Customized interventions improved employees' experience of recovery during the workday.

BACKGROUND: There is a lack of research regarding factors promoting recovery during the workday and effective interventions. OBJECTIVE: To evaluate how different intervention activities may impact employees' experiences of recovery at the workplace. METHODS: Customized intervention activities based on qualitative results and a participatory approach were integrated among the employees at six primary health care centres (PHCCs; n = 166) during one year. Recovery and workplace factors were measured with a questionnaire at the start and end of intervention, and also in a control group (15 PHCCs; n = 328). Group differences were tested (Chi-2) and explanatory factors compared by logistic regression models. RESULTS: The proportion of employees reporting workday recovery increased in the intervention group (19.9%to 29.1%; p = 0.01), whereas the control group showed no significant change. Recovery was explained by self-reflection and reflection with co-workers. After intervention, having influence on work situation, energy-building experience, and opportunity for laughter also contributed significantly to recovery. CONCLUSIONS: The results contribute to work recovery research by confirming that a customized intervention may have an impact on employees' recovery experiences. The study showed that considering the factors of reflection, influence, and companionship can positively impact workplace recovery.

Strengthened workplace relationships facilitate recovery at work - qualitative experiences of an intervention among employees in primary health care.

BACKGROUND: The literature on workplace interventions focusing on recovery is scarce; hence this study intends to expand that knowledge. An intervention was run for one year, aiming at increasing the experience of recovery during the workday among primary health care employees. During the intervention, different forms of recovery activities were integrated into the daily work at six primary health care centres. The aim of this study was to explore the intervention process and its effects. METHODS: After completion of an intervention, 39 employees in seven focus groups were interviewed about their experiences of the intervention. A semi-structured interview guide was used, and the qualitative analysis was conducted by systematic text condensation. RESULTS: Despite different conditions and attitudes when the project was launched, the participants portrayed a positive outcome of the intervention at all six workplaces. Four promoting factors for intervention success were identified: support, legitimacy, customization, and simplicity. Also, three areas of improvement during the intervention period were described: the workplace climate, employee well-being, and recovery awareness, which in turn became promoting factors. CONCLUSIONS: An intervention aiming at increasing workplace recovery can be promoted by support, legitimacy, customization, and simplicity. By using these promoting factors, health care workplaces can implement activity models which could increase employees' experiences of recovery during the workday. Positive effects on workplace climate and employee well-being can also be achieved.

Variation, companionship and manageability important for recovery during working hours: A qualitative focus group study.

BACKGROUND: Lack of recovery from everyday strains and demands is connected to increased levels of stress-related problems and development of ill-health. There is much research on how to handle and prevent fatigue and stress in leisure time, but research on working time is more scarce. A recent study found that employees' experience of recovery during working hours was related to high self-rated health. OBJECTIVE: The aim of this study was to explore the concept of recovery during working hours among primary health care workers. METHODS: Eight focus groups with 50 staff members, men and women, from different professions were conducted in the primary health care sector in southern Sweden. The analysis was inspired by systematic text condensation, a strategy for qualitative analysis. RESULTS: Three main categories were identified as important factors for experiencing recovery during working hours: variation (including changes in location, tasks and tempo) companionship (including helpfulness, appreciation, social chat and laughter) and manageability (including completion, satisfaction, influence, control and reflection). CONCLUSIONS: Recovery during working hours is multifaceted. The categories identified in this study will be further elaborated and tested.

We lived and breathed medicine - then life catches up: medical students' reflections.

BACKGROUND: Reflective writing enhances personal and professional development. It is essential for the teachers to be familiar with the students' perceptions to improve the students' learning. Our aim was to deepen the understanding of the medical students' perceptions of the studies and the coming profession. METHODS: Our theoretical perspective is constructivist, based upon the relativist view that individuals construct realities to understand and navigate the world. Constructivist methodologies are hermeneutic, with the focus on understanding rather than explaining. Thirty-five written reflections were collected in the first and fifth semesters at Lund University Medical School, Sweden. We used a thematic analysis, close to editing style analysis, inspired by K Malterud, who has modified Giorgi's phenomenological method. RESULTS: For first-semester students the focus is on studies and methods to structure them. The fifth semester is permeated by strategies for achieving a sense of 'good enough', qualities of a good doctor and applicability. Clinical placement as a motivating element is important for both semesters. CONCLUSIONS: A sense of 'good enough' is crucial for students to get by. Reflective writing can illuminate the strategies for achieving this. Clinical placement is vital for motivation.

