Psychological stress of general practitioners in the care of patients with palliative care needs: an exploratory study.

BACKGROUND: In Germany, general practitioners play a pivotal role in palliative care provision. Caring for patients with palliative care needs can be a burden for general practitioners, highlighting the importance of self-care and mental health support. This study aimed to explore the role of palliative care in general practitioners' daily work, the stressors they experience, their coping mechanisms, and the potential benefits of Advance Care Planning in this context. METHODS: An exploratory approach was employed, combining a short quantitative survey with qualitative interviews. The analysis was based on a structuring qualitative content analysis, following a deductive-inductive procedure and integrating the Stress-Strain Model and Lazarus' Transactional Model of Stress and Coping. We recruited eleven general practitioners to take part in the study. RESULTS: General practitioners viewed palliative care as integral to their practice but faced challenges such as time constraints and perceived expertise gaps. Societal taboos often hindered conversations on the topic of death. Most general practitioners waited for their patients to initiate the topic. Some general practitioners viewed aspects of palliative care as potentially distressing. They used problem-focused (avoiding negative stressors, structuring their daily schedules) and emotion-focused (discussions with colleagues) coping strategies. Still, general practitioners indicated a desire for specific psychological support options. Advance Care Planning, though relatively unfamiliar, was acknowledged as valuable for end-of-life conversations. CONCLUSIONS: Palliative care can be associated with negative psychological stress for general practitioners, often coming from external factors. Despite individual coping strategies in place, it is advisable to explore concepts for professional psychological relief. TRIAL REGISTRATION: Not registered.

Perceived barriers and facilitators affecting utilisation of radiation therapy services: Scoping review findings - Health professional influences.

The underutilisation of radiation therapy (RT) is contributing to the significant global burden of cancer with studies identifying actual utilisation rates are significantly lower than evidence-based optimal utilisation rates. Attributing factors vary considerably, ranging from patient preference, referrer bias, to geographic variations. The aim of this scoping review is to map and synthesise the current literature reporting on barriers and facilitators influencing utilisation of RT globally. Four online databases; Medline, Embase, Scopus and CINAHL identified articles dated between 1993 and 2023. Study eligibility included reporting on RT services, specifically barriers and influences on utilisation of RT. Title and abstract screening, followed by full text review was performed as per PRISMA guidelines. Variables were extracted and categorised into patient, health professional (HP) and department level influences. In total, 340 studies were included in the scoping review. HP influences (included in this specific review) were reported in 225 (66 %) papers with the most prevalent HP influence being referral (n = 187; 83 %). Of the HP papers, 114 (51 %) identified knowledge and education as an influence on RT utilisation. Subsequently, role interpretation, describing the assumed role adopted by the General Practitioner as the patients advocate, educator, manager or carer was identified in 89 (40 %) studies. This scoping review demonstrates the range of factors impacting RT utilisation. The results suggest referrer knowledge and understanding gaps impact RT utilisation internationally. Future research and intervention into referrer RT education is required to limit the impact of such influences.

Musculoskeletal disorders in Norway: trends in health care utilization and patient pathways: a nationwide register study.

OBJECTIVE: Describe trends in health care utilization, demographic characteristics and patient pathways among patients with musculoskeletal disorders (MSD) in Norway. DESIGN: Register-based cohort study. SETTINGS: Data were obtained from two Norwegian National registries; the Norwegian Control and Payment of Health Reimbursements Database (KUHR) and the Norwegian Patient Registry (NPR). SUBJECTS: Patients with MSD according to ICPC-2 and ICD-10 during 2014-2017. MAIN OUTCOME MEASURES: Patient pathways from the first contact and the following two years, described in a Sankey Diagram for all MSD patients and three common diagnoses: spine pain, osteoarthritis (OA) and fibromyalgia (FM). RESULT: About 26% of the Norwegian population consulted PHC annually while 7% were treated in SHC. Mean age was 47 and 53 years in PHC and SHC, respectively. The proportion of women increased by age. Spine pain was the most common diagnosis; 33% and 22% in PHC and SHC, respectively. Over 90% visited a GP first, 50% of them were treated by PT and/or in SHC during follow-up. Patients visiting the PT first were less likely to be treated in SHC. OA patients were most likely to be treated by more than one health care professional (>70%). CONCLUSION: One third of the Norwegian population consulted health care services due to MSD annually between 2014-2017. GP was the most consulted health care professional. Among MSD patients with long-term use of health care services, 50% were treated by a PT and/or in SHC in addition to a GP.

