Segmenting Patients With Diabetes With the Navigator Service in Primary Care and a Description of the Self-Acting Patient Group: Cross-Sectional Study.

BACKGROUND: The aim of patient segmentation is to recognize patients with similar health care needs. The Finnish patient segmentation service Navigator segregates patients into 4 groups, including a self-acting group, who presumably manages their everyday life and coordinates their health care. Digital services could support their self-care. Knowledge on self-acting patients' characteristics is lacking. OBJECTIVE: The study aims are to describe how Navigator assigns patients with diabetes to the 4 groups at nurses' appointments at a health center, the self-acting patient group's characteristics compared with other patient groups, and the concordance between the nurse's evaluation of the patient's group and the actual group assigned by Navigator (criterion validity). METHODS: Patients with diabetes ≥18 years old visiting primary care were invited to participate in this cross-sectional study. Patients with disability preventing informed consent for participation were excluded. Nurses estimated the patients' upcoming group results before the appointment. We describe the concordance (%) between the evaluation and actual groups. Nurses used Navigator patients with diabetes (n=304) at their annual follow-up visits. The self-acting patients' diabetes care values (glycated hemoglobin [HbA1c], urine albumin to creatinine ratio, low-density lipoprotein cholesterol, blood pressure, BMI), chronic conditions, medication, smoking status, self-rated health, disability (World Health Organization Disability Assessment Schedule [WHODAS] 2.0), health-related quality of life (EQ-5D-5L), and well-being (Well-being Questionnaire [WBQ-12]) and the patients' responses to Navigator's question concerning their digital skills as outcome variables were compared with those of the other patients. We used descriptive statistics for the patients' distribution into the 4 groups and demographic data. We used the Mann-Whitney U test with nonnormally distributed variables, independent samples t test with normally distributed variables, and Pearson chi-square tests with categorized variables to compare the groups. RESULTS: Most patients (259/304, 85.2%) were in the self-acting group. Hypertension, hyperlipidemia, and joint ailments were the most prevalent comorbidities among all patients. Self-acting patients had less ischemic cardiac disease (P=.001), depression or anxiety (P=.03), asthma or chronic obstructive pulmonary disease (P<.001), long-term pain (P<.001), and related medication. Self-acting patients had better self-rated health (P<.001), functional ability (P<.001), health-related quality of life (P<.001), and general well-being (P<.001). All patients considered their skills at using electronic services to be good. CONCLUSIONS: The patients in the self-acting group had several comorbidities. However, their functional ability was not yet diminished compared with patients in the other groups. Therefore, to prevent diabetic complications and disabilities, support for patients' self-management should be emphasized in their integrated care services. Digital services could be involved in the care of patients willing to use them. The study was performed in 1 health center, the participants were volunteers, and most patients were assigned to self-acting patient group. These facts limit the generalizability of our results. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/20570.

Patient enablement after a consultation with a general practitioner-Explaining variation between countries, practices and patients.

BACKGROUND: Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking. OBJECTIVE: To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement. DESIGN: We constructed multi-level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated. SETTING AND PARTICIPANTS: A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data. RESULTS: In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient-level and only a few practice-level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health-care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported. DISCUSSION AND CONCLUSIONS: There are large differences in patient enablement between GPs and countries. Patient characteristics and patients' perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient-reported measures as an indicator of health-care system performance, researchers should be aware of the influence of cultural elements.

Intrahepatic cholestasis of pregnancy and comorbidity: A 44-year follow-up study.

