Academic literature on the topic 'Refugees – Medical care – Canada'

Purpose – Migration is increasing worldwide. health care practitioners must provide care to migrants in a culturally competent manner that is sensitive to cultural, political and economic contexts shaping health and illness. Many studies have provided strong evidence that health providers benefit from training in cross-cultural care. Cultural competence education of medical students during their early learning can begin to address attitudes and responsiveness toward refugees. At Memorial University in Canada, the authors designed “Morning in Refugee Health”, an innovative program in cultural competency training for first year medical students in the Clinical Skills and Ethics course. The purpose of this paper is to discuss these issues. Design/methodology/approach – Here the authors introduce the curriculum and provide the rationale for the specific pedagogical techniques employed, emphasizing the consideration of culture in its relation to political and economic contexts. The authors describe the innovation of training standardized patients (SPs) who are themselves immigrants or refugees. The authors explain how and why the collaboration of community agencies and medical school administration is key to the successful implementation of such a curriculum. Findings – Medical students benefit from early pre-clinical education in refugee health. Specific attention to community context, SP training, small group format, linkages between clinical skills and medical ethics, medical school administrative and community agency support are essential to development and delivery of this curriculum. As a result of the Morning in Refugee Health, students initiated a community medical outreach project for newly arriving refugees. Originality/value – The approach is unique in three ways: integration of training in clinical skills and ethics; training of SPs who are themselves immigrants or refugees; and reflection on the political, economic and cultural contexts shaping health and health care.

ABSTRACTOntario’s Ministry of Health and Long-Term Care released a document in January 2016 regarding medical care of Syrian refugees as an effort to support primary care providers in the care and early assessment of their new patients [1]. The fourteen-page document provides an overview of the transition to Ontario medical care, from the Immigration Medical Examination prior to the refugee’s entry into Canada, to health insurance coverage resources and information [1]. Health care providers may welcome this plethora of informa­tion, but the presence of a language barrier may prove to be the most considerable issue. RÉSUMÉEn janvier 2016, le ministère de la Santé et des Soins de longue durée de l’Ontario a publié un document au sujet des soins médicaux pour les réfugiés syriens, pour appuyer les fournisseurs de soins primaires lorsqu’ils soignent et effectuent l’évaluation initiale de leurs nouveaux patients [1]. Le document de quatorze pages fournit un survol de la transition vers les soins de santé ontariens, allant de l’examen médical aux fins d’immigration précédant l’entrée du réfugié au Canada, à de l’information sur les régimes d’assurance-maladie [1]. Les professionnels de la santé recevront sans doute favorablement cette abondance d’information, mais la présence d’une barrière linguistique pourrait se révéler comme étant le problème le plus substantiel.

Background: Human Immunodeficiency Virus (HIV) prevalence rates in refugee camps are inconclusive in current literature, with some studies highlighting the increased risk of transmission due to poor living conditions and lower levels of education. With the increasing number of refugees from HIV endemic countries, it is important to assess the programs established to support patients upon arrival. Refugees have been reported to have a lower health literacy and face disease-related stigmatization, which must be overcome for the lifelong treatment of HIV. </P><P> Case Presentation: 31-year-old female arrived in Canada as a refugee from Sudan with her 5 children in July of 2017. She was diagnosed with HIV and severe dental carries during her initial medical evaluation and referred to our centre. A lack of social support has resulted in severe psychological stress. The first being stigmatization which has led to her not disclosing the diagnosis to anyone outside her medical care team. Her level of knowledge about HIV is consistent with literature reporting that despite HIV prevention programs in refugee camps, compliance with risk reduction behaviors, especially in females, is low. Lastly, her major concern relates to the cost of living and supporting her children. Conclusion: Assessment of current HIV programs is necessary to recognize and resolve gaps in the system. Focusing on programs which increase both risk reduction behaviors in refugee camps and integration of refugees in a new healthcare system can facilitate an easier transition for patients and aid in the quest for global 90-90-90 targets for HIV.

