Experiences with telemedicine-based follow-up of chronic conditions: the views of patients and health personnel enrolled in a pragmatic randomized controlled trial.

BACKGROUND: Telemedicine is often promoted as a possible solution to some of the challenges healthcare systems in many countries face, and an increasing number of studies evaluate the clinical effects. So far, the studies show varying results. Less attention has been paid to systemic factors, such as the context, implementation, and mechanisms of these interventions. METHODS: This study evaluates the experiences of patients and health personnel enrolled in a pragmatic randomized controlled trial comparing telemedicine-based follow-up of chronic conditions with usual care. Patients in the intervention group received an individual treatment plan together with computer tablets and home telemonitoring devices to report point-of-care measurements, e.g., blood pressure, blood glucose or oxygen saturation, and to respond to health related questions reported to a follow-up service. In response to abnormal measurement results, a follow-up service nurse would contact the patient and consider relevant actions. We conducted 49 interviews with patients and 77 interviews with health personnel and managers at the local centers. The interview data were analyzed using thematic analysis and based on recommendations for conducting process evaluation, considering three core aspects within the process of delivering a complex intervention: (1) context, (2) implementation, and (3) mechanisms of impact. RESULTS: Patients were mainly satisfied with the telemedicine-based service, and experienced increased safety and understanding of their symptoms and illness. Implementation of the service does, however, require dedicated resources over time. Slow adjustment of other healthcare providers may have contributed to the absence of reductions in the use of specialized healthcare and general practitioner (GP) services. An evident advantage of the service is its flexibility, yet this may also challenge cost-efficiency of the intervention. CONCLUSIONS: The implementation of a telemedicine-based service in primary healthcare is a complex process that is sensitive to contextual factors and that requires time and dedicated resources to ensure successful implementation. TRIAL REGISTRATION: The trial was registered in www. CLINICALTRIALS: gov (NCT04142710). Study start: 2019-02-09, Study completion: 2021-06-30, Study type: Interventional, Intervention/treatment: Telemedicine tablet and tools to perform measurements. Informed and documented consent was obtained from all subjects and next of kin participating in the study.

Pragmatic randomized controlled trial comparing a complex telemedicine-based intervention with usual care in patients with chronic conditions.

This study evaluates a complex telemedicine-based intervention targeting patients with chronic health problems. Computer tablets and home telemonitoring devices are used by patients to report point-of-care measurements, e.g., blood pressure, blood glucose or oxygen saturation, and to answer health-related questions at a follow-up center. We designed a pragmatic randomized controlled trial to compare the telemedicine-based intervention with usual care in six local centers in Norway. The study outcomes included health-related quality of life (HRQoL) based on the EuroQol questionnaire (EQ-5D-5L), patient experiences, and utilization of healthcare. We also conducted a cost-benefit analysis to inform policy implementation, as well as a process evaluation (reported elsewhere). We used mixed methods to analyze data collected during the trial (health data, survey data and interviews with patients and health personnel) as well as data from national health registers. 735 patients were included during the period from February 2019 to June 2020. One year after inclusion, the effects on the use of healthcare services were mixed. The proportion of patients receiving home-based care services declined, but the number of GP contacts increased in the intervention group compared to the control group. Participants in the intervention group experienced improved HRQoL compared to the control group and were more satisfied with the follow-up of their health. The cost-benefit of the intervention depends largely on the design of the service and the value society places on improved safety and self-efficacy.

Educational patterns of health behaviors and body mass index: A longitudinal multiple correspondence analysis of a middle-aged general population, 2007-2016.