INTRODUCTION: Intrahepatic cholestasis of pregnancy (ICP) is a reversible liver disorder occurring during pregnancy. It has a typical genetic background with known genetic mutations and can be considered an expression of this genetic predisposition. The objective of this study was to determine whether ICP is associated with specific long-term comorbidity. MATERIAL AND METHODS: The study population comprised 571 women with ICP in at least one pregnancy who were compared with 1333 pregnant women without ICP during 1969-1988 at Tampere University Hospital, Finland. The cohort's follow-up time was 44 years. All ICD-10 classification discharge diagnoses were examined for the women in the ICP group from 1998 to 2013 and ICD-10 diagnoses from outpatient care from 1969 to 2013. RESULTS: At least one disease of the digestive system had been diagnosed in 50.4% (288/571) of the ICP mothers compared with 34.4% (459/1333) of the reference group (P < 0.001). In a more detailed analysis, women with a history of ICP had an increased risk for cholelithiasis and/or cholecystitis (odds ratio [OR] 2.88, 95% confidence interval [CI] 2.17 to 3.84), diseases of the pancreas (OR 2.26, 95% CI 1.20 to 4.27) and hypothyroidism (OR 2.38, 95% CI 1.27 to 4.46) compared with the reference group. Arterial diseases were less common in the ICP mothers than in the reference group (OR 0.38, 95% CI .15 to .99). Regarding other diseases, there were no statistically significant differences between the ICP mothers and reference group. CONCLUSIONS: Half of the women with a history of ICP were diagnosed with at least one disease of the digestive system compared with a third in the reference group. The risk of cholelithiasis, cholecystitis, diseases of the pancreas and hypothyroidism was increased compared with the reference group. These are important facts when counseling women after a pregnancy with ICP. Also, this is of importance for the general practitioners and other physicians who take care of these women.

Comparison of the Patient Enablement Instrument (PEI) with two single-item measures among Finnish Health care centre patients.

BACKGROUND: The Patient Enablement Instrument (PEI) is an established patient-reported outcome measure (PROM) that reflects the quality of appointments with general practitioners (GPs). It is a six-item questionnaire administered to the patient immediately after a consultation. The aim of this study was to evaluate whether a single-item measure could replace the PEI when measuring patient enablement among Finnish health care centre patients. METHODS: Two single-item measures, Q1 and Q2, were chosen for comparison with the PEI. Firstly, a pilot study with questionnaire testing and brief interviews with the respondents were performed in order to assess the content validity of the PEI and the single-item measures. Secondly, a questionnaire study after a single appointment with a GP was carried out in three health care centres in Western Finland in order to evaluate the construct and criterion validity of the single-item measures. A telephone interview was performed 2 weeks after the appointment in order to assess the test-retest reliability of the single-item measures. The sensitivity, specificity, and both positive and negative predictive values of Q1 and Q2 were calculated with different PEI score cut-off points. RESULTS: Altogether 483 patients with a completed PEI were included in the questionnaire study analyses. Altogether 149 and 175 patients had completed Q1 and Q2, respectively, both in the questionnaire and the telephone interview. The correlations between the PEI and Q1 and Q2 were 0.48 and 0.84, respectively. Both the single-item measures had a high sensitivity and a negative predictive value in relation to patients with lower PEI scores. The reliability coefficients were 0.24 for Q1 and 0.76 for Q2. The test-retest values of Q1, Q2, and the PEI were low. CONCLUSIONS: Q2 seems to be a valid and reliable measure of patient enablement. Q1 seems to be less correlated with the PEI, but it also has a high negative predictive value in relation to low enablement scores.

Differences in medical services in Nordic general practice: a comparative survey from the QUALICOPC study.

OBJECTIVE: We aim to describe medical services provided by Nordic general practitioners (GPs), and to explore possible differences between the countries. DESIGN AND SETTING: We did a comparative analysis of selected data from the Nordic part of the study Quality and Costs of Primary Care in Europe. SUBJECTS: 875 Nordic GPs (198 Norwegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answered identical questionnaires regarding their practices. MAIN OUTCOME MEASURES: The GPs indicated which equipment they used in practice, which procedures that were carried out, and to what extent they were involved in treatment/follow-up of a selection of diagnoses. RESULTS: The Danish GPs performed minor surgical procedures significantly less frequent than GPs in all other countries, although they inserted intrauterine devices significantly more often than GPs in Iceland, Sweden and Finland. Finnish GPs performed a majority of the medical procedures more frequently than GPs in the other countries. The GPs in Iceland reported involvement in a more narrow selection of conditions than the GPs in the other countries. The Finnish GPs had more advanced technical equipment than GPs in all other Nordic countries. CONCLUSION: GPs in all Nordic countries are well equipped and offer a wide range of medical services, yet with a substantial variation between countries. There was no clear pattern of GPs in one country doing consistently more procedures, having consistently more equipment and treating a larger diversity of medical conditions than GPs in the other countries. However, structural factors seemed to affect the services offered.

