Objective To explore communication about medication management during annual consultations in primary care. Design: passive participant observations of primary care consultations.

Setting Two primary care centres in southern Sweden.

Participants Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis.

Results Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further.

Conclusion Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.No data are available.

Objectives

Sleep disturbances and delirium are frequently observed complications after surgical aortic valve replacement (SAVR) and transcutaneous aortic valve implantation (TAVI), especially in octogenarian patients. However, a knowledge gap exists on patient experiences of sleep and delirium. In particular, patients' long-term sleep and delirium experiences are unknown. This article explores and describes how octogenarian patients suffering from delirium after aortic valve replacement experience their sleep and delirium situation.

Design

An explorative and descriptive design with a longitudinal qualitative approach was applied. Qualitative content analysis following the recommended steps of Graneheim and Lundman was performed.

Setting

Patients were included at a tertiary university hospital with 1400 beds. Delirium and insomnia screening was performed at baseline and five postoperative days after aortic valve treatment. For qualitative data, 10 patients were interviewed 6-12 months after treatment with focus on delirium. Five of these patients were reinterviewed 4 years after treatment, with focus on their sleep situation.

Participants

Inclusion criteria; age 80+, treated with SAVR or TAVI and had experienced delirium after treatment.

Results

For the initial interview, we included five men and five women, four following TAVI and six following SAVR, mean age 83. One overarching theme revealed from the content analyses; Hours in bed represented emotional chaos. Whereas three subthemes described the patients' experiences with sleep and delirium, a cascade of distressful experiences disturbing sleep, the struggle between sleep and activity and elements influencing sleep. Four years after the treatment, sleep disturbances persisted, and patients still remembered strongly the delirium incidences.

Conclusions

For octogenarian patients, sleep disturbances and delirium are long-term burdens and need a greater attention in order to improve patient care.

Introduction Chronic pain affects about 20%-40% of the population and is linked to mental health outcomes and impaired daily functioning. Pharmacological interventions are commonly insufficient for producing relief and recovery of functioning. Behavioural health treatment is key to generate lasting benefits across outcome domains. However, most people with chronic pain cannot easily access evidence-based behavioural interventions. The overall aim of the DAHLIA project is to develop, evaluate and implement a widely accessible digital behavioural health treatment to improve well-being in individuals with chronic pain. Methods and analysis The project follows the four phases of the mHealth Agile Development and Evaluation Lifecycle: (1) development and pre-implementation surveillance using focus groups, stakeholder interviews and a business model; (2) iterative optimisation studies applying single case experimental design (SCED) method in 4-6 iterations with n=10 patients and their healthcare professionals per iteration; (3) a two-armed clinical randomised controlled trial enhanced with SCED (n=180 patients per arm) and (4) interview-based post-market surveillance. Data analyses include multilevel modelling, cost-utility and indicative analyses. In October 2021, inter-sectorial partners are engaged and funding is secured for four years. The treatment content is compiled and the first treatment prototype is in preparation. Clinical sites in three Swedish regions are informed and recruitment for phase 1 will start in autumn 2021. To facilitate long-term impact and accessibility, the treatment will be integrated into a Swedish health platform (www.1177.se), which is used on a national level as a hub for advice, information, guidance and e-services for health and healthcare. Ethics and dissemination The study plan has been reviewed and approved by Swedish ethical review authorities. Findings will be actively disseminated through peer-reviewed journals, conference presentations, social media and outreach activities for the wider public.

Introduction

Since early 2020, the COVID-19 pandemic has challenged societies and revealed the built-in fragility and dependencies in complex adaptive systems, such as healthcare. The pandemic has placed healthcare providers and systems under unprecedented amounts of strain with potential consequences that have not yet been fully elucidated. This multilevel project aims to explore resilient performance with the purpose of improving the understanding of how healthcare has adapted during the pandemic’s rampage, the processes involved and the consequences on working conditions, ethics and patient safety.

Methods

An emerging explorative multilevel design based on grounded theory methodology is applied. Open and theoretical sampling is performed. Empirical data are gathered over time from written narratives and qualitative interviews with staff with different positions in healthcare organisations in two Swedish regions. The participants’ first-person stories are complemented with data from the healthcare organisations’ internal documents and national and international official documents.

Analysis

Experiences and expressions of resilient performance at different system levels and times, existing influencing risk and success factors at the microlevels, mesolevels and macrolevels and inter-relationships and consequences in different healthcare contexts, are explored using constant comparative analysis. Finally, the data are complemented with the current literature to develop a substantive theory of resilient performance during the pandemic.

Ethics and dissemination

This project is ethically approved and recognises the ongoing strain on the healthcare system when gathering data. The ongoing pandemic provides unique possibilities to study system-wide adaptive capacity across different system levels and times, which can create an important basis for designing interventions focusing on preparedness to manage current and future challenges in healthcare. Feedback is provided to the settings to enable pressing improvements. The findings will also be disseminated through scientific journals and conferences.

Purpose Depression and anxiety afflict millions worldwide causing considerable disability. MULTI-PSYCH is a longitudinal cohort of genotyped and phenotyped individuals with depression or anxiety disorders who have undergone highly structured internet-based cognitive-behaviour therapy (ICBT). The overarching purpose of MULTI-PSYCH is to improve risk stratification, outcome prediction and secondary preventive interventions. MULTI-PSYCH is a precision medicine initiative that combines clinical, genetic and nationwide register data.Participants MULTI-PSYCH includes 2668 clinically well-characterised adults with major depressive disorder (MDD) (n=1300), social anxiety disorder (n=640) or panic disorder (n=728) assessed before, during and after 12 weeks of ICBT at the internet psychiatry clinic in Stockholm, Sweden. All patients have been blood sampled and genotyped. Clinical and genetic data have been linked to several Swedish registers containing a wide range of variables from patient birth up to 10 years after the end of ICBT. These variable types include perinatal complications, school grades, psychiatric and somatic comorbidity, dispensed medications, medical interventions and diagnoses, healthcare and social benefits, demographics, income and more. Long-term follow-up data will be collected through 2029.Findings to date Initial uses of MULTI-PSYCH include the discovery of an association between PRS for autism spectrum disorder and response to ICBT, the development of a machine learning model for baseline prediction of remission status after ICBT in MDD and data contributions to genome wide association studies for ICBT outcome. Other projects have been launched or are in the planning phase.Future plans The MULTI-PSYCH cohort provides a unique infrastructure to study not only predictors or short-term treatment outcomes, but also longer term medical and socioeconomic outcomes in patients treated with ICBT for depression or anxiety. MULTI-PSYCH is well positioned for research collaboration.

Objectives

The aim of this study was to describe challenges in self-management activities among people with multimorbidity during a 4-week post-discharge period.

Design

This is a longitudinal qualitative study using data from a randomised controlled trial (RCT) of motivational interviewing (MI) sessions.

Setting

The RCT was conducted at six wards in two hospitals—one university hospital and one general hospital in Stockholm, Sweden, during 2016–2018.

Participants

Sixteen participants from the intervention group, diagnosed with heart failure or chronic obstructive pulmonary disease and at least one other chronic condition, were purposively selected for this study.

Interventions

Each participant had four or five post-discharge MI sessions with a trained social worker during a period of approximately 4 weeks. The sessions were recorded digitally and analysed using content analysis. Altogether, 70 recorded sessions were analysed.

Results

Self-management after hospital discharge was a dynamic process with several shifting features that evolved gradually over time. Patients with multimorbidity experienced two major challenges with self-management in the first 4 weeks following hospital discharge: ‘Managing a system-centred care’ and ‘Handling the burden of living with multiple illnesses at home post-discharge’.

Conclusions

Self-management for patients with multimorbidity in the first post-discharge period does not equate to a fixed set of tasks, but varies over the post-discharge period. Self-management challenges include not only the burden of the disease itself, but also that of navigating and understanding the healthcare system. Hence, self-management support post-discharge involves both aiding patients with care coordination and meeting their gradually shifting disease-related needs.

Background: Based on guidelines developed by EMS physicians, registered nurses in the Swedish ambulance services sometimes by-pass the emergency department and refer non-urgent patients to primary care and self-care. However, these referrals are associated with problems that may jeopardize patient safety and patient participation.

Aim: To identify the EMS physicians’ perceptions of ambulance nurses’ responsibilities and prerequisites to refer patients to primary care and self-care.

Methods: A national survey of all EMS physicians (n=51) using study specific questions with close-ended and open response options, analysed with descriptive statistics and thematic analysis.

