From abstainer to current drinker: a qualitative investigation of the process of alcohol use initiation among early adolescents in Thailand.

Background: Recent evidence shows that young people started their first alcohol initiation when they were early adolescents (10-14 years of age), while there is still very little scientific understanding concerning the process of alcohol use of this age group. This study examined how adolescents in Thailand emerge to become drinkers. Method: The semi-structured interview with 10-14-year-olds (n = 61) in Chonburi, province of Thailand. Data were collected, and analysis followed the method of content analysis. Results: Our analyzes revealed three steps of alcohol initiation among early adolescents: (a) the pre-stage; (b) the initiation; and (c) the self-adjustment stage. Parent, peer, and the taste of alcohol were noteworthy as the factors that promote young people to accept alcohol sipping and consumption as part of their life. Nevertheless, law, social norms, culture, parents, and health consequences discouraged young people from emerging alcohol initiation. Conclusion: The preliminary evidence from this study recommends the interventions that address both individual-level and interpersonal circumstances as potentially being effective solutions to the provision of precautionary measures against underage alcohol use.

Job satisfaction criteria to improve general practitioner recruitment: a Delphi consensus.

BACKGROUND: The clinical general practitioner (GP) workforce is decreasing. Many studies have analysed the negative aspects of the profession but, few examine the positive aspects and job satisfaction. A European collaborative group including 8 participating countries recently conducted a qualitative study to analyse the positive factors and found 31 job satisfaction factors. OBJECTIVES: To determine which of these 31 factors are important and applicable to future policies to improve family medicine attractiveness, recruitment, and retention in France. METHOD: The Delphi consensus method was chosen. Two Delphi rounds were conducted in March-April 2017 and retained satisfaction factors with at least 70% of scores ≥7. The Nominal Group Technique (NGT) was used to rank these retained factors. Participants assigned 5 points to the factor they considered most important, 3 points to the second, and 1 point to the third. Factors receiving at least 5% (10 points) of the total points (198 points) were included in the final list. The expert panel included GPs and non-GPs. RESULTS: Twenty-nine experts began the procedure and 22 completed it. Thirty factors were retained after the 2 Delphi rounds. The NGT resulted in 8 factors: (i) Engage in family medicine to take care of the patients; (ii) Care coordination, patient advocacy; (iii) Flexibility in work; (iv) Trying to be a person-centred doctor; (v) Involvement in healthcare organization; (vi) Benefiting from a well-managed practice; (vii) Being a teacher, a trainer; (viii) Efficient professional collaboration. CONCLUSION: These 8 job satisfaction factors are important to consider and apply to future policy development.

In Europe, general practitioner (GP) numbers are falling. Policies considering GP job satisfaction could be a solution. GPs with higher job satisfaction have lower levels of stress and burnout, are more interested in their job, and stay in their job for longer. Recently, a European study found 31 GP factors that influence job satisfaction. However, it is not clear which of these 31 factors policy makers could use to improve attractiveness, recruitment, and retention in family medicine in France. A panel of experts consisting of GPs and non-GPs used the Delphi consensus method to agree on which satisfaction factors were relevant and important. These factors were then ranked in order of importance. The experts agreed upon thirty satisfaction factors. From these, 8 were ranked as most important: (i) Engage in family medicine to take care of patients; (ii) Care coordination, patient advocacy; (iii) Flexibility in work; (iv) Trying to be a person-centred doctor; (v) Involvement in the healthcare organization; (vi) Benefiting from a well-managed practice; (vii) Being a teacher, a trainer; (viii) Efficient professional collaboration. These should be considered and applied to future policy development.

Factors associated with alcohol consumption among early adolescents in a province in Eastern region of Thailand: a cross-sectional analysis.

