Put on the sidelines of palliative care: a qualitative study of important barriers to GPs' participation in palliative care and guideline implementation in Norway.

BACKGROUND: Demographic changes, the evolvement of modern medicine and new treatments for severe diseases, increase the need for palliative care services. Palliative care includes all patients with life-limiting conditions, irrespective of diagnosis. In Norway, palliative care rests on a decentralised model where patient care can be delivered close to the patient's home, and the Norwegian guideline for palliative care describes a model of care resting on extensive collaboration. Previous research suggests that this guideline is not well implemented among general practitioners (GPs). In this study, we aim to investigate barriers to GPs' participation in palliative care and implementation of the guideline. METHODS: We interviewed 25 GPs in four focus groups guided by a semi-structured interview guide. The interviews were recorded and transcribed verbatim. Data were analysed qualitatively with reflexive thematic analysis. RESULTS: We identified four main themes as barriers to GPs' participation in palliative care and to implementation of the guideline: (1) different established local cultures and practices of palliative care, (2) discontinuity of the GP-patient relationship, (3) unclear clinical handover and information gaps and (4) a mismatch between the guideline and everyday general practice. CONCLUSION: Significant structural and individual barriers to GPs' participation in palliative care exist, which hamper the implementation of the guideline. GPs should be involved as stakeholders when guidelines involving them are created. Introduction of new professionals in primary care needs to be actively managed to avoid inappropriate collaborative practices. Continuity of the GP-patient relationship must be maintained throughout severe illness and at end-of-life.

According to the Norwegian guideline for palliative care, the GP should have a central position in providing primary palliative care.Recent research and public reports suggest that not all GPs have such a central role or adhere to the guidelines.This study highlights individual and structural barriers that could be addressed to increase GPs' participation in palliative care and aid the implementation of the guidelines for palliative care.

Finding their place - general practitioners' experiences with palliative care-a Norwegian qualitative study.

BACKGROUND: Modern palliative care focuses on enabling patients to spend their remaining time at home, and dying comfortably at home, for those patients who want it. Compared to many European countries, few die at home in Norway. General practitioners' (GPs') involvement in palliative care may increase patients' time at home and achievements of home death. Norwegian GPs are perceived as missing in this work. The aim of this study is to explore GPs' experiences in palliative care regarding their involvement in this work, how they define their role, and what they think they realistically can contribute towards palliative patients. METHODS: We performed focus group interviews with GPs, following a semi-structured interview guide. We included four focus groups with a total of 25 GPs. Interviews were recorded and transcribed verbatim. We performed qualitative analysis on these interviews, inspired by interpretative phenomenological analysis. RESULTS: Strengths of the GP in the provision of palliative care consisted of characteristics of general practice and skills they relied on, such as general medical knowledge, being coordinator of care, and having a personal and longitudinal knowledge of the patient and a family perspective. They generally had positive attitudes but differing views about their formal role, which was described along three positions towards palliative care: the highly involved, the weakly involved, and the uninvolved GP. CONCLUSION: GPs have evident strengths that could be important in the provision of palliative care. They rely on general medical knowledge and need specialist support. They had no consensus about their role in palliative care. Multiple factors interact in complex ways to determine how the GPs perceive their role and how involved they are in palliative care. GPs may possess skills and knowledge complementary to the specialized skills of palliative care team physicians. Specialized teams with extensive outreach activities should be aware of the potential they have for both enabling and deskilling GPs.

Stroke follow-up in primary care: a discourse study on the discharge summary as a tool for knowledge transfer and collaboration.

