Dietary guidance from GPs - what do patients report? / Kostholdsveiledning hos fastlegen ­ hva rapporterer pasientene?

Background: Diet can have a major impact on health. In this study, we surveyed the extent to which the subject of diet was raised by patients in general practice and which patients desired such discussions. Material and method: We conducted a questionnaire-based cross-sectional study of patients ≥ 18 years of age at GP practices in Western Norway in 2022. The questionnaire consisted of nine questions about dietary knowledge, the desire to receive dietary guidance and lose weight, and medication use. Logistic regression was used to identify groups more likely to report a desire to receive guidance on how diet affects health. Results: A total of 2105 of the 2531 (83 %) invited patients ≥ 18 years of age completed the questionnaire, and 2075 of these were included in the analysis. One in three had raised the subject of diet with their GP. A total of 96 % reported having the knowledge they needed about diet, 56 % wanted advice or guidance on how diet affects health, 62 % wanted to lose weight and 40 % reported being confused by diet/dietary advice. Younger patients, men, patients with lower levels of education, patients who wanted to lose weight and patients taking medication for chronic conditions more frequently wanted advice/guidance on how diet affects health. Interpretation: Over half of the patients in the GP practices wanted advice/guidance on how diet affects health. Knowing who is more likely to want guidance can be useful for prioritising which consultations are appropriate for providing guidance on diet and health impacts.

Physical activity and sedentary time after lifestyle interventions at the Norwegian Healthy Life Centres.

AIMS: This study evaluates long-term changes in physical activity and its associations with various predictors after a behavior change program at the Norwegian Healthy Life Centers. BACKGROUND: Physical activity is recommended and is part of public health strategies to prevent noncommunicable diseases. METHODS: This longitudinal cohort, based on a controlled randomized trial, studies a population of 116 Healthy Life Center participants in South-Western Norway who wore SenseWear Armbands to measure time spent in moderate to vigorous physical activity and sedentary time based on metabolic equivalents. The measurements were obtained at baseline, immediately post-intervention, and 24 months after baseline. Linear mixed model analyses were performed to assess predictors for change in physical activity and sedentary time. FINDINGS: High physical activity levels at baseline were maintained during the 24-month study period. Young, male participants with good self-rated health, utilizing local PA facilities were most active, and young participants utilizing local facilities were also less sedentary. The participants with higher levels of education were less active initially but caught up with the difference during follow-up. A high degree of controlled regulation, characterized by bad conscience and external pressure, predicted more sedentary behavior and a trend toward being less physically active. Autonomous motivation was associated with less time spent on sedentary behaviors. People with high self-efficacy for physical activity were more sedentary initially but showed a reduction in their sedentary behavior.The study supports the importance of attending local training facilities and adopting motivation for behavioral change that is not based on guilt and external rewards. Interventions aimed at improving physical activity among people at risk for noncommunicable diseases benefit from habitual use of local training facilities, strengthening their self-perceived health and the development of internalized motivation. However, it has not been shown to mitigate social health disparities.

Primary healthcare service delivery for older people with progressive multimorbidity in low- and middle-income countries: a systematic review.

Ensuring primary healthcare (PHC) accessibility to older people with multimorbidity is vital in preventing unnecessary health deterioration. However, older people ≥50 y of age in low- and middle-income countries (LMICs) face challenges in effectively accessing and utilizing PHC. A systematic review was conducted adopting the Andersen-Newman theoretical framework for health services utilization to assess evidence on factors that affect access to PHC by older people. This framework predicts that a series of factors (predisposing, enabling and need factors) influence the utilization of health services by people in general. Seven publications were identified and a narrative analytical method revealed limited research in this area. Facilitating factors included family support, closeness to the PHC facility, friendly service providers and improved functional status of the older people. Barriers included long distance and disjointed PHC services, fewer health professionals and a lack of person-centred care. The following needs were identified: increasing the number of health professionals, provision of PHC services under one roof and regular screening services. There is a need for more investment in infrastructure development, coordination of service delivery and capacity building of service providers in LMICs to improve access and utilization of PHC services for older people.

Peer Teaching in Undergraduate Medical Education: What are the Learning Outputs for the Student-Teachers? A Systematic Review.