The ESSAG-trial protocol: A randomized controlled trial evaluating the efficacy of offering a self-sampling kit by the GP to reach women underscreened in the routine cervical cancer screening program.

BACKGROUND: In Flanders (Belgium), women not screened for cervical cancer (CC) within the last three years receive an invitation letter from the regional screening organization, the Centre for Cancer Detection (CCD), encouraging them to have a cervical specimen taken by their general practitioner (GP) or gynecologist. However, the coverage for CC screening remains suboptimal (63%). The offer of a self-sampling kit (SSK, for HPV testing) by a GP may trigger participation among women who do not attend regular screening. METHODS: The ESSAG-trial is a cluster-randomized controlled trial with three arms, each including 1125 women aged 31-64 years, who were not screened for CC in the last 6 years. In arm A, GPs offer a SSK when eligible women consult for any reason. In arm B, women receive a personal GP signed invitation letter including an SSK at their home address. In the control arm, women receive the standard invitation letter from the CCD. The primary outcome is the response rate at three months after inclusion. Secondary outcomes are: screen test positivity; compliance with foreseen follow-up among screen-positives; costs per invited and per screened women; as well as contrasts between trial arms and between socio-demographic categories. CONCLUSION: The ESSAG-trial will assess the effect of GP-based interventions using SSKs on CC screening participation among hard-to-reach populations. Findings will inform policymakers about feasible strategies on increasing CC screening that may be rolled-out throughout the whole region. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05656976.

'It is difficult for us to assess the severity!' A qualitative analysis of parents' expectations to postoperative care after ventilation tube surgery.

OBJECTIVE: Surgery with ventilation tubes (VT) in children suffering from otitis media with effusion is quite common. However, the knowledge surrounding parents' expectations to the treatment and postoperative care is sparse. The aim of this study was to describe the parents' expectations to VT surgery and postoperative care shortly after surgery. METHODS: A qualitative study was conducted based on semi-structured individual interviews with parents recruited from a study where postoperative care was randomized to either an otolaryngologist or the patient's general practitioner (GP). The interviews were conducted within the first weeks after surgery and analyzed by reflexive thematic analysis. RESULTS: In total, 13 parents aged 29-42 years participated in the study. We identified three main themes elucidating parents' expectations to VT surgery and postoperative care: 1) Preconceptions about VT surgery and hearing - most parents expected surgery to restore the child's normal hearing, and some were uncertain about their knowledge of normal hearing and VT treatment; 2) A safety net to ensure hearing and function - it was reassuring if the child received structured postoperative care that secured and notified appointments and had quick access to a specialist if needed; 3) High-quality care - most parents expected the otolaryngologist to provide the highest level of quality of care due to their specialist competence, special equipment and sufficient understanding of the problem to communicate well with parents. Postoperative care by the GP was perceived as incomplete among most parents due to a lack of both specialist competence and access to audiometry. CONCLUSION: Parents expect postoperative care to safeguard their child as long as needed after VT surgery, and they expect access to high-quality care. Low health literacy among some parents challenges the current method of postoperative care and requires that more emphasis be set on both informing and educating parents regarding hearing and VT treatment.

Interprofessional follow-up of patients with cancer in France (the SINPATIC study): a preliminary, qualitative study of the patient's perspective.