A cross-sectional study was applied to obtain factors associated with alcohol consumption since information among early adolescents in Thailand is limited. Data was collected from December 2016 to March 2017. A questionnaire was developed through a literature review and tested for validation and reliability. Multi-stage random sampling was used to recruit youths aged 10-14 years from Chonburi Province, Thailand. Descriptive statistics (mean and standard deviation), Chi-squared test, and multivariable logistic regression were used for data analysis. The mean and standard deviation (SD) for the age of participants was 12.07 years (1.42) with 50.23% being male. In total, 10.94% reported drinking alcohol in the past 12 months. Current drinking in the past year was positively associated with older youths of 14 years of age (AOR = 5.34, 95% CI = 2.91-9.81) having a positive attitude toward alcohol consumption behavior (AOR = 4.18 95% CI = 3.36-5.21), direct observation of friends' drinking (AOR = 4.21, 95% CI = 3.32-5.32), direct observation of villagers/community members' drinking (AOR = 1.99, 95% CI = 1.15- 3.48), adolescents whose parents stored alcohol at home (AOR = 1.35, 95% CI = 1.06-1.55), and being exposed to alcohol advertising (AOR = 1.60, 95% CI =1.16-2.23). The factor most inversely associated with current drinking appears to be male gender (AOR = 0.78, 95% CI =0.64-0.94). Strategies for delaying and reducing drinking among early adolescents should accompany these risk factors into any preventive programs.

General practitioners' deprescribing decisions in older adults with polypharmacy: a case vignette study in 31 countries.

BACKGROUND: General practitioners (GPs) should regularly review patients' medications and, if necessary, deprescribe, as inappropriate polypharmacy may harm patients' health. However, deprescribing can be challenging for physicians. This study investigates GPs' deprescribing decisions in 31 countries. METHODS: In this case vignette study, GPs were invited to participate in an online survey containing three clinical cases of oldest-old multimorbid patients with potentially inappropriate polypharmacy. Patients differed in terms of dependency in activities of daily living (ADL) and were presented with and without history of cardiovascular disease (CVD). For each case, we asked GPs if they would deprescribe in their usual practice. We calculated proportions of GPs who reported they would deprescribe and performed a multilevel logistic regression to examine the association between history of CVD and level of dependency on GPs' deprescribing decisions. RESULTS: Of 3,175 invited GPs, 54% responded (N = 1,706). The mean age was 50 years and 60% of respondents were female. Despite differences across GP characteristics, such as age (with older GPs being more likely to take deprescribing decisions), and across countries, overall more than 80% of GPs reported they would deprescribe the dosage of at least one medication in oldest-old patients (> 80 years) with polypharmacy irrespective of history of CVD. The odds of deprescribing was higher in patients with a higher level of dependency in ADL (OR =1.5, 95%CI 1.25 to 1.80) and absence of CVD (OR =3.04, 95%CI 2.58 to 3.57). INTERPRETATION: The majority of GPs in this study were willing to deprescribe one or more medications in oldest-old multimorbid patients with polypharmacy. Willingness was higher in patients with increased dependency in ADL and lower in patients with CVD.

Integration of nurses in general practice: A thematic synthesis of the perspectives of general practitioners, practice nurses and patients living with chronic illness.

AIMS AND OBJECTIVES: To explore the views of general practitioners, practice nurses and patients on interprofessional collaboration in general practice and to understand to what extent the nurse-doctor relationship meets their needs and expectations. BACKGROUND: To address future challenges of primary health care, there is a need for integrated interprofessional collaboration care systems with a patient-centred focus. Worldwide, there is an integration of nurses in general practice. However, in a transitioning Belgian context little is known about the perspectives of three key stakeholder groups. DESIGN: The results of four qualitative descriptive primary studies were triangulated and a secondary analysis resulted in a thematic synthesis within a pragmatic research paradigm. METHODS: Primary data were collected through individual, semi-structured interviews with 7 general practitioners, 19 practice nurses and 21 patients living with chronic illness in 26 primary care centres with different nurse integration levels. We conducted a secondary analysis for the thematic synthesis of the different stakeholders' perspectives. This study was reported in accordance with the COREQ checklist. RESULTS: Four overarching themes were found as follows: vision and mission at general practice level, patient-centred care, practice nurse role development and interprofessional collaboration. Interprofessional collaboration within general practice ensures better response to patient needs. Evolution of the practice nurse role to autonomous decision-making can be facilitated by clear vision and mission, team communication, complementarity of responsibilities and trust-based professional relationships. CONCLUSIONS: The key for patient-centred care in a well-organised practice is a clear vision and mission and well-defined task description for interprofessional collaboration. General practice is urging for systematic guidance for the sustainable integration of a practice nurse. RELEVANCE TO CLINICAL PRACTICE: Our study highlights opportunities and challenges to nurse integration in general practice from key stakeholders' perspectives, which can inform other transitioning contexts.