Introduction: To achieve quality in medical education, peer teaching, understood as students taking on roles as educators for peers, is frequently used as a teaching intervention. While the benefits of peer teaching for learners and faculty are described in detail in the literature, less attention is given to the learning outputs for the student-teachers. This systematic review focuses on the learning outputs for medical undergraduates acting as student-teachers in the last decade (2012-2022). Aim: Our aim is to describe what learning outputs student-teachers have from peer teaching, and map what research methods are used to assess the outputs. We defined learning outputs in a broad sense, including all types of learning experiences, intended and non-intended, associated with being a peer teacher. Methods: A literature search was conducted in four electronic databases. Title, abstract and full text were screened by 8 independent reviewers and selection was based on predefined eligibility criteria. We excluded papers not describing structured peer teaching interventions with student-teachers in a formalized role. From the included articles we extracted information about the learning outputs of being a student-teacher as medical undergraduate. Results: From 668 potential titles, 100 were obtained as full-texts, and 45 selected after close examination, group deliberation, updated search and quality assessment using MERSQI score (average score 10/18). Most articles reported learning outputs using mixed methods (67%). Student-teachers reported an increase in subject-specific learning (62%), pedagogical knowledge and skills (49%), personal outputs (31%) and generic skills (38%). Most articles reported outputs using self-reported data (91%). Conclusion: Although there are few studies that systematically investigate student-teachers learning outputs, evidence suggests that peer teaching offers learning outputs for the student-teachers and helps them become better physicians. Further research is needed to enhance learning outputs for student-teachers and systematically investigate student-teachers' learning outputs and its impact on student-teachers.

Factors associated with self-rated health in primary care in the South-Western health zone of Malawi.

BACKGROUND: Self-rated health (SRH) is a single-item measure of current health, which is often used in community surveys and has been associated with various objective health outcomes. The prevalence and factors associated with SRH in Sub-Saharan Africa remain largely unknown. This study sought to investigate: (1) the prevalence of poor SRH, (2) possible associations between SRH, and socio-demographic and clinical parameters, and (3) associations between SRH and the patients' assessment of the quality of primary care. METHODS: A cross-sectional study was conducted in 12 primary care facilities in Blantyre, Neno, and Thyolo districts of Malawi among 962 participants who sought care in these facilities. An interviewer-administered questionnaire containing the Malawian primary care assessment tool, and questions on socio-demographic characteristics and self-rated health was used for data collection. Descriptive statistics were used to determine the distribution of variables of interest and binary logistic regression was used to determine factors associated with poor SRH. RESULTS: Poor SRH was associated with female sex, increasing age, decreasing education, frequent health care attendance, and with reported disability. Patients content with the service provided and who reported higher scores of relational continuity from their health care providers reported better SRH as compared with others. CONCLUSION: This study reports findings from a context where SRH is scarcely examined. The prevalence of poor SRH in Malawi is in line with findings from clinical populations in other countries. The associations between poor SRH and socio-demographic factors are also known from other populations. SRH might be improved by emphasizing continuity of care in primary care services.

Healthy and unhealthy eating after a behaviour change intervention in primary care.

BACKGROUND: To prevent and reduce non-communicable diseases, the Norwegian Directorate of Health encourages Healthy Life Centres (HLCs) in all municipalities. AIMS: This study investigates whether the behaviour change interventions at HLCs positively affected participants' diet and to evaluate predictors for healthy and unhealthy eating. Our data are part of the Norwegian Healthy Life Centre Study, a 6-month, pragmatic randomised controlled trial (RCT). METHODS: Totally, 118 participants ≥18 years old were randomised to an intervention group (n 57), or a waiting list (control group) (n 61). Eighty-six participants met at the 6 months follow-up visit. We merged the participants to one cohort for predictor analyses, using linear regressions. FINDINGS: The RCT of the HLCs' interventions had no effect on healthy and unhealthy eating 6 months after baseline compared with controls. A short, additional healthy eating education programme produced a modest, statistically significant improvement in healthy eating compared with controls. This did not, however, reduce unhealthy eating. Higher income predicted unhealthier eating over time. Increasing body mass index and impaired physical functioning also led to an increase in unhealthy eating. Healthy eating at 6 months was predicted by self-rated health (SRH), vitality and life satisfaction, and hampered by musculo-skeletal challenges and impaired self-esteem (SE). SRH impacted improvement in healthy eating during the 6 months. The effect of interventions on healthier eating may be improved by an emphasis on developing positive self-concepts like better SRH, vitality, life satisfaction, and SE.

How do general practitioners handle couple relationship problems in consultations? A focus group study.