There are knowledge gaps in our understanding of the development of chronic disease risks in children, especially with regard to the risk differentials experienced by immigrants and refugees. The Healthy Immigrant Children study employed a mixed-methods cross-sectional study design to characterize the health and nutritional status of 300 immigrant and refugee children aged 3–13 years who had been in Canada for less than 5 years. Quantitative data regarding socioeconomic status, food security, physical activity, diet, and bone and body composition and anthropometric measurements were collected. Qualitative data regarding their experiences with accessing health care and their family lifestyle habits were gathered through in-depth interviews with the parents of newcomer children. Many newcomers spoke about their struggles to attain their desired standard of living. Regarding health outcomes, significantly more refugees (23%) had stunted growth when compared with immigrants (5%). Older children, those with better-educated parents, and those who consumed a poorer-quality diet were at a higher risk of being overweight or obese. Sixty percent of refugees and 42% of immigrants had high blood cholesterol. Significant health concerns for refugee children include stunting and high blood cholesterol levels, and emerging trends indicate that older immigrant children from privileged backgrounds in low-income countries may be more at risk of overweight and obesity. A variety of pathways related to their families’ conceptualization of life in Canada and the social structures that limit progress to meeting their goals likely influence the development of health inequity among refugee and immigrant children. Public health initiatives should address these health inequities among newcomer families.

Purpose Between 2012 and 2016, the Government of Canada modified health insurance for refugees and asylum seekers. In Quebec, this resulted in refusals of care and uncertainties about publicly reimbursed services, despite guaranteed coverage for people with this status under the provincial plan. The Chronic Viral Illness Service (CVIS) at the McGill University Health Centre in Montreal continued to provide care to refugees and asylum seekers living with HIV. The purpose of this paper is to explain how and why challenges brought by this policy change could be overcome. Design/methodology/approach A qualitative case study was conducted using interviews with patients and staff members, observation sessions and a review of media, documents and articles. A discussion group validated the interpretation of preliminary results. Findings The CVIS provides patient-centered care through a multidisciplinary team. It collectively responds to medical, social and legal issues specific to refugees. Its organizational culture and expertise explain the sustained provision of care. The team’s empathetic view of patients, anchored in the service’s history, care for men who have sex with men and commitment to human rights, is key. A culture of care developed over time thanks to the commitment of exemplary figures. Because they countered the team’s values, changes in refugee healthcare coverage strengthened the service’s culture of care. However, the healthcare system reform launched in 2014 in Quebec is perceived as jeopardizing the culture of care, as it makes, refugee and asylum-seeker patients a non-lucrative venture for providers. Originality/value This research analyzes the origin of sustained provision of care to refugees and asylum seekers living with HIV through the lens of culture of care. It considers the historical and political contexts in which this culture developed.

Objectives: To examine the relationship between prepregnancy chronic medical conditions (CMCs) and the risk of acute perinatal psychiatric health-care encounters (i.e., psychiatric emergency department visits, hospitalizations) among refugees, nonrefugee immigrants, and long-term residents in Ontario. Methods: We conducted a population-based study of 15- to 49-year-old refugees ( N = 29,189), nonrefugee immigrants ( N = 187,430), and long-term residents ( N = 641,385) with and without CMC in Ontario, Canada, with a singleton live birth in 2005 to 2015 and no treatment for mental illness in the 2 years before pregnancy. Modified Poisson regression was used to estimate the relative risk of a psychiatric emergency department visit or hospitalization from conception until 1 year postpartum among women with versus without CMC, stratified by migrant status. An unstratified model with an interaction term between CMC and migrant status was used to test for multiplicativity of effects. Results: The association between CMC and risk of a psychiatric emergency department visit or hospitalization was stronger among refugees (adjusted relative risk [aRR] = 1.87; 95% confidence interval [CI], 1.36 to 2.58) compared to long-term residents (aRR = 1.39; 95% CI, 1.30 to 1.48; interaction P = 0.047). The strength of the association was no different in nonrefugee immigrants (aRR = 1.26; 95% CI, 1.05 to 1.51) compared to long-term residents (interaction P = 0.45). Conclusion: Our study identifies refugee women with CMC as a high-risk group for acute psychiatric health care in the perinatal period. Preventive psychosocial interventions may be warranted to enhance supportive resources for all women with CMC and, in particular refugee women, to reduce the risk of acute psychiatric health care in the perinatal period.