A Qualitative Study About How Nurses in Belgium Offer Relationship Support to Couples in Palliative Care.

Although palliative care nurses are identified as key players in supporting couples during advanced illness, there is a lack of evidence about their knowledge and experiences with this particular role. The aim of the study was to explore palliative care nurses' attitudes, roles, and experiences in addressing relationship functioning of couples in daily practice. A qualitative study was conducted using in-depth interviews, observational research, and peer debriefing groups with palliative care nurses in Flanders, Belgium. Nurses support relationship functioning by creating a couple-positive care environment, by being present/acknowledging feelings, and by rectifying imbalances between couples. They do so in a proactive way, backed up by team support. Nurses hesitate toward explicitly unraveling and intervening in relationship problems, in favor of providing comfort or offering a strengths-based approach. The findings offer an urgent call to enhance the educational programs for palliative care nurses by integrating the theories and practice frameworks that guide relational assessment and intervention, which are being used in family nursing.

Addressing sexual issues in palliative care: A qualitative study on nurses' attitudes, roles and experiences.

AIM: To explore palliative care nurses' attitudes, roles and concrete experience with regard to addressing sexual issues in their daily practice. BACKGROUND: Patients and their partners in palliative care might experience dramatic changes in their sexuality and want nurses to provide the opportunity to address them. Moreover, it is argued that the holistic philosophy of palliative care encourages nurses working in this area to include sexual issues in their daily care. It is, however, unknown how palliative care nurses address sexual issues. DESIGN: A generic qualitative study was performed. METHODS: In total, 21 in-depth interviews were done with nurses from different facilities of palliative care networks in Flanders. Data were collected between September 2014 - September 2016 and thematic analysis was used to analyse the data. RESULTS: It was found that the way palliative care nurses addressed sexual issues was clearly influenced by their own interpretation of the philosophical principles underlying palliative care. The different interpretations of these basic principles create tensions for nurses about how to address sexual issues in the daily practice of palliative care and nurses vary in their reactions to these tensions. The present findings show that palliative care nurses - when they were able to overcome these tensions - use a "sex-positive approach" that fits with their tendency to focus on quality of life. CONCLUSION: Out of the results of this study, we made a list of good practices for palliative care nurses addressing sexual issues. This list can be used in nursing educational programs.

Predictors of burnout, work engagement and nurse reported job outcomes and quality of care: a mixed method study.

BACKGROUND: High levels of work-related stress, burnout, job dissatisfaction, and poor health are common within the nursing profession. A comprehensive understanding of nurses' psychosocial work environment is necessary to respond to complex patients' needs. The aims of this study were threefold: (1) To retest and confirm two structural equation models exploring associations between practice environment and work characteristics as predictors of burnout (model 1) and engagement (model 2) as well as nurse-reported job outcome and quality of care; (2) To study staff nurses' and nurse managers' perceptions and experiences of staff nurses' workload; (3) To explain and interpret the two models by using the qualitative study findings. METHOD: This mixed method study is based on an explanatory sequential study design. We first performed a cross-sectional survey design in two large acute care university hospitals. Secondly, we conducted individual semi-structured interviews with staff nurses and nurse managers assigned to medical or surgical units in one of the study hospitals. Study data was collected between September 2014 and June 2015. Finally, qualitative study results assisted in explaining and interpreting the findings of the two models. RESULTS: The two models with burnout and engagement as mediating outcome variables fitted sufficiently to the data. Nurse-reported job outcomes and quality of care explained variances between 52 and 62%. Nurse management at the unit level and workload had a direct impact on outcome variables with explained variances between 23 and 36% and between 12 and 17%, respectively. Personal accomplishment and depersonalization had an explained variance on job outcomes of 23% and vigor of 20%. Burnout and engagement had a less relevant direct impact on quality of care (≤5%). The qualitative study revealed various themes such as organisation of daily practice and work conditions; interdisciplinary collaboration, communication and teamwork; staff nurse personal characteristics and competencies; patient centeredness, quality and patient safety. Respondents' statements corresponded closely to the models' associations. CONCLUSION: A deep understanding of various associations and impacts on studied outcome variables such as risk factors and protective factors was gained through the retested models and the interviews with the study participants. Besides the softer work characteristics - such as decision latitude, social capital and team cohesion - more insight and knowledge of the hard work characteristic workload is essential.

