A Saga-In-Progress: Challenges and Milestones on Our Way Toward the Nordic Core Values and Principles of Family Medicine/General Practice.

Late in 2020, the Nordic Colleges of General Practice published a joint statement specifying what General Practitioners stand for and intend to act upon, our Core Values and Principles. In this article, the authors describe and analyze challenges and milestones encountered on our 50-year journey toward the creation of that document. The shaping of Family Medicine/General Practice as an academic discipline began in the 1960's. During an initial, descriptive phase, the new specialty was defined, its educational curricula formulated, and the core competencies required to earn the title, Specialist in Family Medicine, were identified. Focus was not yet placed directly on the relationship between viable working principles and values, however. Then, the 1978 WHO Alma Ata Declaration affirmed health to be a fundamental human right, with primary health care as the heart of sustainable health care systems, indirectly mandating that the field of Family Medicine deliver value-based health care. A major step in that process was taken in 2001: The Norwegian College of General Practice launched their statement identifying the seven theses, Sju teser, that characterize the principles, purposes-and core values-of General Practice. Later, the Nordic colleges worked together to formulate the 2020 joint statement. We are confident that Family Medicine will continue to provide sustainable, relationship-based care, and to protect the human side of medicine. Sharing core values and principles can help us mobilize as effective advocates for our discipline and for our patients, the citizens whom we serve.

History of violence and subjective health of mother and child.

OBJECTIVE: To study the self-reported prevalence of experienced violence among a cohort of women about two years after giving birth, their health during pregnancy, pregnancy outcomes and their experience of their child's health. SETTING AND SUBJECTS: In 2011, a total of 657 women participated in phase III of the Childbirth and Health Cohort Study in Icelandic Primary Health Care, 18 to 24 months after delivery. The women had previously participated in phase I around pregnancy week 16 and phase II 5-6 months after delivery. Data were collected by postal questionnaires. MAIN OUTCOME MEASURES: Women's reported history of experienced violence, sociodemographic and obstetric background, self-perceived health, the use of medications and their child's perceived health. RESULTS: In phase III, 16% of women reported experiencing violence. These women felt less support from their current partner (p < 0.001), compared to those who did not report violence. Their pregnancies were more frequently unplanned (p < 0.001), deliveries more often by caesarean section (p < 0.05), and their self-perceived health was worse (p < 0.001). They reported more mental and somatic health complaints, and their use of antidepressant drugs was higher (p < 0.001). Furthermore, women with a history of violence considered their child's general health as worse (p = 0.008). CONCLUSIONS: Our study confirms that a history of violence is common among women. A history of violence is associated with various maternal health problems during and after pregnancy, a higher rate of caesarean sections and maternal reports of health problems in their child 18-24 months after birth. KEY POINTS Violence is a major concern worldwide. Understanding the impact of violence on human health and developing effective preventive measures are important elements of any public health agenda. • The reported prevalence of experiencing violence was 16% among women attending antenatal care in the primary health care setting in Iceland. • Women with a history of violence reported worse health in general during pregnancy and delivered more often by caesarean section, compared to women with no such history. • Mothers with a history of violence also evaluated the general health of their child as worse than women with no such history. • The findings of this study support the importance of recognizing and addressing experienced violence among women in primary care.

Multimorbidity and use of hypnotic and anxiolytic drugs: cross-sectional and follow-up study in primary healthcare in Iceland.