Introduction The identification and treatment of latent tuberculosis infection (LTBI) among immigrants from high-incidence regions who move to low-incidence countries is generally considered an ineffective strategy because only ≈14% of them comply with the multiple steps of the ‘cascade of care’ and complete treatment. In the Estrie region of Canada, a refugee clinic was opened in 2009. One of its goals is LTBI management. Methods Key components of this intervention included: close collaboration with community organizations, integration within a comprehensive package of medical care for the whole family, timely delivery following arrival, shorter treatment through preferential use of rifampin, and risk-based selection of patients to be treated. Between 2009–2020, 5131 refugees were evaluated. To determine the efficacy and benefit-cost ratio of this intervention, records of refugees seen in 2010–14 (n = 1906) and 2018–19 (n = 1638) were reviewed. Cases of tuberculosis (TB) among our foreign-born population occurring before (1997–2008) and after (2009–2020) setting up the clinic were identified. All costs associated with TB or LTBI were measured. Results Out of 441 patients offered LTBI treatment, 374 (85%) were compliant. Adding other losses, overall compliance was 69%. To prevent one case of TB, 95.1 individuals had to be screened and 11.9 treated, at a cost of $16,056. After discounting, each case of TB averted represented $32,631, for a benefit-cost ratio of 2.03. Among nationals of the 20 countries where refugees came from, incidence of TB decreased from 68.2 (1997–2008) to 26.3 per 100,000 person-years (2009–2020). Incidence among foreign-born persons from all other countries not targeted by the intervention did not change. Conclusions Among refugees settling in our region, 69% completed the LTBI cascade of care, leading to a 61% reduction in TB incidence. This intervention was cost-beneficial. Current defeatism towards LTBI management among immigrants and refugees is misguided. Compliance can be enhanced through simple measures.

Introduction: The number of refugees accepted to Canada grew from 24,600 in 2014 to 46,700 in 2016. Many of these refugees have young families and the number of child refugees has increased accordingly. Although child refugee health care has been in the forefront of media and medical attention recently, there is limited data on injury patterns in this population. Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) collects data on injuries in children presenting to the emergency department (ED). Our objective is to examine the clinical presentations and outcomes of refugee children with injuries presenting to a tertiary care paediatric ED. Methods: Our paediatric hospital has approximately 70,000 ED visits per year of which 13,000 are due to injuries and/or poisonings. The CHIRPP database was accessed to identify children with injuries presenting to our ED from April 2014 to March 2017 with Interim Federal Health Program (IFHP) registration status. All patient charts were reviewed to extract demographic and clinical care information. Results: There were 74 children with 81 ED visits during the study period of whom 19% were transferred from other facilities. Most of them (72%) were males with a mean age of 8.7 years (standard deviation 4.29). There were significant medical histories in 32% of children. The presentation to our ED (greater than 24 hours post-injury) was seen in 25% of visits. Twenty five percent of injured children were seen in our ED. The distribution of Canadian Triage Acuity Score (CTAS) scores 1, 2, 3, 4, and 5 were 0%, 16%, 37%, 46% and 1% respectively. However, subspecialty consultations were required in 69%, 60% and 27% of CTAS 2, 3 and 4 children respectively. Overall, 46% of all patients required subspecialty consults. The top three categories of injuries include fractures (23%), soft tissue injuries (20%) and lacerations (17%). More than half (56%) required diagnostic imaging. Most (89%) were treated in ED and discharged (average length-of-stay 3 hours 55 minutes) and 11% required admissions. 47% of children lacked primary care physicians. Conclusion: Almost half of refugee children with IFHP status require DI testing, sub-specialty consultations and primary care referrals when presenting to our ED with injuries. Follow up arrangements are needed as many do not have access to primary care providers. This demonstrates a need for securing primary care providers early for this vulnerable population.

