A comparison of small-area deprivation indicators for public-health surveillance in Sweden.

AIMS: The aims of this study were to construct a small-area index of multiple deprivation (IMD) from single deprivation indicators (SDIs) and to compare the explanatory power of the IMD and SDIs with regard to mortality. We considered a small-area division of Sweden consisting of 5985 DeSO (Demografiska statistikområden), each with a population size between 653 and 4243 at the end of 2018. METHODS: Four SDIs were provided by open-source data: (a) the proportion of inhabitants with a low economic standard; (b) the proportion of inhabitants aged 25-64 years with ⩽12 years of schooling; (c) the proportion of inhabitants aged 16-64 years who were not in paid employment; and (d) the proportion of inhabitants who lived in a rented apartment/house. A four-indicator IMD was constructed using factor analysis. As a validation, the IMD and SDIs were compared by exploring their DeSO-level associations with spatially smoothed death rates, with robustness checks of associations across different small-area contexts defined by degree of urbanisation and distribution of immigrants from non-Western countries. RESULTS: The constructed IMD and SDI1 performed essentially equally and outperformed SDI2, SDI3 and SDI4. Associations between IMD/SDI1 and the spatially smoothed death rates were most pronounced within the age range 60-79 years, showing 5-8% lowered rates among those categorised in the least deprived quintiles of IMD and SDI1, respectively, and 7-9% elevated rates among those categorised in the most deprived quintiles. These associations were consistent within each small-area context. CONCLUSIONS: We suggest prioritisation of SDI1, that is, a DeSO-level deprivation indicator based on open-access data on economic standard, for public-health surveillance in Sweden.

Evidence-based practice in primary healthcare from the managerial point of view - a national survey.

BACKGROUND: The vast availability of and demand for evidence in modern primary healthcare force clinical decisions to be made based on condensed evidence in the form of policies and guidelines. Primary healthcare managers play a key role in implementing these governing documents. Thus, the aim of this article is to investigate the use and availability of evidence-based practice resources from the perspective of first-line primary healthcare managers. METHODS: The study is based on a national survey of primary healthcare managers, consisting of 186 respondents, recruited nationally from Sweden. The data was analysed using empirically constructed concepts and validated using factor analysis. A chi-square test was utilized to determine the statistical significance of comparisons. Associations between variables were calculated using Spearman's correlation coefficients. All tests were two-sided, and the significance level was set to 0.05. RESULTS: A majority (97 %) of managers stated that guidelines and policy documents impacted primary healthcare; 84 % of managers observed a direct effect on daily practices. Most of the managers (70 %) stated that some adaptation was needed when new evidence was introduced. The managers emphasized the importance of keeping themselves updated and open to new information about work routines (96 %). CONCLUSIONS: The study illustrates a nearly unanimous response about the influence of clinical evidence on daily practice. The emphasis on the importance of all staff members keeping their professional knowledge up to date is viewed as a direct result of this effect on daily practice. An information-dense organization such as a primary healthcare organization would have much to gain from increased cooperation with regional information resources such as clinical libraries.

Likelihood of admission to hospital from the emergency department is not universally associated with hospital bed occupancy at the time of admission.

BACKGROUND: The decision to admit into the hospital from the emergency department (ED) is considered to be important and challenging. The aim was to assess whether previously published results suggesting an association between hospital bed occupancy and likelihood of hospital admission from the ED can be reproduced in a different study population. METHODS: A retrospective cohort study of attendances at two Swedish EDs in 2015 was performed. Admission to hospital was assessed in relation to hospital bed occupancy together with other clinically relevant variables. Hospital bed occupancy was categorized and univariate and multivariate logistic regression were performed. RESULTS: In total 89,503 patient attendances were included in the final analysis. Of those, 29.1% resulted in admission within 24 h. The mean hospital bed occupancy by the hour of the two hospitals was 87.1% (SD 7.6). In both the univariate and multivariate analysis, odds ratio for admission within 24 h from the ED did not decrease significantly with an increasing hospital bed occupancy. CONCLUSIONS: A negative association between admission to hospital and occupancy level, as reported elsewhere, was not replicated. This suggests that the previously shown association might not be universal but may vary across sites due to setting specific circumstances.