Social differences in body mass index and health behaviors are a major public health challenge. The uneven distribution of unhealthy body mass index and of unhealthy behaviors such as smoking, physical inactivity, and harmful alcohol consumption has been shown to mediate social inequalities in chronic diseases. While differential exposures to these health variables have been investigated, the extent to which they vary over the lifetime in the same population and their relationship with level of education is not well understood. This study examines patterns of body mass index and multiple health behaviors (smoking, physical activity and alcohol consumption), and investigates their association with education level among adults living in Northern Norway. It presents findings from a longitudinal multiple correspondence analysis of the Tromsø Study. Longitudinal data from 8,906 adults aged 32-87 in 2007-2008, with repeated measurements in 2015-2016 were retrieved from the survey's sixth and seventh waves. The findings suggest that most in the study population remained in the same categories of body mass index and the three health behaviors at the follow-up, with a clear educational gradient in healthy patterns. That is, both healthy changes and maintained healthy categories were associated with the highest education levels. Estimating differential exposures to mediators of health inequalities could benefit policy priority setting for tackling inequalities in health.

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.

Tension between local, regional and national level in Norwegian handling of COVID-19.

INTRODUCTION: The initial phase of the COVID-19 pandemic can be described as a crisis - a threat that must be urgently addressed under conditions of deep uncertainty. We wanted to explore the tension between local, regional and national authorities evoked by some rural municipalities' decisions to impose local infection control measures during the first weeks of the COVID-19 pandemic in Norway. METHODS: Eight municipal chief medical officers of health (CMO) and six crisis management teams participated in semi-structured and focus group interviews. Data were analyzed with systematic text condensation. Boin and Bynander's interpretation of crisis management and coordination and Nesheim et al.'s framework for non-hierarchical coordination in the state sector inspired the analysis. RESULTS: Uncertainty in the face of a pandemic with unknown damage potential, lack of infection control equipment, patient transport challenges, vulnerable staff situation and planning of local COVID-19 beds were some of the reasons for rural municipalities imposing local infection control measures. Local CMOs' engagement, visibility and knowledge contributed to trust and safety. Differences in perspectives between local, regional and national actors created tension. Existing roles and structures were adjusted, and new informal networks arose. DISCUSSION: Strong municipal responsibility in Norway and the quite unique arrangement with local CMOs in every municipality with legal right to decide temporary local infection control measures seemed to facilitate a fruitful balance between top-down and bottom-up decision-making. The following dialogue and mutual adjustment of perspectives led to appropriate balance between national and local measures in Norway's handling of the COVID-19 pandemic.

Which types of mental health/substance misuse treatment services are available in primary care for adults in rural municipalities in Norway?

INTRODUCTION: In Norway, the municipalities are responsible for providing primary health care, including mental health care. National rules, regulations and guidelines are the same throughout the country, but the municipalities can organise the service as they see fit. In rural areas, distance and time to specialised health care, recruitment and retention of professionals, and the care needs in the community will likely play a part in how the services are organised. There is a lack of knowledge of the variation of services, and which factors affect availability, capacity and organisation of mental health/substance-misuse treatment services for adults in rural municipalities. AIM: The aim of this study is to explore how mental health/substance-misuse treatment services in rural areas are organised and assigned, and which professionals provide the services. METHODS: This study will be based on collected data from municipal plans and available statistic recourses on how the services are organised. These data will be contextualised with focused interviews with leaders in primary health care. RESULTS: The study is ongoing. Results will be presented in June 2022. DISCUSSION: Results from this descriptive study will be discussed in light of the development of mental health/substance-misuse health care with special focus on challenges and possibilities in rural areas.

Educational interventions to ensure provision of doctors in rural areas - a systematic review.

INTRODUCTION: Recruiting doctors in rural areas is challenging. Various educational interventions have been introduced in many countries. This study aimed to explore undergraduate medical education interventions introduced to recruit doctors to rural areas, and the results of these interventions. METHODS: We undertook a systematic search using search words 'rural', 'remote', 'workforce', 'physicians', 'recruitment' and 'retention'. We included articles meeting the following criteria: educational interventions clearly described; study population consisted of medical graduates; and outcome measures included place of work (rural/non-rural) after graduation. RESULTS: The analysis included 58 articles and encompassed educational interventions in ten countries. There were five main types of interventions, often used in combination: preferential admission from rural areas; curriculum relevant to rural medicine; decentralised education; practice-oriented learning in rural areas; and compulsory service periods in rural areas after graduation. The majority of the studies (42) compared place of work (rural/non-rural) of doctors graduated with and without these interventions. In 26 studies, odds ratio for rural place of work was significant at a level of 5%, with odds ratios between 1.5 and 17.2. Significant differences in the proportion with a rural/non-rural place of work were shown in 14 studies, differences ranging from 11 to 55 percentage points. DISCUSSION: Changing focus of undergraduate medical education towards development of knowledge, skills and teaching arenas that equip doctors with competencies to work in rural areas has an impact on the recruitment of doctors in rural areas. Concerning preferential admission from rural areas, we will discuss if national and local contexts makes a difference.

