in Askøy municipality, Norway in 2019. Over 2000 individuals were infected., Subjects: Patients in contact with GPs and the OOH service during the outbreak and a control period., Main Outcome Measures: Patient contacts with GPs and the OOH service during the outbreak and a control period., Results: There was a 36% increase in contacts during the outbreak compared to the control period (4798 vs. 3528), with the OOH service handling 78% of outbreak-related contacts. Telephone advice was the dominant method for managing the increase in contacts to primary care, both in OOH services and daytime general practice (OR 3.73 CI: [3.24-4.28]). Children aged 0-4 years had increased use of primary care during the outbreak (OR 1.51 CI: [1.28-1.78]). GPs referred 25% and OOH services referred 75% of 70 hospitalized cases., Conclusion: The OOH service handled most of the patients during the outbreak, with support from daytime general practice. The outbreak caused a shift towards telephone advice as a means of providing care. Young children significantly increased their use of primary care during the outbreak.

Objective: This Swedish study aimed to assess the prevalence, associated clinical factors, and mortality rates of heart failure patients diagnosed without echocardiograms in both hospital and primary care settings., Design: We conducted a retrospective population-based study using data from the Region Halland healthcare database in Sweden covering 330,000 residents., Subjects: From 2013-2019, 3,903 patients received an incidental heart failure diagnosis without an echocardiogram and they were followed for one year., Main Outcome Measures: Using logistic and Cox regression analyses, we evaluated the prevalence, clinical characteristics, and all-cause mortality at intervals of 30, 100, and 365 days post-diagnosis., Results: In this Swedish cohort, the one-year all-cause mortality rate was markedly higher for patients diagnosed in hospitals (42%) compared to those in primary care (20%, p  < 0.001). Patients diagnosed in primary care were older and had fewer comorbidities and lower NT-proBNP levels. Hospital-diagnosed patients faced a significantly higher mortality rate in the initial 30 days but saw similar rates to primary care patients thereafter., Conclusion: In a Swedish region, heart failure diagnoses without echocardiograms were more common in hospitals, and these patients initially faced worse prognoses. After the first month, however, the prognosis of hospital-diagnosed patients mirrored that of those diagnosed in primary care. These findings emphasize the need for improved diagnostic and treatment approaches in both care settings to enhance outcomes.

Objective: Trainees or medical residents' experiences of hospital rotations and training have not been sufficiently studied. More empirical holistic studies of experiences of General Practice/Family Medicine (GP/FM) residents in Sweden are needed. The purpose of this study was to describe experiences of hospital rotation during residency., Design: Empirical-holistic study., Setting: GP/FM residents were invited by email to participate in the study. They could describe their experiences anonymously by answering two questions via an esMaker internet survey. Analyses of the responses were carried out with content analysis as the analytical methodology. Both manifest and latent responses were analyzed., Subjects: Fifty-nine GP/FM residents participated in the study., Main Outcome Measure: The results identified four main topics: structure, resources, effects, and constructive supervision., Results: GP/FM residents experienced hospital rotations as effective when there was a structured schedule and adequate time allotted for introduction and meeting patients. Hospital rotations that lacked, or had unstructured, supervision caused uncertainty and insecurity, which led to rotations being experienced as less beneficial, which was, from a GP/FM perspective, not constructive., Conclusion: The study suggests that family medicine residents required a structured and planned schedule during hospital rotations. This study may contribute to increased quality of hospital rotations during residency as a family physician.

Objective: Diagnosis of cancer is challenging in primary care due to the low incidence of cancer cases in primary care practice. A prolonged diagnostic interval may be due to doctor, patient or system factors, or may be due to the characteristics of the cancer itself. The objective of this study was to learn from Primary Care Physicians' (PCP) experiences of incidents when they had failed to think of, or act on, a cancer diagnosis., Design: A qualitative, online survey eliciting PCP narratives. Thematic analysis was used to analyse the data., Setting and Subjects: A primary care study, with narratives from 159 PCPs in 23 European countries., Main Outcome Measures: PCPs' narratives on the question 'If you saw this patient with cancer presenting in the same way today, what would you do differently?, Results: The main themes identified were: thinking broadly; improvement in communication and clinical management; use of other available resources and 'I wouldn't do anything differently'., Conclusion (implications): To achieve more timely cancer diagnosis, PCPs need to provide a long-term, holistic and active approach with effective communication, and to ensure shared decision-making, follow-up and continuing re-assessment of the patients' clinical conditions.