Stroke and unsteadiness - a cross-sectional study from primary health care.

BACKGROUND: Dizziness is seldom the only symptom among patients who develop stroke but patients, hospitalized for vertigo are at higher risk of stroke than the general population. The proportions of patients who have remaining dizziness after a stroke seem to be unclear. OBJECTIVES: To study the frequency of dizziness among stroke patients referred to rehabilitation in primary health care and to study the relation between dizziness and gender, age, activity and self-rated health. METHODS: Patients with first-time stroke who were referred to rehabilitation in primary health care after the initial hospital stay were included. Dependence/independence in daily activities and self-rated health was measured. A question about whether the patient had experienced any dizziness or unsteadiness was asked. RESULTS: Sixty three patients were included in the study, (39 men, 24 women) aged 36-85 years. The majority of patients were dizzy (70%). Being female increased the risk of being dizzy substantially (OR 9.43). Patients with dizziness had poorer self-rated health than patients without dizziness (p = 0.001). CONCLUSION: Dizziness is a common symptom among patients with stroke, especially among female patients, and is associated with lower self-rated health. Therefore, it is important to address dizziness in the rehabilitation of stroke patients.

Physical activity on prescription (PAP) from the general practitioner's perspective - a qualitative study.

BACKGROUND: Physical activity on prescription (PAP) is a successful intervention for increasing physical activity among patients with a sedentary lifestyle. The method seems to be sparsely used by general practitioners (GPs) and there is limited information about GPs' attitudes to counselling using PAP as a tool. The aim of the study was to explore and understand the meaning of prescribing physical activity from the general practitioner's perspective. METHODS: Three focus group interviews were conducted with a purposive sample of 15 Swedish GPs in the south of Sweden. Participants were invited to talk about their experience of using PAP. The interviews were transcribed verbatim, analysed using qualitative content analysis. RESULTS: The analysis resulted in four categories: The tradition makes it hard to change attitude, Shared responsibility is necessary, PAP has low status and is regarded with distrust and Lack of procedures and clear guidelines. Traditionally GPs talk with patients about the importance of an increased level of physical activity but they do not prescribe physical activity as a treatment. Physician's education focuses on the use of pharmaceuticals. The responsibility for patients' physical activity level is shared with other health professionals, the patient and society. The GPs express reservations about prescribing physical activity. A heavy workload is a source of frustration. PAP is regarded with distrust and considered to be a task of less value and status. Using a prescription to emphasize an increased level is considered to be redundant and the GPs think it should be administered by someone else in the health care system. Scepticism about the result of the method was also expressed. CONCLUSIONS: There is uncertainty about using PAP as a treatment since physicians lack education in non-pharmaceutical methods. The GPs do not regard the written referral as a prioritized task and rather refer to other professionals in the health care system to prescribe PAP. GPs pointed out a need to create routines and arrangements for the method to gain credibility and become everyday practice among GPs.

"I'm Dr Jekyll and Mr Hyde": are GPs' antibiotic prescribing patterns contextually dependent? A qualitative focus group study.

OBJECTIVE: To explore factors and circumstances contributing to prudent antibiotic prescribing for respiratory tract infections in primary care. DESIGN: Two focus groups representing rural and urban areas. A semi-structured interview guide with open-ended questions and an editing analysis style was used. They were examined to identify meaning units that were sorted into categories in an iterative process throughout the analysis. SETTING: Primary health care in two counties in southern Sweden. SUBJECTS: Two groups including seven and six general practitioners (GPs) respectively, men and women of different ages with different professional experiences. MAIN OUTCOME MEASURES: Exploration of categories, determination of themes, construction of models. RESULTS: The decision to prescribe antibiotics takes place in the encounter between GP and patient, initially characterized by harmony or fight and the subsequent process by collaboration or negotiation, resulting in agreement, compromise, or disagreement. Several factors influence the meeting and contribute to enhancing the conditions for rational prescribing. These conditions are connected to the GP, the relationship, and the setting; organization as well as professional culture. The findings indicate synergies between the factors, and that one factor can sometimes compensate for lack of another. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills. CONCLUSIONS: The findings emphasize the importance of the encounter between the GP and the patient for prudent antibiotic prescribing. Furthermore, the importance of an appropriate organization of primary care, which promotes continuity and encourages professional autonomy, is demonstrated.