Results: The response rate was 78% (n=40). The majority of the physicians (95%) perceived that nurses should be able to refer patients to primary care and self-care. One fourth (25%) perceived specialist nurses in ambulance care as the most appropriate professionals. The majority of the physicians (65%) perceived that referral to primary care maintain patient safety, whereas fewer (50%) assessed the referral as safe for the patient. All perceived that feedback should be given to nurses when the referral was incorrect. The majority perceived it important to extend the nurses’ authority to refer to primary care (63%) and self-care (55%).

Conclusion: There is no consensus among the EMS physicians regarding responsibilities and conditions for nurses’ referral of patients. Registered nurses with basic education are expected to be able to refer, while there is varying opinion regarding requirements of specialist trained ambulance nurses to refer patients. Professional experience as a nurse is perceived more important than formal education.

Objectives: To identify which patient characteristics are associated with silence towards the healthcare system after experiences of abusive or ethically wrongful transgressive behaviour by healthcare staff.

Design: Cross-sectional questionnaire study using the Transgressions of Ethical Principles in Health Care Questionnaire.

Setting: A women's clinic in the south of Sweden.

Participants: Selection criteria were: consecutive female patients coming for an outpatient appointment, ≥18-year-old, with the ability to speak and understand the Swedish language, and a known address.

Questionnaires were answered by 534 women (60%) who had visited the clinic, of which 293 were included in the present study sample.

Primary outcome measure: How many times the respondent remained silent towards the healthcare system relative to the number of times the respondent spoke up.

Results: Associations were found between patients’ silence towards the healthcare system and young age as well as lower self-rated knowledge of patient rights. Both variables showed independent effects on patients’ silence in a multivariate model. No associations were found with social status, country of birth, health or other abuse.

Conclusions: The results offer opportunities for designing interventions to stimulate patients to speak up and open up the clinical climate, for which the responsibility lies in the hands of staff; but more research is needed.

Objectives This study psychometrically evaluated GeneralSelf-Efficacy (GSE) Scale in patients planned for bariatricsurgery in Sweden.Design A cross-sectional psychometric study. Thepsychometric evaluation was guided by the COnsensus-based Standards for the selection of health statusMeasurement Instruments checklist for health-relatedreported-patient outcomes.Setting Three bariatric centres in Sweden.Participants Adult patients≥18 years old scheduled forprimary bariatric surgery (with sleeve gastrectomy orRoux-en-Y gastric bypass).Primary and secondary measures Psychometricproperties of the GSE.Results In total, 704 patients were included in theanalysis. Mean values for GSE items were 2.9–3.4 and themean GSE sum score was 31.4 (SD 4.7). There were nofloor or ceiling effects. Cronbach’s alpha was 0.89. Menreported a higher mean GSE than did women, that is, 31.2(SD 4.8) for women versus 32.1 (SD 4.3) for men, p=0.03.Correlation coefficients were weak or negligible: GSE andmental component summary score of 36-Item Short FormHealth Survey (SF-36)/RAND 36, r=0.18 (p<0.00); GSEand physical component summary score of SF-36/RAND36, r=0.07 (p=0.138); GSE and obesity- related problemscale r=−0.15 (p=0.001) and GSE and level of education,r=0.04 (p=0.35). Confirmatory factor analysis indicateda one-factor construct with a satisfactory goodness of fit,that is, Comparative Fit Index=0.927, root mean squareerror of approximation=0.092 and standardised root meansquare residual=0.045. The factor GSE explained almosthalf or over half of the variance of each item (0.45–0.75,p-values<0.001).Conclusions The GSE scale is a valid and reliable scalethat can be used to assess general self-efficacy in patientsundergoing bariatric surgery.

Objective Safety is essential to support independent living among the rising number of people with long-term healthcare and social care needs. Safety performance in home care leans heavily on the capacity of unlicensed staff to respond to problems and changes in the older patients’ functioning and health. The aim of this study is to explore assistant nurses’ adaptive responses to everyday work to ensure safe care in the home care context.

Design A qualitative approach using the drama-based learning and reflection technique forum play with subsequent group interviews. The audio-recorded interviews were transcribed and analysed with thematic analysis.

Setting Home care services organisations providing care to older people in their private homes in two municipalities in southern Sweden.Participants Purposeful sampling of 24 assistant nurses and three managers from municipal home care services and a local geriatric hospital clinic.

Results Home care workers’ adaptive responses to provide safe home care were driven by an ambition to ‘make it work in the best interests of the person’ by adjusting to and accommodating care recipient needs and making autonomous decisions that expanded the room for manoeuvrability, while weighing risks of a trade-off between care standards and the benefits for the community-dwelling older people’s independent living. Adaptations to ensure information transfer and knowledge acquisition across disciplines and borders required reciprocity.

Conclusions Safety performance in home care service is dependent on the staff closest to the older people, who deal with safety risks and ethical dilemmas on a day-to-day basis and their access to information, competence, and resources that fit the demands. A proactive leadership characterised by mutual trust and adequate support for decision making is suggested. Managers and decision-makers across healthcare and social care need to consider how they can develop interprofessional collaborations and adaptive routines supporting safety from a broader perspective.

Objective

To explore how primary healthcare workers in Sweden experienced and perceived the long-term impact of the pandemic on their work.

Design

This is a descriptive qualitative study with individual semistructured interviews conducted 2 years after the onset of COVID-19. Data were analysed using an inductive thematic approach.

Setting

Swedish primary healthcare units in rural and urban locations.

Participants

29 healthcare providers (6 registered nurses, 7 assistant nurses, 8 physicians and 8 managers) in Swedish primary healthcare.

Results

Data analysis yielded three overarching themes: (1) primary healthcare still affected by the pandemic; (2) primary healthcare changes made permanent; and (3) lessons learnt for handling future crises affecting primary healthcare. The participants experienced a high workload, even after the pandemic, and concluded that it would take years to catch up both mentally and workwise. Four lessons were learnt for future handling of crises that might affect primary healthcare: the importance of creating a cohesive primary healthcare management system to provide clarity regarding recommendations for how primary healthcare personnel should work, the need for management support at all levels, restricting and adapting the flow of information for primary healthcare and ascertaining the necessary resources if primary healthcare is to take on additional tasks.

Conclusion

Two years after the onset of the COVID-19 pandemic, primary healthcare workers in Sweden experienced that their work was still affected by the pandemic. Our findings highlight the importance of ensuring sufficient recovery time and providing opportunities for reflection on the experiences of primary healthcare personnel. This also includes preparedness for managing the heavy workload and strained energy levels of healthcare workers in the aftermath of a crisis.

Objective

The aim of this study was to explore how the COVID-19 pandemic changed the working conditions of physicians in Swedish primary healthcare.

Design

This is a descriptive, qualitative study with individual semistructured interviews. Data were analysed using inductive content analysis.

Setting

Swedish primary healthcare units in both rural and urban areas.

Participants

A total of 11 primary care physicians fulfilled participation.

Results

Two main categories emerged: ‘work organisation and routines’ and ‘psychosocial work environment’, containing three and five subcategories, respectively. The pandemic enforced changes in work organisation and routines. Increased flexibility, including more patient-oriented delivery of care, and novel means of interorganisational and intraorganisational interactions were perceived as positive by physicians. The pandemic also caused several changes in physicians’ psychosocial work environment. Increased workload, information overload, as well as ethical considerations and feelings of uncertainty made the work environment stressful for physicians.

Conclusions

The COVID-19 pandemic affected the working conditions of physicians in Swedish primary healthcare in numerous ways. The pandemic enforced changes in work organisation and routines for physicians in primary healthcare. Further research is needed to investigate how the pandemic will affect primary healthcare in the longer term. Learning from the pandemic is important because this will not be the last crisis that primary care and its healthcare professionals will face.

Introduction Deficient hospital discharging and patients struggling to handle postdischarge self-management have been identified as potential causes of re-hospitalisation rates. Despite an increased interest in interventions aiming to reduce re-hospitalisation rates, there is yet no best evidence on how to support patients in being active participants in their self-management postdischarge. The aim of this paper is to describe the study protocol for an upcoming randomised controlled trial (RCT) of the Supporting Patient in Activation to Home (sPATH) intervention. Methods/analysis The described study is a randomised, controlled, analysis-blinded, two-site trial, with primary outcome re-hospitalisation within 90 days. In total, 290 participants aged 18 years or older with chronic obstructive pulmonary disease or congestive heart failure who are admitted to hospital and who are living in an own home will be eligible for inclusion into an intervention (n=145) or control group (n= 145). Patients who need an interpreter to communicate in Swedish, or who have a diagnosis of dementia or cognitive impairment, will be excluded from inclusion. The sPATH intervention, developed with a theoretical base in the self-determination theory, consists of five postdischarge motivational interviewing sessions (face to face or by phone). The intervention covers the self-management areas medication management, follow-up/care plan, symptoms/signs of worsening condition and relations/contacts with healthcare providers. This RCT will add to the literature on evidence to support patient activation in postdischarge selfmanagement. Ethics and dissemination The study is approved by the Regional Research Ethics Committee (No. 2014/149831/ 2) in Stockholm, Sweden. The results of the study will be published in peer-reviewed journals and presented at international and national scientific conferences.

