Dietary guidance from GPs - what do patients report?

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.

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.

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.

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.

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.

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.

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.

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 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 / β = 0.16, CI = .05–.28), accommodation of consultations (r = .71, CI = .62–.80 / β = 0.25, CI = .06–.45 / β = 0.27, CI = .09–.44), providing adequate information about the following treatment (r = .66, CI = .55–.77 / β = 0.26, CI = .09–.43), and collaboration between different departments at the hospital (r = .68, CI = .57–.78 / β = 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.

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.

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.

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.

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.

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.

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.

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.

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.

Participants at Norwegian Healthy Life Centres: Who are they, why do they attend and how are they motivated? A cross-sectional study

AIMS

We examine the characteristics of participants entering Norwegian Healthy Life Centres, their reasons for attending and whether socio-economic status, motivation, self-efficacy and social support relate to physical activity and sedentary behaviour.

METHODS

This cross-sectional study is part of a randomised controlled trial. Inclusion criteria are that participants should be ≥ 18 years old and able to take part in a physical activity group intervention. Exclusion criteria are severe mental illness and general learning disability. We analysed data using simple and multiple linear regression analyses.

RESULTS

We recruited 118 participants from eight Norwegian municipalities between June 2014 and September 2015. Of these, 77% were female, mean (standard deviation) age 48.6 (13.4) years, body mass index 34.0 (5.8) kg/m² and mean gross family income €61,000. The proportion of participants with upper-secondary school or less as their highest level of education was 55%. The most frequent reasons given for attendance at Healthy Life Centres were being overweight, increasing physical activity, improving diet and having musculoskeletal health challenges. Participants had high levels of autonomous motivation and 79% achieved national recommendations for physical activity. Respect and appreciation in childhood, self-esteem and self-rated health were associated with self-efficacy and social support for physical activity.

CONCLUSIONS

Participants were predominantly obese, physically active, female and motivated for change. A high proportion had low educational attainment and low incomes. The trial will reveal whether interventions succeed in increasing physical activity further, or in decreasing sedentary behaviour, and whether health inequalities narrow or widen across groups.

High prevalence of insomnia and hypnotic use in patients visiting their general practitioner

BACKGROUND

Sleep problems are common in the general population, but there are few prevalence studies among patients visiting their GP. Since sleep problems frequently co-occur with existing psychological and somatic conditions, the prevalence is likely to be higher in patients visiting their GPs compared to the prevalence in the general population.

OBJECTIVES

To estimate the prevalence of insomnia [based on the Diagnostic and Statistical Manual for Mental disorders (DSM)-version IV] and hypnotic use among patients in general practice and to evaluate whether the prevalence depended on sex and age.

METHODS

Questionnaire data were collected by 66 medical students while deployed in different general practices during their last year of school. A total of 1346 (response rate 74%) consecutive and unselected patients visiting their GPs answered the validated Bergen Insomnia Scale (BIS) and single questions on self-reported sleep problems and hypnotic use.

RESULTS

The prevalence of insomnia according to BIS was 53.6%. Sleep problems (based on the single question) were self-reported by 55.8%, with 18.0% reporting to experience sleep problems a lot/very much. Hypnotic use was reported by 16.2% (daily use by 5.5%). Insomnia and hypnotic use were all more prevalent in females compared with males. Hypnotic use increased with age, whereas the prevalence of insomnia was highest in the younger age groups.

CONCLUSIONS

Insomnia and hypnotic use were very prevalent among patients visiting their GPs. As insomnia can be effectively treated, we maintain that the diagnosis has a high pay-off and should earn greater awareness in GP's diagnostic evaluation and management.

The Norwegian Healthy Life Study: protocol for a pragmatic RCT with longitudinal follow-up on physical activity and diet for adults

BACKGROUND

The Norwegian Directorate of Health recommends that Healthy Life Centres (HLCs) be established in primary health care to support behaviour change and reduce the risk of non-communicable diseases. The aim of the present study protocol is to present the rationale, design and methods of a combined pragmatic randomized controlled trial (RCT) and longitudinal cohort study of the effects of attending HLCs concerning physical activity, sedentary behaviour and diet and to explore how psychological well-being and motivational factors may mediate short- and long-term effects.

METHODS

The present study will combine a 6-month RCT with a longitudinal cohort study (24 months from baseline) conducted at six HLCs from June 2014 to Sept 2017. Participants are randomized to behavioural change interventions or a 6-month waiting list control group.

DISCUSSION

A randomized trial of interventions in HLCs has the potential to influence the development of policy and practice for behaviour change interventions and patient education programmes in Norway. We discuss some of the important preconditions for obtaining valid results from a complex intervention and outline some of the characteristics of ecological approaches in health care research that can enable a pragmatic intervention study.

TRIAL REGISTRATION

The study was retrospectively registered on September 19, 2014 and is available online at ClinicalTrials.gov (ID: NCT02247219 ).