Inter-rater reliability among psychiatrists when assessing depression according to the Montgomery-Åsberg Depression Rating Scale.

INTRODUCTION: Montgomery-Åsberg Depression Rating Scale (MADRS) is a validated tool for rating the depth of depression. The structured interview guide for the MADRS (SIGMA) is an interview guide that has been developed in order to increase the inter-rater reliability. Patients often meet more than one psychiatrists during their hospitalization for depression. A divergent rating of depression between psychiatrists could affect both the treatment and the outcome. This makes knowledge of the inter-rater reliability among psychiatrists important. AIM: The primary aim of this study was to measure the inter-rater reliability between psychiatrists when rating depression using the MADRS. METHODS: Ten in-patients, who were diagnosed with depression, were filmed while being interviewed using the SIGMA. The patients were after that instructed to rate themselves using the self-rating version of the MADRS. Ten psychiatrists rated the pre-recorded interviews according to the MADRS. The inter-rater reliability was measured using intra-class correlation (ICC). RESULTS: The mean ICC for the total MADRS score was 0.952 (95% CI 0.891-0.986; p<.001) and Cronbach's alpha 0.961. ICC values for each item ranged between 0.866 and 0.978 (p<.001). Cronbach's alpha ranged between 0.905 and 0.984. The ICC values, when comparing the psychiatrists rating to the patients rating, ranged between 0.307 and 0.809 (p<.001). CONCLUSION: All of the ICC values in the study, except when comparing the psychiatrists rating to the patients self-rating, were considered to be excellent. This study confirms the findings of reliability found in similar studies which involved fewer raters and not exclusively psychiatrists.

Disease mapping of early- and late-stage cancer to monitor inequalities in early detection: a study of cutaneous malignant melanoma.

We consider disease mapping of early- and late-stage cancer, in order to identify and monitor inequalities in early detection. Our method is demonstrated by mapping cancer incidence at high geographical resolution using data on 10,302 cutaneous malignant melanoma (CMM) cases within the 3.7 million population of South-West Sweden. The cases were geocoded into small-areas, each with a population size between 600 and 2600 and accessible socio-demographic data. Using the disease mapping application Rapid Inquiry Facility (RIF) 4.0, we produced regional maps to visualise spatial variations in stage I, II and III-IV CMM incidences, complemented by local maps to explore the variations within two urban areas. Pronounced spatial disparities in stage I CMM incidence were revealed by the regional and local maps. Stage I CMM incidence was markedly higher in wealthier small-areas, in particular within each urban area. A twofold higher stage I incidence was observed, on average, in the wealthiest small-areas (upper quintile) than in the poorest small-areas (lower quintile). We identified in the regional map of stage III-IV CMM two clusters of higher or lower than expected late-stage incidences which were quite distinct from those identified for stage I. In conclusion, our analysis of CMM incidences supported the use of this method of cancer stage incidence mapping for revealing geographical and socio-demographic disparities in cancer detection.

Exposure to surgery is associated with better long-term outcomes in patients admitted to Swedish intensive care units.