BACKGROUND: In 2020, 19.2 million people were diagnosed with cancer, and nearly 10 million cancer patients died worldwide. An effective cancer care pathway must be based on coordination, multidisciplinarity, a personalized approach, and collaboration between stakeholders. Follow-up can be improved by good collaboration and communication between GPs and the cancer care team at a common level of organization. OBJECTIVES: To study patients with solid cancers and assess their perceptions of the care pathway, the roles of the healthcare professionals involved, and interprofessional collaboration. METHODS: In a preliminary, qualitative study (part of the SINPATIC study of general practitioners, oncologists, nurses, and patients), adult patients with cancer in the Paris area of France were interviewed between January and April 2018. Using purposive sampling, 10 patients were recruited from hospital departments and primary care. An interview guide explored 3 themes: the care pathway, the stakeholders' roles in follow-up, and interprofessional collaboration. RESULTS: For patients, dealing with cancer is a complex process of awareness, care provision, decision-making, task assignment, a lack of clarification of professional roles, a piecemeal announcement of the diagnosis of cancer by several stakeholders, organizational and administrative difficulties, non-formal collaboration in inertia (tending towards collaboration under construction), and with cancer follow-up that was usually parallel, sometimes shared, rarely sequential. CONCLUSION: This SINPATIC substudy provided us a better understanding of the complexity of the patient care pathway. Looking forward, the present findings might stimulate thoughts on the design and development of interventional studies.

Perceptions and beliefs of general practitioners on their role in the cancer screening programmes in the Netherlands: a mixed-methods study.

BACKGROUND: In the Netherlands, population-based cancer screening programmes (CSPs) are organized aiming at cervical, breast and colorectal cancer. For a CSP to be effective, high participation rates are essential; however, there is an alarming downward trend, including wide regional variation in screening uptake. General practitioner (GP) involvement can have a stimulating effect on screening participation. Current GP involvement is however, limited, varies between the programmes and has changed over time. Unexplored is what GPs think of their role(s) in the CSPs. The aim of this study was therefore to map the perceptions and beliefs of GPs regarding their current and future role in the Dutch CSPs. METHODS: A mixed-methods sequential explanatory study was conducted in the Leiden/The Hague area of the Netherlands, between the end of 2021 and 2022. A questionnaire was developed and distributed among 110 GPs. The aggregated results obtained from the questionnaires served as starting points for conducting semi-structured interviews, with purposefully selected GPs. With this sequential approach we aimed to further enhance the understanding of the questionnaire data, and delved into the topics that emerged from the questionnaire responses. RESULTS: In total, 46 GPs completed the online questionnaire (response rate 42%). Subsequent five semi-structured comprehensive interviews were conducted. GPs indicated that they frequently encounter the CSP in their daily practice and consider it important. They also emphasised it is important that GPs remain closely involved with the CSPs in the future. Nevertheless, GPs also repeatedly mentioned that they are not eager to take on more logistical/organizational tasks. They are however willing to empower CSPs in a positive manner. CONCLUSION: GPs were generally positive about the CSPs and their current role within these programmes. Nevertheless, several options have been proposed to improve the CSPs, especially to increase screening uptake for populations in a socioeconomically disadvantaged position. Since it is of utmost importance to screen those who are most at risk of developing the screening-specific tumours, efforts should be made to achieve this goal.

Sex matters in the association between cardiovascular health and incident dementia: evidence from real world data.