Tension between local, regional and national levels in Norway's handling of COVID-19.

AIMS: This study aimed to explore the tension between local, regional, and national authorities evoked by some rural municipalities' decisions to impose local infection-control measures during the first weeks of the COVID-19 pandemic in Norway. METHODS: Eight municipal Chief Medical Officers of Health (CMOs) participated in semi-structured interviews, and six crisis management teams participated in focus-group interviews. Data were analysed with systematic text condensation. Boin and Bynander's interpretation of crisis management and coordination and Nesheim et al.'s framework for non-hierarchical coordination in the state sector inspired the analysis. RESULTS: Uncertainty in the face of a pandemic with unknown damage potential, lack of infection-control equipment, patient transport challenges, vulnerable staff situation and planning of local COVID-19 beds were some of the reasons for rural municipalities imposing local infection-control measures the first weeks of the pandemic. Local CMOs' engagement, visibility and knowledge contributed to trust and safety. Differences in perspectives between local, regional and national actors created tension. Existing roles and structures were adjusted, and new informal networks arose. CONCLUSIONS: Strong municipal responsibility in Norway and the quite unique arrangement with local CMOs in every municipality with the legal right to decide temporary local infection-control measures seemed to facilitate a balance between top-down and bottom-up decision making. Tension between rural, regional and national actors that arose due to local infection-control measures, and the following dialogue and mutual adjustment of perspectives, led to a fruitful balance between national and local measures in Norway's handling of the COVID-19 pandemic.

Inequality of opportunity in a land of equal opportunities: The impact of parents' health and wealth on their offspring's quality of life in Norway.

BACKGROUND: The literature on Inequality of opportunity (IOp) in health distinguishes between circumstances that lie outside of own control vs. efforts that - to varying extents - are within one's control. From the perspective of IOp, this paper aims to explain variations in individuals' health-related quality of life (HRQoL) by focusing on two separate sets of variables that clearly lie outside of own control: Parents' health is measured by their experience of somatic diseases, psychological problems and any substance abuse, while parents' wealth is indicated by childhood financial conditions (CFC). We further include own educational attainment which may represent a circumstance, or an effort, and examine associations of IOp for different health outcomes. HRQoL are measured by EQ-5D-5L utility scores, as well as the probability of reporting limitations on specific HRQoL-dimensions (mobility, self-care, usual-activities, pain & discomfort, and anxiety and depression). METHOD: We use unique survey data (N = 20,150) from the egalitarian country of Norway to investigate if differences in circumstances produce unfair inequalities in health. We estimate cross-sectional regression models which include age and sex as covariates. We estimate two model specifications. The first represents a narrow IOp by estimating the contributions of parents' health and wealth on HRQoL, while the second includes own education and thus represents a broader IOp, alternatively it provides a comparison of the relative contributions of an effort variable and the two sets of circumstance variables. RESULTS: We find strong associations between the circumstance variables and HRQoL. A more detailed examination showed particularly strong associations between parental psychological problems and respondents' anxiety and depression. Our Shapley decomposition analysis suggests that parents' health and wealth are each as important as own educational attainment for explaining inequalities in adult HRQoL. CONCLUSION: We provide evidence for the presence of the lasting effect of early life circumstances on adult health that persists even in one of the most egalitarian countries in the world. This suggests that there may be an upper limit to how much a generous welfare state can contribute to equal opportunities.

The association between health anxiety, physical disease and cardiovascular risk factors in the general population - a cross-sectional analysis from the Tromsø study: Tromsø 7.