BACKGROUND: Long-term outcomes of patients admitted to intensive care units (ICUs) after surgery are unknown. We investigated the long-term effects of surgical exposure prior to ICU admission. METHODS: Registry-based cohort study. The adjusted effect of surgical exposure for mortality was examined using Cox regression. Secondary analysis with conditional logistic regression in a case-control subpopulation matched for age, gender, and Simplified Acute Physiology Score III (SAPS3) was also conducted. RESULTS: 72 242 adult patients (56.9% males, median age 66 years [IQR 50-76]), admitted to Swedish ICUs in 3-year (2012-2014) were followed for a median of 2026 days (IQR 1745-2293). Cardiovascular diseases (17.5%), respiratory diseases (15.8%), trauma (11.2%), and infections (11.4%) were the leading causes for ICU admission. Mortality at longest follow-up was 49.4%. Age; SAPS3; admissions due to malignancies, respiratory, cardiovascular and renal diseases; and transfer to another ICU were associated with increased mortality. Surgical exposure prior to ICU admission (adjusted hazard ratio [aHR] 0.90; 95% CI 0.87-0.94; P < .001), admissions from the operation theatre (aHR 0.94; CI 0.90-0.99; P = .022) or post-anaesthesia care unit (aHR 0.92; CI 0.87-0.97; P = .003) were associated with decreased mortality. Conditional logistic regression confirmed the association between surgical exposure and decreased mortality (adjusted odds ratio 0.82; CI 0.75-0.91; P < .001). CONCLUSIONS: Long-term ICU mortality was associated with known risk factors such as age and SAPS3. Transfer to other ICUs also appeared to be a risk factor and requires further investigation. Prior surgical exposure was associated with better outcomes, a noteworthy observation given limited ICU admissions after surgery in Sweden.

Two-year weight, risk and health factor outcomes of a weight-reduction intervention programme: Primary prevention for overweight in a multicentre primary healthcare setting.

Objective: To study the long-term effects of weight reduction, quality of life and sense of coherence in a primary health care (PHC)-based programme with two different intensities.Design: Prospective two-armed randomised intervention.Setting: Three PHC centres in south west of Sweden.Subjects: In total, 289 women and men aged 40-65 years with a BMI of 28-35 were recruited for a two-year weight-reduction programme. Participants were randomized to high-intensity or low-intensity groups. Blood samples, physical measurements and questionnaires were analysed. Participants received cookbooks and dietary lectures. The high-intensity group also received Motivational interviewing (MI), dietary advice on prescription (DAP- advice), a grocery store lecture, a website and weekly e-mails.Main outcome measures: Weight, quality of life, risks and health factors.Results: In total, 182 (64%) participants completed the 2-year follow-up. The total sample reduced their weight by 1 kg (p = 0.006). No significant differences regarding weight were found between the groups. Anxiety/depression decreased in EQ5-D (p = 0.021), EQ5-D VAS (p = 0.002) and SOC (p = 0.042). Between the groups, there were significant differences in EQ5-D usual activities (p = 0.004), anxiety/depression (p = 0.013), pain/discomfort (p = 0.041), fruit and vegetables (p = 0.005), HLV anxiety (p = 0.005), and visits to nurses (p = 0.012).Conclusion: The total population lost weight, and the high-intensity and low-intensity programmes did not result in significant differences in terms of weight. The high-intensity programme reported health benefits linked to lower levels of anxiety and depression, increased activity and intake of greens and reduced visits to physicians and nurses.Key pointsBoth groups had a consisting weight- reduction after two years.High intensity did not lead to a significant difference in weight reduction between the groups.The high-intensity group reported more health effects, such as better quality of life, reduced anxiety, and increased greenery intake. It is unknown how much support patients in a weight- reduction programme in PHC require to succeed with weight loss and a healthy lifestyle.

Promoting the creation of R&D intentions in primary healthcare measured by a validated instrument.