BACKGROUND: Cardiovascular health has been associated with dementia onset, but little is known about the variation of such association by sex and age considering dementia subtypes. We assessed the role of sex and age in the association between cardiovascular risk and the onset of all-cause dementia, Alzheimer's disease, and vascular dementia in people aged 50-74 years. METHODS: This is a retrospective cohort study covering 922.973 Catalans who attended the primary care services of the Catalan Health Institute (Spain). Data were obtained from the System for the Development of Research in Primary Care (SIDIAP database). Exposure was the cardiovascular risk (CVR) at baseline categorized into four levels of Framingham-REGICOR score (FRS): low (FRS < 5%), low-intermediate (5% ≤ FRS < 7.5%), high-intermediate (7.5% ≤ FRS < 10%), high (FRS ≥ 10%), and one group with previous vascular disease. Cases of all-cause dementia and Alzheimer's disease were identified using validated algorithms, and cases of vascular dementia were identified by diagnostic codes. We fitted stratified Cox models using age parametrized as b-Spline. RESULTS: A total of 51,454 incident cases of all-cause dementia were recorded over a mean follow-up of 12.7 years. The hazard ratios in the low-intermediate and high FRS groups were 1.12 (95% confidence interval: 1.08-1.15) and 1.55 (1.50-1.60) for all-cause dementia; 1.07 (1.03-1.11) and 1.17 (1.11-1.24) for Alzheimer's disease; and 1.34 (1.21-1.50) and 1.90 (1.67-2.16) for vascular dementia. These associations were stronger in women and in midlife compared to later life in all dementia types. Women with a high Framingham-REGICOR score presented a similar risk of developing dementia - of any type - to women who had previous vascular disease, and at age 50-55, they showed three times higher risk of developing dementia risk compared to the lowest Framingham-REGICOR group. CONCLUSIONS: We found a dose‒response association between the Framingham-REGICOR score and the onset of all dementia types. Poor cardiovascular health in midlife increased the onset of all dementia types later in life, especially in women.

Primary, allied health, selected specialists, and mental health service utilisation by home care recipients in Australia before and after accessing the care, 2017-2019.

OBJECTIVES: To examine changes in primary, allied health, selected specialists, and mental health service utilisation by older people in the year before and after accessing home care package (HCP) services. METHODS: A retrospective cohort study using the Registry of Senior Australians Historical National Cohort (≥ 65 years old), including individuals accessing HCP services between 2017 and 2019 (N = 109,558), was conducted. The utilisation of general practice (GP) attendances, health assessments, chronic disease management plans, allied health services, geriatric, pain, palliative, and mental health services, subsidised by the Australian Government Medicare Benefits Schedule, was assessed in the 12 months before and after HCP access, stratified by HCP level (1-2 vs. 3-4, i.e., lower vs. higher care needs). Relative changes in service utilisation 12 months before and after HCP access were estimated using adjusted risk ratios (aRR) from Generalised Estimating Equation Poisson models. RESULTS: Utilisation of health assessments (7-10.2%), chronic disease management plans (19.7-28.2%), and geriatric, pain, palliative, and mental health services (all ≤ 2.5%) remained low, before and after HCP access. Compared to 12 months prior to HCP access, 12 months after, GP after-hours attendances increased (HCP 1-2 from 6.95 to 7.5%, aRR = 1.07, 95% CI 1.03-1.11; HCP 3-4 from 7.76 to 9.32%, aRR = 1.20, 95%CI 1.13-1.28) and allied health services decreased (HCP 1-2 from 34.8 to 30.7%, aRR = 0.88, 95%CI 0.87-0.90; HCP levels 3-4 from 30.5 to 24.3%, aRR = 0.80, 95%CI 0.77-0.82). CONCLUSIONS: Most MBS subsidised preventive, management and specialist services are underutilised by older people, both before and after HCP access and small changes are observed after they access HCP.

Urologists' and general practitioners' knowledge, beliefs and practice relevant for opportunistic prostate cancer screening: a PRISMA-compliant systematic review.