BACKGROUND: Couple relationship problems are common and associated with health problems. The aim of this study was to explore general practitioners' (GPs') experiences, expectations, and educational needs when dealing with couple relationship problems in consultations. METHODS: We conducted an exploratory qualitative study by carrying out 3 semistructured focus group interviews with 18 GPs. We used systematic text condensation for the analyses. RESULTS: Participants shared their experiences of handling couple relationship problems in consultations. Three main themes emerged: (i) pragmatic case-finding: golden opportunities to reveal patients' couple relationship problems; (ii) conceptual and role confusion; (iii) professional competence and personal experience. While issues in relationships could serve as an explanation for relevant clinical problems, some GPs questioned whether relationship issues are strictly medical. All participants had engaged in individual supportive therapy, but none saw themselves as therapists. The interviews revealed that an individual supportive focus might lead to a consolidation of 1 partner's view, rather than challenging their position. Long-term doctor-patient relationships made it easier to talk about these issues. CONCLUSIONS: This study revealed several paradoxes. GPs are confident in offering individual supportive therapy for couple relationship issues but should be aware of substantial pitfalls such as side-taking and constraining change. Despite dealing with relationship problems, GPs do not see themselves as therapists. They use professional and personal experience but would benefit from increasing their skills in cognitive restructuring promoting behavioural flexibility facing relationship problems.

Couple relationship problems are common and often raised in general practitioner (GP) consultations as they are associated with health problems. We lack knowledge about what experiences, expectations, and educational needs GPs have when dealing with these problems. In 2020, we interviewed 18 GPs about how they handle couple relationship problems in their practice. Three main themes emerged: (i) Patients seldom present their relationship as the main problem. GPs conduct pragmatic case-finding to reveal relational problems that might be connected to, or be a risk factor for, health problems. (ii) GPs deal with couple relationship problems in several ways. Some think that they are not a medical problem, while others take a more holistic approach. In both cases, GPs lack the tools to assess couple relationship problems and to offer brief interventions. (iii) The most experienced doctors emphasized that their professional and personal experience qualified them to support their patients. Continuity in the doctor­patient relationship was also considered important. We revealed that taking a biopsychosocial approach can be challenged by searching for biomedical causes for problems. GPs should be aware of the pitfalls of individual supportive therapy in dealing with couple relationship issues, such as taking sides and impeding change.

How is motivational interviewing (un)related to self-determination theory: An empirical study from different healthcare settings.

To explore how quality aspects and clients' verbal behaviors in Motivational Interviewing sessions correspond with counsellors' support of basic psychological needs described in Self-determination Theory, we conducted a mixed method study with quantitative analyses of transformed qualitative data from counselling sessions. Coding manuals identified if the counselling was consistent with Motivational Interviewing and the support of basic psychological needs. The study supported a conceptual relationship between motivational interviewing (MI) and self-determination theory (SDT), except for autonomy support which was conceptualized differently in the two approaches. Relational support in SDT and MI were closely linked to each other and were also strongly related to other MI-congruent and promotive counselors' verbal behavior. Client amotivation in SDT and change talk in MI were negatively correlated, and clients' autonomous motivation in SDT was related to change talk in MI. Counselors emphasized relational support, using decisional balance comprehensively, but offered competence support less often. The counseling was, however, sensitive to the clients' motivational regulation of behavior change.

Patients want their doctors' help to increase physical activity: a cross sectional study in general practice.

BACKGROUND: Inactivity is prevalent in patients presenting in general practice, and the health benefits of increased physical activity (PA) are well known. Few studies have explored whether patients want their general practitioner's (GPs) contribution in facilitating a lifestyle change. OBJECTIVE: To identify the characteristics of patients who expect help from their doctor in increasing levels of PA. DESIGN: We collected data via questionnaires for this cross-sectional study from general practices. SETTING: General practices in Norway, during Spring 2019. SUBJECTS: A total of 2104 consecutive patients (response rate 75%) participated. MAIN OUTCOME MEASURES: The questionnaire included questions about self-rated health, level of physical activity, the desire to become more physically active, and questions about the role of the GP in increasing the level of physical activity in their patients. We analysed our data using Pearson chi-square and binary logistic regression. RESULTS: Female patients were less active, but their motivation to increase activity and their expectations of receiving help from their doctor were similar to males. Younger patients were more motivated for increased activity, and to manage without help from their doctors. Impaired self-rated health (SRH) was associated with inactivity and, at the same time, with the motivation to become more active with help from general practitioners. CONCLUSION: Most patients in the GPs' office are physically inactive. This study revealed an important message for GPs: in clinical work, emphasise physical activity for health gains, especially for patients with impaired SRH.Key PointsFour out of five patients attending Norwegian general practice are inactiveMore than 85% of these patients want to increase their physical activity levelMore than 50% would like help from their GP to achieve this goal.