BACKGROUND: Primary healthcare has a long and successful patient care history in Sweden. Nevertheless, a research-oriented attitude has been more or less absent in this context. In society today, access to information has significantly influenced the nature of patients' demand for up-to-date healthcare. A prerequisite for this new demand is health professionals who are interested in novel ways of thinking and view a change of work practices as necessary. One way to achieve this goal is by means of strategic communication, which is a relatively new interdisciplinary field. The aim of this study was to analyse the role of strategic communication in the creation of intentions in Research and Development (R&D) among primary healthcare staff as measured by a validated instrument. METHODS: An intervention study on staff was performed. A 15-item questionnaire was validated and implemented. All primary healthcare staff from the southwestern Swedish province of Halland were included. In total, 846 employees (70%) agreed to participate in the measurements. After 12 years, 352 individuals who had participated in the intervention and remained in the organisation were identified and followed up. The intervention comprised established communication channels. The measurements were performed after 7 and 12 years. A questionnaire was designed for this purpose. The questions were validated by a factor analysis, and the degree of reliability was measured with Cronbach's alpha coefficient. χ2 and Fisher's exact tests were used as statistical tests in comparisons. RESULTS: Factor analysis identified five pure factors (most Cronbach's alpha > 0.70). Strategic communication contributed to a significant improvement in the staff members' interest in R&D and willingness to change in both the short (P < 0.05) and long (P < 0.05) term. The positive attitude was stable over time. CONCLUSIONS: Strategic communication seems to be a significant tool for creating a stable positive attitude towards R&D in the primary healthcare context. The creation of a positive attitude towards a scientific approach is a relevant finding that deserves special attention in a context as complex as healthcare. Using a validated instrument seems to contribute to pure results in this case.

Swedish surgical outcomes study (SweSOS): An observational study on 30-day and 1-year mortality after surgery.

BACKGROUND: The European Surgical Outcomes Study (EuSOS) revealed large variations in outcomes among countries. In-hospital mortality and ICU admission rates in Sweden were low, going against the assumption that access to ICU improves outcome. Long-term mortality was not reported in EuSOS and is generally poorly described in the current literature. OBJECTIVE: To describe the characteristics of the Swedish subset of EuSOS and identify predictors of short and long-term mortality after surgery. DESIGN: An observational cohort study. SETTING: Six universities and two regional hospitals in Sweden. PATIENTS: A cohort of 1314 adult patients scheduled for surgery between 4 April and 11 April 2011. MAIN OUTCOME MEASURES: 30-day and 1-year mortality. RESULTS: A total of 303 patients were lost to follow-up, leaving 1011 for analysis; 69% of patients were classified as American Society of Anesthesiologists' physical status 1 or 2, and 68% of surgical procedures were elective. The median length of stay in postanaesthesia care units (PACUs) was 175 min (interquartile range 110-270); 6.6% of patients had PACU length of stay of more than 12 h and 3.6% of patients were admitted to the ICU postoperatively. Thirty-day mortality rate was 1.8% [95% confidence interval (CI) 1.0-2.6] and 8.5% (CI 6.8-10.2) at 1 year (n = 18 and 86). The risk of death was higher than in an age and sex-matched population after 30 days (standardised mortality ratio 10.0, CI 5.9-15.8), and remained high after 1 year (standardised mortality ratio 3.9, CI 3.1-4.8). Factors predictive of 30-day mortality were age, American Society of Anesthesiologists' physical status, number of comorbidities, urgency of surgery and ICU admission. For 1-year mortality, age, number of comorbidities and urgency of surgery were independently predictive. ICU admission and long stay in PACU were not significant predictors of long-term mortality. CONCLUSION: Mortality rate increased almost five-fold at 1 year compared with 30-day mortality after surgery, demonstrating a significantly sustained long-term risk of death in this surgical population. In Sweden, factors associated with long-term postoperative mortality were age, number of comorbidities and surgical urgency.

Satisfaction with housing and housing support for people with psychiatric disabilities.

The aim of this study was to investigate the degree of satisfaction with housing and housing support for people with psychiatric disabilities in Sweden. A total of 370 residents, in supported housing and in ordinary housing with housing support, completed a new questionnaire and reported a high degree of overall satisfaction, but many of them wanted to move somewhere else. Differences were found between the two different types of housing concerning satisfaction with housing support, social life and available choices. Security and privacy, as well as other's influence on the choice of residential area and dwelling proved to be important predictors for satisfaction.

Impact of the organisational culture on primary care staff members' intention to engage in research and development.