Background: Recent guidelines on opportunistic prostate cancer screening conclude that the decision to screen with prostate-specific antigen should be made by each patient individually together with the clinician. However, there is evidence of a lack of clinicians' awareness of prostate cancer screening. This study sought to assess the recent evidence of clinicians' knowledge, beliefs, and practice regarding opportunistic prostate cancer screening comparing urologists and generals practitioners. Methods: A systematic search was conducted in 3 online databases: MEDLINE, Web of Science and EMBASE (from January 1, 2015, to January 9th, 2023). Studies that explored clinicians' knowledge, beliefs, and practices regarding opportunistic prostate cancer screening were included. Studies were assessed for quality reporting according to the Strengthening the Reporting of Observational studies in Epidemiology guidelines. Results: A total of 14 studies met the inclusion criteria: ten studies included primary care health professionals, three studies included urologists, and one study included both. Studies involving general practitioners showed a generally low level of awareness of the recommended uses of the test, and urologists showed a greater knowledge of clinical practice guidelines. General practitioners' opinion of prostate-specific antigen was generally unfavourable in contrast to urologists' who were more likely to be proactive in ordering the test. Less than half of the included studies evaluated shared-decision making in practice and 50% of clinicians surveyed implemented it. Conclusion: General practitioners had less knowledge of prostate cancer risk factors and clinical practice guidelines in the use of PSA than urologists, which makes them less likely to follow available recommendations. A need to carry out education interventions with trusted resources based on the available evidence and the current guidelines was identified.

Mental Health Polypharmacy in "Non-Coded" Primary Care Patients: The Effect of Deprescribing.

Background: Mental health (MH) polypharmacy, defined as prescribing multiple mental health medications for the same condition, presents significant challenges in clinical practice. With varying prevalence rates and an increasing trend, particularly in the UK, this deprescribing prospective quality improvement project aimed to address the complexities and risks associated with MH polypharmacy. Patients and Methods: A large primary care centre in London was selected for this project. Electronic records of 667 patients (non-coded in mental health lists) were analysed as a result of the absence of a Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) for mental health. Seventy-two non-coded patients exhibiting "same-class" as well as "adjunctive" and "augmentation" polypharmacy were identified. Their demographic and health data, including MH diagnoses, physical status, and lifestyle habits, were evaluated. This deprescribing prospective project included 68 patients and employed a model inspired by the Plan-Do-Study-Act (PDSA) cycle, focusing on reducing psychotropic, adjunctive, and augmentative medications while monitoring mental health control through face-to-face consultations using the Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder Assessment-7 (GAD-7) scores, alongside physical health parameters. Results: The project revealed a significant decrease in the average number of psychotropic and adjunct medications from initial consultations to the end of the 18-month period. Additionally, a marked reduction in reported side effects and drug interactions was observed. Improvements in mental health control, as evidenced by PHQ-9 and GAD-7 scores, were noted. Physical health parameters, including BMI, blood pressure, heart rate, HbA1c, and cholesterol levels, also showed significant improvements. Educational initiatives for patients and clinicians were successfully implemented, contributing to these positive outcomes. Discussion: The project faced challenges like balancing medication reduction with mental health stability, patient apprehension, and the absence of standardised protocols. However, the successful reduction in medication numbers and the improvement in health outcomes highlight the effectiveness of the model. This project underscores the necessity of a tailored approach to MH polypharmacy, emphasising continuous education, clinical titration, and adherence to guidelines. Future research is needed to develop clear guidelines for medication combination in mental health care and to understand the long-term effects of polypharmacy in mental health populations. Conclusions: This project demonstrates the potential for significant improvements in the management of MH polypharmacy. By carefully managing medication reductions and employing a comprehensive care approach, including patient education and clinician training, the project achieved improvements in both mental and physical health outcomes. These findings suggest a promising direction for future practices in MH polypharmacy management.

'Why do we have to be the gatekeepers?' Australian general practitioners' knowledge, attitudes and prescribing intentions on e-cigarettes as a smoking cessation aid.