Factors Predicting Physical Activity and Sports Participation in Adolescence.

Physical activity is important for children's health and wellbeing, yet participation declines across teenage years. It is important to understand the mechanisms that could support adolescents to maintain physical activity participation. The aim of this study was firstly to examine change in sports and nonsports activities over two years during adolescence. Secondly, we explored possible predictors of physical activity and sports participation after two years. Method. A longitudinal cohort study was conducted between 2011 and 2013. Our data were collected from 1225 Norwegian adolescents who were followed over a two-year period, from 6th to 8th grade (11 to 13 years) and from 8th to 10th grade (13 to 15 years). We examined the relations between physical activity and predictors such as peer support, parent support, socioeconomic status (SES), attitude towards physical education, active transportation to school, self-rated health, body image, and change of nonsports activities. We used linear regression analyses and binary logistic regression to explore possible predictors of physical activity and sports participation after two years. Results. We found a significant reduction in sports participation during early adolescence, most pronounced, from 8th to 10th grade (from 13 to 15 years). Factors which predicted physical activity after two years were a positive attitude towards physical education, perceived support from parents, if the student travelled to school in an active way (by walk or bicycle) and also how the student rated his/her own health. The last three factors also predicted improvements of physical activity during the two years. Possible predictors of persisting or starting doing sports were increasing levels of self-rated health, increasing socioeconomic status, whereas increasing engagement in nonsports activities predicted reduced participation in sports. Conclusion. Health promotive efforts aiming at increasing active school transportation, parental support, and subjective health seem important for maintenance of physical activity and sports participation during adolescence. Attitudes may improve by adapting physical education to individual needs and interests and can function as an additional promotive factor.

Couple relationship problems-a task for the general practitioner? A cross-sectional survey from Norway.

BACKGROUND: A healthy couple relationship is a predictor of good health. There is a lack of knowledge about what role family and couples counselling should have in general practice. OBJECTIVES: To identify the prevalence of patients who have talked, or want to talk, with their general practitioner (GP) about their couple relationship, to investigate what characterizes these patients and to explore whether they believe that couple relationship problems should be dealt with in general practice. METHODS: We conducted a cross-sectional survey in 70 general practices in Norway during spring 2019. A questionnaire was answered by 2178 consecutive patients (response rate 75%) in GP waiting rooms. Data were examined using frequencies and linear and logistic regression models. RESULTS: We included 2097 responses. Mean age was 49.0 years and 61.3% were women. One in four (25.0%) had already talked with their GP about couple relationship problems, while one in three (33.5%) wanted to talk with their GP about their couple relationship problems. These patients more frequently had experience of divorce, poor self-rated health, an opinion that their couple relationship had a significant impact on their health and lower couple relationship quality when adjusted for age, sex, present marital status and children living at home. We found that 46.4% of patients believed that GPs should be interested in their couple relationship problems. CONCLUSION: Relationship problems are frequently addressed in general practice. GPs should be prepared to discuss this issue to facilitate help for couples earlier than they might otherwise expect.

How are body mass and body attitude impacted by a behaviour change intervention in primary care? A pragmatic randomised controlled trial.

Aims:This study evaluated the effect of behaviour change interventions at Norwegian Healthy Life Centres on change in body mass index (BMI) and body attitude, and explored the predictors for change after 6 months. Methods: We randomised 118 participants to either an intervention or a control group. Eligible participants: ⩾18 years and able to take part in group-based interventions. Body attitude, weight, and height were assessed at inclusion and after 6 months. We analysed the data using simple and multiple regression. Results: Eighty-six participants completed 6-month follow-up. The study found no intervention effect on BMI or body attitude across the two groups. However, an interaction effect indicated that the leaner participants in the intervention group reduced their weight significantly (b 0.94, p < 0.001). BMI reduction was predicted by self-efficacy for physical activity and autonomous motivation for change. Weight loss was associated with impaired body attitude, body shape concern, impaired weight-related self-esteem, weight cycling, and controlled motivation for change. Improvement in body attitude was positively impacted by self-rated health, the experience of childhood respect, life satisfaction, and self-efficacy for physical activity. Impaired body attitude was predicted by body shape concern, impaired weight-related self-esteem, and controlled motivation. Conclusions: The interventions did not affect body mass on average, but promoted weight loss among the leaner participants. Because weight reduction was associated body shape concern and impaired body attitude, the study supports the claim that interventions should be weight neutral and aim to improve body image and psychological well-being rather than weight reduction.