Satisfaction with rehabilitation in relation to self-perceived quality of life and function among patients with stroke - a 12 month follow-up.

BACKGROUND AND PURPOSE: Stroke causes complex disability and function, and perceived quality of life has been shown to correlate with satisfaction with care as well as with life in general among stroke patients. The aim of this study was to study the relation of satisfaction with how rehabilitation was provided with self-perceived quality of life, self-perceived function and rehabilitation received, 12 months after the incidence. METHOD: The subjects were assessed 12 months after the onset of stroke. The Barthel index was used to measure function, and the EuroQol-5D to measure quality of life. To measure satisfaction with how rehabilitation was provided, a questionnaire from the Swedish Stroke Register was used. RESULTS: Two hundred and eighty-three patients participated in the follow-up, 137 women and 146 men, aged between 42 and 95 years (mean age 75.2, SD 11.8). For the majority of patients rehabilitation was initiated at in-hospital care (directly after onset). One hundred and sixty-eight patients considered that rehabilitation was well provided for. Sixty-six regarded that the rehabilitation was only partly provided for and 35 that it was not provided for at all. High value on Barthel Index was associated with satisfaction with how rehabilitation was provided for (OR 2.81). Also, rehabilitation on three or more levels was negatively associated with satisfaction with rehabilitation provision (OR 0.24) and so was being male (OR 0.49). CONCLUSION: In this study, patients with higher values on Barthel Index were more satisfied with how rehabilitation was provided for. However, male patients and patients who received rehabilitation on three or more levels of care were less satisfied. Given the assumption that patients with more severe dysfunction after stroke are being rehabilitated on more levels, this might imply that it is not the amount of rehabilitation that gives satisfaction but the patients self-perceived function after rehabilitation.

Snus user identity and addiction: a Swedish focus group study on adolescents.

BACKGROUND: The teenage years are the years when adolescents seek their identity, and part of this involves experimenting with tobacco. The use of tobacco as such, and norms among their friends, is more important to the adolescents than the norms of parents when it comes to using tobacco or not. The aim was to explore the significance of using snus for adolescents, and attitudes to snus, as well as the reasons why they began using snus and what maintained and facilitated the use of snus. METHODS: Adolescents who use snus were interviewed in focus groups. The material was analysed using content analysis. RESULTS: Four groups of boys and one group of girls were interviewed, a total of 27 students from the upper secondary vocational program. Three themes related to the students' opinions on and experiences of using snus were found: Circumstances pertaining to snus debut indicate what makes them start using snus. Upholding, which focuses on the problem of becoming addicted and development of identity, and approach, where the adolescents reflect on their snus habits in relation to those around them. A number of factors were described as relevant to behaviour and norm building for the development into becoming a snus user. Attitudes and actions from adults and friends as well as - for the boys - development of an identity as a man and a craftsman influenced behaviour. CONCLUSIONS: The results showed that development of identity was of major importance when adolescents start using snus. The adolescents were initially unable to interpret the early symptoms of abstinence problems, but subsequently became well aware of being addicted. Once they were stuck in addiction and in the creation of an image and identity, it was difficult to stop using snus. These factors are important when considering interventions of normative changes and tobacco prevention in schools as well as among parents.

Frail elderly patients' experiences of information on medication. A qualitative study.

BACKGROUND: Older patients generally have only poor knowledge about their medicines. Knowledge is important for good adherence and for participating in decisions about treatment. Patients are entitled to be informed on an individual and adequate level. The aim of the study was to explore frail elderly patients' experiences of receiving information about their medications and their views on how the information should best be given. METHODS: The study was qualitative in design and was carried out in 2011. Twelve frail elderly (aged 68-88) participants taking cardiovascular medications participated in semi-structured interviews covering issues related to receiving information about prescribed medicines. The interviews were recorded, transcribed and subjected to content analysis, in which the text was analysed in five steps, inspired by Graneheim and Lundman. RESULTS: The results revealed that the experiences which the elderly participants had regarding the receiving of medical information fell into two main categories: "Comfortable with information" or "Insecure with information". The elderly felt comfortable when they trusted their physician or their medication, when they received enough information from the prescriber or when they knew how to find out sufficient information by themselves. They felt insecure if they were anxious, if the availability of medical care was poor or if they did not receive enough information. CONCLUSIONS: Factors that frequently caused insecurity about information and anxiety were too short consultations, lack of availability of someone to answer questions or of the opportunity to contact the physician if adverse effects are suspected. These factors could easily be dealt with and there must be improvements in the clinics if the patients' feelings of security are to be increased.