BACKGROUND: The acute treatment for stroke takes place in hospitals and in Norway follow-up of stroke survivors residing in the communities largely takes place in general practice. In order to provide continuous post stroke care, these two levels of care must collaborate, and information and knowledge must be transferred between them. The discharge summary, a written report from the hospital, is central to this communication. Norwegian national guidelines for treatment of stroke, issued in 2010, therefore give recommendations on the content of the discharge summaries. One ambition is to achieve collaboration and knowledge transfer, contributing to integration of the health care services. However, studies suggest that adherence to guidelines in general practice is weak, that collaboration within the health care services does not work the way the authorities intend, and that health care services are fragmented. This study aims to assess to what degree the discharge summaries adhere to the guideline recommendations on content and to what degree they are used as tools for knowledge transfer and collaboration between secondary and primary care. METHODS: The study was an analysis of 54 discharge summaries for home-dwelling stroke patients. The patients had been discharged from two Norwegian local hospitals in 2011 and 2012 and followed up in primary care. We examined whether content was according to guidelines' recommendations and performed a descriptive and interpretative discourse analysis, using tools adapted from an established integrated approach to discourse analysis.  RESULTS: We found a varying degree of adherence to the different advice for the contents of the discharge summaries. One tendency was clear: topics relevant here and now, i.e. at the hospital, were included, while topics most relevant for the later follow-up in primary care were to a larger degree omitted. In most discharge summaries, we did not find anything indicating that the doctors at the hospital made themselves available for collaboration with primary care after dischargeof the patient. CONCLUSIONS: The discharge summaries did not fulfill their potential to serve as tools for collaboration, knowledge transfer, and guideline implementation. Instead, they may contribute to sustain the gap between hospital medicine and general practice.

Palliative care in general practice; a questionnaire study on the GPs role and guideline implementation in Norway.

BACKGROUND: Patients in need of palliative care often want to reside at home. Providing palliative care requires resources and a high level of competence in primary care. The Norwegian guideline for palliative care points to the central role of the regular general practitioner (RGP), specifying a high expected level of competence. Guideline implementation is known to be challenging in primary care. This study investigates adherence to the guideline, the RGPs experience with, and view of their role in palliative care. METHODS: A questionnaire was distributed, by post, to all 246 RGPs in a Norwegian county. Themes of the questionnaire focused on experience with palliative and terminal care, the use of recommended work methods from the guideline, communication with partners, self-reported role in palliative care and confidence in providing palliative care. Data were analyzed descriptively, using SPSS. RESULTS: Each RGP had few patients needing palliative care, and limited experience with terminal care at home. Limited experience challenged RGPs possibilities to maintain knowledge about palliative care. Their clinical approach was not in agreement with the guideline, but most of them saw themselves as central, and were confident in the provision of palliative care. Rural RGPs saw themselves as more central in this work than their urban colleagues. CONCLUSIONS: This study demonstrated low adherence of the RGPs, to the Norwegian guideline for palliative care. Guideline requirements may not correspond with the methods of general practice, making them difficult to adopt. The RGPs seemed to have too few clinical cases over time to maintain skills at a complex and specialized level. Yet, there seems to be a great potential for the RGP, with the inherent specialist skills of the general practitioner, to be a key worker in the palliative care trajectory.

Stroke follow-up in primary care: a Norwegian modelling study on the implications of multimorbidity for guideline adherence.

BACKGROUND: Specialized acute treatment and high-quality follow-up is meant to reduce mortality and disability from stroke. While the acute treatment for stroke takes place in hospitals, the follow-up of stroke survivors largely takes place in general practice. National guidelines give recommendations for the follow-up. However, previous studies suggest that guidelines are not sufficiently adhered to. It has been suggested that this might be due to the complexity of general practice. A part of this complexity is constituted by patients' multimorbidity; the presence of two or more chronic conditions in the same person. In this study we investigated the extent of multimorbidity among stroke survivors residing in the communities. The aim was to assess the implications of multimorbidity for the follow-up of stroke in general practice. METHODS: The study was a cross sectional analysis of the prevalence of multimorbidity among stroke survivors in Mid-Norway. We included 51 patients, listed with general practitioners in 18 different clinics. The material consists of the general practitioners' medical records for these patients. The medical records for each patient were reviewed in a search for diagnoses corresponding to a predefined list of morbidities, resulting in a list of chronic conditions for each participant. These 51 lists were the basis for the subsequent analysis. In this analysis we modelled different hypothetical patients and assessed the implications of adhering to all clinical guidelines affecting their diseases. RESULT: All 51 patients met the criteria for multimorbidity. On average the patients had 4.7 (SD: 1.9) chronic conditions corresponding to the predefined list of morbidities. By modelling implications of guideline adherence for a patient with an average number of co-morbidities, we found that 10-11 annual consultations with the general practitioner were needed for the follow-up of the stable state of the chronic conditions. More consultations were needed for patients with more complex multimorbidity. CONCLUSIONS: Multimorbidity had a clear impact on the basis for the follow-up of patients with stroke in general practice. Adhering to the guidelines for each condition is challenging, even for patients with few co-morbidities. For patients with complex multimorbidity, adhering to the guidelines is obviously unmanageable.