Introduction: Swedish Physical Activity on Prescription (PAP) has been shown to increase physical activity levels, which is known to lead to positive health effects. PAP is being implemented in Swedish healthcare to various extents. However, there is a lack of knowledge about how Swedish general practitioners (GPs) work with PAP and what hinders and facilitates wider implementation., Aims: This study aimed to survey GPs' use and views of PAP, identify barriers and facilitators for implementing PAP, and explore associations to gender, practice location, and experience., Methods: The study was framed by the Normalization Process Theory. A survey was sent to 463 GPs at 69 different healthcare centres in Region Västra Götaland. Data were analysed using multiple logistic and linear regressions., Results: A total of 143 GPs completed the survey (response rate 31%). Views on PAP were generally positive amongst respondents, but only 27% reported using PAP regularly. The most prominent reported barriers were insufficient training and resources. Positive views and willingness to collaborate in using PAP were identified as facilitators. Responding GPs in Gothenburg used PAP more often (OR 6.4; 95% CI 2.7-14.8) and were significantly more positive to the method than GPs in other areas of the region. GPs with more than 10 years of practice used PAP more often (OR 2.5; 95% CI 1.1-6.0) than less experienced GPs. Few of the investigated variables were associated with gender., Conclusions: The positive views amongst responding GPs are helpful, but more education, training and resources are needed for successful implementation of PAP in Swedish primary health care.

Objective: This study aimed to examine primary health care (PHC) service utilization and mortality in older patients with type 2 diabetes (T2D) with or without comorbidities., Design and Setting: A cohort study in PHC in the city of Vantaa, Finland. Follow-up period was set between the years 2011 and 2018., Subjects: PHC patients aged 60 years or more with a T2D were included., Main Outcome Measures: Service utilization was defined as the number of face-to-face appointments and telephone contacts between a patient and general practitioner (GP) or nurse. The presence of comorbidities was defined using the Charlson Comorbidity Index (CCI). Mortality was assessed using hazard ratio (HR) and standardized mortality ratio (SMR)., Results: In total, 11,020 patients were included and followed for 71,596 person years. Mean age of the women and men in the beginning of follow-up were 71 and 69 years, respectively. The patients in the study cohort had a mean of eight appointments per person year to the GPs or nurses. Patients with T2D with comorbidities had more appointments than patients with T2D without comorbidities (incidence rate ratio (IRR) 1.44 [95% CI 1.39-1.49]). Increase in the number of all appointments reduced mortality in patients with T2D with and without comorbidities. Between patients with T2D with comorbidities and patients with T2D without comorbidities, the age and sex adjusted HR for death was 1.50 (95% CI 1.39-1.62). The SMR was higher in patients with T2D with comorbidities (1.83 [95% CI 1.74-1.92]) than in patients with T2D without comorbidities (0.91 [95% CI 0.86-0.96])., Conclusions: In older patients with T2D, the presence of comorbidities was associated with increased use of PHC services and increased mortality. Increase in the number of appointments was associated with reduced mortality in patients with T2D with or without comorbidities.Key PointsIn older patients with T2D, it has not been studied whether and to what extend multimorbidity affects use of PHC services and mortality.The presence of comorbidities according to the Charlson Comorbidity Index (CCI) was associated with increased use of PHC services.The number of appointments to GPs or nurses was associated with reduced mortality in patients with T2D with or without comorbidities according to the CCI.