GP's adherence to guidelines for cardiovascular disease among elderly: a quality development study.

BACKGROUND: Evidence-based guidelines should in most cases be followed also in the treatment of elderly. Older people are often suboptimally treated with the recommended drugs. OBJECTIVES: To describe how well general practitioners adhere to current guidelines in the treatment of elderly with cardiovascular disease and evaluate local education as a tool for improvement. METHOD: Data was collected from the medical records of patients aged ≥ 65, who visited a primary health care center in Sweden 2006 and had one or more of the following diagnoses: hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation, or prior stroke. Local education was organized and included feed-back to the patient's doctor and discussion about regional guidelines. Repeated measurements were performed in 2008. RESULTS AND CONCLUSION: The adherence to guidelines was low. Approximately one-third of the patients with hypertension reached target blood pressure, stroke patients more often. More patients with heart failure were treated with angiotensin converting enzyme inhibitor than in other European countries, but still only 60%. Half of the patients with chronic atrial fibrillation were treated with Warfarin, although more than two-thirds had a CHADS(2) score indicating the need. Educational efforts appeared to increase the adherence and hence should be encouraged.

Exploring workplace related health resources from a salutogenic perspective. Results from a focus group study among healthcare workers in Sweden.

OBJECTIVE: The aim of this study was to explore healthcare workers' opinions on workplace related health resources relevant to promotion of their health. PARTICIPANTS: 16 registered nurses and 19 assistant nurses, from a medical emergency ward at a medium sized hospital in the south of Sweden, participated in the study. METHODS: Eight focus group interviews were conducted, the material was condensed and conventional qualitative content analysis was used to elicit and identify patterns in the expressed opinions of the participants. RESULTS: The analysis yielded four themes that were labelled the reward, the team, the mission and the context. An explanatory model was constructed consisting of concentric circles, with the reward at the core. The qualitative analysis also revealed two divergent patterns; some of the participants associated positive health with stability while others referred to flexibility. CONCLUSIONS: The results from this study have contributed to the body of knowledge regarding salutogenic health indicators in the field of work and health research in particular as well as in health promotion in general. The findings show that individuals can have diverse responses to any given work situation, and this should be taken into account before implementation of salutogenic health promotion programs.

Can the APO method be used for measuring soft data?: a pilot study.

OBJECTIVES: The aims were to develop auditing according to the APO (Audit Project Odense) method for measuring soft data, exemplified by a holistic view, and to test the instrument. DESIGN: A descriptive study of the development of an APO chart and a test registration. SETTING: Primary health care, Blekinge County, Sweden. SUBJECTS: Ten general practitioners (GPs) were invited to transform categories of the concept of a holistic view obtained in an earlier study, into 30 variables on an APO registration chart. The participants chose to study different kinds of knowledge as aspects of holistic care. MAIN OUTCOME MEASURE: An APO registration chart and test of the instrument. RESULTS: After three meetings the group had drawn up an APO registration chart supplemented with Likert scales. A pilot audit was performed. Eight doctors registered 255 consultations. In assessment of the patients' problems, factual medical knowledge was important in 83% of the cases, familiarity in 53%, and a capacity for judgement in 36%. In decision-making factual medical knowledge was used in 88% and capacity for judgement in 58%. A holistic view was necessary for the outcome in 43% and valuable in 25%. The GPs used the Likert scales in a majority of the cases. CONCLUSIONS: In this first step in developing an instrument, the results indicate that the APO method could be an alternative for studying what happens in the consultation, and the occurrence of an abstract phenomenon such as the use of different kinds of knowledge as part of a holistic view.

Pain, power and patience--a narrative study of general practitioners' relations with chronic pain patients.