General practice patients treated for substance use problems: a cross-national observational study in Belgium.

BACKGROUND: General Practitioners (GPs) are well placed to care for patients with (chronic) substance use problems. This pilot was carried out to study the feasibility and usefulness of a continuous surveillance of substance use problems among general practice patients. The objectives were (i) to describe variables with missing values exceeding 1% and whether patients were reported without substance-related problems; (ii) the profile and the magnitude of the patient population that is treated for substance use problems. METHODS: Observational study by the Belgian Network of Sentinel General Practices (SGP) in 2013. Baseline (at the first encounter) and 7-month follow-up data were reported of all patients treated for substance use problems. Two main measurements were type of substance use and patient status at follow-up. Multiple logistic regression analysis was used to examine patient status at follow-up. RESULTS: Of 479 patients, 47.2% had problems with alcohol alone, 20.3% with prescription drugs, 16.7% with illicit drugs other than heroin or methadone and 15.9% with heroin or methadone. Problems with alcohol alone were more prevalent in Flanders (53.0%; 95% confidence interval (CI) 46.8-59.1%) than in Wallonia-Brussels (39.8%; 95% CI 33.1-46.8%), while problems with heroin or methadone were more prevalent in Wallonia-Brussels (27.0%; 95% CI 21.1-33.5%) than in Flanders (7.1%; 95% CI 4.3-10.9%). At follow-up, 32.8% of the patients had dropped out, 29.0% had discontinued GP treatment and 38.2% had continued GP treatment. Overall, 32.4% of 479 patients had continued GP treatment for substance use problems during the study period. In Wallonia-Brussels, this proportion was higher (42.7%; 95% CI 35.9-49.6%) than in Flanders (24.3%; 95% CI 19.2-29.8%). CONCLUSIONS: A continuous surveillance of the general practice population treated for substance use problems seems to be feasible and useful. The latter is suggested by the specific profile and the relative magnitude of the population. Inter-regional health system differences should be taken into account to estimate the epidemiology of substance use problems among general practice patients.

How do GP practices and patient characteristics influence the prescription of antidepressants? A cross-sectional study.

BACKGROUND: Under-prescription of antidepressants (ADs) among people meeting the criteria for major depressive episodes and excessive prescription in less symptomatic patients have been reported. The reasons influencing general practitioners' (GPs) prescription of ADs remain little explored. This study aimed at assessing the influence of GP and patient characteristics on AD prescription. METHODS: This cross-sectional study was based on a sample of 816 GPs working within the main health care insurance system in the Seine-Maritime district of France during 2010. Only GPs meeting the criteria for full-time GP practice were included. The ratio of AD prescription to overall prescription volume, a relative measure of AD prescription level, was calculated for each GP, using the defined daily dose (DDD) concept. Associations of this AD prescription ratio with GPs' age, gender, practice location, number of years of practice, number of days of sickness certificates prescribed, number of home visits and consultations, number and mean age of registered patients, mean patient income, and number of patients with a chronic condition were assessed using univariate and multivariate analysis. RESULTS: The high prescribers were middle-aged (40-59) urban GPs, with a moderate number of consultations and fewer low-income and chronic patients. GPs' workload (e.g., volume of prescribed drug reimbursement and number of consultations) had no influence on the AD prescription ratio. GPs with more patients with risk factors for depression prescribed fewer ADs, however, which could suggest the medications were under-prescribed among the at-risk population. CONCLUSIONS: Our study described a profile of the typical higher AD prescriber that did not include heavy workload. In future work, a more detailed assessment of all biopsychosocial components of the consultation and other influences on GP behavior such as prior training would be useful to explain AD prescription in GP's practice.

What factors determine Belgian general practitioners' approaches to detecting and managing substance abuse? A qualitative study based on the I-Change Model.