How can we improve specialist health services for children with multi-referrals? Parent reported experience.

BACKGROUND: Children with combined mental and somatic conditions pose a challenge to specialized health services. These cases are often characterized by multi-referrals, frequent use of health services, poor clinical and cost effectiveness, and a lack of coordination and consistency in the care. Reorganizing the health services offered to these children seems warranted. Patient reported experiences give important evidence for evaluating and developing health services. The aim of the present descriptive study was to explore how to improve specialist health services for children with multiple referrals for somatic and mental health conditions. Based on parent reported experiences of health services, we attempted to identify key areas of improvement. METHODS: As part of a larger, ongoing project; "Transitioning patients' Trajectories", we asked parents of children with multiple referrals to both somatic and mental health departments to provide their experiences with the services their children received. Parents/guardians of 250 children aged 6-12 years with multi-referrals to the Departments of Pediatrics and Child and Adolescent Mental Health at Haukeland University Hospital between 2013 and 2015 were invited. Their experience was collected through a 14 items questionnaire based on a generic questionnaire supplied with questions from parents and health personnel. Possible associations between overall experience and possible predictors were analyzed using bivariate regression. RESULTS: Of the 250 parents invited, 148 (59%) responded. Mean scores on single items ranged from 3.18 to 4.42 on a 1-5 scale, where five is the best possible experience. In the multiple regression model, perception of wait time (r = .56, CI = .44-.69 / ß = 0.16, CI = .05-.28), accommodation of consultations (r = .71, CI = .62-.80 / ß = 0.25, CI = .06-.45 / ß = 0.27, CI = .09-.44), providing adequate information about the following treatment (r = .66, CI = .55-.77 / ß = 0.26, CI = .09-.43), and collaboration between different departments at the hospital (r = .68, CI = .57-.78 / ß = 0.20, CI = -.01-.40) were all statistically significantly associated with parents overall experience of care. CONCLUSIONS: The study support tailored interdisciplinary innovations targeting wait time, accommodation of consultations, communication regarding the following treatment and collaboration within specialist health services for children with multi-referrals to somatic and mental specialist health care services.

Performance of primary care in different healthcare facilities: a cross-sectional study of patients' experiences in Southern Malawi.

OBJECTIVE: In most African countries, primary care is delivered through a district health system. Many factors, including staffing levels, staff experience, availability of equipment and facility management, affect the quality of primary care between and within countries. The purpose of this study was to assess the quality of primary care in different types of public health facilities in Southern Malawi. STUDY DESIGN: This was a cross-sectional quantitative study. SETTING: The study was conducted in 12 public primary care facilities in Neno, Blantyre and Thyolo districts in July 2018. PARTICIPANTS: Patients aged ≥18 years, excluding the severely ill, were selected to participate in the study. PRIMARY OUTCOMES: We used the Malawian primary care assessment tool to conduct face-to-face interviews. Analysis of variance at 0.05 significance level was performed to compare primary care dimension means and total primary care scores. Linear regression models at 95% CI were used to assess associations between primary care dimension scores, patients' characteristics and healthcare setting. RESULTS: The final number of respondents was 962 representing 96.1% response rate. Patients in Neno hospitals scored 3.77 points higher than those in Thyolo health centres, and 2.87 higher than those in Blantyre health centres in total primary care performance. Primary care performance in health centres and in hospital clinics was similar in Neno (20.9 vs 19.0, p=0.608) while in Thyolo, it was higher at the hospital than at the health centres (19.9 vs 15.2, p<0.001). Urban and rural facilities showed a similar pattern of performance. CONCLUSION: These results showed considerable variation in experiences among primary care users in the public health facilities in Malawi. Factors such as funding, policy and clinic-level interventions influence patients' reports of primary care performance. These factors should be further examined in longitudinal and experimental settings.

The Norwegian Healthy Life Centre Study: A pragmatic RCT of physical activity in primary care.