Objectives Patients >= 65 years old represent 30%-50% of all ambulance assignments (AAs), and the knowledge of which care level they are disposed to is limited and diverging. The aim of this study was therefore to describe and compare characteristics of patients' aged >= 65 years dispositions during AA, including determining changes over time and factors associated with non-conveyance to hospitals. Design A longitudinal and comparative database study. Setting Ambulance service in a Swedish region. Participants 32 085 AAs with patients >= 65 years old during the years 2014, 2016 and 2018. Exclusion criteria: AAs with interhospital patient transfers and lack of patients' dispositions data. Outcome measures Dependent factors: conveyance and non-conveyance to hospitals. Independent factors: age, sex, symptom, triage level, scene, time, day and season. Results The majority (n=29 060; 90.6%) of patients' dispositions during AA were conveyance to hospitals. In total, the most common symptoms were circulatory (n=4953; 15.5%) and respiratory (n=4529; 14.1%). A significant increase, p<0.01, of non-conveyance to hospitals was shown during 2014 and 2018, from 801 (7.8%) to 1295 (11.4%). Increasing age was associated with decreasing odds of non-conveyance, 85-89 years (OR=0.85, 95 % CI=0.72 to 0.99) and 90 years or older (OR=0.80, 95 % CI=0.68 to 0.93). Several factors were associated with non-conveyance, for example, symptoms of diabetes (OR=8.57, 95 % CI=5.99 to 12.26) and mental disorders (OR=5.71, 95 % CI=3.85 to 8.48) in comparison with infections. Conclusions The study demonstrates several patient characteristics, and factors associated with non-conveyance to hospitals, such as age, symptom, triage level, scene, time, day and season. The increasing non-conveyance trend highlights the importance of further studies on optimal care levels for patients >= 65 years old.

Objective To explore the lived experience of women with gestational diabetes mellitus (GDM) living in China in order to add knowledge about how the Chinese women suffer from GDM. Design A qualitative interpretive interview study. Data were collected with a snowball sampling technique. Phenomenological hermeneutics was used as the analysis method based on Ricoeur's phenomenological hermeneutical interpretation theory. Setting The study was performed at the participants' work places, or at the obstetric clinics or wards at two provincial hospitals and one municipal hospital in the southeast of China. Participants Inclusion criteria were age >= 18 years, diagnosis of GDM without other pregnancy complications, in 34th gestational weeks-postpartum 4th weeks and speaking Mandarin Chinese without speech impediment. 62 women, who met the inclusion criteria, took part in the study. Results The lived experience of the women with GDM living in China was formulated into a main theme: 'longing for caring care'. The main theme was derived from four themes: being stricken by GDM, wishing to receive caring GDM care, being left alone to struggle with GDM and trying to adjust and adapt to life with GDM. Conclusion The eagerness for caring care in China was highlighted. The lack of caring care could be one of the possible reasons why the professional-patient relations were deteriorating in China. It could be useful for health providers and health policymakers to receive education and training about caring care. Using the health metaphor of balance and 'patient participation' and 'patient-centred' approaches may benefit women with GDM and thus improve the quality of care in China.

Objective: To improve primary prevention of human papillomavirus (HPV) infection by promoting vaccination and increased condom use among upper secondary school students. Design: Cluster randomised controlled trial. Setting: 18 upper secondary schools in Sweden. Participants: Schools were first randomised to the intervention or the control group, after which individual classes were randomised so as to be included or not. Of the 832 students aged 16 years invited to participate during the regular individual health interview with the school nurse, 751 (90.2%) agreed to participate and 741 (89.1%) students completed the study. Interventions: The intervention was based on the Health Belief Model (HBM). According to HBM, a person’s health behaviour can be explained by individual beliefs regarding health actions. School nurses delivered 30 min face-to-face structured information about HPV, including cancer risks and HPV prevention, by propagating condom use and HPV vaccination. Students in the intervention and the control groups completed questionnaires at baseline and after 3 months. Main outcome measures: Intention to use condom with a new partner and beliefs about primary prevention of HPV, and also specifically vaccinationstatus and increased condom use. Results: All statistical analyses were performed at the individual level. The intervention had a significant effect on the intention to use condom (p=0.004). There was also a significant effect on HBM total score ( p=0.003), with a 2.559 points higher score for the intervention group compared to the controls. The influence on the HBM parameters susceptibility and severity was also significant (p<0.001 for both variables). The intervention also influenced behaviour: girls in the intervention group chose to have themselves vaccinated to a significantly higher degree than the controls ( p=0.02). No harms were reported. Conclusions: The school-based intervention had favourable effects on the beliefs about primary prevention of HPV, and increased the HPV vaccination rates in a diverse population of adolescents.

OBJECTIVES: The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.

DESIGN: Prospective observational study using the Work Observation Method By Activity Timing tool.

SETTING: An OR department at a county hospital in Sweden.

PARTICIPANTS: OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).

RESULTS: The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.

CONCLUSIONS: The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.

TRIAL REGISTRATION NUMBER: 2016/264.

Background National European cancer survival rates vary widely. Prolonged diagnostic intervals are thought to be a key factor in explaining these variations. Primary care practitioners (PCPs) frequently play a crucial role during initial cancer diagnosis; their knowledge could be used to improve the planning of more effective approaches to earlier cancer diagnosis. Objectives This study sought the views of PCPs from across Europe on how they thought the timeliness of cancer diagnosis could be improved. Design In an online survey, a final open-ended question asked PCPs how they thought the speed of diagnosis of cancer in primary care could be improved. Thematic analysis was used to analyse the data. Setting A primary care study, with participating centres in 20 European countries. Participants A total of 1352 PCPs answered the final survey question, with a median of 48 per country. Results The main themes identified were: patient-related factors, including health education; care provider-related factors, including continuing medical education; improving communication and interprofessional partnership, particularly between primary and secondary care; factors relating to health system organisation and policies, including improving access to healthcare; easier primary care access to diagnostic tests; and use of information technology. Re-allocation of funding to support timely diagnosis was seen as an issue affecting all of these. Conclusions To achieve more timely cancer diagnosis, health systems need to facilitate earlier patient presentation through education and better access to care, have well-educated clinicians with good access to investigations and better information technology, and adequate primary care cancer diagnostic pathway funding.

OBJECTIVES: Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.

DESIGN: Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making.

SETTING: A primary care study; 25 participating centres in 20 European countries.

PARTICIPANTS: 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.

OUTCOME MEASURES: The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons.

RESULTS: Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.

CONCLUSIONS: Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

IntroductionMaking decisions about the appropriate level of care is a significant challenge for healthcare professionals, especially when older patients present with diffuse symptoms. Collaboration between ambulance services and primary care may promote a comprehensive understanding of patient needs. However, such collaboration remains limited, potentially leading to lower care quality and higher costs. There is a need to understand how collaboration can be effectively implemented. This scoping review aims to explore existing models of collaboration between ambulance services and primary care, identifying their characteristics, outcomes and current research gaps.

Methods and analysisThis scoping review will follow the methodological framework proposed by Arksey and O’Malley, supplemented with recommendations from the Joanna Briggs Institute Handbook for Scoping Reviews. A comprehensive literature search will be conducted in PubMed, CINAHL, Web of Science and Scopus. In addition, Google Scholar, Overton, SwePub and the Swedish national library database Libris will be searched for relevant grey literature. The review will include studies published from January 2014 to the present. Data will be analysed descriptively, with findings categorised by collaboration models and patterns identified through inductive analysis to address the research questions. The review will apply the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews to present the results.

Ethics and dissemination This review is the first stage of an overarching research study to develop a model for extended collaboration between ambulance services and primary care (the ECAP project). Results will be disseminated through peer-reviewed publications, conference presentations and sharing with ambulance services and primary care stakeholders to inform practice and policy. This scoping review protocol has been registered on the Open Science Framework (https://osf.io/nrkm5/). No participants will be involved at this stage, and the selected literature is publicly available, so no ethical approval will be required for this scoping review.

Objective: The decision whether to initiate intensivecare for the critically ill patient involves ethical questions regarding what is good and right for the patient. It isnot clear how referring doctors negotiate these issuesin practice. The aim of this study was to describe and understand consultants’ experiences of the decision- making process around referral to intensive care.

Design: Qualitative interviews were analysed according to a phenomenological hermeneutical method.