Stroke follow-up in primary care: a prospective cohort study on guideline adherence.

BACKGROUND: After a stroke, a person has an increased risk of recurrent strokes. Effective secondary prevention can provide significant gains in the form of reduced disability and mortality. While considerable efforts have been made to provide high quality acute treatment of stroke, there has been less focus on the follow-up in general practice after the stroke. One strategy for the implementation of high quality, evidence-based treatment is the development and distribution of clinical guidelines. However, from similar fields of practice, we know that guidelines are often not adhered to. The purpose of this study was to investigate to what degree patients who have suffered a stroke are followed up in general practice, if recommendations in the national guidelines are followed, and if patients achieve the treatment goals recommended in the guidelines. METHODS: The study included patients with cerebral infarction identified by the ICD-10 discharge diagnoses I63.0 trough I63.9 in two Norwegian local hospitals. In total 51 patients participated. They were listed with general practitioners in 18 different clinics. The material consists of the general practitioners' (GPs') medical records for these patients in the first year of follow-up; in total 381 consultations. RESULTS: Of the 381 consultations during the first year of follow-up, 71 (19%) had stroke as the main topic. The blood pressure (BP) target value < 140/90 mmHg was reached by 24 patients (47%). The low density lipoprotein (LDL) cholesterol target value < 2.0 mmol/L was reached by 14 (27%) of the 51 patients. In total six patients (12%) got advice on physical activity and three (6%) received dietary advice. No advice about alcohol consumption was recorded. CONCLUSIONS: The findings support earlier claims that the development and distribution of guidelines alone is not enough to implement a certain practice. Despite being a serious condition, stroke gets limited attention in the first year of follow-up in general practice. This can be explained by the complexity of general practice, where even a serious condition loses the competition for attention to other apparently equally important issues.

Patient experiences and the association with organizational factors in general practice: results from the Norwegian part of the international, multi-centre, cross-sectional QUALICOPC study.

BACKGROUND: General practitioners (GPs) constitute a vital part of a strong primary health care system. We need further knowledge concerning factors that may affect the patients' experiences in their meetings with the GPs. We investigated to what degree organizational factors and GP characteristics are associated with patients' communicative experiences in a consultation. METHODS: We used data from the Norwegian part of the international, multi-center study Quality and Costs of Primary Care in Europe (QUALICOPC). We included 198 Norwegian GPs and 1529 patients. The patients completed a survey concerning experiences in a consultation with a GP on the inclusion day. The GPs completed a survey regarding organizational aspects of their own practice. Main outcome measures were seven statements concerning how the patients experienced the communication with the GP during the consultation. A generalized estimating equation logistic regression model was used to identify variations in patient experiences associated with characteristics of the GPs and their practices. RESULTS: The patients reported overall positive experiences with their GP consultations. Patients who consulted a GP with a short patient list were less likely than patients who consulted a GP with a medium sized list to regard the GP as polite (Odds Ratio (OR) 0.2; 95 % CI 0.1-0.7), to report that the GP asked questions about their health problems (OR 0.6; 0.4-1.0) or that the GP used sufficient time (OR 0.5; CI 0.3-0.9). Patients who consulted a GP with a long patient list compared to patients who consulted a GP with a medium sized list were less likely to feel that they could cope better after the GP visit (OR 0.5; 0.3-0.9) and more likely to feel that the GP hardly looked at them while talking (OR 1.8; 1.0-3.0). No associations with patient experiences were found with the average duration of the consultations, whether the GP worked in a fee-for-service model or whether the GP was the patient's regular doctor. CONCLUSIONS: Norwegian patients report predominantly positive experiences when consulting a GP. Positive communication experiences are most likely to be reported when the GP has a medium sized patient list.

Applying clinical guidelines in general practice: a qualitative study of potential complications.

BACKGROUND: Clinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners' (GPs') experiences with and reflections upon the consequences for general practice of applying multiple guidelines. METHODS: Qualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach. RESULTS: The GPs' responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice 'defensive medicine'. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life. CONCLUSIONS: The GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs' courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.