AIMS: The aim of this study was to evaluate the effect of behaviour change interventions at Norwegian Healthy Life Centres (HLCs) on participants' moderate to vigorous intensity physical activity (MVPA) six months after baseline. We also explore predictors of change in MVPA, and if level of education and MVPA at baseline modify the effect. METHODS: A randomised controlled trial with inclusion criteria age ⩾ 18 years and ability to participate in group-based physical activity. Participants were randomised to either behaviour change interventions or a waiting list (control). Objective recordings of physical activity were the main outcome, analysed with simple and multiple linear regression. RESULTS: We recruited 118 participants from six HLCs. Participants with mental, musculoskeletal, or chronic somatic disease were more likely to drop out. We revealed no differences in MVPA or sedentary time between the groups. Types of motivation or several characteristics of disadvantage at baseline could not explain changes in MVPA. Across both groups, 83% achieved the recommended 150 minutes of MVPA per week, and participants with a lower level of education were less likely to improve. Participants in the intervention group who were least active at baseline significantly increased their MVPA. CONCLUSIONS: The study revealed that the intervention had no short-term effect on time spent on MVPA or sedentary. This study does not support a strong emphasis on behaviour change on an individual level as a way of targeting general health and risk reduction at a population level. Although less active people benefitted more from the HLC intervention, the intervention was unable to counteract widening of inequity across educational groups.

Quality of primary care from patients' perspective: a cross sectional study of outpatients' experience in public health facilities in rural Malawi.

BACKGROUND: Assessing patients' experience with primary care complements measures of clinical health outcomes in evaluating service performance. Measuring patients' experience and satisfaction are among Malawi's health sector strategic goals. The purpose of this study was to investigate patients' experience with primary care and to identify associated patients' sociodemographic, healthcare and health characteristics. METHODS: This was a cross sectional survey using questionnaires administered in public primary care facilities in Neno district, Malawi. Data on patients' primary care experience and their sociodemographic, healthcare and health characteristics were collected through face to face interviews using a validated Malawian version of the primary care assessment tool (PCAT-Mw). Mean scores were derived for the following dimensions: first contact access, continuity of care, comprehensiveness, community orientation and total primary care. Linear regression models were used to assess association between primary care dimension scores and patients' characteristics. RESULTS: From 631 completed questionnaires, first contact access, relational continuity and comprehensiveness of services available scored below the defined minimum. Sex, geographical location, self-rated health status, duration of contact with facility and facility affiliation were associated with patients' experience with primary care. These factors explained 10.9% of the variance in total primary care scores; 25.2% in comprehensiveness of services available and 29.4% in first contact access. CONCLUSION: This paper presents results from the first use of the validated PCAT-Mw. The study provides a baseline indicating areas that need improvement. The results can also be used alongside clinical outcome studies to provide comprehensive evaluation of primary care performance in Malawi.

First four years of operation of a municipal acute bed unit in rural Norway.

OBJECTIVE: To evaluate the use of a small municipality acute bed unit (MAU) in rural Norway resulting from the Coordination reform regarding occupancy-rate, patient characteristics and healthcare provided during the first four years of operation. Further, to investigate whether implementation of the new municipal service avoided acute hospital admissions. DESIGN: Observational study. SETTING: A two-bed municipal acute bed unit. SUBJECTS: All patients admitted to the unit between 2013 and 2016. MAIN OUTCOME MEASURES: Demographics, comorbidity, main diagnoses and level of municipal care on admission and discharge, diagnostic and therapeutic initiatives, MAU occupancy rate, and acute hospital admission rate. RESULTS: Altogether, 389 admissions occurred, 215 first-time admissions and 174 readmissions. The mean MAU bed occupancy rate doubled from of 0.26 in 2013 to 0.50 in 2016, while acute hospital admission rates declined. The patients (median age 84.0 years, 48.9% women at first time admission) were most commonly admitted for infections (28.0%), observation (22.1%) or musculoskeletal symptoms (16.2%). Some 52.7% of the patients admitted from home were discharged to a higher care level; musculoskeletal problems as admission diagnosis predicted this (RR =1.43, 95% CI 1.20-1.71, adjusted for age and sex). CONCLUSION: Admission rates to MAU increased during the first years of operation. In the same period, there was a reduction in acute hospital admissions. Patient selection was largely in accordance with national and local criteria, including observational stays. Half the patients admitted from home were discharged to nursing home, suggesting that the unit was used as pathway to a higher municipal care level. Key Points Evaluation of the first four years of operation of a municipality acute bed unit (MAU) in rural Norway revealed: • Admission rates to MAU increased, timely coinciding with decreased acute admission rates to hospital medical wards. • Most patients were old and had complex health problems. • Only half the patients were discharged back home; musculoskeletal symptoms were associated with discharge to a higher care level.