BACKGROUND: General practitioners (GPs) are considered to play a major role in detecting and managing substance abuse. However, little is known about how or why they decide to manage it. This study investigated the factors that influence GP behaviours with regard to the abuse of alcohol, illegal drugs, hypnotics, and tranquilisers among working Belgians. METHODS: Twenty Belgian GPs were interviewed. De Vries' Integrated Change Model was used to guide the interviews and qualitative data analyses. RESULTS: GPs perceived higher levels of substance abuse in urban locations and among lower socioeconomic groups. Guidelines, if they existed, were primarily used in Flanders. Specific training was unevenly applied but considered useful. GPs who accepted abuse management cited strong interpersonal skills and available multidisciplinary networks as facilitators.GPs relied on their clinical common sense to detect abuse or initiate management. Specific patients' situations and their social, psychological, or professional dysfunctions were cited as cues to action.GPs were strongly influenced by their personal representations of abuse, which included the balance between their professional responsibilities toward their patients and the patients' responsibilities in managing their own health as well the GPs' abilities to cope with unsatisfying patient outcomes without reaching professional exhaustion. GPs perceived substance abuse along a continuum ranging from a chronic disease (whose management was part of their responsibility) to a moral failing of untrustworthy people. Alcohol and cannabis were more socially acceptable than other drugs. Personal experiences of emotional burdens (including those regarding substance abuse) increased feelings of empathy or rejection toward patients.Multidisciplinary practices and professional experiences were cited as important factors with regard to engaging GPs in substance abuse management. Time constraints and personal investments were cited as important barriers.Satisfaction with treatment was rare. CONCLUSIONS: Motivational factors, including subjective beliefs not supported by the literature, were central in deciding whether to manage cases of substance abuse. A lack of theoretical knowledge and training were secondary to personal attitudes and motivation. Personal development, emotional health, self-awareness, and self-care should be taught to and fostered among GPs to help them maintain a patient-centred focus. Health authorities should support collaborative care.

Evidence of prescription of antidepressants for non-psychiatric conditions in primary care: an analysis of guidelines and systematic reviews.

BACKGROUND: Antidepressants (ADs) are commonly prescribed in primary care and are mostly indicated for depression. According to the literature, they are now more frequently prescribed for health conditions other than psychiatric ones. Due to their many indications in a wide range of medical fields, assessing the appropriateness of AD prescription seems to be a challenge for GPs. The aim of this study was to review evidence from guidelines for antidepressant prescription for non-psychiatric conditions in Primary Care (PC) settings. METHODS: Data were retrieved from French, English and US guideline databases. Guidelines or reviews were eligible if keywords regarding 44 non-psychiatric conditions related to GPs' prescription of ADs were encountered. After excluding psychiatric and non-primary care conditions, the guidelines were checked for keywords related to AD use. The latest updated version of the guidelines was kept. Recent data was searched in the Cochrane Database of Systematic Reviews and in PubMed for updated reviews and randomized control trials (RCTs). RESULTS: Seventy-eight documents were retrieved and were used to assess the level of evidence of a potential benefit to prescribing an AD. For 15 conditions, there was a consensus that prescribing an AD was beneficial. For 5 others, ADs were seen as potentially beneficial. No proof of benefit was found for 15 conditions and proof of no benefit was found for the last 9. There were higher levels of evidence for pain conditions, (neuropathic pain, diabetic painful neuropathy, central neuropathic pain, migraine, tension-type headaches, and fibromyalgia) incontinence and irritable bowel syndrome. There were difficulties in summarizing the data, due to a lack of information on the level of evidence, and due to variations in efficacy between and among the various classes of ADs. CONCLUSIONS: Prescription of ADs was found to be beneficial for many non-psychiatric health conditions regularly encountered in PC settings. On the whole, the guidelines were heterogeneous, seemingly due to a lack of trials assessing the role of ADs in treatment strategies.

From qualitative data to GP training on CRC screening.

Colorectal cancer (CRC) is the third most common cancer worldwide. In France, although mass screening has been performed using the guaiac fecal occult blood test since 2008, the participation rate remains too low. Previous studies have explored the perspectives of doctors and patients as well as the performance of general practitioners (GPs) by recording and analyzing consultations in which patients came and asked for fecal occult blood test. Results indicated that improvement was needed in patient-centered communication. This research aims to develop educational material and training programs for GPs in order to enhance their communication with patients on CRC screening, based on data from two qualitative studies. Triangulation of all qualitative data was performed and discussed with communication experts in order to develop educational material and training programs based on the patient-centered clinical method. Two different scenarios were developed to improve communication with patients: one for a compliant patient and another for a noncompliant patient. Two videos were made featuring a doctor and a simulated patient. A two-sequence training program was built, including role-playing and presentation of the video followed by a discussion. The qualitative data helped us to produce a useful, relevant training program for GPs on CRC screening.