BACKGROUND: Chronic pain patients are common in general practice. In this study "chronic pain" is defined as diffuse musculoskeletal pain not due to inflammatory diseases or cancer. Effective patient-physician relations improve treatment results. The relationship between doctors and chronic pain patients is often dysfunctional. Consultation training for physicians and medical students can improve the professional ability to build effective relations, but this demands a thorough understanding of the problems in the relation. Several studies have defined the issues that frequently cause problems, but few have described the process. The aim of this study was to understand and illustrate what GPs' experience in contact with chronic pain patients and what works and does not work in these consultations. METHODS: Our theoretical perspective is constructivist, based upon the relativist view that individuals construct realities to understand and navigate the world. Five Swedish General Practitioners (GPs), two male and three female, were interviewed and asked to tell a story about a difficult encounter with a chronic pain patient. Tapes of the interviews were transcribed and analysed using narrative analysis. Three GPs told narratives suited for our analytic tools and these were included in the final results. RESULTS: Each narrative highlights a certain dilemma and a strategy. The dilemmas were: power game; good intentions that fail when a patient is persuaded against her own conviction; persuasion of the unwilling; transferred tiredness; distrust and dissociation from the patient. Professional strategies of listening, encouraging and teamwork were central to handling difficult situations. CONCLUSIONS: The narratives show that GP's consultations with chronic pain patients sometimes are characterized by conflicts and difficult situations. They are facilitated by methods such as active listening and teamwork, but still may remain hard to handle. This has not before been studied among Swedish GPs. Narratives based on experience are known to be successful in education and this study suggest how narratives can serve as a training of consultation for medical students, but also in Continuing Professional Development groups for experienced doctors in practice.

The meaning of quality work from the general practitioner's perspective: an interview study.

BACKGROUND: The quality of health care and its costs have been a subject of considerable attention and lively discussion. Various methods have been introduced to measure, assess, and improve the quality of health care. Many professionals in health care have criticized quality work and its methods as being unsuitable for health care. The aim of the study was to obtain a deeper understanding of the meaning of quality work from the general practitioner's perspective. METHODS: Fourteen general practitioners, seven women and seven men, were interviewed with the aid of a semi-structured interview guide about their experience of quality work. The interviews were tape-recorded and transcribed verbatim. Data collection and analysis were guided by a phenomenological approach intended to capture the essence of the statements. RESULTS: Two fundamentally different ways to view quality work emerged from the statements: A pronounced top-down perspective with elements of control, and an intra-profession or bottom-up perspective. From the top-down perspective, quality work was described as something that infringes professional freedom. From the bottom-up perspective the statements described quality work as a self-evident duty and as a professional attitude to the medical vocation, guided by the principles of medical ethics. Follow-up with a bottom-up approach is best done in internal processes, with the profession itself designing structures and methods based on its own needs. CONCLUSIONS: The study indicates that general practitioners view internal follow-up as a professional obligation but external control as an imposition. This opposition entails a difficulty in achieving systematism in follow-up and quality work in health care. If the statutory standards for systematic quality work are to gain a real foothold, they must be packaged in such a way that general practitioners feel that both perspectives can be reconciled.

Humanities for medical students? A qualitative study of a medical humanities curriculum in a medical school program.

BACKGROUND: Today, there is a trend towards establishing the medical humanities as a component of medical education. However, medical humanities programs that exist within the context of a medical school can be problematic. The aim of this study was to explore problems that can arise with the establishment of a medical humanities curriculum in a medical school program. METHODS: Our theoretical approach in this study is informed by derridean deconstruction and by post-structuralist analysis. We examined the ideology of the Humanities and Medicine program at Lund University, Sweden, the practical implementation of the program, and how ideology and practice corresponded. Examination of the ideology driving the humanities and medicine program was based on a critical reading of all available written material concerning the Humanities and Medicine project. The practice of the program was examined by means of a participatory observation study of one course, and by in-depth interviews with five students who participated in the course. Data was analysed using a hermeneutic editing approach. RESULTS: The ideological language used to describe the program calls it an interdisciplinary learning environment but at the same time shows that the conditions of the program are established by the medical faculty's agenda. In practice, the "humanities" are constructed, defined and used within a medical frame of reference. Medical students have interesting discussions, acquire concepts and enjoy the program. But they come away lacking theoretical structure to understand what they have learned. There is no place for humanities students in the program. CONCLUSION: A challenge facing cross-disciplinary programs is creating an environment where the disciplines have equal standing and contribution.