Can general practitioners do the follow-ups after surgery with ventilation tubes in the tympanic membrane? Two years audiological data.

BACKGROUND: A university hospital in Mid-Norway has modified their guidelines for follow-up after insertion of ventilation tubes (VTs) in the tympanic membrane, transferring the controls of the healthiest children to general practitioners (GPs). The aim of this study was to evaluate the implementation of these guidelines by exploring audiological outcome and subjective hearing complaints two years after surgery, assessing if follow-ups in general practice resulted in poorer outcome. METHODS: A retrospective observational study was performed at the university hospital and in general practice in Mid-Norway. Children below 18 years who underwent surgery with VTs between Nov 1st 2007 and Dec 31st 2008 (n = 136) were invited to participate. Pure tone audiometry, speech audiometry and tympanometry were measured. A self-report questionnaire assessed subjective hearing, ear complaints and the location of follow-ups. This study includes enough patients to observe group differences in mean threshold (0.5-1-2-4 kHz) of 9 dB or more. RESULTS: There were no preoperative differences in audiometry or tympanometry between the children scheduled for follow-ups by GPs (n = 23) or otolaryngologists (n = 50). Two years after surgery there were no differences between the GP and otolaryngologist groups in improvement of mean hearing thresholds (12.8 vs 12.6 dB, p = 0.9) or reduction of middle ears with effusion (78.0 vs 75.0%, p = 0.9). We found no differences between the groups in terms of parental reports of child hearing or ear complaints. CONCLUSIONS: Implementation of new clinical guidelines for follow-ups after insertion of VTs did not negatively affect audiological outcomes or subjective hearing complaints two years after surgery.

Implementing guidelines for follow-up after surgery with ventilation tube in the tympanic membrane in Norway: a retrospective study.

BACKGROUND: When clinical guidelines are being changed a strategy is required for implementation. St. Olavs University Hospital in Norway modified their guidelines for the follow-up care of children after insertion of ventilation tubes (VT) in the tympanic membrane, transferring the controls of the healthiest children to General Practitioners (GPs). This study evaluates the implementation process in the hospital and in general practice by exploring two issues: 1) Whether the hospital discharged the patients they were supposed to and 2) whether the children consulted a GP for follow-up care. METHODS: A retrospective observational study was performed at St. Olavs University Hospital, Norway and general practice in Mid-Norway. Children under the age of 18 who underwent insertion of VT between Nov 1st 2007 and Dec 31st 2008 (n = 136) were included. Degree of guideline adherence at the hospital and in general practice was measured. RESULTS: The hospital adhered to the guidelines in two-thirds (68.5%) of the patients, planning more patients for follow-up by their GP than recommended in the guidelines (25.8% vs. 12.4%). All except one contacted their GP for control. In total 60% were referred back to specialist health services within two years. CONCLUSIONS: The methods for guideline implementation were successful in securing consultations for follow-up care in general practice. Lack of guideline adherence in the hospital can partly be explained by the lack of quality of the guideline. Further studies are needed to evaluate the quality of controls done by the GPs in order to consider implications for follow-up after VT surgery.

Rethinking scientific responsibility.

Researchers should be made co-responsible for the wider consequences of their research focus and the application of their findings. This paper describes a meta-reflection procedure that can be used as a tool to enhance scientific responsibility and reflective practice. The point of departure is that scientific practice is situated in power relations, has direction and, consequently, power implications. The contextual preconditions and implications of research should be stated and discussed openly. The reflection method aims at revealing both upstream elements, such as for instance preconceptions, and downstream elements, for example, public consequences of research. The validity of research might improve from such discussions. Validity should preferably be understood as a broader concept than the methodological concerns in science.

[Blood pressure monitors in primary healthcare centres]. / Blodtrykksapparater på legekontorer.