Background: Despite the overrepresentation of immigrants and refugees (newcomers) in the HIV epidemic in Canada, research on their HIV treatment outcomes is limited. This study addressed this knowledge gap by describing treatment outcomes of newcomers in comparison with Canadian-born persons living with HIV in Manitoba. Methods: Clinical data from 1986 to 2017 were obtained from a cohort of people living with HIV and receiving care from the Manitoba HIV Program. Retrospective cohort analysis of secondary data was completed using univariate and multivariate statistics to compare differences in socio-demographic and clinical characteristics and treatment outcomes among newcomers, Canadian-born Indigenous persons, and Canadian-born non-Indigenous persons on entry into HIV care. Results: By end of 2017, 86 newcomers, 259 Canadian-born Indigenous persons, and 356 Canadian-born non-Indigenous persons were enrolled in the cohort. Newcomers were more likely than Canadian-born Indigenous and non- Indigenous cohort participants to be younger and female and have self-reported HIV risk exposure as heterosexual contact. Average CD4 counts at entry into care did not differ significantly between groups. A higher proportion of newcomers was also diagnosed with tuberculosis within 6 months of entry into care (21%), compared with 6% and 0.6% of Canadian-born Indigenous non-Indigenous persons, respectively. Newcomers and Canadian-born non-Indigenous persons had achieved viral load suppression (< 200 copies/mL) at a similar proportion (93%), compared with 82% of Canadian-born Indigenous participants ( p < 0.05). Conclusions: The distinct demographic and clinical characteristics of newcomers living with HIV requires a focused approach to facilitate earlier diagnosis, engagement, and support in care.

Introduction: In June 2012, the federal government made cuts to the Interim Federal Health (IFH) Program that reduced or eliminated health insurance for refugee claimants in Canada. The purpose of this study was to examine the effect of the cuts on emergency department (ED) use among patients claiming IFH benefits. Methods: We conducted a health records review at two tertiary care EDs in Ottawa. We reviewed all ED visits wherein an IFH claim was made at triage, for 18 months before and 18 months after the changes to the program on June 30, 2012 (2011-2013). Claims made before and after the cuts were compared in terms of basic demographics, chief presenting complaints, acuity, diagnosis, presence of primary care, and financial status of the claim. Results: There were a total of 612 IFH claims made in the ED from 2011-2013. The demographic characteristics, acuity of presentation and discharge diagnosis were similar during both the before and after periods. Overall, 28.6% fewer claims were made under the IFH program after the cuts. Of the claims made, significantly more were rejected after the cuts than before (13.7% after vs. 3.9% before, p<0.05). The majority (75.0%) of rejected claims have not been paid by patients. Fewer patients after the cuts indicated that they had a family physician (20.4% after vs. 30% before, p<0.05) yet a higher proportion of these patients were still advised to follow up with their family doctor during the after period (67.2% after vs. 41.8% before, p<0.05). Conclusion: A higher proportion of both rejected and subsequently unpaid claims after the IFH cuts in June 2012 represents a potential barrier to emergency medical care, as well as a new financial burden to be shouldered by patients and hospitals. A reduction in IFH claims in the ED and a reduction in the number of patients with access to a family physician also suggests inadequate care for this population. Yet, the lack of primary care was not reflected in the follow-up advice offered by ED physicians to patients.

This study examines the importance of age, education, and the health system reforms in the mid 1990's on the utilization of five health services: specialists' visits, family doctor visits, non-physician health professional visits, hospital use, and home care services. The analysis focuses on the Canadians 45 and over, and uses data from the National Population Health Survey.
Results. Age per se has only a minor effect on utilization; the relative high utilization rates observed among the aged relate to the use of services by people with chronic conditions, whose prevalence is higher among the aged. Education has little impact on use of services among the aged. The reforms had only significant effect for four services. They increased utilization of non-medical health professional consults, and increased probability of consulting a specialist. They reduced length of stay, and decreased the number of visits made to family doctors.