Differences in medical services in Nordic general practice: a comparative survey from the QUALICOPC study.

OBJECTIVE: We aim to describe medical services provided by Nordic general practitioners (GPs), and to explore possible differences between the countries. DESIGN AND SETTING: We did a comparative analysis of selected data from the Nordic part of the study Quality and Costs of Primary Care in Europe (QUALICOPC). SUBJECTS: A total of 875 Nordic GPs (198 Norwegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answered identical questionnaires regarding their practices. MAIN OUTCOME MEASURES: The GPs indicated which equipment they used in practice, which procedures that were carried out, and to what extent they were involved in treatment/follow-up of a selection of diagnoses. RESULTS: The Danish GPs performed minor surgical procedures significantly less frequent than GPs in all other countries, although they inserted IUDs significantly more often than GPs in Iceland, Sweden and Finland. Finnish GPs performed a majority of the medical procedures more frequently than GPs in the other countries. The GPs in Iceland reported involvement in a more narrow selection of conditions than the GPs in the other countries. The Finnish GPs had more advanced technical equipment than GPs in all other Nordic countries. CONCLUSIONS: GPs in all Nordic countries are well equipped and offer a wide range of medical services, yet with a substantial variation between countries. There was no clear pattern of GPs in one country doing consistently more procedures, having consistently more equipment and treating a larger diversity of medical conditions than GPs in the other countries. However, structural factors seemed to affect the services offered.

Do clinicians understand the size of treatment effects? A randomized survey across 8 countries.

BACKGROUND: Meta-analyses of continuous outcomes typically provide enough information for decision-makers to evaluate the extent to which chance can explain apparent differences between interventions. The interpretation of the magnitude of these differences - from trivial to large - can, however, be challenging. We investigated clinicians' understanding and perceptions of usefulness of 6 statistical formats for presenting continuous outcomes from meta-analyses (standardized mean difference, minimal important difference units, mean difference in natural units, ratio of means, relative risk and risk difference). METHODS: We invited 610 staff and trainees in internal medicine and family medicine programs in 8 countries to participate. Paper-based, self-administered questionnaires presented summary estimates of hypothetical interventions versus placebo for chronic pain. The estimates showed either a small or a large effect for each of the 6 statistical formats for presenting continuous outcomes. Questions addressed participants' understanding of the magnitude of treatment effects and their perception of the usefulness of the presentation format. We randomly assigned participants 1 of 4 versions of the questionnaire, each with a different effect size (large or small) and presentation order for the 6 formats (1 to 6, or 6 to 1). RESULTS: Overall, 531 (87.0%) of the clinicians responded. Respondents best understood risk difference, followed by relative risk and ratio of means. Similarly, they perceived the dichotomous presentation of continuous outcomes (relative risk and risk difference) to be most useful. Presenting results as a standardized mean difference, the longest standing and most widely used approach, was poorly understood and perceived as least useful. INTERPRETATION: None of the presentation formats were well understood or perceived as extremely useful. Clinicians best understood the dichotomous presentations of continuous outcomes and perceived them to be the most useful. Further initiatives to help clinicians better grasp the magnitude of the treatment effect are needed.

What predicts doctors' satisfaction with their chosen medical specialty? A Finnish national study.

BACKGROUND: In Finland the number of medical specialists varies between specialties and regions. More regulation of the post-graduate medical training is planned. Therefore, it is important to clarify what predicts doctors' satisfaction with their chosen specialty. METHODS: A random sample contained 50% of all Finnish doctors under 70 years of age. The respose rate was 50.5%. Working-age specialists were asked to value their motives when choosing a specialty. They were also asked if they would choose the same specialty again. The odds ratios for not choosing the same specialty again were tested. RESULTS: Diversity of work was the most important motive (74% of respondents). Seventeen percent of GPs would not choose the same specialty again, compared to 2% of ophthalmologists and 4% of pediatricians. A major role of Diversity of work and Prestigious field correlated with satisfaction whereas Chance with dissatisfaction with the specialty. DISCUSSION: Motives and issues related to the work and training best correlate with satisfaction with the specialty. CONCLUSIONS: When the numbers of Finnish postgraduate medical training posts become regulated, a renewed focus should be given to finding the most suitable speciality for each doctor. Information about employment and career advice should play an important role in this.