PURPOSE: The purpose of this paper is to understand how organisational culture influences the intentions of primary care staff members (PCSM) to engage in research and development (R&D). DESIGN/METHODOLOGY/APPROACH: The participants (n=30) were PCSM employed in a care centre in south-western Sweden. The study had an observational design with an ethnographic approach. The data were collected by means of observations, interviews and analysis of documents. FINDINGS: The results revealed the perceptions of PCSM in two domains, research and clinical practice, both of which existed at three different cultural levels: visible (structures and policy), semi-visible (norms and values) and invisible (taken-for-granted attitudes). RESEARCH LIMITATIONS/IMPLICATIONS: It is difficult to conduct a purely objective ethnographic study because the investigation is controlled by its context. However, it is necessary to highlight and discuss the invisible level to improve understanding of negative attitudes and preconceptions related to the implementation of R&D in the clinical setting. PRACTICAL IMPLICATIONS: By highlighting the invisible level of culture, the management of an organisation has the opportunity to initiate discussion of issues related to concealed norms and values as well as attitudes towards new thinking and change in the primary health context. ORIGINALITY/VALUE: This paper is one of the very few studies to investigate the influence of organisational culture on the intentions of PCSM to engage in R&D.

GP and patient predictions of sick-listing duration: how well do they correspond? A prospective observational study.

OBJECTIVE: To explore how well physicians and patients predict sick-listing duration and the correspondence between their respective predictions. To study possible gender differences concerning prediction accuracy. DESIGN: Prospective observational study. SETTING: Two medium-sized primary care centres (PCC) in western Sweden. SUBJECTS: GPs at the PCCs and attending patients sick-listed for > 14 days. MAIN OUTCOME MEASURES: Sick-listing duration; patients' and GPs' predictions of the total duration of the individual patient's sick-listing. RESULTS: A total of 127 patients (93 women, 34 men, mean age 45 years) and 10 GPs participated in the study. Neither the GPs nor the patients were able to predict the interval until return to work with high accuracy. The GPs' and the patients' perceptions concurred in only 26% of cases. There was a significant difference in the correspondence between the GPs' and patients' respective predictions of sick-listing duration compared with the actual duration. GPs' predictions were more accurate for medium-length duration (1.5-6 months), while patients' predictions were more accurate for long-duration (> 6 months) sick-listing. Patients with less education predicted long duration of sick-listing more accurately than those with more education. There was no significant difference between male and female patients' accuracy of prediction, or between GPs' accuracy of prediction of male vs. female patients' sick-listing duration. CONCLUSIONS: Prediction of total sick-listing duration was hard for both GP and patient; their respective predictions corresponded in only one-quarter of the cases. No gender differences were observed in the accuracy of prediction.

The dilemma of the split between theory and reality as experienced by primary healthcare professionals: a mixed methods study of evidence-based practice in a primary care context.

BACKGROUND: Primary care depends upon a good information flow across professional and structural boundaries to provide the best care for patients. Previous research has mainly focused on Evidence-Based Practice (EBP) within specific professions. Mapping of pan-professional experiences of and attitudes to EBP in publicly funded clinical practice is necessary to deepen the understanding of EBP and its implementation. Thus, this study aimed to investigate healthcare professionals' experiences of and attitudes towards working in accordance with EBP in primary care. METHODS: The study used a convergent mixed methods design divided into two strands: a quantitative enquiry tool (Evidence-Based Practice Attitude Scale, EBPAS) and a set of qualitative interviews analysed by means of qualitative content analysis. Both strands included all primary care employees with patient interaction in the studied county (n = 625), including doctors, nurses, physiotherapists, psychologists and assistant nurses. Out of the original 625 healthcare professionals, 191 finished the first strand and 8 volunteered for the second strand (2 nurses, 2 physiotherapists, 1 psychiatrist and 3 doctors). RESULTS: The EBPAS value of 2.8 (max 4) indicated a generally positive attitude towards EBP amongst the population, which was also evident in the interviews. However, there were additional experiences of not having the ability or resources to engage in EBP. This was illustrated by the theme that emerged from the qualitative content analysis: "The dilemma of the split between theory and reality". Due to the organisational and managerial focus on efficiency rather than quality of care, there were few or no incentives for promoting individual educational or research development. CONCLUSIONS: Although the general attitude towards EBP is positive, experiences of practising it differ. There is a need to increase knowledge of EBP concepts, requirements and implementation in the clinical setting. The absence of opportunities to do research and collegial debate about new ways of finding and implementing research-based evidence results might influence the quality of care.