BACKGROUND: Health anxiety (HA) is defined as a worry of disease. An association between HA and mental illness has been reported, but few have looked at the association between HA and physical disease. OBJECTIVE: To examine the association between HA and number of diseases, different disease categories and cardiovascular risk factors in a large sample of the general population. METHODS: This study used cross-sectional data from 18,432 participants aged 40 years or older in the seventh survey of the Tromsø study. HA was measured using a revised version of the Whiteley Index-6 (WI-6-R). Participants reported previous and current status regarding a variety of different diseases. We performed exponential regression analyses looking at the independent variables 1) number of diseases, 2) disease category (cancer, cardiovascular disease, diabetes or kidney disease, respiratory disease, rheumatism, and migraine), and 3) cardiovascular risk factors (high blood pressure or use of cholesterol- or blood pressure lowering medication). RESULTS: Compared to the healthy reference group, number of diseases, different disease categories, and cardiovascular risk factors were consistently associated with higher HA scores. Most previous diseases were also significantly associated with increased HA score. People with current cancer, cardiovascular disease, and diabetes or kidney disease had the highest HA scores, being 109, 50, and 60% higher than the reference group, respectively. CONCLUSION: In our general adult population, we found consistent associations between HA, as a continuous measure, and physical disease, all disease categories measured and cardiovascular risk factors.

Combining education and income into a socioeconomic position score for use in studies of health inequalities.

BACKGROUND: In studies of social inequalities in health, there is no consensus on the best measure of socioeconomic position (SEP). Moreover, subjective indicators are increasingly used to measure SEP. The aim of this paper was to develop a composite score for SEP based on weighted combinations of education and income in estimating subjective SEP, and examine how this score performs in predicting inequalities in health-related quality of life (HRQoL). METHODS: We used data from a comprehensive health survey from Northern Norway, conducted in 2015/16 (N = 21,083). A composite SEP score was developed using adjacent-category logistic regression of subjective SEP as a function of four education and four household income levels. Weights were derived based on these indicators' coefficients in explaining variations in respondents' subjective SEP. The composite SEP score was further applied to predict inequalities in HRQoL, measured by the EQ-5D and a visual analogue scale. RESULTS: Education seemed to influence SEP the most, while income added weight primarily for the highest income category. The weights demonstrated clear non-linearities, with large jumps from the middle to the higher SEP score levels. Analyses of the composite SEP score indicated a clear social gradient in both HRQoL measures. CONCLUSIONS: We provide new insights into the relative contribution of education and income as sources of SEP, both separately and in combination. Combining education and income into a composite SEP score produces more comprehensive estimates of the social gradient in health. A similar approach can be applied in any cohort study that includes education and income data.

Health anxiety is an important driver of healthcare use.

BACKGROUND: Healthcare use is increasing, and health anxiety (HA) is recognized as an important associated factor. Previous research on the association between HA and healthcare use has mostly explored HA as a dichotomous construct, which contrasts the understanding of HA as a continuous construct, and compared healthcare use to non-use. There is a need for studies that examine the association between healthcare use and the continuum of HA in a general population. AIM: To explore the association between HA and primary, somatic specialist and mental specialist healthcare use and any differences in the association by level of healthcare use. METHODS: This study used cross-sectional data from the seventh Tromsø study. Eighteen thousand nine hundred sixty-seven participants aged 40 years or older self-reported their primary, somatic specialist and mental specialist healthcare use over the past 12 months. Each health service was categorized into 5 groups according to the level of use. The Whiteley Index-6 (WI-6) was used to measure HA on a 5-point Likert scale, with a total score range of 0-24. Analyses were conducted using unconstrained continuation-ratio logistic regression, in which each level of healthcare use was compared with all lower levels. Morbidity, demographics and social variables were included as confounders. RESULTS: HA was positively associated with increased utilization of primary, somatic specialist and mental specialist healthcare. Adjusting for confounders, including physical and mental morbidity, did not alter the significant association. For primary and somatic specialist healthcare, each one-point increase in WI-6 score yielded a progressively increased odds ratio (OR) of a higher level of use compared to all lower levels. The ORs ranged from 1.06 to 1.15 and 1.05 to 1.14 for primary and somatic specialist healthcare, respectively. For mental specialist healthcare use, the OR was more constant across levels of use, ranging between 1.06 and 1.08. CONCLUSIONS: In an adult general population, HA, as a continuous construct, was significantly and positively associated with primary, somatic specialist and mental healthcare use. A small increase in HA was associated with progressively increased healthcare use across the three health services, indicating that the impact of HA is more prominent with higher healthcare use.