[Pregnancy contraception (Current Care Guideline)]. / KÄYPÄ HOITO -SUOSITUS (Tiivistelmä). Raskauden ehkäisy.

There are no age limits for the start or use of contraception. Prior gynecological examination or cervical smear is not needed. Condom is the only method that protects from sexually transmitted diseases. An increase in the risk of venous thromboembolism (VTE) is associated only with combined contraceptives. However, the risk is remarkably higher with pregnancy, puerperium or with smoking. The most effective reversible methods are intrauterine devices (IUD) and implants, as these do not depend on daily memory. Natural family planning methods are not reliable, and effective contraception should be easily available for all at all times.

[Acute head injuries in primary health care--internet survey conducted with general practitioners]. / Pään vammat perusterveydenhuollossa--kyselytutkimus Pirkanmaan sairaanhoito- piirin terveyskeskuslääkäreille.

Patients with head injury constitute a large population treated in primary health care. It is essential to recognize patients with traumatic brain injury among this notable population to determine the need for more specific evaluation. General practitioners (n=331) in Pirkanmaa hospital district in Finland received an email link to answer the survey. The response rate was 54.1% (n=179). Mean survey score was 20.5 points (max. 25). Only acquaintance with the national traumatic brain injury practice guidelines was associated with greater survey scores. The general practitioners' level of knowledge in managing head injuries was good. Deficiencies were found in the questions dealt with post-traumatic amnesia and the definition of traumatic brain injury.

Experiences of patients with fibromyalgia at a Finnish Health Centre: A qualitative study.

BACKGROUND: Fibromyalgia is a functional syndrome. Despite recent findings, there is still considerable uncertainty about its diagnostic process. OBJECTIVES: This study aimed to explore patients' experiences with fibromyalgia during the diagnostic process in primary health care. Moreover, we tried to determine how diagnostic consultation could be improved. METHODS: This study is based on data from patients with fibromyalgia in a primary health care study conducted in Nokia, Finland. Patients with fibromyalgia were identified from electronic medical records. Focus-group participants with fibromyalgia diagnoses were selected using a purposive sampling method to gather a maximum variation sample. Qualitative thematic analysis was used for the coded data from four focus-group discussions in 2018. A description of the coding tree was provided and researchers organised the codes. Finally, all researchers identified themes from the data. RESULTS: The main unifying entities were the uncertainty and contradictions fibromyalgia patients faced on several occasions. Physicians sometimes offered other diagnoses - like depression - as an explanation for the symptoms, or used repetitive tests to eliminate other possible diagnoses. Furthermore, patients expressed their wishes for a holistic, empathetic, and up-to-date approach to their symptoms. CONCLUSION: In our interviews, a good doctor-patient relationship and continuity of care were necessary, as were the physician's attitude and knowledge of fibromyalgia. Our findings also suggest avoiding repeated or unnecessary rule-out tests and the overdiagnosis of psychiatric disorders is necessary.

Provision of contraception: a survey among primary care physicians in Finland.