BACKGROUND: A significant policy change impacting the availability of nicotine for use in electronic cigarettes (e-cigarettes) in Australia took effect from October 1, 2021. This change meant that nicotine containing liquids for use with e-cigarettes would only be available by prescription from a medical practitioner as part of a smoking cessation plan. This study aimed to explore general practitioners (GPs) perceptions about the role of e-cigarettes, and understand factors informing their intentions to prescribe e-cigarettes as part of a smoking cessation plan. METHODS: In-depth semi-structured interviews were conducted with thirteen GPs. Purposeful sampling was used to recruit participants. Interviews were audio recorded and transcribed verbatim. Thematic analysis was used to classify, describe and report themes in the data. QSR NVivo was used to aid coding, thematic analysis and retrieval of quotes. RESULTS: Participants had diverse views on recommending and prescribing e-cigarettes as smoking cessation aids to patients. Some participants were willing to prescribe e-cigarettes to patients if other methods of smoking cessation had not worked but there were concerns, and uncertainty, about the safety and efficacy of e-cigarettes for smoking cessation. There was poor understanding of the current policy and legislation about e-cigarettes in Australia. Mostly the participants in this sample did not feel confident or comfortable to prescribe, or have discussions about e-cigarettes with patients. CONCLUSION: The participants of this study held diverse attitudes on recommending and prescribing e-cigarettes for smoking cessation. Clarity in guidelines and consumer product information are required to enable GPs to provide consistent and accurate advice to patients that wish to use e-cigarettes as a smoking cessation aid.

Development and validation of the screening tool for age-related hearing loss in the community based on the information platform.

INTRODUCTION: Currently, age-related hearing loss has become prevalent, awareness and screening rates remain dismally low. Duing to several barriers, as time, personnel training and equipment costs, available hearing screening tools do not adequately meet the need for large-scale hearing detection in community-dwelling older adults. Therefore, an accurate, convenient, and inexpensive hearing screening tool is needed to detect hearing loss, intervene early and reduce the negative consequences and burden of untreated hearing loss on individuals, families and society. OBJECTIVES: The study harnessed "medical big data" and "intelligent medical management" to develop a multi-dimensional screening tool of age-related hearing loss based on WeChat platform. METHODS: The assessment of risk factors was carried out by cross-sectional survey, logistic regression model and receiver operating characteristic (ROC) curve analysis. Combining risk factor assessment, Hearing handicap inventory for the elderly screening version and analog audiometry, the screening software was been developed by JavaScript language and been evaluated and verified. RESULTS: A total of 401 older adults were included in the cross-sectional study. Logistic regression model (univariate, multivariate) and reference to literature mention rate of risk factors, 18 variables (male, overweight/obesity, living alone, widowed/divorced, history of noise, family history of deafness, non-light diet, no exercising habit, smoking, drinking, headset wearer habit, hypertension, diabetes, hyperlipidemia, cardiovascular and cerebrovascular diseases, hyperuricemia, hypothyroidism, history of ototoxic drug use) were defined as risk factors. The area under the ROC curve (AUC) of the cumulative score of risk factors for early prediction of age-related hearing loss was 0.777 [95% CI (0.721, 0.833)]. The cumulative score threshold of risk factors was defined as 4, to classify the older adults into low-risk (< 4) and high-risk (≥ 4) hearing loss groups. The sensitivity, specificity, positive predictive value, and negative predictive value of the screen tool were 100%, 65.5%, 71.8%, and 100.0%, respectively. The Kappa index was 0.6. CONCLUSIONS: The screening software enabled the closed loop management of real-time data transmission, early warning, management, whole process supervision of the hearing loss and improve self-health belief in it. The software has huge prospects for application as a screening approach for age-related hearing loss.

Mind the gap: Concordance between perceptions regarding vaccination as declared by patients and their evaluation by their general practitioner.