Perceived vision-related quality of life and risk of falling among community living elderly people.

Falls and fall injuries among the elderly population are common, since ageing is a risk factor of falling. Today, this is a major problem because the ageing population is increasing. There are predictive factors of falling and visual impairment is one of them. Usually, only visual acuity is considered when measuring visual impairment, and nothing regarding a person's functional visual ability is taken into account. Therefore, the aim of this study was to assess the perceived vision-related quality of life among the community living elderly using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and to investigate whether there was any association among vision-related quality of life and falls. There were 212 randomly selected elderly people participating in the study. Our study indicated that the participants had an impaired perceived vision-related health status. General health was the only NEI VFQ-25 variable significantly associated with falls in both men and women. However, among men, near and distance activities, vision-specific social functioning, role difficulties and dependency, color and peripheral vision were related to falls.

Psychometric evaluation of 'The 25-item Sex after MI Knowledge Test' in a Swedish context.

The patients' sexual life after a myocardial infarction is important for his/her quality of life. In spite of this, many patients are in doubt regarding their sex life after a myocardial infarction (MI) and the sexual information received, and counselling from health care providers has been seen to be insufficient. The purpose of this study was to evaluate the psychometric properties of 'The 25-item Sex after MI Knowledge Test' in a Swedish context. A convenience sample was recruited. The scale was translated into Swedish and completed by 79 former patients from The Heart and Lung Patients' National Association on two occasions, with an interval of 2 weeks. The scale was tested for face and content validity, internal consistency and test-retest reliability. The result in this study indicates that the instrument has good face and content validity and displayed a moderate internal consistency (alpha 0.61). The instrument showed some level of instability in test-retest reliability with 60% of the items presenting moderate or strong agreement between the test and retest. Further studies that use this instrument in larger and more diverse samples are thus needed.

The Association Between Sublingual Varices and Cardiovascular Risk Factors.

Objective: To study the association between sublingual varices (SV) and cardiovascular (CVD) risk factors. Methods: A total of 989 consecutive dental patients aged 55-84 years participated in the study, which applied a survey about risk factors, diseases and medications. Digital photos of the lateral borders of the tongue, height, weight, waist, hip and blood pressure were registered, and blood samples were analyzed. Those with SV were compared with those without SV (nSV). Results: Those with SV had more hypertension 41.8% vs 27.0% (p<0.0001), a higher systolic blood pressure (BP) 139.5 (SD 18.6) mmHg vs 134.3 (SD 18.8) mmHg (95% CI -7.73 ─ -2.72), more diabetes type 2 (DM-2) 7.4% vs 3.8% (p=0.014), a higher fasting plasma glucose 5.9 (SD 1.5) mmol/L vs 5.7 (SD 1.0) mmol/L (95% CI -0.42 ─ -0.05), more dyslipidemia 24.1% vs 17.7% (p=0.018), lower HDL 1.6 vs 1.7 (p=0.003), a greater waist circumference 97.0 cm vs 93.9 cm (95% CI -4.66 ─ -1.46), a greater waist/hip ratio 0.92 cm/cm vs 0.90 cm/cm (95% CI -0.03 ─ -0.01), and a higher BMI 26.6 kg/m2 vs 26.0 kg/m2 (95% CI -1.11 ─ -0.03). The following associations with SV were found in multivariate analysis: hypertension OR=1.6 (95% CI 1.19 ─2.13), a high systolic BP OR =1.5 (95% CI 1.11 ─2.13), a high fP-glucose OR= 1.8 (95% CI 1.03 ─3.21), a low HDL OR= 1.8 (95% CI 1.15 ─2.92), a greater waist circumference OR= 1.68 (95% CI 1.10 ─2.58), a greater waist/hip ratio OR=2.21 (95% CI 1.36 ─3.58), and a higher BMI OR=1.05 (95% CI 1.02 ─1.09). Conclusion: This study shows an association between SV and a high BP, a high fP-glucose, hypertension, diabetes mellitus type 2, dyslipidemia, abdominal obesity, older age and smoking.