Setting and participants: Consultant doctors (n=27) from departments regularly referring patients to intensive care in six UK hospitals.

Results: In the precarious and uncertain situation of critical illness, trust in the decision-making process is needed and can be enhanced through the way in which the process unfolds. When there are no obvious right or wrong answers as to what ought to be done, how the decision is made and how the process unfolds is morally important. Through acknowledging the burdensome doubts in the process, contributing to an emerging, joint understanding of the patient’s situation, and respondingto mutual moral duties of the doctors involved, trust in the decision-making process can be enhanced and a shared moral responsibility between the stake holding doctors can be assumed.

Conclusion: The findings highlight the importance of trust in the decision-making process and how the relationships between the stakeholding doctors are crucial to support their moral responsibility for the patient. Poor interpersonal relationships can damage trust and negatively impact decisions made on behalf of a critically ill patient. Forthis reason, active attempts must be made to foster good relationships between doctors. This is not only important to create a positive working environment, but a mechanism to improve patient outcomes.

Introduction Ten per cent of all pregnant women are depressed. Standard therapy of pregnant women with moderate depression is selective serotonin reuptakeinhibitors (SSRI). Observational studies on neurodevelopment after fetal SSRI exposure show conflicting results. Our primary objective is to compare the cognitive development in children exposed to sertraline and maternal depression with those exposed to maternal depression and placebo in utero. We hypothesise that there is a significant neurodevelopmental difference between the groups. As a secondary objective, we study the add-on effect of sertraline to internet-based cognitive behavioural therapy (ICBT) to treat moderate depression during pregnancy. Methods and analysis MAGDALENA is a randomised, placebo-controlled, double-blinded trial in Stockholm Healthcare Region with 2.3 million inhabitants. The women are recruited in weeks 9-21 of pregnancy either through Antenatal Health Clinics or through social media. They are to be diagnosed with moderate depression without ongoing antidepressive therapy or any serious comorbidity. The women in the intervention arm receive sertraline combined with a 12-week period of ICBT; the control arm is treated with placebo and ICBT. We assess the cognitive development in the offspring at the age of 2 years using Bayley Scales of Infant and Toddler Development, third edition (BSID-III). We aim at recruiting 200 women, 100 women in each treatment arm, to ensure statistical power to detect a clinically relevant difference between the groups. Ethics and dissemination This randomised trial will provide long-sought evidence about the effects of SSRI and maternal depression during pregnancy on the neurodevelopment in the offspring. The study is approved by the Regional Ethical Review Board at Karolinska Institutet in Stockholm and the Swedish Medical Products Agency. It is registered with the European Clinical Trials Database (EudraCT), Number: 2013-004444-31. Results will be disseminated at scientific conferences, published in peer-reviewed journals and made available to the public.

Objective

We studied characteristics, survival, causes of cardiac arrest, conditions preceding cardiac arrest, predictors of survival and trends in the prevalence of COVID-19 among in-hospital cardiac arrest (IHCA) cases.

Design and setting

Registry-based observational study.

Participants

We studied all cases (>= 18 years of age) of IHCA receiving cardiopulmonary resuscitation in the Swedish Registry for Cardiopulmonary Resuscitation during 15 March 2020 to 31 December 2020. A total of 1613 patients were included and divided into the following groups: ongoing infection (COVID-19+; n=182), no infection (COVID-19-; n=1062) and unknown/not assessed (n=369).

Main outcomes and measures

We studied monthly trends in proportions of COVID-19 associated IHCAs, causes of IHCA in relation to COVID-19 status, clinical conditions preceding the cardiac arrest and predictors of survival.

Results

The rate of COVID-19+ patients suffering an IHCA increased to 23% during the first pandemic wave (April), then abated to 3% in July, and then increased to 19% during the second wave (December). Among COVID-19+ cases, 43% had respiratory insufficiency or infection as the underlying cause of the cardiac arrest, compared with 18% among COVID-19- cases. The most common clinical sign preceding cardiac arrest was hypoxia (57%) among COVID-19+ cases. OR for 30-day survival for COVID-19+ cases was 0.50 (95% CI 0.33 to 0.76), compared with COVID-19- cases.

Conclusion

During pandemic peaks, up to one-fourth of all IHCAs are complicated by COVID-19, and these patients have halved chance of survival, with women displaying the worst outcomes.

Objectives

Acute care units manage high risk patients at the edge of scientifically established treatments and organisational constraints while aiming to balance reliability to standards with the needs of situational adaptation (resilience). First-line managers are central in coordinating clinical care. Any systemic brittleness will be evident only in retrospect through, for example, care quality measures and accident statistics. This challenges us to understand what successful managerial strategies for adaptation are and how they could be improved. The managerial work of balancing reliability and adaptation is only partially understood. This study aims to explore and describe how system resilience is enhanced by naturally occurring coordination performed in situ by a management team under variable circumstances.

Design

An explorative observational study of a tertiary neonatal intensive care unit (NICU) in Sweden. One year of broad preparatory work followed by focused shadowing observations of coordination analysed through inductive–deductive content analysis from a perspective of resilience engineering.

Participants

A team of managers (ie, clinical coordinators, head nurses, senior medical doctors).

Results

The results describe a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Managers focused on maintaining coherence in escalating problematic situations by facilitating teamwork through goalsetting, problem-solving and circumventing the technical systems’ limitations.

Conclusions

Coordination supports a coherent goal setting by increased team collaboration and is supported by team members’ abilities to predict the behaviour of each other. Our findings suggest that in design of future research or training for coordination, the focus of assessment and reflection on adaptive managerial responses may lie on situations where the system was ‘stretched’ or ‘needed reorganisation’ and that learning should be about whether the actions were able to achieve short-term goals while preserving the long-term goals.

OBJECTIVES: The aim was to psychometrically test and evaluate the Swedish functional health literacy scale and the Swedish communicative and critical health literacy scale in patients undergoing bariatric surgery.

DESIGN: A prospective cross-sectional psychometric study.

SETTING: Patients from three bariatric centres in Sweden were consecutively included in this study.

PARTICIPANTS: A total of 704 patients undergoing bariatric surgery filled in the questionnaires preoperatively. Inclusion criteria were scheduled for primary bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) and greater than 17 years, proficiency in Swedish.

PRIMARY AND SECONDARY MEASURES: Psychometric outcomes of the Swedish Functional Health Literacy scale and the Swedish Communicative and Critical Health Literacy scale.

RESULTS: There was a higher proportion of females (74.4%, n=523) to males (25.6%, n=180). The mean age was 42 years (SD 11.5). Limited functional health literacy and limited communicative and critical health literacy (including both inadequate and problematic health literacy) was reported in 55% (n=390) and 40% (n=285), respectively. Cronbach alpha for the Swedish Functional Health Literacy scale was α=0.86 and for the Swedish Communicative and Critical Health Literacy scale, α=0.87. Construct validity showed weak to negative correlations between the Swedish Functional Health Literacy scale and income, education and SF-36/RAND36 summary scores. Confirmatory factor analysis showed a one-factor solution for the Swedish Functional Health Literacy scale and a two-factor solution for the Swedish Communicative and Critical Health Literacy scale.

CONCLUSIONS: The Swedish Functional Health Literacy scale and the Swedish Communicative and Critical Health Literacy scale are valid and reliable to use for patients undergoing bariatric surgery in a Swedish context. Measuring dimensions of health literacy can be used as a guide for the development of health literacy friendly patient information in patients undergoing bariatric surgery.

Objective: The objective of this article is to explorethe educational needs and design aspects ofpersonalised internet-enabled education for patientswith diabetes in Iran.Design: Data were collected using semistructuredinterviews and then qualitatively analysed usinginductive content analysis.Participants: 9 patients with type 2 diabetes wereincluded. Inclusion criteria were access to andknowledge on how to use the internet. The selectionensured representation based on gender, age,occupation and educational background.Setting: The sample population was patients withdiabetes who were admitted to an outpatient diabetesclinic in Mashhad, a large city of Iran with about 3million inhabitants.Results: 4 core categories emerged from the data: (1)seeking knowledge about diabetes, including specificknowledge acquisition, patient’s interactions andlearning requirements; (2) teaching and learning,including using different teaching methods anddifferent ways to learn about the disease; (3)facilitators, including internet and mobile phone use tolearn about the disease; and (4) barriers, including lackof internet access, uncertainty of access to the internetand lack of website in the local language and alsoperceived cultural barriers, such as patients’ fears ofthe internet, lack of time and awareness.Conclusions: This study provides a betterunderstanding of the patient’s educational expectationsand technical needs in relation to internet-enablededucation. This knowledge will inform the developmentof functional mock-ups in the next research phaseusing a design-based research approach in order todesign internet-enabled patient education for selfmanagementof diabetes.