Understanding factors affecting implementation success and sustainability of a comprehensive prevention program for cardiovascular disease in primary health care: a qualitative process evaluation study combining RE-AIM and CFIR.

AIM: Our aim was to evaluate the implementation process of a comprehensive cardiovascular disease prevention program in general practice, to enhance understanding of influencing factors to implementation success and sustainability, and to learn how to overcome barriers. BACKGROUND: Cardiovascular disease and its risk factors are the world's leading cause of mortality, yet can be prevented by addressing unhealthy lifestyle behavior. Nevertheless, the transition toward a prevention-oriented primary health care remains limited. A better understanding of factors facilitating or hindering implementation success and sustainability of prevention programs, and how barriers may be addressed, is needed. This work is part of Horizon 2020 project 'SPICES', which aims to implement validated preventive interventions in vulnerable populations. METHODS: We conducted a qualitative process evaluation with participatory action research approach of implementation in five general practices. Data were collected through 38 semi-structured individual and small group interviews with seven physicians, 11 nurses, one manager and one nursing assistant, conducted before, during, and after the implementation period. We applied adaptive framework analysis guided by RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) and Consolidated Framework for Implementation Research (CFIR). FINDINGS: Multiple facilitators and barriers affected reach of vulnerable target populations: adoption by primary health care providers, implementation and fidelity and intention to maintain the program into routine practice. In addition, our study revealed concrete actions, linked to implementation strategies, that can be undertaken to address identified barriers. Prioritization of prevention in general practice vision, ownership, and shared responsibility of all team members, compatibility with existing work processes and systems, expanding nurse's roles and upskilling competence profiles, supportive financial and regulatory frameworks, and a strong community - health care link are crucial to increase implementation success and long-term maintenance of prevention programs. COVID-19 was a major barrier to the implementation. RE-AIM QuEST, CFIR, and participatory strategies are useful to guide implementation of prevention programs in primary health care.

Prevention of Cardiovascular Diseases in Community Settings and Primary Health Care: A Pre-Implementation Contextual Analysis Using the Consolidated Framework for Implementation Research.

Cardiovascular diseases are the world's leading cause of mortality, with a high burden especially among vulnerable populations. Interventions for primary prevention need to be further implemented in community and primary health care settings. Context is critically important to understand potential implementation determinants. Therefore, we explored stakeholders' views on the evidence-based SPICES program (EBSP); a multicomponent intervention for the primary prevention of cardiovascular disease, to inform its implementation. In this qualitative study, we conducted interviews and focus groups with 24 key stakeholders, 10 general practitioners, 9 practice nurses, and 13 lay community partners. We used adaptive framework analysis. The Consolidated Framework for Implementation Research guided our data collection, analysis, and reporting. The EBSP was valued as an opportunity to improve risk awareness and health behavior, especially in vulnerable populations. Its relative advantage, evidence-based design, adaptability to the needs and resources of target communities, and the alignment with policy evolutions and local mission and vision, were seen as important facilitators for its implementation. Concerns remain around legal and structural characteristics and intervention complexity. Our results highlight context dimensions that need to be considered and tailored to primary care and community needs and capacities when planning EBSP implementation in real life settings.

Examining positive views from students, trainees and GPs about general practice: a generational problem? A set of qualitative studies in France.

OBJECTIVE: This study aimed to explore the positive factors related to working in general practice in France, from a student studying medicine, trainee general practitioner (GP) and GP point of view. SETTING: Primary care, France. DESIGN: Nine different qualitative studies involving medical students, trainees and GPs. PARTICIPANTS: Sixty-seven medical students, 22 trainees in general practice and 71 GPs. RESULTS: The final codebook contained 66 interpretative codes and 8 positive themes. The themes were general practice as a commitment, doctor-patient care and relationships, skills and competencies in general practice, practice organisation and work-life balance, relationship with the professional community, GPs and university, GPs in the social community and private life, relatives and family. Positive feelings about being a GP are similar throughout the different age groups, from young students to older professionals. DISCUSSION AND CONCLUSION: This study provided a comprehensive picture of the satisfied GP across different ages. This picture describes GPs as patient-centred professionals who need to have the freedom to choose an efficient working environment, organise their practice, have opportunities for professional development and acquire specific competencies. Both younger and older GPs believe in the future of general practice.

Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis.

In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is "an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias." Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I 2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.

Reanalysis of a Randomized Controlled Trial on Promoting Influenza Vaccination in General Practice Waiting Rooms: A Zelen Design.

In 2014-2015, we conducted a randomized controlled trial (RCT) assessing the effect of an advertising campaign for influenza vaccination using posters and pamphlets in general practitioner (GP) waiting rooms. No effect of the intervention could be demonstrated, but the immunization uptake increased in both arms of the study. In 2019, we deepened the investigations explaining the increased uptake conducting a registry-based 4/2/1 cluster RCT designed by Zelen with two extra years of follow-up of the study cohort. The study population included 23,024 patients eligible to be vaccinated who were registered with 175 GPs. The main outcome remained the number of vaccination units delivered per study group. Data were extracted from the SNIIRAM warehouse claim database for the Lille-Douai district (northern France). No difference in vaccination uptake was found in the Zelen versus the control group of the initial RCT. Overall, the proportion of vaccinated patients increased in the cohort from 51.4% to 70.4% over the three years. Being vaccinated the previous year was a strong predictor of being vaccinated in a subsequent year. The increase in vaccination uptake, especially among people older than 65, can be explained by a cohort effect. Health promotion and the promotion of primary health care may play an important role in this increase.

Obstacles to colorectal screening in general practice: a qualitative study of GPs and patients.

BACKGROUND: The faecal occult blood test (FOBT) has proven efficiency at screening populations for an average risk of colorectal cancer. Mortality related to this cancer decreases by 15-18% among adults, 50-74 years old, tested every 2 years. A participation rate of at least 50% is desirable. This rate has not yet been reached in most French regions. OBJECTIVE: To explore the obstacles to mass colorectal screening in France. METHOD: In 2009, five focus groups were conducted in different areas to explore physicians' obstacles to FOBT screening. The patients' obstacles were assessed in semi-structured interviews. A purposive sampling had been carried out for both GPs and patients. The focus groups were coded using Nvivo 8(®) software by three researchers; the interviews manually coded by two researchers. RESULTS: GPs reported insufficient training and some doubted the relevance of screening. They expressed concern of having insufficient time for the test during a consultation, as well as practical and administrative obstacles. Some GPs experienced difficulty persuading patients who had no signs of colorectal disease. Obstacles for patients were mainly difficulties in doing screening themselves and a perception of health care that didn't match with screening. Information and organization were also important points to improve. The screening process was considered complex both by GPs and by patients. CONCLUSIONS: Numerous obstacles to colorectal screening, from both the physicians' and the patients' perspectives, were found. The major goal to improve mass screening may be to increase awareness and understanding of both physicians and patients regarding this process.

Understanding the prescription of antidepressants: a Qualitative study among French GPs.

BACKGROUND: One-tenth of France's population is prescribed at least one antidepressant, primarily by General Practitioners. The reasons for this high prescription rate remain unclear. One-third of these prescriptions may not comply with clinical practice guidelines, and 20% are potentially unrelated to any psychiatric condition. Our aim was to explore how GPs declare they use antidepressants in daily practice and understand their reasons for prescribing them. METHOD: Six focus groups including a total of 56 rural and urban GPs, with four interviews were performed. The topic guide focused on reasons for prescribing antidepressants in various primary care situations. Phenomenological analysis was performed by four researchers. RESULTS: Antidepressants were seen as useful and not harmful. Personal assessment based on experience and feeling determined the GPs' decisions rather than the use of scales. Twenty-four "non-psychiatric" conditions possibly leading to prescription of antidepressants in primary care were found. CONCLUSIONS: The GPs reported prescribing antidepressants for a wide range of conditions other than depression. The GPs' decision making process is difficult and complex. They seemed to prefer to focus on their difficulties in diagnosing depression rather than on useless overtreatment. Instead of using the guidelines criteria to detect potential cases of useful prescription, physicians tend to use their own tools based on gut feelings, knowledge of the patient and contextual issues.