BACKGROUND: Blood pressure monitoring is one of the most common procedures in clinical medicine. Evaluation and treatment of hypertension are costly and have considerable implications for the individuals involved. Mercury manometers have been dominant for a century, but are currently being replaced by other types of equipment. No national guidelines/recommendations exist on types of blood pressure monitors to be used. The aim of this study was to assess the types of blood pressure monitors used in Norwegian general practice, and to what extent routines have been established for control and calibration of the equipment. MATERIAL AND METHODS: In 2007, a questionnaire was distributed to 65 university-affiliated primary healthcare centres in Mid-Norway. The questions included what type of blood pressure monitors are in use and whether routines exist for calibration of them. RESULTS: 45 healthcare centres with a total of 173 general practitioners (corresponding to 74 % of the doctors) responded. 18 (6 %) of the 320 monitors identified were of the mercury type, the rest were aneroid or oscillometric. Many centres had 24-hour monitors. Two healthcare centres (4 % of the doctors) had established routines for calibration of their blood pressure monitors. INTERPRETATION: Routines should be established for quality assurance of blood pressure monitors in Norwegian primary healthcare services.

Current European guidelines for management of arterial hypertension: are they adequate for use in primary care? Modelling study based on the Norwegian HUNT 2 population.

BACKGROUND: Previous studies indicate that clinical guidelines using combined risk evaluation for cardiovascular diseases (CVD) may overestimate risk. The aim of this study was to model and discuss implementation of the current (2007) hypertension guidelines in a general Norwegian population. METHODS: Implementation of the current European Guidelines for the Management of Arterial Hypertension was modelled on data from a cross-sectional, representative Norwegian population study (The Nord-Trøndelag Health Study 1995-97), comprising 65,028 adults, aged 20-89, of whom 51,066 (79%) were eligible for modelling. RESULTS: Among individuals with blood pressure >or=120/80 mmHg, 93% (74% of the total, adult population) would need regular clinical attention and/or drug treatment, based on their total CVD risk profile. This translates into 296,624 follow-up visits/100,000 adults/year. In the Norwegian healthcare environment, 99 general practitioner (GP) positions would be required in the study region for this task alone. The number of GPs currently serving the adult population in the study area is 87 per 100,000 adults. CONCLUSION: The potential workload associated with the European hypertension guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthy-living nations, by international comparison. Large-scale, preventive medical enterprises can hardly be regarded as scientifically sound and ethically justifiable, unless issues of practical feasibility, sustainability and social determinants of health are considered.

[A different cardiovascular epidemiology]. / En annen kardiovaskulaer epidemiologi.

BACKGROUND: Cardiovascular diseases constitute the leading cause of sickness and death in Western countries. They are therefore embraced with much attention in medical research, treatment and preventive programmes for which quantifiable biological risk factors comprise the common conceptual basis. We want to demonstrate that the current narrow biological focus may prohibit a deeper understanding of the sickness expressions. THEORY, MATERIAL AND METHOD: The present paper is grounded in a theory of human beings as self-reflecting and capable of creating and conveying meaning affected by culture, time and relationships with others. From such a perspective, the human body is seen as a lived body, a centre for expression of experience. Two cases are interpreted in light of more recent epidemiological evidence of associations between traumatic experiences and cardiovascular disease. RESULTS: Research shows that traumatic experiences in general and early trauma in particular are potent pathogens. Different types of trauma are, however, not consistently related to specific diseases, but rather to complex patterns of so called co-morbidity. These patterns blur the mind-body-distinction and thereby the classification systems for somatic and mental diseases. When such patterns are interpreted as expressions of embodied life, insight is provided into how traumatic experience informs the lived body. INTERPRETATION: Correlations between traumatic experience and cardiovascular disease challenge the dominating biological framework of cardiovascular epidemiology. An analysis of the evidence by means of two cases opens up new perspectives. Knowledge about the path from particular and painful experience to particular and painful disease is an inevitable premise for an adequate treatment of the individual. It is also a prerequisite for development of adequate preventive measures.

Medicine's perception of reality - a split picture: critical reflections on apparent anomalies within the biomedical theory of science.

Escalating costs, increasing multi-morbidity, medically unexplained health problems, complex risk, poly-pharmacy and antibiotic resistance can be regarded as artefacts of the traditional knowledge production in Western medicine, arising from its particular worldview. Our paper presents a historically grounded critical analysis of this view. The materialistic shift of Enlightenment philosophy, separating subjectivity from bodily matter, became normative for modern medicine and yielded astonishing results. The traditional dichotomies of mind/body and subjective/objective are, however, incompatible with modern biological theory. Medical knowledge ignores central tenets of human existence, notably the physiological impact of subjective experience, relationships, history and sociocultural contexts. Biomedicine will not succeed in resolving today's poorly understood health problems by doing 'more of the same'. We must acknowledge that health, sickness and bodily functioning are interwoven with human meaning-production, fundamentally personal and biographical. This implies that the biomedical framework, although having engendered 'success stories' like the era of antibiotics, needs to be radically revised.