ObjectiveThis study had two aims: (1) to determine the prevalence of musculoskeletal complaints among staff in primary care and (2) to determine to what extent lean maturity of the primary care unit can predict musculoskeletal complaints 1 year later.DesignDescriptive, correlational and longitudinal design.SettingPrimary care units in mid-Sweden.ParticipantsIn 2015, staff members responded to a web survey addressing lean maturity and musculoskeletal complaints. The survey was completed by 481 staff members (response rate 46%) at 48 units; 260 staff members at 46 units also completed the survey in 2016.Outcome measuresAssociations with musculoskeletal complaints were determined both for lean maturity in total and for four Lean domains entered separately in a multivariate model, that is, philosophy, processes, people and partners, and problem solving.ResultsThe shoulders (12-month prevalence: 58%), neck (54%) and low back (50%) were the most common sites of 12-month retrospective musculoskeletal complaints at baseline. Shoulders, neck and low back also showed the most complaints for the preceding 7 days (37%, 33% and 25%, respectively). The prevalence of complaints was similar at the 1-year follow-up. Total lean maturity in 2015 was not associated with musculoskeletal complaints, neither cross-sectionally nor 1 year later, for shoulders (1 year beta: -0.002, 95% CI -0.03 to 0.02), neck (beta: 0.006, 95% CI -0.01 to 0.03), low back (beta: 0.004, 95% CI -0.02 to 0.03) and upper back (beta: 0.002, 95% CI -0.02 to 0.02).ConclusionThe prevalence of musculoskeletal complaints among primary care staff was high and did not change within a year. The extent of lean maturity at the care unit was not associated with complaints among staff, neither in cross-sectional analyses nor in a 1-year predictive analysis.

Objective To describe the pharmacists' workflow, including tasks and time spent, to better understand their work capacity.

Design Cross-sectional, observational, time and motion study.

Setting Community pharmacies in Western Australia and New South Wales, Australia.

Participants Currently registered and practising pharmacists were approached using snowball sampling and selected using purposive techniques to obtain balance representation of metropolitan and rural pharmacies, as well as high and low script volumes where possible.

Results Twenty-four pharmacists across 15 pharmacies participated during the 135 sessions totalling over 274 hours of observation. Dispensing (30%), indirect patient services (17%), counselling (15%) and professional management activities (15%) were the top four duties pharmacists performed, while only 2% of time was spent on professional services such as pain clinics and influenza vaccinations. Tasks were frequently interrupted and often performed simultaneously. Breaks and consumer-contact times were limited. More time was spent on professional service activities in non-metropolitan pharmacies, in pharmacies with greater daily prescription volumes and those with one or more support pharmacists.

Conclusions This is the first study to quantify the pharmacists' tasks in Australian community pharmacies. Much time is being spent on dispensing, supply and management activities with little time for providing additional professional services. An extra supporting pharmacist is likely necessary to increase professional services. These findings could support future research around barriers and enablers of conducive workflows and of extended professional services.

Objective As 'critical illness' and 'critical care' lack consensus definitions, this study aimed to explore how the concepts' are used, describe their defining attributes, and propose potential definitions. Design and methods We used the Walker and Avant approach to concept analysis. The uses and definitions of the concepts were identified through a scoping review of the literature and an online survey of 114 global clinical experts. We used the Arksey and O'Malley framework for scoping reviews and searched in PubMed and Web of Science with a strategy including terms around critical illness/care and definitions/etymologies limited to publications in English between 1 January 2008 and 1 January 2020. The experts were selected through purposive sampling and snowballing, with 36.8% in Africa, 25.4% in Europe, 22.8% in North America, 10.5% in Asia, 2.6% in South America and 1.8% in Australia. They worked with anaesthesia or intensive care 59.1%, emergency care 15.8%, medicine 9.5%, paediatrics 5.5%, surgery 4.7%, obstetrics and gynaecology 1.6% and other specialties 3.9%. Through content analysis of the data, we extracted codes, categories and themes to determine the concepts' defining attributes and we proposed potential definitions. To assist understanding, we developed model, related and contrary cases concerning the concepts, we identified antecedents and consequences to the concepts, and defined empirical referents. Results Nine and 13 articles were included in the scoping reviews of critical illness and critical care, respectively. A total of 48 codes, 14 categories and 4 themes were identified in the uses and definitions of critical illness and 60 codes, 13 categories and 5 themes for critical care. The defining attributes of critical illness were a high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility. The defining attributes of critical care were the identification, monitoring and treatment of critical illness; vital organ support; initial and sustained care; any care of critical illness; and specialised human and physical resources. The defining attributes led to our proposed definitions of critical illness as, 'a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility', and of critical care as, 'the identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions.' Conclusion The concepts critical illness and critical care lack consensus definitions and have varied uses. Through concept analysis of uses and definitions in the literature and among experts, we have identified the defining attributes of the concepts and proposed definitions that could aid clinical practice, research and policy-making.

Objectives The purpose of this study was to describe the experiences and actions of part-time firefighters’ family members in rural areas in Sweden.Design The study had an inductive descriptive design and used the critical incident technique.Setting Rural areas, primarily served by a part-time fire station, across Sweden.Participants The study included 25 participants (21 females and 4 males) with experiences of being a family member of a part-time firefighter. Family members who themselves served as firefighters were excluded.Results Being a part-time firefighter’s family member was described into three main areas of experiences: ‘affecting everyday life’, ‘dealing with uncertainty’ and ‘being in this together’. Actions taken were divided into two main areas: ‘pursuing adaptations’ and ‘alleviating difficulties’.Conclusions Family members of part-time firefighters faced increased responsibility at home, managing personal inconvenience and frustration. They offered emotional support for the firefighter, however, expressing a need for guidance on handling firefighters’ emotions and mental health after call-outs. Despite their crucial role, they often felt unrecognised by the fire and rescue service. Nonetheless, they took pride in their firefighter’s contribution to the community and noted positive impacts on the family.

Objective The aim was to compare self-reported health between cardiac arrest survivors with good cerebral performance (CPC 1) and survivors with moderate cerebral disability (CPC 2). Methods This comparative register study was based on nationwide data from the Swedish Register of Cardiopulmonary Resuscitation. The study included 2058 in-hospital and out-of-hospital cardiac arrest survivors with good cerebral performance or survivors with moderate cerebral disability, 3-6 months postcardiac arrest. Survivors completed a questionnaire including the Hospital Anxiety and Depression Scale (HADS) and EQ-5D five-levels (EQ-5D-5L). Data were analysed using ordinal and linear regression models. Results For all survivors, the prevalence of anxiety and depression symptoms measured by the HADS was 14% and 13%, respectively. Using the EQ-5D-5L, the cardiac arrest survivors reported most health problems relating to pain/discomfort (57%), followed by anxiety/depression (47%), usual activities (46%), mobility (40%) and self-care (18%). Compared with the survivors with good cerebral performance, survivors with moderate cerebral disability reported significantly higher symptom levels of anxiety and depression measured with HADS, and poorer health in all dimensions of the EQ-5D-5L after adjusting for age, sex, place of cardiac arrest, aetiology and initial rhythm (p<0.001). Conclusions These findings stress the importance of screening for health problems in all cardiac arrest survivors to identify those in need of professional support and rehabilitation, independent on neurological outcome.

Introduction The aim of the Common factors, Responsiveness and Outcome in Psychotherapy (CROP) study is to identify client and psychologist characteristics and therapeutic processes associated with the outcome of psychotherapy delivered by psychologists employed in the Danish primary sector or fully self-employed. The study addresses two main questions. First, how are specific characteristics of clients and psychologists related to the outcome of therapy and do these characteristics moderate the outcome of different psychotherapeutic approaches? Second, to what extent do therapists adapt their approach to client characteristics and preferences and how does such responsiveness impact the process and outcome of therapy? Methods and analysis The study is a naturalistic prospective cohort study carried out in collaboration with psychologists in private practice in Denmark. Self-reported data are collected from the participating psychologists and their participating clients before, during (weekly and postsession) and after psychotherapy (at end of treatment and 3 months follow-up). The estimated target sample size is 573 clients. The data are analysed using multilevel modelling and structural equation modelling approaches to capture predictors and moderators of the effect and rate of change in psychotherapy as well as session-to-session changes during the therapy process. Ethics and dissemination The study has been approved by the IRB at the Department of Psychology, University of Copenhagen (IRB number: IP-IRB/01082018) and the Danish Data Protection Agency. All study data are fully anonymised and all clients have given informed consent to participation in the study. The study findings will be presented in articles in international, peer-reviewed journals as well as to psychotherapy practitioners and other professionals across Denmark. Trial registration number NCT05630560.