Doctors educated in Bodø - who are they and where do they work? / Leger utdannet i Bodø ­ hvem er de og hvor blir de av?

BACKGROUND: Every year since 2009, up to 24 medical students at UiT The Arctic University of Norway have undertaken the last two years of their undergraduate medical education in Bodø (referred to as the Bodø model). We mapped the municipalities where the students had grown up, their preferences as to future specialties, where they worked and what they worked with after Part 1 of their specialist training. MATERIAL AND METHOD: Medical students who graduated from the Bodø model in the period 2012-18 completed a questionnaire in the first week of their sixth year of study, containing questions about where they had grown up and their preferences for future place of work and specialty. We mapped their place of work and specialty as of January 2021 as well as that of the two cohorts graduating in 2010-11. The place where the latter had grown up was mapped via direct contact, contact with their cohort or open internet sources. The covariation between where they grew up and their place of work, specialty preferences and choice of specialty were analysed using chi-square tests and logistic regression. RESULTS: Out of a total of 146 doctors, 91 of whom were women (62.3 %), who had completed their undergraduate medical education under the Bodø model as well as Part 1 of their specialist training, 40 (27.4 %) had grown up in Bodø municipality and for 56 (38.4 %) this was their place of work. For the remainder of the county of Nordland, the corresponding figures were 54 (37.0 %) and 38 (26.0 %), for Troms og Finnmark 23 (15.8) and 19 (13 %) and for the remainder of Norway 29 (19.9 %) and 33 (22.6 %). A total of 51 (34.9 %) worked as GPs, of whom 34 (66.7 %) worked in rural municipalities. There was a higher probability of working in a rural area if the doctor had grown up in a rural community (odds ratio (OR) 3.0 (95 % CI 1.5 to 6.1)) and of working in general medicine if this had been their preference as a student (OR 3.7 (95 % CI 1.8 to 7.6)). INTERPRETATION: The Bodø model has mainly attracted students with an affiliation to the region. At the time of the survey, a large percentage of the graduates who took part of their undergraduate medical education in Bodø worked at the Nordland Hospital in Bodø and in general practice, particularly in rural municipalities.

Educational interventions to ensure provision of doctors in rural areas - a systematic review. / Tiltak i grunnutdanningen for å sikre leger til distrikt ­ en systematisk oversikt.

BACKGROUND: Recruiting doctors in rural areas is challenging, and various educational interventions to ensure the provision of doctors in rural areas have been introduced in many countries. This study aimed to collect knowledge about the undergraduate medical education interventions that have been introduced in order to recruit doctors to rural areas, and the results of these interventions. MATERIAL AND METHOD: We undertook a systematic search in the databases Cinahl, Eric, Medline and PsycInfo using the search words rural, remote, workforce, physicians, recruitment and retention. We included articles that met the following criteria: the educational interventions were clearly described, the study population consisted of medical graduates, and outcome measures included place of work (rural/non-rural) after graduation. RESULTS: The analysis included 58 articles and encompassed educational interventions in ten countries. There were five main types of interventions, often used in combination: preferential admission from rural areas, curriculum relevant to rural medicine, decentralised education, practice-oriented learning in rural areas, and compulsory service periods in rural areas after graduation. The majority of the studies (42) compared place of work (rural/non-rural) of doctors who had graduated with and without these interventions - only two of the studies reported non-significant differences in place of work. In 26 studies, the odds ratio for rural place of work was significant at a level of 5 %, with odds ratios between 1.5 and 17.2. In 14 studies there were significant differences in the proportion with a rural/ non-rural place of work, with differences ranging from 11 to 55 percentage points. INTERPRETATION: Changing the focus of undergraduate medical education towards the development of knowledge, skills and teaching arenas that equip doctors with competencies to work in rural areas has an impact on the recruitment of doctors in rural areas.