"It's not like a fat camp" - A focus group study of adolescents' experiences on group-based obesity treatment

Background

The health burden related to obesity is rising among children and adolescents along with the general population worldwide. For the individual as well as the society this trend is alarming. Several factors are driving the trend, and the solution seems to be multifaceted because long-lasting treatment alternatives are lacking. This study aims to explore adolescents’ and young adults’ motivation for attending group-based obesity treatment and social and environmental factors that can facilitate or hinder lifestyle change.

Methods

In this study, we arranged three focus groups with 17 participants from different obesity treatment programs in the west and south of Norway. The content in these programs differed, but they all used Motivational Interviewing as a teaching method. We conducted a data-driven analysis using systematic text condensation. Self-determination theory has been used as an explanatory framework.

Results

We identified four major themes: 1) motivation, 2) body experience and self-image, 3) relationships and sense of belonging, and 4) the road ahead. Many of the participants expressed external motivation to participate but experienced increasing inner motivation and enjoyment during the treatment. Several participants reported negative experiences related to being obese and appreciated group affiliation and sharing experiences with other participants.

Conclusion

Motivation may shift during a lifestyle course. Facilitating factors include achieving and experiencing positive outcomes as well as gaining autonomy support from other course participants and friends. Obstacles to change were a widespread obesogenic environment as well as feelings of guilt, little trust in personal achievements and non-supporting friends.

No difference in lifestyle changes by adding individual counselling to group-based rehabilitation RCT among coronary heart disease patients

Aims: First, to examine whether autonomy-supportive and self-efficacy-enhancing individual lifestyle counselling was associated with improved maintenance of heart-protective diets and smoking cessation compared with group-based counselling. Second, to investigate to what extent reported motivation was associated with maintenance of dietary changes. Methods: A randomized controlled trial and longitudinal study of predictor variables in a four-week heart rehabilitation setting with two years follow-up. A total of 176 (38 female) patients were included, mainly with coronary heart disease. The main outcome measures were dietary changes and smoking cessation. Motivational factors were tested for predictive power in the three dietary outcomes: daily intake of fruit and vegetables, a low saturated fat diet, and weekly intake of fish dinners. Results: No clinically significant difference in improvement of dietary maintenance was found between the two groups. The between-group difference in smoking status change was statistically insignificant (p=0.12). Both groups showed an improvement in their dietary measures. Self-efficacy predicted an increased frequency of eating fish dinners (p=0.001) and more daily units of fruit and vegetables (p<0.001). Autonomous motivation had a marginal association with increased intake of fruits and vegetables (p=0.08) and was significantly associated with a lower saturated fat diet (p=0.001). Conclusions: Among this highly motivated group of rehabilitation patients, no effect was found of adding autonomy-supportive, individual counselling to group-based interventions. Based on longitudinal documentation, this cardiac rehabilitation programme improves long-term maintenance of dietary changes, and this maintenance is related to autonomous motivation and self-efficacy.

Examining the ``Matthew Effect'' on the motivation and ability to make lifestyle changes in 217 heart rehabilitation patients

Aims: Those who are socioeconomically disadvantaged and people with emotional problems have a poorer prognosis for cardiovascular disease. The authors wanted to examine: (1) what effect household income, emotional status, high-risk smoking status, and severity of heart disease had on the ability of individuals to make dietary and exercise improvements after heart disease and (2) to what extent unfavourable lifestyle outcomes among disadvantaged people were mediated by motivational problems. Methods: A two-year follow-up study of the combined cohorts of a randomized controlled trial. Level of exercise and present dietary habits were measured at inclusion and after 6 and 24 months. Different motivational factors and emotional distress were measured during rehabilitation. Results: Autonomous self-regulation was lowest among smokers (b=-0.31, p=0.02) and female participants (b=0.39, p=0.004). Participants with high scores of emotional distress predicted lower motivation for all the measures. We found no association between socioeconomic status (household income) and the ability to perform lifestyle changes. Current smoking status predicted lower ability to obtain lifestyle changes on all measures. Emotional distress was related to lower ability to increase physical activity at 6 months' but not at 24 months' follow-up. The mediating effects of motivational factors were insignificant. Conclusions: The results of this study do not support the suspicion that preventive efforts accentuate the socioeconomic differences in cardiovascular health. Health-promotive efforts after heart disease should safeguard that high-risk groups such as smokers are not discouraged from improving their lifestyle in other areas.

Stakeholders' expectations of Healthy Life Centers: A focus group study

AIMS

The aims of this study were to explore stakeholders' expectations of municipal Healthy Life Centers (HLCs) in Norway, and to evaluate whether these expectations were compatible with current guidelines and recommendations.