OBJECTIVES: Non-conveyed patients represent a significant proportion of all patients cared for by ambulance services in the western world. However, scientific knowledge on non-conveyance is sparse. Therefore, the aim of this study was to describe the prevalence of non-conveyance, investigate associations and compare patients' characteristics, drug administration, initial problems and vital signs between non-conveyed and conveyed patients.

DESIGN: A population-based retrospective cohort study.

SETTING: The study setting area, Stockholm, Sweden, has a population of 2.3 million inhabitants, with seven emergency hospitals. Annually, approximately 210 000 assignments are performed by 73 ambulances. All ambulance assignments performed from 1 January to 31 December 2015 were included.

RESULTS: In total, 23 603 ambulance assignments ended in non-conveyance-13.8% of all ambulance assignments performed in 2015. Compared with conveyed patients, non-conveyed patients were younger and more often female (median age 50.1 years for non-conveyed vs 61.7 years for conveyed; female=52 %, both p values <0.001). Approximately half of all ambulance assignments ending in non-conveyance were initially prioritised and dispatched as the highest priority. Non-conveyed patients were more often assessed by ambulance clinicians as presenting non-specific symptoms or symptoms related to psychiatric problems. Low blood glucose levels were highly associated with non-conveyance (adjusted OR (AOR): 15; 95 % CI 11.18 to 20.13), although non-conveyed patients presented abnormal vital signs across all categories of vital signs. Moreover, drugs were more often administered to younger non-conveyed patients. Older patients were more often conveyed and administered drugs once conveyed (AOR: 1.29; 95 % CI 1.07 to 1.56).

CONCLUSIONS: This study shows that non-conveyed patients represent a non-negligible proportion of all patients in contact with ambulance services. In general, most cases of non-conveyance occur at the highest dispatch level, to a large extent involve younger patients, and features problems assessed by ambulance clinicians as non-specific or related to psychiatric symptoms.

Objectives To combat overcrowding in emergency departments, ambulance clinicians (ACs) are being encouraged to make on-site assessments regarding patients' need for conveyance to hospital, and this is creating new and challenging demands for ACs. This study aimed to describe ACs' experiences of assessing non-conveyed patients. Design A phenomenological interview study based on a reflective lifeworld research approach. Setting The target area for the study was Stockholm, Sweden, which has a population of approximately 2.3 million inhabitants. In this area, 73 ambulances perform approximately just over 200000 ambulance assignments annually, and approximately 25000 patients are non-conveyed each year. Informants 11 ACs. Methods In-depth open-ended interviews. Results ACs experience uncertainty regarding the accuracy of their assessments of non-conveyed patients. In particular, they fear conducting erroneous assessments that could harm patients. Avoiding hasty decisions is important for conducting safe patient assessments. Several challenging paradoxes were identified that complicate the non-conveyance situation, namely; responsibility, education and feedback paradoxes. The core of the responsibility paradox is that the increased responsibility associated with non-conveyance assessments is not accompanied with appropriate organisational support. Thus, frustration is experienced. The education paradox involves limited and inadequate non-conveyance education. This, in combination with limited support from non-conveyance guidelines, causes the clinical reality to be perceived as challenging and problematic. Finally, the feedback paradox relates to the obstruction of professional development as a result of an absence of learning possibilities after assessments. Additionally, ACs also described loneliness during non-conveyance situations. Conclusions This study suggests that, for ACs, performing non-conveyance assessments means experiencing a paradoxical professional existence. Despite these aggravating paradoxes, however, complex non-conveyance assessments continue to be performed and accompanied with limited organisational support. To create more favourable circumstances and, hopefully, safer assessments, further studies that focus on these paradoxes and non-conveyance are needed.

Objectives: The aim of this study was to estimate the prevalence and causes of vision impairment (VI) in Portugal.

Setting Information about people with VI was obtained from primary care centres, blind association (ACAPO) and from hospitals (the PCVIP study) in the Northwest of Portugal during a period spanning years 2014–2015. Causes of VI were obtained from hospitals.

Participants Administrative and medical records of people with visual acuity in the better seeing eye of 0.5 decimal (0.30logMAR) or worse and/or visual field less than 20° were investigated. Capture–recapture with log-linear models was applied to estimate the number of individuals missing from lists of cases obtained from available sources.

Primary and secondary outcome measures Log-linear models were used to estimate the crude prevalence and the category specific prevalence of VI.

Results Crude prevalence of VI was 1.97% (95% CI 1.56% to 2.54%), and standardised prevalence was 1% (95% CI 0.78% to 1.27%). The age-specific prevalence was 3.27% (95% CI 2.36% to 4.90%), older than 64 years, 0.64% (95% CI 0.49% to 0.88%), aged 25–64 years, and 0.07% (95% CI 0.045% to 0.13%), aged less than 25 years. The female-to-male ratio was 1.3, that is, higher prevalence among females. The five leading causes of VI were diabetic retinopathy, cataract, age-related macular degeneration, glaucoma and disorders of the globe.

Conclusions The prevalence of VI in Portugal was within the expected range and in line with other European countries. A significant number of cases of VI might be due to preventable cases and, therefore, a reduction of the prevalence of VI in Portugal seems possible. Women and old people were more likely to have VI and, therefore, these groups require extra attention. Future studies are necessary to characterise temporal changes in prevalence of VI in Portugal.No data are available. Raw data can be requested from the first author.

OBJECTIVE: Home healthcare is the fastest growing arena in the healthcare system but patient safety research in this context is limited. The aim was to explore how patient safety in Swedish specialised home healthcare is described and adressed from multidisciplinary teams' and clinical managers' perspectives.

DESIGN: An explorative qualitative study.

SETTING: Multidisciplinary teams and clinical managers were recruited from three specialised home healthcare organisations in Sweden.

METHODS: Nine focus group interviews with multidisciplinary teams and six individual interviews with clinical managers were conducted, in total 51 participants. The data were transcribed verbatim and analysed using qualitative content analysis.

RESULTS: Patient safety was inherent in the well-established care ideology which shaped a common mindset between members in the multidisciplinary teams and clinical managers. This patient safety culture was challenged by the emerging complexity in which priority had to be given to standardised guidelines, quality assessments and management of information in maladapted communication systems and demands for required competence and skills. The multiple guidelines and quality assessments that aimed to promote patient safety from a macro-perspective, constrained the freedom, on a meso-level and micro-level, to adapt to challenges based on the care ideology.

CONCLUSION: Patient safety in home healthcare is dependent on adaptability at the management level; the team members' ability to adapt to the varying conditions and on patients being capable of adjusting their homes and behaviours to reduce safety risks. A strong culture related to a patient's value as a person where patients' and families' active participation and preferences guide the decisions, could be both a facilitator and a barrier to patient safety, depending on which value is given highest priority.

Objective To determine the impact on emergency department (ED) throughput times and proportion of patients who leave without being seen by a physician (LWBS) of two triage interventions, where comprehensive nurse-led triage was first replaced by senior physician-led triage and then by interprofessional teamwork. Design Single-centre before-and-after study. Setting Adult ED of a Swedish urban hospital. Participants Patients arriving on weekdays 08: 00 to 21: 00 during three 1-year periods in the interval May 2012 to November 2015. A total of 185 806 arrivals were included. Interventions Senior physicians replaced triage nurses May 2013 to May 2014. Interprofessional teamwork replaced the triage process on weekdays 08: 00 to 21: 00 November 2014 to November 2015. Main outcome measures Primary outcomes were the median time to physician (TTP) and the median length of stay (LOS). Secondary outcome was the LWBS rate. Results The crude median LOS was shortest for teamwork, 228 min (95% Cl 226.4 to 230.5) compared with 232 min (95% Cl 230.8 to 233.9) for nurse-led and 250 min (95% Cl 248.5 to 252.6) for physician-led triage. The adjusted LOS for the teamwork period was 16 min shorter than for nurse-led triage and 23 min shorter than for physician-led triage. The median TTP was shortest for physician-led triage, 56 min (95% Cl 54.5 to 56.6) compared with 116 min (95% Cl 114.4 to 117.5) for nurse-led triage and 74 min (95% Cl 72.7 to 74.8) for teamwork. The LWBS rate was 1.9% for nurse-led triage, 1.2% for physician-led triage and 3.2% for teamwork. All outcome measure differences had two-tailed p values< 0.01. Conclusions Interprofessional teamwork had the shortest length of stay, a shorter time to physician than nurse-led triage, but a higher LWBS rate. Interprofessional teamwork may be a useful approach to reducing ED throughput times.