Distribution of health anxiety in a general adult population and associations with demographic and social network characteristics.

BACKGROUND: Health anxiety (HA) is associated with increased risk of disability, increased health care utilization and reduced quality of life. However, there is no consensus on which factors are important for the level of HA. The aim of this study was to explore the distribution of HA in a general adult population and to investigate whether demographic and social factors were associated with HA. METHODS: This study used cross-sectional data from the seventh Tromsø study. A total of 18 064 participants aged 40 years or older were included in the analysis. The six-item Whiteley Index (WI-6) with a 5-point Likert scale was used to measure HA. Sociodemographic factors included age, sex, education, household income, quality of friendship and participation in an organized activity. RESULTS: HA showed an exponential distribution among the participants with a median score of 2 points out of 24 points. In total, 75% had a total score of 5 points or less, whereas 1% had a score >14 points. Education, household income, quality of friendship and participation in organized activity were significantly associated with HA. The variable quality of friendship demonstrated the strongest association with HA. CONCLUSION: Our study showed an exponential distribution of HA in a general adult population. There was no evident cut-off point to distinguish participants with severe HA based on their WI-6 score, indicating the importance of analysing HA as a complex, continuous construct. HA demonstrated strong associations with quality of friendship and participation in an organized activity.

Who keeps on working? The importance of resilience for labour market participation.

BACKGROUND: It is widely recognized that individuals' health and educational attainments, commonly referred to as their human capital, are important determinants for their labour market participation (LMP). What is less recognised is the influence of individuals' latent resilience traits on their ability to sustain LMP after experiencing an adversity such as a health shock. AIM: We investigate the extent to which resilience is independently associated with LMP and moderates the effect of health shocks on LMP. METHOD: We analysed data from two consecutive waves of a Norwegian prospective cohort study. We followed 3,840 adults who, at baseline, were healthy and worked full time. Binary logistic regression models were applied to explain their employment status eight years later, controlling for age, sex, educational attainment, health status at baseline, as well as the occurrences of three types of health shocks (cardiovascular diseases, cancer, psychological problems). Individuals' resilience, measured by the Resilience Scale for Adults (RSA), entered as an independent variable and as an interaction with the indicators of health shocks. In separate models, we explore the role of two further indicators of resilience; locus of control, and health optimism. RESULTS: As expected, health shocks reduce the probability to keep on working full-time. While both the RSA and the two related indicators all suggest that resilience increases the probability to keep on working, we did not find evidence that resilience moderates the association between health shocks and LMP. CONCLUSION: Higher levels of resilience is associated with full-time work as individuals age.

Organizing work in local service implementation: an ethnographic study of nurses' contributions and competencies in implementing a municipal acute ward.

BACKGROUND: The increased prevalence of chronic diseases and an ageing population challenge healthcare delivery, particularly hospital-based care. To address this issue, health policy aims to decentralize healthcare by transferring responsibility and introducing new services in primary healthcare. In-depth knowledge of associated implementation processes is crucial for health care managers, policymakers, and the health care personnel involved. In this article, we apply an ethnographic approach in a study of nurses' contributions to the implementation of a new inpatient service in an outpatient primary care emergency clinic and explore the competencies involved. The approach allowed us to explore the unexpressed yet significant effort, knowledge and competence of nurses that shaped the new service. METHODS: The study combines observations (250 h) and several in situ interviews with healthcare personnel and individual in-depth interviews with nurses (n = 8) at the emergency clinic. In our analysis, we draw on a sociological perspective on healthcare work and organization that considers nursing a practice within the boundaries of clinical patient work, organizational structures, and managerial and professional requirements. RESULTS: We describe the following three aspects of nurses' contributions to the implementation of the new service: (1) anticipating worst-case scenarios and taking responsibility for preventing them, (2) contributing coherence in patient care by ensuring that new and established procedures are interconnected, and (3) engaging in "invisible work". The nurses draw on their own experiences from their work as emergency nurses and knowledge of the local and regional contexts. They utilize their knowledge, competence, and organizing skills to influence the implementation process and ensure high-quality healthcare delivery in the extended service. CONCLUSIONS: Our study illustrates that nurses' contributions are vital to coordinating and adjusting extended services. Organizing work, in addition to clinical work, is a crucial aspect of nursing work. It 'glues' the complex and varied components of the individual patient's services into coherent and holistic care trajectories. It is this organizing competence that nurses utilize when coordinating and adjusting extended services. We believe that nurses' organizing work is generally invaluable in implementing new services, although it has not been well emphasized in practice and research.