Meeting and treating cultural difference in primary care: a qualitative interview study.

BACKGROUND: Primary care doctors see patients from diverse cultural backgrounds and communication plays an important role in diagnosis and treatment. Communication problems can arise when patient and doctor do not share the same cultural background. OBJECTIVE: The aim of this study was to examine how consultations with immigrant patients are understood by GPs and how GPs manage these consultations. METHODS: Semi-structured interviews with GPs about their experiences with immigrant patients were recorded on audio-tape, transcribed and analysed using a qualitative thematic analysis methodology. A constructivist approach was taken to analysis and interpretation. RESULTS: Culture is not in focus when GPs meet immigrant patients. The consultation is seen as a meeting between individuals, where cultural difference is just one of many individual factors that influence how well doctor and patient understand each other. However, when mutual understanding is poor and the consultation not successful, cultural differences are central. The GPs try to conduct their consultations with immigrant patients in the same way that they conduct all their consultations. There is no specific focus on culture, instead, GPs tend to avoid addressing even pronounced cultural differences. CONCLUSION: This study indicates that cultural difference is not treated in GPs consultation with immigrant patients. Learning about cultural difference's effect on mutual understanding between doctor and patient could improve GPs cross-cultural communication. Increased awareness of the culture the doctor brings to the consultation could facilitate management of cross-cultural consultations.

General practitioners' conceptions of depressive disorders in relation to regional sales levels of antidepressive drugs. A study based on a postal survey and ecological data.

OBJECTIVES: To examine how local sales levels of antidepressive agents (ADs) correlated with GPs' conceptions of depressive disorders and of factors that may influence their work with depressed patients. DESIGN: A postal questionnaire survey to GPs requesting their conceptions of depression and their opinions of additional factors that may influence their work with depressed patients. GPs' conceptions and opinions were compared with local sales rates of ADs. SETTINGS: Three selected groups of Swedish municipalities: those with the highest, the average, and the lowest sales rates of ADs. SUBJECTS: All 535 GPs who worked in the selected municipalities. MAIN OUTCOME MEASURES: Spearman rank correlations for responses to the questionnaire with the sales levels of ADs. RESULTS: High sales levels correlated positively with a high evaluation of ADs' effectiveness in depression and panic disorders and were inversely correlated with the degree of appreciation of psychotherapy-based treatments. High sales levels were also associated with a high evaluation of GPs' own clinical and private experience, with a positive appreciation of the work with depressed patients and with a high level of participation in the pharmaceutical companies' activities. The demonstrated statistical correlations were not particularly strong and included less than half of the items. CONCLUSIONS: This ecological study confirms a number of statistical associations between sales levels of ADs and GPs' prevailing conceptions of factors related to depression. However, their explanatory value of the geographical sale variation appears limited. To further clarify this variation, studies employing information on individual GPs' conceptions and prescribing are required.

Influence of self-registration on audit participants and their non-participating colleagues. A retrospective study of medical records concerning prescription patterns.

OBJECTIVE: To compare participants and non-participants early in the process of an audit on treatment of respiratory tract infections (RTIs) and to analyse any effect of the actual self-registration on the prescription of antibiotics in both groups. DESIGN: All 80 general practitioners (GPs) at 14 health centres were invited to audit their use of antibiotics and 45 agreed to participate. There were both participants and non-participants at all centres. Data were collected retrospectively from the electronic patient records of all visits for RTI during five periods including the self-registration period. Comparisons were made over time within and between the groups. SETTING: Primary health care in Blekinge county, Southern Sweden. SUBJECTS: 80 GPs: 45 participants and 35 non-participants. MAIN OUTCOME MEASURE: Proportion of patients with RTI who received antibiotics. RESULTS: At the start, the difference in prescription frequency between participants and non-participants was six percentage points (RR = 0.92; 95% CI = 0.87-0.97), and at the end seven percentage points (0.88; 0.81-0.95). The proportion of RTIs treated with antibiotics fell for both groups, (0.86; 0.80-0.92 and 0.90; 0.83-0.97, respectively). CONCLUSIONS: GPs who chose to take part in the audit had a different prescription pattern from the non-participants right from the start. Both groups reduced their prescription of antibiotics during the study period. Either the registration had no effect on the participants or it had an effect on both the participants and the non-participants.