Introduction Globally, nurse practitioner (NP) has become an important nursing role in the pursuit of a more efficient healthcare, possessing the necessary expert skills to work as autonomous practitioners. Nevertheless, there are barriers in the implementation of this role. One barrier concerns the different levels of education required for NPs. Previous studies demonstrate the importance of acting for a uniform international education. The aim of the scoping review was to compile research about education to become an NP, focusing on the content of curricula and learning objectives.

Methods and analysis The six-stage methodological framework by Arksey and O’Malley will guide the scoping review through the following stages: identifying the research questions; identifying relevant studies; study selection; charting the data; collating, summarising and reporting the results; and consultation. The research questions are as follows: What is the content of curricula in NP programmes? What are the learning objectives in NP programmes? The literature searches will be conducted between March and June 2019 in the following databases: PubMed, CINAHL and ERIC, followed by hand searching reference lists of key studies. Grey literature will be searched in Google Scholar, Libsearch, existing networks and relevant organisations. Two researchers will screen titles and abstracts. Included full-text articles will be screened by three researchers and assessed for their methodological quality by the use of the Critical Appraisal Skills Programme. The PreferredReporting Items for Systematic Reviews and Meta-Analyses flow diagram will be used to demonstrate included and excluded articles. The findings will be presented through a numerical summary of the included articles, followed by a thematic analysis.

Ethics and dissemination Research ethics approval is not required for a scoping review. The scoping review will be submitted to a peer-reviewed journal. Additionally, the findings will be disseminated to stakeholders representing political, educational, professional and union organisations through a Delphi study as part of the consultation stage of the Arksey and O’Malleys framework.

Introduction Elder abuse is prevalent and associated with different forms of ill health. Despite this, healthcare providers are often unaware of abusive experiences among older patients and many lack training about elder abuse. The overall aim of this study is to determine the effectiveness of an educational intervention on healthcare providers' propensity to ask older patients questions about abusive experiences. Methods and analysis Healthcare providers at hospital clinics and primary healthcare centres in Sweden will undergo full-day education about elder abuse between the fall of 2021 and spring of 2023. The education consists of (1) theory and group discussions; (2) forum theatre, a form of interactive theatre in which participants are given the opportunity to practise how to manage difficult patient encounters; and (3) post-training reflection on changing practices. The design is a non-randomised cluster, stepped wedge trial in which all participants (n=750) gradually transit from control group to intervention group with 6-month interval, starting fall 2021. Data are collected using the Responding to Elder Abuse in GERiAtric care-Provider questionnaire which was distributed to all clusters at baseline. All participants will also be asked to answer the questionnaire in conjunction with participating in the education as well as at 6-month and 12-month follow-up. Main outcome is changes in self-reported propensity to ask older patients questions about abuse post-intervention compared with pre-intervention. Linear mixed models including cluster as a random effect will be used to statistically evaluate the outcome. Ethics and dissemination The study has been approved by the Swedish Ethical Review Authority. The results will be published in peer-reviewed journals and conference proceedings. If the intervention is successful, a manual of the course content will be published so that the education can be disseminated to other clinics.

Objectives Preventing adverse events (AEs) after orthopaedic surgery is a field with great room for improvement. A Swedish instrument for measuring AEs after hip arthroplasty based on administrative data from the national patient register is used by both the Swedish Hip Arthroplasty Register and the Swedish Association of Local Authorities and Regions. It has never been validated and its accuracy is unknown. The aim of this study was to validate the instrument’s ability to detect AEs, and to calculate the incidence of AEs following primary hip arthroplasties.

Design Retrospective cohort study using retrospective record review with Global Trigger Tool methodology in combination with register data.

Setting 24 different hospitals in four major regions of Sweden.

Participants 2000 patients with either total or hemi-hip arthroplasty were recruited from the SHAR. We included both acute and elective patients.

Primary and secondary outcome measures The sensitivity and specificity of the instrument. Adjusted cumulative incidence and incidence rate.

Results The sensitivity for all identified AEs was 5.7% (95% CI: 4.9% to 6.7%) for 30 days and 14.8% (95% CI: 8.2 to 24.3) for 90 days, and the specificity was 95.2% (95% CI: 93.5% to 96.6%) for 30 days and 92.1% (95% CI: 89.9% to 93.8%) for 90 days. The adjusted cumulative incidence for all AEs was 28.4% (95% CI: 25.0% to 32.3%) for 30 days and 29.5% (95% CI: 26.0% to 33.8%) for 90 days. The incidence rate was 0.43 AEs per person-month (95% CI: 0.39 to 0.47).

Conclusions The AE incidence was high, and most AEs occurred within the first 30 days. The instrument sensitivity for AEs was very low for both 30 and 90 days, but the specificity was high for both 30 and 90 days. The studied instrument is insufficient for valid measurements of AEs after hip arthroplasty.

Objectives

To analyse the temporal and geographical diffusion of antivascular endothelial growth factor (anti-VEGF) interventions, and its determinants in a National Health System (NHS).

Setting

NHS Portuguese hospitals.

Participants

All inpatient and day cases related to eye diseases at all Portuguese public hospitals for the period 2002–2012 were selected on the basis of four International Classification of Diseases 9th revision, Clinical Modification (ICD-9-CM) codes for procedures: 1474, 1475, 1479 and 149.

Primary and secondary outcome measures

We measured anti-VEGF treatment rates by year and county. The determinants of the geographical diffusion were investigated using generalised linear modelling.

Results

We analysed all hospital discharges from all NHS hospitals in Portugal (98 408 hospital discharges corresponding to 57 984 patients). National rates of hospitals episodes for the codes for procedures used were low before anti-VEGF approval in 2007 (less than 12% of hospital discharges). Between 2007 and 2012, the rates of hospital episodes related to the introduction of anti-VEGF injections increased by 27% per year. Patients from areas without ophthalmology departments received fewer treatments than those from areas with ophthalmology departments. The availability of an ophthalmology department in the county increased the rates of hospital episodes by 243%, and a 100-persons greater density per km² raised the rates by 11%.

Conclusions

Our study shows a large but unequal diffusion of anti-VEGF treatments despite the universal coverage and very low copayments. The technological innovation in ophthalmology may thus produce unexpected inequalities related to financial constraints unless the implementation of innovative techniques is planned and regulated

Objectives The aims of this study were to assess the regional differences in domestic violence among pregnant women in the capital district and in the tea plantation sector of Sri Lanka, to explore potential contributory factors and to assess whether healthcare workers addressed domestic violence and disclosure among survivors. Design A cross-sectional study was carried out using interviewer-administered Abuse Assessment Screen. Setting Fifty-seven antenatal clinic centres in the capital district and 30 in the tea plantation sector. Participants Pregnant women between 6 and 40 weeks of gestational age. In the capital district, 1375 women were recruited from antenatal clinic centres in the urban (n= 25) and in the rural areas (n= 32), and 800 women from 30 centres in the tea plantation sector. The response rate in the capital district was 95.6% and 96.7% in the tea plantation sector. Results Among the total sample of pregnant women (n= 2088), the prevalence of 'ever abused' was 38.6%, and the prevalence of 'currently abused' was 15.9%. 'Ever abused' (31.5% vs 50.8%) and 'currently abused' (10% vs 25.8%) were significantly higher (P< 0.001) among the women living in the tea plantation sector. 'Ever abused' was associated with living in the tea plantation sector, being employed, living far from gender-based violence care centre and of Muslim ethnicity, after adjusting for age, education and family income. Only 38.8% of all participants had been asked by healthcare workers about abuse. Living in the tea plantation sector and lower level of education were associated with not being asked. Among those who reported 'ever abused', only 8.7% had disclosed the experience to a healthcare worker. Conclusion Domestic violence was prevalent and highest among women in the tea plantation sector compared with the capital district. The capacity of healthcare workers in addressing domestic violence should be increased.

Objective To evaluate patients' experiences of using a web-based application, especially its usability as support for self-care activities after prostate cancer surgery. Design A deductive content analysis was used, stemming from the Fit between Individuals, Task and Technology (FITT) framework. Setting One surgical department in south of Sweden between October 2015 and April 2016 and between September 2017 and July 2018. Participants Fifteen men who had undergone radical prostatectomy for prostate cancer. Results By organising data in accordance with the FITT model, three main categories with ten subcategories were identified. Patients gave feedback on functions that suited them and their needs, as well as potential adjustments and improvements. Patients experienced that ePATH gave them easy access to reliable information regarding their rehabilitation. Directed information about ePATH at enrolment was seen as important. ePATH was perceived to have a logical structure that was easy to follow. However, when the structure was unclear, patients became less motivated to use a function. Conclusions Patients experienced ePATH as satisfactorily user-friendly and useful as a complementary self-management support after prostate cancer surgery, especially when the information and tasks were tailored to their preferences and the system design features supported individual autonomy.