OBJECTIVE: To investigate self-reported practices of contraceptive provision among primary care physicians. DESIGN: A cross-sectional questionnaire study. SETTING: All community health centers (n = 63) in an university hospital area in Western Finland. SAMPLE AND METHODS: A total of 122 health center physicians involved in contraceptive counseling (CC) were invited to participate in self-administered survey. Data were obtained on initiation of contraceptive methods and the limits and contraindications applied when prescribing combined hormonal contraception (CHC), and they were assessed against Finnish and WHO guidelines. MAIN OUTCOME MEASURES: Distribution of initiated contraceptive methods and of examinations and tests included, application of limits and contraindications in relation to age, smoking, body mass index or weight, blood pressure (BP) and migraine with aura when prescribing CHC (combined oral contraceptives (COCs), vaginal ring and contraceptive patch). RESULTS: Responded physicians (n = 83.68%) said they most frequently prescribed the COC pill. Progestin-only pills, levonorgestrel-releasing intrauterine system and copper-releasing intrauterine device were also provided regularly. Most of the respondents routinely took numerous examinations and tests when initiating contraception, including also unnecessary ones. There were gaps in their knowledge about the limits and contraindications for CHC. For example, 41% of the respondents did not recognize migraine with aura as a contraindication and only 19% reported applying the recommended BP limit of 140/90 mmHg. CONCLUSIONS: The range of contraceptives available and examinations and tests offered were comprehensive. However, the inadequate procedures regarding assessment of contraindications for CHC suggests that updating CC practices is challenging in primary care.

The use of the vaginal ring and transdermal patch among adolescent girls in Finland.

OBJECTIVE: Little is known about the use of the vaginal ring and transdermal patch in representative adolescent populations although these contraceptives are supposed to be a good option for that age group. The aim of this study was to determine the use of the vaginal ring and that of the transdermal patch and to compare these with the use of oral contraceptives (OCs) and emergency contraception in adolescent girls residing in Finland. METHODS: As part of the Adolescent Health and Lifestyle Survey a questionnaire was mailed to a representative sample of girls aged 14, 16 or 18 years residing in Finland. Of these 3029 (72%) responded. RESULTS: The use of the vaginal ring (0.9%) and that of the transdermal patch (0.1%) were uncommon whereas OCs were commonly resorted to (20%). Only 0.6% of girls aged 16 and 2.5% of those aged 18 used the vaginal ring or the transdermal patch. Fifteen percent of girls had ever used emergency contraception. CONCLUSION: The vaginal ring and the transdermal patch are rarely used by adolescents. Our findings suggest that these novel contraceptive methods have not been adopted by family planning services.

Quality of the contraceptive service structure: a pilot study in Finnish health centre organisations.

OBJECTIVES: To evaluate the quality of the contraceptive service structure in health centre organisations (HCOs) in western Finland and to establish whether the characteristics of the HCOs are associated with the quality measured. METHODS: Survey data were collected from all HCOs in a university hospital area in western Finland (N = 63). Quality was evaluated using a score of ten indicators. Associations between the score and the characteristics of the HCOs were studied using rank correlation analysis and a multivariate ordered logit model. RESULTS: Among 51 HCOs yielding complete data for the evaluation, the quality score ranged from 3 to 10, the mean being 5.8. From 25 variables studied, 'a chief nursing officer or leading nurse engaged in the HCO' (p = 0.001) and 'an appointed person responsible for management of health promotion' (p = 0.006) were found to be associated with a good score in the rank correlation analysis, and they also remained significant in multivariate analysis (Odds Ratio [OR] = 11.5, 95% confidence interval [CI] 2.3-56.5 and OR = 5.9, 95% CI 1.6-21.5, respectively). CONCLUSIONS: In the majority of the HCOs involved, the quality of service structure was rated average, but there was much variation between the HCOs. The results of the multivariate analysis emphasise the importance of good management of services.

Web-Based Patient Segmentation in Finnish Primary Care: Protocol for Clinical Validation of the Navigator Service in Patients With Diabetes.