Objective: There have been few studies predicting institutionalization or death in home care settings. We examined risk factors for nursing home placement (NHP) and death among home care patients., Design: A prospective one-year follow-up study., Settings and Subjects: Persons aged ≥65 years living in Eastern Finland and receiving regular home care services ( n  = 293)., Main Outcome Measures: Risk factors for NHP or death were investigated using Cox proportional hazards model. Explanatory variables included demographics, health status (Charlson Comorbidity Index, CCI), physical (Timed Up and Go, TUG), and cognitive (Mini-Mental State Examination, MMSE) functioning, Basic and Instrumental Activities of Daily Living (BADL, IADL) and mood (Geriatric Depression Scale, GDS-15)., Results: Of the 293 patients (mean age 82.6 years, 70.6% women), 27 (9.2%) moved to a nursing home and 25 (6.9%) died during the follow-up (mean 350 days). The combined outcome of NHP or death was predicted by BADL (HR 0.73, CI 95% 0.62-0.86), IADL (0.75, 0.65-0.87) MMSE (0.92, 0.87-0.96), and TUG (1.02, 1.01-1.03). NHP alone was predicted by BADL (0.62, 0.50-0.78), IADL (0.57, 0.45-0.73), and MMSE (0.88, 0.82-0.94) and mortality by TUG (1.02, 1.01-1.03)., Conclusion: Basic measures of functioning can be used to identify high-risk patients in home care. Decreasing BADL, IADL and MMSE predict NHP and longer TUG-times death within a year.

Objective: Patient education based on the patient's individual needs and circumstances is known to be associated with positive changes in clinical outcomes in chronic obstructive pulmonary disease (COPD). We aimed to assess the levels of patients' subjective needs for information about COPD before and after their general practitioners had taken part in a COPD education., Design: A secondary analysis of a cluster randomized controlled trial., Setting: 22 PHCCs in Stockholm, Sweden., Subjects: Randomly selected primary care patients with COPD in GOLD stages 2 and 3 ( n  = 293)., Outcome Measures: Scores in the Lung Information Needs Questionnaire (LINQ) at baseline and 18 months, spirometry results, and self-reported, descriptive patient data., Results: GPs' improved skills in COPD did not affect patients' self-management skills over time. In general, patients' information needs remained great in issues concerning diet, exercise and self-management. However, 43% of the patients reported reduced and 57% increased or unchanged information needs, over time. Reduced information needs were mainly associated with a high level of information needs at baseline (OR = 3.17 [95% CI 1.93-5.23], p  < .01) and establishing contact with a physiotherapist (OR = 2.26 [95% CI 1.05-4.86], p  = .038). Patients in a mild or stable phase of COPD with no recent exacerbations reported greater needs than those with unstable, deteriorated COPD., Conclusion: Patients' information needs are substantial in most areas of self-management of COPD, and seem to covary with the patient's current clinical status. Care providers should thus continuously be vigilant about offering all patients with COPD support and education., Trial Registration: Clinicaltrials.gov, 10 August 2014, Identifier NCT02213809.

Objective: Cardiovascular disease can be prevented through lifestyle changes, but such changes are often hard to attain. Text message interventions with lifestyle advice have shown small but promising effects. Our objective was to explore participant experience of a text message lifestyle intervention for patients with hypertension, and implications for future lifestyle interventions., Design and Subjects: Fourteen participants were purposefully selected for telephone interviews after completion of a text message lifestyle intervention. A semi-structured interview guide with open-ended questions was used. Interviews were recorded and transcribed verbatim. The material was analyzed through systematic text condensation as described by Malterud, a data-driven analysis style that includes deductive elements., Setting: Primary care in three regions in southern Sweden., Results: The analysis resulted in three themes. 'Blood pressure and lifestyle, how seriously to take it?' revealed a remaining need for knowledge regarding to what extent lifestyle affects risk for cardiovascular disease. 'The text messages - a useful reminder in need of tailoring' described that the design of the intervention was satisfactory, but suggested improvements through increased individualization. Finally, 'Water off a duck's back or a kick in the pants - when does behavior change?' showed how some participants responded to the push to change while others did not, supplying material for further analysis in a framework of behavioral change theory., Conclusion: A key to adoption was advice that was applicable in daily life. Timing in relation to a diagnosis of hypertension or other motivational factors, and tailoring to prior knowledge, habits, and limitations could increase effectiveness.