BACKGROUND: The prevalence of multimorbidity is increasing worldwide, presumably leading to an increased use of medicines. During the last decades the use of hypnotic and anxiolytic benzodiazepine derivatives and related drugs has increased dramatically. These drugs are frequently prescribed for people with a sleep disorder often merely designated as "insomnia" in the medical records and lacking a clear connection with the roots of the patients' problems. Our aim was to analyse the prevalence of multimorbidity in primary healthcare in Iceland, while concurrently investigating a possible association with the prevalence and incidence of hypnotic/anxiolytic prescriptions, short-term versus chronic use. METHODS: Data were retrieved from a comprehensive database of medical records from primary healthcare in Iceland to find multimorbid patients and prescriptions for hypnotics and anxiolytics, linking diagnoses (ICD-10) and prescriptions (2009-2012) to examine a possible association. Nearly 222,000 patients, 83 % being local residents in the capital area, who contacted 16 healthcare centres served in total by 140 general practitioners, were set as a reference to find the prevalence of multimorbidity as well as the prevalence and incidence of hypnotic/anxiolytic prescriptions. RESULTS: The prevalence of multimorbidity in the primary care population was 35 %, lowest in the young, increasing with age up to the 80+ group where it dropped somewhat. The prevalence of hypnotic/anxiolytic prescriptions was 13.9 %. The incidence rate was 19.4 per 1000 persons per year in 2011, and 85 % of the patients prescribed hypnotics/anxiolytics were multimorbid. Compared to patients without multimorbidity, multimorbid patients were far more likely to be prescribed a hypnotic and/or an anxiolytic, OR = 14.9 (95 % CI = 14.4-15.4). CONCLUSIONS: Patients with multiple chronic conditions are common in the primary care setting, and prevalence and incidence of hypnotic/anxiolytic prescriptions are high. Solely explaining use of these drugs by linear thinking, i.e. that "insomnia" leads to their prescription is probably simplistic, since the majority of patients prescribed these drugs are multimorbid having several chronic conditions which could lead to sleeping problems. However, multimorbidity as such is not an indication for hypnotics, and doctors should be urged to greater caution in their prescribing, bearing in mind non-pharmacological therapy options.

A 32-year longitudinal study of alcohol consumption in Swedish women: Reduced risk of myocardial infarction but increased risk of cancer.

OBJECTIVE: To assess associations between the intake of different types of alcoholic beverages and the 32-year incidence of myocardial infarction, stroke, diabetes, and cancer, as well as mortality, in a middle-aged female population. DESIGN: Prospective study. SETTING: Gothenburg, Sweden, population about 430 000. SUBJECTS: Representative sample of a general population of women (1462 in total) aged 38 to 60 years in 1968-1969, followed up to the ages of 70 to 92 years in 2000-2001. MAIN OUTCOME MEASURES: Associations between alcohol intake and later risk of mortality and morbidity from myocardial infarction, stroke, diabetes, and cancer, studied longitudinally. RESULTS: During the follow-up period, 185 women developed myocardial infarction, 162 developed stroke, 160 women became diabetic, and 345 developed cancer. Women who drank beer had a 30% lower risk (hazards ratio (HR) 0.70, 95% confidence interval (CI) 0.50-0.95) of developing myocardial infarcion and almost half the risk (HR 0.51 CI 0.33-0.80). A significant association between increased risk of death from cancer and high spirits consumption was also shown (hazards ratio [HR] 1.47, CI 1.06-2.05). CONCLUSIONS: Women with moderate consumption of beer had a reduced risk of developing myocardial infarction. High spirits consumption was associated with increased risk of cancer mortality.

Drug use during early pregnancy: cross-sectional analysis from the Childbirth and Health Study in Primary Care in Iceland.

OBJECTIVE: To analyse drug use in early pregnancy with special focus on socio-demographic factors associated with psychotropic and analgesic drug use. DESIGN: Cross-sectional study. SETTING AND SUBJECTS: A total of 1765 women were invited via their local health care centres, and 1111 participated at 11-16 weeks of pregnancy by filling out a postal questionnaire concerning socio-demographic and obstetric background, stressful life events, and drug use. MAIN OUTCOME MEASURES: Drug use prior to and early on in pregnancy, socio-demographic factors, smoking, and adverse life events were investigated. Drug categories screened for were psychotropics (collective term for antidepressants, relaxants, and sleep medication), analgesics, hormones, nicotine, vitamins/minerals, and homeopathic medicine. RESULTS: Drug use from the aforementioned drug categories, excluding vitamins/minerals and homeopathic medicine, was reduced by 18% during early pregnancy, compared with six months prior to conception (49% vs. 60%). Psychotropic drug use during early pregnancy was associated with elementary maternal education (p < 0.5), being unemployed (p < 0.001), being single/divorced/separated (p < 0.01), smoking prior to or during pregnancy (p < 0.01), forced to change job/move house (p < 0.001), and psychotropic drug use six months prior to pregnancy (p < 0.001). No items on the stressful life events scale were associated with increased analgesic use, which increased only with multiparity. CONCLUSIONS: Use of analgesics and psychotropic drugs seems common in pregnancy. Our results indicate that lack of a support network, stressful life events, and lower status in society may predispose women to more drug use. GPs and midwives responsible for maternity care could take this into account when evaluating risk and gain for women and foetuses in the primary care setting.

Smoking during pregnancy: childbirth and health study in primary care in Iceland.