Factors associated with self-rated health in primary care.

BACKGROUND: Self-rated health (SRH) measures one's current general health and is a widely used health indicator. Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships are suspected to influence SRH, but studies in primary health care settings are sparse. OBJECTIVE: To examine the associations between patients' self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships. DESIGN: We collected data via questionnaires for this cross-sectional study from general practice. SETTING: Primary health care in Norway. SUBJECTS: 1302 consecutive patients participated. MAIN OUTCOME MEASURES: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models. RESULTS: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis. CONCLUSION: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH. Key Points There was a high prevalence of reduced SRH in clinical general practice Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH These predictors are all modifiable with a potential to improve SRH.

Trustingly bewildered. How first-year medical students make sense of their learning experience in a traditional, preclinical curriculum.

BACKGROUND: Traditional preclinical curricula based on memorization of scientific facts constitute learning environments which may negatively influence both factual understanding and professional identity development in medical students. Little is known of how students themselves experience and interpret such educational milieus. OBJECTIVE: To investigate first-year medical students' view of the physician role, and their perception of the relevance and quality of teaching in a science-based preclinical curriculum. DESIGN: Focus group interviews with thematic text analysis. RESULTS: Students portrayed the good physician as communicative, humble, and open, combining biomedical knowledge and moral strength. When asked how medical school supported the development of such characteristics, two partly contradictory discourses emerged. The critical discourse identified decontextualized knowledge, poor pedagogy, lack of critical thinking, and contact with faculty. Students who voiced critical comments also articulated trust that the system would provide the competence they needed, that basic biological knowledge is needed before clinical practice, and that being on your own conveys freedom and responsibility, and helps you grow up. CONCLUSION: Trust in the educational system, within a substandard learning environment, created cognitive dissonance that students resolved through rationalization, whereby they negated that factual overload and lack of relevance, reflection, and personal feedback was problematic. The cost of this mechanism is possibly that inferior teaching is perceived as normal, necessary, and good enough. If so, these future physicians' ability to critically evaluate and create quality in medical education and practice, may be weakened.

Development and validation of a Malawian version of the primary care assessment tool.

BACKGROUND: Malawi does not have validated tools for assessing primary care performance from patients' experience. The aim of this study was to develop a Malawian version of Primary Care Assessment Tool (PCAT-Mw) and to evaluate its reliability and validity in the assessment of the core primary care dimensions from adult patients' perspective in Malawi. METHODS: A team of experts assessed the South African version of the primary care assessment tool (ZA-PCAT) for face and content validity. The adapted questionnaire underwent forward and backward translation and a pilot study. The tool was then used in an interviewer administered cross-sectional survey in Neno district, Malawi, to test validity and reliability. Exploratory factor analysis was performed on a random half of the sample to evaluate internal consistency, reliability and construct validity of items and scales. The identified constructs were then tested with confirmatory factor analysis. Likert scale assumption testing and descriptive statistics were done on the final factor structure. The PCAT-Mw was further tested for intra-rater and inter-rater reliability. RESULTS: From the responses of 631 patients, a 29-item PCAT-Mw was constructed comprising seven multi-item scales, representing five primary care dimensions (first contact, continuity, comprehensiveness, coordination and community orientation). All the seven scales achieved good internal consistency, item-total correlations and construct validity. Cronbach's alpha coefficient ranged from 0.66 to 0.91. A satisfactory goodness of fit model was achieved (GFI = 0.90, CFI = 0.91, RMSEA = 0.05, PCLOSE = 0.65). The full range of possible scores was observed for all scales. Scaling assumptions tests were achieved for all except the two comprehensiveness scales. Intra-class correlation coefficient (ICC) was 0.90 (n = 44, 95% CI 0.81-0.94, p < 0.001) for intra-rater reliability and 0.84 (n = 42, 95% CI 0.71-0.96, p < 0.001) for inter-rater reliability. CONCLUSIONS: Comprehensive metric analyses supported the reliability and validity of PCAT-Mw in assessing the core concepts of primary care from adult patients' experience. This tool could be used for health service research in primary care in Malawi.