Objective: Severe trauma patients need immediate prehospital intervention and transfer to a specialised trauma hospital. In Norway, primary care doctors (PCDs) are an integrated part of the prehospital trauma care. The aim of this study was to investigate the degree to which PCDs were involved in prehospital care of severe trauma patients and how factors related to patients and doctors were associated with call-outs to these incidents., Design: This was a registry-based study in Norway on severe trauma patients with acute hospital admission during the period 2012-2018., Setting: Data was obtained from three Norwegian official registries., Subjects: By linking the registries, we studied the actions taken by the PCDs, whether they called out to severe trauma incidents., Main Outcome Measures: In multivariable regression models, we investigated whether factors related to the PCDs (age, sex, specialisation in general practice (GP)) and patients (age, sex, duration of hospital stay, type of injury) were associated with call-outs., Results: Out of 4342 severe trauma incidents, PCDs had documented involvement in 1683 (39%) and called out to 644 (15%). Increased proportions of PCD call-outs to severe trauma incidents were significantly associated with lower age of PCD, being a GP specialist, lower patient age, being a male patient, increased length of hospital stay and injuries to the head and the neck., Conclusions: PCDs called out to a relatively low proportion of severe trauma patients. Several factors related to patients and doctors were associated with call-outs to severe trauma incidents in Norway.

Aim: To investigate trends in the haemoglobin (Hb) level in middle-aged Swedish women from 1968 to 2017 and to examine the potential association between Hb and the use of hormonal contraceptives (HCs)., Design: A prospective observational population study of representative 38- and 50-year-old women of Gothenburg, Sweden., Setting: The population study of women in Gothenburg started in 1968-1969 and has continued since then with new examinations every 12 years, including both follow-ups and new recruited cohorts. The study consists of both physical examinations and questionnaires., Subjects: Two thousand four hundred eighty-eight women aged 38 and 50 participated in the study from 1968 to 2017., Statistical Methods: Linear regression model analyses were used to analyse linear and non-linear trends in the level of Hb. Linear and logistic regression models were used to analyse possible associations between HC and Hb and possible associations between the use of HC and anaemia, respectively., Main Outcome Measures and Covariates: Hb was measured in g/L. HC included any ongoing use of HC therapy. Covariates were smoking, body mass index (BMI), alcohol consumption and education., Results: A non-linear U-shaped trend in mean Hb was seen in the two age groups, 38- and 50-years old. After adjusting for covariates, a significantly higher mean Hb was seen in the 2016-2017 examination compared to 1980-1981, 1992-1993 and 2004-2005. In 38-year-olds, using HC was associated with a reduced risk of anaemia (OR 0.35, 95% CI 0.13-0.75). In both age groups, the use of HC was significantly associated with having a higher Hb., Conclusions: Mean levels of Hb in middle-aged women of the general population seem to be increasing again after lower levels in the 1980s and 1990s. The use of HC was associated with having a higher Hb and a lower risk of anaemia in 38-year-old women.

Objective: The aim of this study was to explore patients' experiences and management of pain in connection with a migraine attack in episodic migraine., Design, Setting and Subjects: This qualitative study used a semi-structured interview format based on functional behavioural analysis as commonly used in cognitive behavioural therapy. We interviewed eight participants and analysed their responses using systematic text condensation., Results: Participants' descriptions of their experiences and management of pain from episodic migraine were sorted into three description First physical sensations, Automatic reactions and Acts according to the interpretation., Conclusion: From a biopsychosocial perspective, a migraine attack is much more complex than just an experience of pain. The purely biological pain prompts a number of automatic reactions leading to strategies for pain management.