BACKGROUND: An aging population and increasing multimorbidity challenge health care systems worldwide. Patient segmentation aims to recognize groups of patients with similar needs, offer targeted services to these groups, and reduce the burden of health care. In this study, the unique Finnish innovation Navigator, a web-based service for patient segmentation, is presented. Both patients and health care professionals complete the electronic questionnaire concerning patients' coping in everyday life and health state. Thus, it considers the patient perspective on self-care. One of four customership-strategy (CS) groups (self-acting, community, cooperating, and network) is then proposed in response to the answers given. This resulting strategy helps both professionals to coordinate patient health care and patients to utilize appropriate health services. OBJECTIVE: This study aims to determine the feasibility, validity, and reliability of the Navigator service in the segmentation of patients with diabetes into four CS groups in a primary care setting. Patient characteristics concerning demographic status, chronic conditions, disabilities, health-related quality of life, and well-being in different CS groups will be described. We hypothesize that patients in the network group will be older, have more illnesses, chronic conditions or disabilities, and require more health care services than patients in the self-acting group. METHODS: In this mixed methods study, data collection was based on questionnaires (user experience of Navigator, demographic and health status, World Health Organization Disability Assessment Schedule 2.0, EuroQol 5D, Wellbeing Questionnaire 12, and the Diabetes Treatment Satisfaction Questionnaire) issued to 300 patients with diabetes and on user-experience questionnaires for and semistructured focus-group interviews with 12 nurses. Navigator-database reports and diabetes-care values (blood pressure, BMI, HbA1c, low-density lipoprotein, albumin-creatinine, smoking status) were collected. Qualitative and descriptive analyses were used to study the feasibility, content, concurrent, and face validity of Navigator. While criterion and concurrent validity were examined with correlations, reliability was examined by calculating Cohen kappa and Cronbach alpha. Construct validity is studied by performing exploratory-factor analysis on Navigator data reports and by hypothesis testing. The values, demographics, and health status of patients in different groups were described, and differences between groups were studied by comparing means. Linear regression analysis was performed to assess which variables affect CS group variation. RESULTS: Data collection was completed in September 2019, and the first feasibility results are expected by the end of 2020. Further results and publications are expected in 2021 and 2022. CONCLUSIONS: This is the first scientific study concerning Navigator's psychometric properties. The study will examine the segregation of patients with diabetes into four CS groups in a primary care setting and the differences between patients in groups. This study will assist in Navigator's further development as a patient segmentation method considering patients' perspectives on self-care. This study will not prove the effectiveness or efficacy of Navigator; therefore, it is essential to study these outcomes of separate care pathways. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20570.

The validity and reliability of the patient enablement instrument (PEI) after GP appointments in Finnish health care centres.

BACKGROUND: The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility. RESULTS: The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach's α = 0.93). The PEI score diminished strongly over the two-week period. CONCLUSIONS: The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Adolescent sexual behavior during periods of increase and decrease in the abortion rate.

OBJECTIVE: To study changes in adolescent sexual behavior in periods of increase (1994-2000) and decrease (2001-2007) in the abortion rate. METHODS: School surveys with self-administered questionnaires were carried out annually among eighth graders (mean age 14.8 years) and ninth graders (mean age 15.8 years) (N=286,665) in 1996/1997 and 2006/2007. Schools participated biennially. The proportions of respondents reporting noncoital (kissing, light petting, heavy petting) and coital (ever had sexual intercourse, intercourse at least 10 times, at least three partners) sexual experience and nonuse of contraception were studied. RESULTS: Among adolescents, both coital and noncoital sexual experiences and the proportion of those not using contraception increased between 1996-1997 and 2000-2001 (P for trend <.01, all) and decreased from 2000-2001 onward (P<.001, all), except the proportion of at least 10 coital events, which did not decrease. Among sexually experienced adolescents, a similar increase in coital experiences (intercourse at least 10 times from 38.2% to 41.5%, at least three partners from 27.8% to 30.7%, P<.001) and in not using contraception (from 17.2% to 19.1%, P=.002) was seen before 2000-2001, but after that the only significant change was a further increase in the proportion of those reporting intercourse at least 10 times (from 41.5% to 47.8%, P<.001). CONCLUSION: The proportion of adolescents reporting noncoital sexual experiences, intercourse, or not using contraception increased in the 1990s and decreased in the 2000s, reflecting the changes in the abortion rate. However, as the abortion rate decreased, the intensity of sexual activity further increased among sexually experienced adolescents, suggesting that the fall in the abortion rate may be due to contraception and more effective sexual education. LEVEL OF EVIDENCE: : III.

Risk-taking behaviour is more frequent in teenage girls with multiple sexual partners.