Explaining subjective social status in two countries: The relative importance of education, occupation, income and childhood circumstances.

In the literature on social inequalities in health, subjective socioeconomic position (SEP) is increasingly applied as a determinant of health, motivated by the hypothesis that having a high subjective SEP is health-enhancing. However, the relative importance of determinants of subjective SEP is not well understood. Objective SEP indicators, such as education, occupation and income, are assumed to determine individuals' position in the status hierarchy. Furthermore, an extensive literature has shown that past childhood SEP affects adult health. Does it also affect subjective SEP? In this paper, we estimate the relative importance of i) the common objective SEP indicators (education, occupation and income) in explaining subjective SEP, and ii) childhood SEP (childhood financial circumstances and parents' education) in determining subjective SEP, after controlling for objective SEP. Given that the relative importance of these factors is expected to differ across institutional settings, we compare data from two countries: Australia and Norway. We use data from an online survey based on adult samples, with N ≈ 1400 from each country. Ordinary least squares regression is conducted to assess how objective and childhood SEP indicators predict subjective SEP. We use Shapley value decomposition to estimate the relative importance of these factors in explaining subjective SEP. Income was the strongest predictor of subjective SEP in Australia; in Norway, it was occupation. Of the childhood SEP variables, childhood financial circumstances were significantly associated with subjective SEP, even after controlling for objective SEP. This association was the strongest in the Norwegian sample. Only the mother's education had a significant impact on subjective SEP. Our findings highlight the need to understand the specific mechanisms between objective and subjective SEP as determinants of inequalities in health, and to assess the role of institutional factors in influencing these complex relationships.

Medical malpractice in Norway: frequency and distribution of disciplinary actions for medical doctors 2011-2018.

BACKGROUND: Physicians who perform unsafe practices and harm patients may be disciplined. In Norway, there are five types of disciplinary action, ranging from a warning for the least serious examples of malpractice to loss of licence for the most serious ones. Disciplinary actions always involve medical malpractice. The aims of this study were to investigate the frequency and distribution of disciplinary actions by the Norwegian Board of Health Supervision for doctors in Norway and to uncover nation-wide patient safety issues. METHODS: We retrospectively investigated all 953 disciplinary actions for doctors given by the Board between 2011 and 2018. We categorized these according to type of action, recipient's profession, organizational factors and geographical location of the recipient. Frequencies, cross tables, rates and linear regression were used for statistical analysis. RESULTS: Rural general practitioners received the most disciplinary actions of all doctors and had their licence revoked or restricted 2.1 times more frequently than urban general practitioners. General practitioners and private specialists received respectively 98.7 and 91.0 disciplinary actions per 1000 doctors. Senior consultants and junior doctors working in hospitals received respectively 17.0 and 6.4 disciplinary actions per 1000 doctors. Eight times more actions were received by primary care doctors than secondary care doctors. Doctors working in primary care were given a warning 10.6 times more often and had their licence revoked or restricted 4.6 times more often than those in secondary care. CONCLUSION: The distribution and frequency of disciplinary actions by the Norwegian Board of Health Supervision clearly varied according to type of health care facility. Private specialists and general practitioners, especially those working in rural clinics, received the most disciplinary actions. These results deserve attention from health policy-makers and warrant further studies to determine the factors that influence medical malpractice. Moreover, the supervisory authorities should assess whether their procedures for reacting to malpractice are efficient and adequate for all types of physicians working in Norway.