OBJECTIVE: To study the prevalence and possible predictors for smoking during pregnancy in Iceland. DESIGN: A cross-sectional study. SETTING: Twenty-six primary health care centres in Iceland 2009-2010. SUBJECTS. Women attending antenatal care in the 11th-16th week of pregnancy were invited to participate by convenient consecutive manner, stratified according to residency. A total of 1111 women provided data in this first phase of the cohort study. MAIN OUTCOME MEASURES: Smoking habits before and during early pregnancy were assessed with a postal questionnaire, which also included questions about socio-demographic background, physical and emotional well-being, and use of medications. RESULTS: The prevalence of smoking prior to pregnancy was 20% (223/1111). During early pregnancy, it was 5% (53/1111). In comparison with women who stopped smoking during early pregnancy, those who continued to smoke had on average a significantly lower level of education, had smoked more cigarettes per day before pregnancy, and were more likely to use nicotine replacement therapy in addition to smoking during pregnancy. A higher number of cigarettes consumed per day before pregnancy and a lower level of education were the strongest predictors for continued smoking during pregnancy. CONCLUSION: The majority of Icelandic women who smoke stop when they become pregnant, and the prevalence of smoking during pregnancy in Iceland is still about 5%. Our results indicate stronger nicotine dependence in women who do not stop smoking during pregnancy. Awareness of this can help general practitioners (GPs) and others providing antenatal care to approach these women with more insight and empathy, which might theoretically help them to quit.

Gatekeeping and referrals to cardiologists: general practitioners' views on interactive communications.

OBJECTIVE: Referrals to specialists have not been compulsory in Iceland since 1984. In 2006, referrals were again required for patients to receive reimbursement for part of the cost of appointments with cardiologists. The aim of this study was to explore GPs' attitudes to the referral system and possible professional gain by interactive communications. DESIGN: Cross-sectional questionnaire survey. SETTING, SUBJECTS, AND MAIN OUTCOME MEASURES: This is part of a larger study in 2007 on referrals from GPs to cardiologists. A questionnaire was sent to all working GPs in Iceland (n = 201 and responsible for 307 000 inhabitants) regarding the referral process, reasons for referrals, how often a response letter was received, and GPs' attitudes to the referral system. Responses from doctors working in rural areas were compared with those working in Reykjavik and nearby urban areas. RESULTS: The response rate was 63% (126 answers). The mean age of participants was 51; 89% were GP specialists and 60% worked in Reykjavik and nearby urban areas. Almost all respondents (98%) thought that report letters from cardiologists were helpful; 64% (95% confidence interval 53-73) thought that the recently introduced referral system did increase useful information that was beneficial to their patients. There was a statistically significant difference between colleagues working in rural areas and those working in Reykjavik and nearby urban areas regarding several aspects of the referral process. CONCLUSION: A referral system increases the flow of information and mutual communications between general practitioners and specialists to the benefit of the patients. The geographical location of the health care centre may be of importance regarding the value of the referrals.

Milestones in the development of Nordic general practice*.

The common history and development of Nordic family medicine is important and interesting. This paper looks back on the aspects and factors influencing academic family medicine in the Nordic countries and especially the central position of the Nordic Congresses and the Scandinavian Journal of Primary Health Care. The importance of pioneers and bringing people together is emphasized. More than 30 years of Nordic academic family medicine has indeed had an incredible impact and has initiated development from only a few people to become world leading.

Marginal public health gain of screening for colorectal cancer: modelling study, based on WHO and national databases in the Nordic countries.

AIMS: To estimate the potential gain of national screening programmes for colorectal cancer (CRC) by stool occult blood testing in the Nordic countries, with comparative reference to the burden of other causes of premature death. METHODS: Implementation of national screening programmes for CRC was modelled among people 55-74 years in accordance with the 2011 Cochrane review of biannual screening, using the faecal occult blood test (FOBT) for 10 years, resulting in 15% relative risk reduction in CRC deaths among all those invited [intention-to-treat; relative risk 0.85; confidence interval (CI) 0.78 to 0.92]. Our calculations are based on the World Health Organization and national databanks on death causes (ICD-10) and the mid-year number of inhabitants in the target group. For Finland, Denmark, Norway and Sweden, we used data for 2009. For Iceland, due to the population's small size, we calculated mean mortality for the period 2005-2009. RESULTS: Invitation to a CRC screening programme for 10 years could influence 0.5-0.9% (95%CI 0.4-1.2) of all deaths in the age group 65-74 years. Among the remaining 99% of premature deaths, around 50% were caused by lung cancer, other lung diseases, cardiovascular diseases and accidents, with some national variations. CONCLUSIONS AND IMPLICATIONS: Establishment of a screening programme for CRC for people aged 55-74 can be expected to affect only a minor proportion of all premature deaths in the Nordic setting. From a public health perspective, prioritizing preventive strategies targeting more prevalent causes of premature death may be a superior approach.

Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study.

RATIONALE, AIMS AND OBJECTIVES: Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well-defined, general Norwegian population without known CVD at baseline. METHODS: We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20-74, who participated in the Nord-Trøndelag Health Study (HUNT 2, 1995-1997) and were followed-up on cause-specific mortality for 10 years (510 297 person-years in total). RESULTS: Among women, cholesterol had an inverse association with all-cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89-0.99 per 1.0 mmol L(-1) increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88-1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92-1.24) was not linear but seemed to follow a 'U-shaped' curve, with the highest mortality <5.0 and ≥7.0 mmol L(-1) . Among men, the association of cholesterol with mortality from CVD (HR: 1.06; 95% CI: 0.98-1.15) and in total (HR: 0.98; 95% CI: 0.93-1.03) followed a 'U-shaped' pattern. CONCLUSION: Our study provides an updated epidemiological indication of possible errors in the CVD risk algorithms of many clinical guidelines. If our findings are generalizable, clinical and public health recommendations regarding the 'dangers' of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial.

Body configuration as a predictor of mortality: comparison of five anthropometric measures in a 12 year follow-up of the Norwegian HUNT 2 study.

BACKGROUND: Distribution of body fat is more important than the amount of fat as a prognostic factor for life expectancy. Despite that, body mass index (BMI) still holds its status as the most used indicator of obesity in clinical work. METHODS: We assessed the association of five different anthropometric measures with mortality in general and cardiovascular disease (CVD) mortality in particular using Cox proportional hazards models. Predictive properties were compared by computing integrated discrimination improvement and net reclassification improvement for two different prediction models. The measures studied were BMI, waist circumference, hip circumference, waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR). The study population was a prospective cohort of 62,223 Norwegians, age 20-79, followed up for mortality from 1995-1997 to the end of 2008 (mean follow-up 12.0 years) in the Nord-Trøndelag Health Study (HUNT 2). RESULTS: After adjusting for age, smoking and physical activity WHR and WHtR were found to be the strongest predictors of death. Hazard ratios (HRs) for CVD mortality per increase in WHR of one standard deviation were 1.23 for men and 1.27 for women. For WHtR, these HRs were 1.24 for men and 1.23 for women. WHR offered the greatest integrated discrimination improvement to the prediction models studied, followed by WHtR and waist circumference. Hip circumference was in strong inverse association with mortality when adjusting for waist circumference. In all analyses, BMI had weaker association with mortality than three of the other four measures studied. CONCLUSIONS: Our study adds further knowledge to the evidence that BMI is not the most appropriate measure of obesity in everyday clinical practice. WHR can reliably be measured and is as easy to calculate as BMI and is currently better documented than WHtR. It appears reasonable to recommend WHR as the primary measure of body composition and obesity.

"No doubt this childhood disease on Vestmannö can be prevented"--neonatal tetanus on the Westman Islands.

At the beginning of the 1800 s neonatal tetanus was a major health hazard on the Westman Islands, an archipelago immediately south of Iceland. Up to 60­70% of newborn babies died in the course of the first two weeks of life, and Danish health authorities were almost helpless in the face of this mysterious disease. In 1847 the young Danish doctor Peter Anton Schleisner (1818-1900) was sent to the islands to investigate the conditions there. He established a maternity hospital, gave advice on hygiene and encouraged breast-feeding and a number of changes in diet. Since there was no known treatment, Schleisner's only option was to resort to preventive measures. He dressed the umbilical stump with balsamum copaivae and tried well-established methods such as opium tincture with saffron and mercurial ointment if there was any sign of infection. By the time he returned to Denmark after nine months, mortality had been halved. Neonatal mortality on the Westman Islands remained at the same low level throughout the rest of the 19th century. According to popular belief this was due to the naflaolian (navel oil) which Schleisner introduced. Nevertheless, it can be partly attributed to generally improved living standards, a relatively higher number of mothers in better social circumstances, a greater urban influence, changed lifestyle and hygienic measures. Schleisner's efforts are considered to have had major significance when conditions are compared with those on the Scottish island of St Kilda where the situation was the same and improved only just before the turn of the century.

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.