Tinnitus in the general population with a focus on noise and stress: a public health study.

OBJECTIVES: To evaluate the influence of noise and stress on the probability of tinnitus in the general population. DESIGN: Questionnaire data were obtained from 12,166 subjects. RESULTS: Each year of age increased the odds ratio of tinnitus by about 3%. Men generally showed a higher risk for tinnitus compared with women. Exposure to noise and stress emerged important for the probability of tinnitus. However, for the transition from mild to severe tinnitus, stress turned out to be especially important. CONCLUSIONS: Stress management strategies should be included in hearing conservation programs, especially for individuals with mild tinnitus who report a high stress load.

Patient participation in the emergency department: an evaluation using a specific instrument to measure patient participation (PPED).

AIM: This study aimed at evaluating patient participation from the perspective of patients who received care in emergency departments, with a separate examination of the relationship between participation and age, gender, education and priority level. BACKGROUND: International and national guidelines encourage patient participation. High patient participation is required to ensure a high quality of care. No studies evaluating patient participation at an emergency department have been published. METHODS: An evaluating study, with the Patient Participation Emergency Department questionnaire, was conducted at emergency departments in Sweden. A consecutive sample of 356 patients participated. Data were collected in 2008: participants were 49% women and with an average age of 56 years. The statistical methods used were Student's t-test, one-way ANOVA and Spearman correlation. RESULTS: The results revealed that patients experienced good requirement for participation such as time and information. Mutual participation demonstrated a reasonable level, but patient participation is low in two dimensions (Fight for participation, Participation in getting basic needs satisfied). Young and well-educated patients fought more to participate in their care and gained less attention for basic needs than older and less well-educated patients. CONCLUSIONS: Patient participation in a mutual care situation between patients and healthcare professionals requires further improvement to ensure that patients are satisfied and do not have to struggle and fight to participate in their care.

Questionnaire for patient participation in emergency departments: development and psychometric testing.

AIM: The aim of the study was to develop and test the psychometric properties of a patient participation questionnaire in emergency departments. BACKGROUND: Patient participation is an important indicator of the quality of healthcare. International and national healthcare policy guidelines promote patient participation. While patients cared for in emergency departments generally express dissatisfaction with their care, a review of the literature fails to reveal any scientifically tested instruments for assessing patient participation from the perspective of patients. METHODS: A methodological study was conducted involving a convenience sample of 356 patients recently cared for in emergency departments in Sweden. Data were collected in 2008 and analysed for construct and criterion validity, also homogeneity and stability reliability. RESULTS: A 17-item questionnaire was developed. Two separate factor analyses revealed a distinct 4-factor solution which was labelled: Fight for participation, Requirement for participation, Mutual participation and Participating in getting basic needs satisfied. Criterion validity testing showed 9 out of 20 correlations above 0.30 and, of these, three were moderate correlations of 0.62, 0.63 and 0.70. Cronbach's alpha coefficient ranged from 0.63 to 0.84 and test-retest varied between 0.59 and 0.93. CONCLUSION: The results signify evidence of acceptable validity and reliability, and the questionnaire makes it possible to evaluate patient participation in emergency department caring situations. In addition, it produces data which are usable by a diverse range of healthcare professionals.