OBJECTIVE: To investigate associations between sexual behaviour and risk-taking health behaviour among adolescent females in our changing sexual culture. DESIGN: A questionnaire study. Girls who had had multiple sexual partners (at least five in their lifetime or four during the last six months) were compared with those with fewer partners. Logistic regression was applied. SETTING: The Adolescent Clinic, a primary healthcare unit in the city of Tampere, Finland. SUBJECTS: A sample of 247 female clients aged 15-18 years who had experienced sexual intercourse. MAIN OUTCOME MEASURES: Contraceptive practices, substance use, and sexual attitudes. RESULTS: Girls with multiple sexual partners (n = 69) and the reference group (n = 178) did not differ from each other significantly by age, age at menarche, or educational status. In univariate analysis, age at sexual debut, contraceptive practices, and various substance uses were strongly associated with having multiple sexual partners. Ever-use of emergency contraception was marginally associated, while ever-use of conventional hormonal contraception or condoms was not. In multivariate analysis, low age at sexual debut (OR 8.75 for age 11-13), omitting contraception at the most recent intercourse (OR 3.48), ever-use of withdrawal as a contraceptive method (OR 2.34), and repeated use of drugs (OR 4.10) were associated with having multiple sexual partners. CONCLUSION: Different types of risk-taking behaviour are still interlinked. In discussions with adolescents showing one type of risk behaviour health service providers should make an effort to identify other modes of risk-taking.

Initiation of postpartum contraception: a survey among health centre physicians and nurses in Finland.

OBJECTIVE: To examine self-reported professional practices of postpartum contraceptive counselling at Finnish community health centres. DESIGN: A survey study with self-administered online questionnaires. SETTING: All local municipalities (n = 107) in the Expert Responsibility Area of Tampere University Hospital in Western Finland in 2005. SUBJECTS: A total of 69 (64% of 107) health centre physicians and 80 (75%) nurses performing postpartum check-ups. MAIN OUTCOME MEASURES: Contraceptive method most often initiated or recommended to breastfeeding women at postpartum visit; timing of postpartum initiation of hormonal and intrauterine contraceptive methods in relation to breastfeeding and resumption of menses. RESULTS: The most common contraceptive method initiated or recommended to breastfeeding women by both physicians (41%) and nurses (45%) was the condom, followed by progestin-only pills and intrauterine contraception. Few professionals recommended breastfeeding (lactational amenorrhea) as the only contraceptive method. Only eight (12%) physicians inserted a copper-releasing intrauterine device and five (7%) a levonorgestrel-releasing intrauterine system typically at the postpartum visit; the majority delayed the insertions until the resumption of menses. Fifty-three (77%) physicians initiated combined oral contraceptives mostly when breastfeeding was terminated and menses had returned. Over half of the municipalities involved in the study did not provide any medical contraceptives free of charge postpartum. CONCLUSION: Professionals' reports indicate that initiation of effective contraceptive methods is delayed after childbirth. In order to promote better postpartum contraception practices, updated evidence-based guidelines are needed.

Sexual behavior and drinking style among teenagers: a population-based study in Finland.

In this large-scale study, we examined the relationship between an adolescent's sexual behavior and drinking style. Three aspects of sexual risk-taking were included: early activity, unprotected sexual intercourse and having sex with multiple partners. A distinction was made between different drinking styles, i.e. alcohol drinking and drunkenness-related drinking. Cross-sectional school survey data from the School Health Promotion Study was collected in Finland in 2002-2003. The national sample consisted of adolescents from the eighth and ninth grades (n = 100,790). The mean ages were 14.8 and 15.8 years. Using logistic regression analysis, we investigated the association between sexual behavior and drinking style among teenagers. The likelihood of engaging in sexual intercourse increased with the frequency of alcohol use. In particular, frequent drunkenness-related drinking increased the probability that the teenager had experienced sexual intercourse. The likelihood of engaging in unprotected sex and/or having multiple sexual partners was many-fold for adolescents drinking frequently until they were in a state of drunkenness. Particularly for girls, weekly drunkenness-related drinking was associated with multiple partners. The vast majority of sexually experienced under-aged adolescents drink alcohol, many of them until they are drunk. Thus, it could be effective to combine both alcohol education and sex education, including contraceptive counseling, in early adolescence.