Does 'existential unease' predict adult multimorbidity? Analytical cohort study on embodiment based on the Norwegian HUNT population.

OBJECTIVES: Multimorbidity is prevalent, and knowledge regarding its aetiology is limited. The general pathogenic impact of adverse life experiences, comprising a wide-ranging typology, is well documented and coherent with the concept allostatic overload (the long-term impact of stress on human physiology) and the notion embodiment (the conversion of sociocultural and environmental influences into physiological characteristics). Less is known about the medical relevance of subtle distress or unease. The study aim was to prospectively explore the associations between existential unease (coined as a meta-term for the included items) and multimorbidity. SETTING: Our data are derived from an unselected Norwegian population, the Nord-Trøndelag Health Study, phases 2 (1995-1997) and 3 (2006-2008), with a mean of 11 years follow-up. PARTICIPANTS: The analysis includes 20 365 individuals aged 20-59 years who participated in both phases and was classified without multimorbidity (with 0-1 disease) at baseline. METHODS: From HUNT2, we selected 11 items indicating 'unease' in the realms of self-esteem, well-being, sense of coherence and social relationships. Poisson regressions were used to generate relative risk (RR) of developing multimorbidity, according to the respondents' ease/unease profile. RESULTS: A total of 6277 (30.8%) participants developed multimorbidity. They were older, more likely to be women, smokers and with lower education. 10 of the 11 'unease' items were significantly related to the development of multimorbidity. The items 'poor self-rated health' and 'feeling dissatisfied with life' exhibited the highest RR, 1.55 and 1.44, respectively (95% CI 1.44 to 1.66 and 1.21 to 1.71). The prevalence of multimorbidity increased with the number of 'unease' factors, from 26.7% for no factor to 49.2% for 6 or more. CONCLUSIONS: In this prospective study, 'existential unease' was associated with the development of multimorbidity in a dose-response manner. The finding indicates that existential unease increases people's vulnerability to disease, concordant with current literature regarding increased allostatic load.

Self Reported Childhood Difficulties, Adult Multimorbidity and Allostatic Load. A Cross-Sectional Analysis of the Norwegian HUNT Study.

BACKGROUND: Multimorbidity receives increasing scientific attention. So does the detrimental health impact of adverse childhood experiences (ACE). Aetiological pathways from ACE to complex disease burdens are under investigation. In this context, the concept of allostatic overload is relevant, denoting the link between chronic detrimental stress, widespread biological perturbations and disease development. This study aimed to explore associations between self-reported childhood quality, biological perturbations and multimorbidity in adulthood. MATERIALS AND METHODS: We included 37 612 participants, 30-69 years, from the Nord-Trøndelag Health Study, HUNT3 (2006-8). Twenty one chronic diseases, twelve biological parameters associated with allostatic load and four behavioural factors were analysed. Participants were categorised according to the self-reported quality of their childhood, as reflected in one question, alternatives ranging from 'very good' to 'very difficult'. The association between childhood quality, behavioural patterns, allostatic load and multimorbidity was compared between groups. RESULTS: Overall, 85.4% of participants reported a 'good' or 'very good' childhood; 10.6% average, 3.3% 'difficult' and 0.8% 'very difficult'. Childhood difficulties were reported more often among women, smokers, individuals with sleep problems, less physical activity and lower education. In total, 44.8% of participants with a very good childhood had multimorbidity compared to 77.1% of those with a very difficult childhood (Odds ratio: 5.08; 95% CI: 3.63-7.11). Prevalences of individual diseases also differed significantly according to childhood quality; all but two (cancer and hypertension) showed a significantly higher prevalence (p<0.05) as childhood was categorised as more difficult. Eight of the 12 allostatic parameters differed significantly between childhood groups. CONCLUSIONS: We found a general, graded association between self-reported childhood difficulties on the one hand and multimorbidity, individual disease burden and biological perturbations on the other. The finding is in accordance with previous research which conceptualises allostatic overload as an important route by which childhood adversities become biologically embodied.