Introduction Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care.

Objective To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process.

Methods Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool.

Results High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia.

Conclusion The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity and adaptivity of the nature of RNAs' work should be taken into consideration in future management, development, research and education.

Objective To determine patient perceptions of generic medicines 2 and 6 months after percutaneous coronary intervention (PCI), and to determine whether these perceptions moderate medication adherence. Design Prospective multicentre cohort study with repeated measures of perceptions of generic medicines and medication adherence. Setting The CONCARD(PCI) study conducted at seven large referral PCI centres in Norway and Denmark between June 2017 and May 2020. Participants A total of 3417 adults (78% men), using both generic and brand name medicines, with a mean age of 66 years (SD 11) who underwent PCI were followed up 2 and 6 months after discharge from hospital. Main outcome measures Perceptions of generic medicines were the main outcome. The secondary outcome was medication adherence. Results Perceptions of generic medicines were significantly more negative at 2 than at 6 months (1.10, 95% CI 0.41 to 1.79, p=0.002). Female sex (-4.21, 95% CI -6.75 to -1.71, p=0.001), older age (-0.12, 95% CI -0.23 to -0.02, p=0.020), lower education level (overall p<0.001), ethnicity (overall p=0.002), Norwegian nationality (10.27, 95% CI 8.19 to 12.40, p<0.001) and reduced self-reported health status (0.19, 95% CI 0.09 to 0.41, p=0.003) were significantly associated with negative perceptions of generic medicines. There was no evidence to suggest that perceptions of generic medicines moderate the association between sociodemographic and clinical variables and medication adherence (p >= 0.077 for all covariates). Moreover, self-reported medication adherence was high, with 99% scoring at or above the Medication Adherence Report Scale midpoint at both time points. There were no substantial correlations between negative perceptions of generic medicines and medication non-adherence at 2 months (r=0.041, 95% CI 0.002 to 0.081, p=0.037) or 6 months (r=0.038, 95% CI -0.005 to 0.081, p=0.057). Conclusions Mistrust and uncertainty about the safety and efficacy of generic medicines remains in a sizeable proportion of patients after PCI. This applies especially to those of lower socioeconomic status, older age, female sex, immigrants and those with poorer mental health. However, this study demonstrated a shift towards more positive perceptions of generic medicines in the longer term.

Aims The arrival of anti-vascular endothelial growth factor (anti-VEGF) therapies represented a treatment shift for several ophthalmological disorders and led to an increasing number of patients undergoing intravitreal injections. The aims of this observational study were to assess the expansion of anti-VEGF intravitreal injections in the Portuguese National Health System (NHS) and to identify factors correlated with geographical variations in episode rates.

Methods Administrative database on discharge from Portuguese NHS hospitals was analysed for annual values and rates of intravitreal anti-VEGF injections at a national and regional level, between 2013 and 2018.

Results The number of episodes of anti-VEGF treatment and patients treated increased 16% and 9% per year, respectively, between 2013 and 2018. During the study period around 72% of patients were treated in the Metropolitan areas of Lisbon and Porto and in the Central region. Intravitreal anti-VEGF treatment rates in 2018 were 560 per 100 000 population and presented high variability between municipalities. Higher anti-VEGF treatment rates at the municipality level were associated with shorter distances between their residence and the hospital. At the hospital level, higher ratio of ophthalmologists and higher organisational level were associated with higher anti-VEGF treatment rates.

Conclusion The number of episodes and patients treated with anti-VEGF injections has been growing in recent years. Proximity to healthcare, more access to ophthalmologists and hospitals with higher organisational levels are associated with higher anti-VEGF treatment rates. Improving access is crucial to reduce regional discrepancies and ensure optimal treatment frequency, which may improve health outcomes.

Objectives: The International Cancer Benchmarking Partnership (ICBP) is a collaboration between 6 countries and 12 jurisdictions with similar primary care-led health services. This study investigates primary care physician (PCP) behaviour and systems that may contribute to the timeliness of investigating for cancer and subsequently, international survival differences. Design: A validated survey administered to PCPs via the internet set out in two parts: direct questions on primary care structure and practice relating to cancer diagnosis, and clinical vignettes, assessing management of scenarios relating to the diagnosis of lung, colorectal or ovarian cancer. Participants: 2795 PCPs in 11 jurisdictions: New South Wales and Victoria (Australia), British Columbia, Manitoba, Ontario (Canada), England, Northern Ireland, Wales (UK), Denmark, Norway and Sweden. Primary and secondary outcome measures: Analysis compared the cumulative proportion of PCPs in each jurisdiction opting to investigate or refer at each phase for each vignette with 1-year survival, and conditional 5-year survival rates for the relevant cancer and jurisdiction. Logistic regression was used to explore whether PCP characteristics or system differences in each jurisdiction affected the readiness to investigate. Results: 4 of 5 vignettes showed a statistically significant correlation (p<0.05 or better) between readiness to investigate or refer to secondary care at the first phase of each vignette and cancer survival rates for that jurisdiction. No consistent associations were found between readiness to investigate and selected PCP demographics, practice or health system variables. Conclusions: We demonstrate a correlation between the readiness of PCPs to investigate symptoms indicative of cancer and cancer survival rates, one of the first possible explanations for the variation in cancer survival between ICBP countries. No specific health system features consistently explained these findings. Some jurisdictions may consider lowering thresholds for PCPs to investigate for cancer-either directly, or by specialist referral, to improve outcomes.

Objectives The aim was to describe the strengths and weaknesses, from team member perspectives, of working with the Global Trigger Tool (GTT) method of retrospective record review to identify adverse events causing patient harm.

Design A qualitative, descriptive approach with focus group interviews using content analysis.

Setting 5 Swedish hospitals in 2011.

Participants 5 GTT teams, with 5 physicians and 11 registered nurses.

Intervention 5 focus group interviews were carried out with the five teams. Interviews were taped and transcribed verbatim.

Results 8 categories emerged relating to the strengths and weaknesses of the GTT method. The categories found were: Usefulness of the GTT, Application of the GTT, Triggers, Preventability of harm, Team composition, Team tasks, Team members’ knowledge development and Documentation. Gradually, changes in the methodology were made by the teams, for example, the teams reported how the registered nurses divided up the charts into two sets, each being read respectively. The teams described the method as important and well functioning. Not only the most important, but also the most difficult, was the task of bringing the results back to the clinic. The teams found it easier to discuss findings at their own clinics.

Conclusions The GTT method functions well for identifying adverse events and is strengthened by its adaptability to different specialties. However, small, gradual methodological changes together with continuingly developed expertise and adaption to looking at harm from a patient's perspective may contribute to large differences in assessment over time.

Objective Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare.

Design A study using retrospective record review and trigger tool methodology. setting and methods Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 prede ned triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed. Primary and secondary outcome measures The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs.

results The patients were aged 20–79 years, 280 men and 320 women. The review teams identi ed 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers.

conclusions AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies. 

Objective Sport and scholastic factors are known to be associated with cigarette smoking in adolescence, but little is known about the causality of this association. The aim of this study was to prospectively explore the relationships of different sport and scholastic factors with smoking prevalence initiation in older adolescents from Bosnia and Herzegovina.

Methods In this 2-year prospective cohort study, there were 872 adolescent participants (16 years at baseline; 46% females). The study consisted of baseline tests at the beginning of the third year (September 2013) and follow-up at the end of the fourth year of high school (late May to early June 2015). The independent variables were scholastic and sport-related factors. The dependent variables were (1) smoking at baseline, (2) smoking at follow-up and (3) smoking initiation over the course of the study. Logistic regressions controlling for age, gender and socioeconomic status were applied to define the relationships between independent and dependent variables.

Results School absence at the baseline study was a significant predictor of smoking initiation during the course of the study (OR 1.4, 95% CI 1.1 to 1.8). Those who reported quitting sports at baseline showed an increased risk of smoking at the end of the study (OR 1.4, 95% CI 1.1 to 2.0) and of smoking initiation (OR 1.8, 95% CI 1.3 to 2.0). Adolescents who reported lower competitive achievements in sport were at a higher risk of (1) smoking at baseline (OR 1.5, 95% CI 1.1 to 2.1), (2) smoking at follow-up (OR 1.5, 95% CI 1.1 to 2.1) and (3) smoking initiation (OR 1.6, 95% CI 1.1 to 2.6).

Conclusions In developing accurate antismoking public health policies for older adolescents, the most vulnerable groups should be targeted. The results showed that most participants initiated smoking before 16 years of age. Therefore, further investigations should evaluate the predictors of smoking in younger ages.