METHODS

A multidisciplinary team of researchers arranged focus group sessions with Healthy Life Centre staff, municipality administration, county administration, general practitioners and representatives of three patient organizations. We audiotaped and transcribed the sessions verbatim. In analyses we used Systematic Text Condensation and an editing analysis style.

RESULTS

Expectations spanned from primary prevention among children to rehabilitation of adults with established disease, depending on the stakeholders' assumptions of the role of HLCs. Healthcare providers emphasized person-centered advice based on the participant's willingness to change, and their impressions of the participant's presenting condition and life circumstances. Many participants represented underprivileged groups, not reached by population-based information strategies. Consistent with self-determination theory, participants who contacted the HLCs themselves more often expressed a will for lifestyle change than those referred from general practitioners, and less often dropped out. Participants with complex challenges and insufficient coping strategies often strived with follow-up. Among these, many suffered from mental health problems.

CONCLUSIONS

The Norwegian HLC is still a concept in development and is trying to define its position in the public healthcare system. In accordance with national recommendations to reduce social health inequalities, the stakeholders emphasized providing effective, evidence-based HLC programs including underprivileged groups. They also expressed concern about prioritizing between an individual and population approach, and between different target groups and tasks.

Two Valid Measures of Self-rated Physical Activity and Capacity

Objectives:

Questionnaires on physical activity (PA) and physical capacity (PC) are valuable tools, as they are cost beneficial, and have high response rates. The validity of short versions of such questionnaires has not been examined satisfactorily. Therefore, we aimed at examining the validity of a set of questions coding for PA and PC.

Design:

The questions were administered to 217 men and women attending a cardiac rehabilitation program. Participants also gave blood samples, measuring HDL cholesterol, triglycerides (TG), insulin, glucose, and microCRP. The relations between PA and PC and biological markers were examined by linear regression analyses.

Results:

Measures for PC and for PA were identified by factor analysis, which proved internally consistent. TG, homeostatic model assessment (HOMA) score, and mCRP were all significantly associated with the measures of PC and PA.

Conclusions:

The measures of PA and PC are valid compared with biological markers, allowing cost-beneficial and time-efficient evaluation of important measures for cardiovascular health.

Examining the Matthew effect on the motivation and ability to stay at work after heart disease

AIMS

Cardiac rehabilitation should safeguard that socioeconomic factors or other differences that affect people's cardiovascular health are not further aggravated after healthcare treatment. The study examines whether socioeconomic status, emotional problems, or the severity of disease affect people's ability to continue to work after heart disease. We also examined if these effects can be explained by differences in motivational factors.

METHODS

217 patients (41 women) from the Krokeide Rehabilitation Centre in Bergen participated. Multiple linear regression analysis was used to examine motivational differences, and logistic regression analysis was used to examine whether socioeconomic factors or other differences affected people's ability to continue to work after heart disease.

RESULTS

Self-efficacy for future work strongly impacted the likelihood of being incapacitated for work during the 2-year follow-up. The household's total income and emotional problems were statistically significant related to patients dropping out from work in the course of the observation. The association between emotional problems and future work was mediated by motivational problems. The relation between income and future incapacity for work could not be explained by motivational factors.

CONCLUSIONS

The study shows a clear Matthew effect on people's ability to continue to work after heart disease as low-income groups and people with emotional problems are more at risk of dropping out of work. This Matthew effect was, however, only explained by the motivational difficulties for the association between emotional distress and dropping out of work and not for the impact of household income on the likelihood of leaving work.

How important are individual counselling, expectancy beliefs and autonomy for the maintenance of exercise after cardiac rehabilitation?

Aims: We examined whether autonomy supportive and self-efficacy enhancing individual lifestyle counselling was associated with improved maintenance of exercise and physical capacity compared with group based counselling. We also tested whether self-efficacy beliefs and autonomous motivation was associated with improved maintenance of exercise over time. Methods: Randomised controlled trial and longitudinal study of predictor variables. One hundred and seventy six (38 female) patients mainly with coronary heart disease were randomized to either have standard group based rehabilitation or to additionally receive the intervention. Patients were recruited from a 4-week cardiac rehabilitation programme with two years follow-up at Krokeide Centre in Bergen, Norway. Results: We found no statistically significant between-group differences. The groups showed an overall improvement of their self-evaluated physical capacity during the two years of the study, corresponding 7% change of score (p<0.001). The composite exercise score improved 6% during follow-up (p<0.001). Intensity of exercise activities improved 17% from inclusion to 24 months' follow-up (p<0.001). Self-efficacy for increased exercise, general expectancy and autonomous motivation were significant predictors of increased exercise and physical capacity. Controlled motivation hampered physical capacity improvement. Conclusions: Among this self-selected and motivated group of rehabilitation patients we found no additional effect of adding individual counselling to group-based interventions. Based on longitudinal documentation this cardiac rehabilitation programme improves long-term maintenance of exercise and physical capacity and this maintenance is related to autonomous motivation, general expectancy and self-efficacy.