BACKGROUND: The high level of vaccine hesitancy reported in the French population may lead general practitioners to anticipate difficult discussions on this topic. We aimed to assess the extent to which general practitioners' evaluation of their patients' vaccine hesitancy was correlated with the real vaccine hesitancy expressed by these patients. METHODS: The study was based on two brief paper questionnaires completed in private by the general practitioner and the patient at the beginning of a medical appointment: one for the physician to evaluate on three quantitative and non-graduated visual scales (then analysed as a 0-100 scale) their patients' perceptions regarding vaccine safety, vaccine efficacy and 'being in favour of vaccination'; and one for the patient to express their perceptions for the same three axes using the same scales. RESULTS: Overall, 31 physicians participated in the study, with 540 physician-patient pairs being included. The physicians' evaluation of patient perceptions was more positive when the physician was male (vs female), when the patient was male (vs female) and when both were males (vs both females). The median differences (in absolute values) between the physician evaluations and the patient perceptions were between 9 and 11 (on the 0-100 scale) for the three axes (vaccine safety, vaccine efficacy and 'being in favour'). A correlation was observed between the physicians' evaluation and the patients' declaration (Kendall test: vaccine efficacy: tau = 0.199, p < 0.001; vaccine safety: tau = 0.234, p < 0.001; being in favour of vaccination: tau = 0.365, p < 0.001). Physicians correctly classified 83.4 % of the patients with high perceptions of vaccine safety and efficacy (>75/100 for both scales) but only 54.5 % of those with low perceptions (<75/100 for both scales). CONCLUSION: Physicians tend to correctly identify patients with the most favourable perceptions about vaccination but not those with the least favourable perceptions.

Dying at "home" - a qualitative study of end-of-life care in rural Northern Norway from the perspective of health care professionals.

BACKGROUND: 'Most patients want to die at home' is a familiar statement in palliative care. The rate of home deaths is therefore often used as a success criterion. However, providing palliative care and enabling patients to die at home in rural and remote areas may be challenging due to limited health care resources and geographical factors. In this study we explored health care professionals' experiences and reflections on providing palliative care to patients at the end of life in rural Northern Norway. METHODS: This is a qualitative focus group and interview study in rural Northern Norway including 52 health care professionals. Five uni-professional focus group discussions were followed by five interprofessional focus group discussions and six individual interviews. Transcripts were analysed thematically. RESULTS: Health care professionals did their utmost to fulfil patients' wishes to die at home. They described pros and cons of providing palliative care in rural communities, especially their dual roles as health care professionals and neighbours, friends or even relatives of patients. Continuity and carers' important contributions were underlined. When home death was considered difficult or impossible, nurses expressed a pragmatic attitude, and the concept of home was extended to include 'home place' in the form of local health care facilities. CONCLUSIONS: Providing palliative care in patients' homes is professionally and ethically challenging, and health care professionals' dual roles in rural areas may lead to additional pressure. These factors need to be considered and addressed in discussions of the organization of care. Nurses' pragmatic attitude when transfer to a local health care facility was necessary underlines the importance of building on local knowledge and collaboration. Systematic use of advance care planning may be one way of facilitating discussions between patients, family carers and health care professionals with the aim of achieving mutual understanding of what is feasible in a rural context.

Expanding general practice with interprofessional teams: a mixed-methods patient perspective study.

BACKGROUND: Across healthcare systems, current health policies promote interprofessional teamwork. Compared to single-profession general practitioner care, interprofessional primary healthcare teams are expected to possess added capacity to care for an increasingly complex patient population. This study aims to explore patients' experiences when their usual primary healthcare encounter with general practice shifts from single-profession general practitioner care to interprofessional team-based care. METHODS: Qualitative and quantitative data were collected through interviews and a survey among Norwegian patients. The interviews included ten patients (five women and five men) aged between 28 and 89, and four next of kin (all women). The qualitative analysis was carried out using thematic analysis and a continuity framework. The survey included 287 respondents, comprising 58 per cent female and 42 per cent male participants, aged 18 years and above. The respondents exhibited multiple diagnoses and often a lengthy history of illness. All participants experienced the transition to interprofessional teamwork at their general practitioner surgery as part of a primary healthcare team pilot. RESULTS: The interviewees described team-based care as more fitting and better coordinated, including more time and more learning than with single-profession general practitioner care. Most survey respondents experienced improvements in understanding and mastering their health problems. Multi-morbid elderly interviewees and interviewees with mental illness shared experiences of improved information continuity. They found that important concerns they had raised with the nurse were known to the general practitioner and vice versa. None of the interviewees expressed dissatisfaction with the inclusion of a nurse in their general practitioner relationship. Several interviewees noted improved access to care. The nurse was seen as a strengthening link to the general practitioner. The survey respondents expressed strong agreement with being followed up by a nurse. The interviewees trusted that it was their general practitioner who controlled what happened to them in the general practitioner surgery. CONCLUSION: From the patients' perspective, interprofessional teamwork in general practice can strengthen management, informational, and relational continuity. However, a prerequisite seems to be a clear general practitioner presence in the team.

Mistrust in government and National Health Insurance: A qualitative study of solo private practitioners in Cape Town.

BACKGROUND:  The participation of independent private general practitioners (GPs) is of fundamental importance to the successful implementation of key elements of the proposed National Health Insurance (NHI) reform, notably the contracting units for primary health care (CUPS). This study explored knowledge and perceptions of the NHI reforms of private GPs following the tabling of the NHI Bill in parliament in 2019. METHODS:  An explorative qualitative research methodology was adopted. Using a semi-structured guide, nine solo private GPs, purposefully selected to represent the range of practices in the southern peninsula of Cape Town were interviewed in depth by B.L.P. over the period from January 2021 to March 2022. RESULTS:  The GPs indicated support for the values of greater equity outlined in the NHI proposals. However, they had little engagement on or knowledge of their potential future roles in NHI. Concerns over financial viability and design were underpinned by an overall mistrust in the public sector to implement and manage NHI. CONCLUSION:  The study concurs with previous research that private GPs are broadly in support of the principles of, and are potential allies, in advancing NHI. General practitioners need a platform to share their concerns and contribute as co-designers of NHI reforms. In the interim, steps to increase collaboration between private and public sectors at local and provincial level through, for example, referral processes may help to build the trust that is necessary between the sectors.Contribution: This study foregrounds the role of trust relationships in advancing NHI.

Can physicians and schools mitigate social inequalities in human papillomavirus vaccine awareness, uptake and vaccination intention among adolescents? A cross-sectional study, France, 2021 to 2022.

BackgroundIn France, human papillomavirus (HPV) vaccination coverage varies across socioeconomic levels.AimWe aimed at assessing HPV vaccine awareness, uptake and vaccination intention among adolescents in France.MethodsIn a cluster-randomised study, 13-15-year-old students in 61 French middle schools completed a web-based questionnaire. We used multivariable logistic regression to evaluate determinants of HPV vaccine awareness, self-reported uptake and vaccination intention among unvaccinated students and interaction terms to explore effects of visits to family physician and remembering school lessons on vaccination. The French deprivation index of school municipalities served as proxy for socioeconomic levels.ResultsAmong 6,992 participants, awareness was significantly associated with parental education (odds ratio (OR) = 0.82; 95% confidence interval (CI): 0.71-0.95), language spoken at home (OR = 0.59; 95% CI: 0.52-0.66) and deprivation level (OR = 0.57; 95% CI: 0.44-0.71), regardless of physician visit or school lessons. Vaccine uptake was associated with parental education without a recent physician visit (OR = 0.31; 95% CI: 0.16-0.59, vs OR = 0.64; 95% CI: 0.52-0.78 with a visit, interaction p = 0.045). Vaccination intention among unvaccinated was associated with deprivation level (moderate-low vs low) among students not remembering school lessons on vaccination (OR = 0.17; 95% CI: 0.05-0.62, vs OR = 0.93; 95% CI: 0.51-1.67 remembering school lessons, interaction p = 0.022). Parental education was associated with vaccination intention among students reporting a physician visit (OR = 0.41; 95% CI: 0.26-0.64 vs OR = 1.05; 95% CI: 0.50-2.20 without a visit, interaction p = 0.034).ConclusionOur results suggest that healthcare and school could promote vaccination and mitigate social inequalities in HPV vaccination coverage.