Population aging in Canada is expected to result in a sharp increase in the use of health services by the aged. The purpose of this thesis, is to enhance the knowledge of the utilization of the health system by the elderly. For this, an analysis of the utilization of three health services was pursued, using data from two health surveys, and two general social surveys in a statistical examination; to describe age-use; identify the major determinants of utilization; and to discover the sources of change in use. The results show that the aged were the highest users of health services among all age groups. Use increased for some services, and decreased for others. Changes in how people were managed by the health system, and to a lesser extent a rise in disease prevalence, were the primary sources of variations in utilization. There was no conclusive evidence of the presence of supplier induced demand. Population aging was not a significant determinant of changes in health service use, but rather factors associated with the management of the elderly by the health system; this includes technological changes in medicine, and changes in treatment patterns.

Telehealth is defined by Jocelyne Picot as "the use of communications and information technology to deliver health and health care services and information over large and small distances" (Telehealth Industry 1). Current research in telehealth focuses on the evaluation of applications and projects, on the competitiveness of the telehealth industry, and on its role in international development. In contrast, this dissertation contextualizes telehealth in social history and theory. In so doing, it adopts an analytical, cultural studies approach rather than an empirical one. It also studies the extent of citizen involvement in current telehealth initiatives in Canada. More specifically, the dissertation examines whether the forms of involvement promoted by telehealth initiatives empower Canadian citizens. The examination is conducted through a five-step process. The first four steps involve an overview of the following: (1) histories of medical technology; (2) critiques of medical technology; (3) history and critique of the Canadian health care system; (4) critiques of information and communications technology and policy. The fifth step consists in mapping out the current state of telehealth development in Canada, including policy, applications and projects, as well as distinguishing the main roles of citizens in such initiatives. In closing, ways of achieving citizen empowerment through telehealth are suggested, whether it is found to be achieved in recent initiatives or not. Theoretical frameworks with the aim of positioning new technology in order that it may accomplish social change and citizen empowerment are put forward as an innovative means of evaluating current telehealth applications and projects in Canada.

This multi-sited ethnography focuses on beliefs and practices associated with death, dying, and palliative care among the Low German-Speaking (LGS) Mennonites. The qualitative data, collected through participant-observation fieldwork and interviews conducted in three LGS Mennonite communities in Mexico and Canada, show a gap between official definitions of palliative care and its practice in real life. The LGS Mennonites’ care for their dying members, in reality, is integrated into their community lives that emphasize or reinforce discipleship by promoting the practices of mutual aid, social networks, and brotherhood/sisterhood among community members. This study also offers ethnographic insights into some difficulties that healthcare providers face while delivering the “holistic” palliative care services to their patients in general, and to the LGS Mennonites in particular. Finally, it provides some suggestions that may aid healthcare providers in developing culturally safe and competent health care services for the LGS Mennonite people living in Canada.
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This thesis considers the rationalization of health care in Canada. It focuses on the conflicting roles modern physicians play in our system, acting as both patient advocate and social agent. It begins by tracing the origin of both of these duties. It then examines the ethical, professional, and legal issues which arise in the limited circumstances where front-line physicians must participate in the rationing of health care. It offers a framework for resolving the double agent dilemma and states five interlocking recommendations which are the building blocks of the resolution.

A number of theoretical explanations seek to describe the factors that have led to the position of the United States as the last industrialized Western nation without a universal health care program. Theories focus on institutional arrangement, historic precedent, and the influence of the private sector and market forces. This study explores another factor: the role of underlying social values. The research examines differences in values among ten European countries, the United States and Canada, and analyzes the associations between the values that have been seen to contribute the individualism-collectivism dynamic in the United States. The hypothesis that equality and generalized trust are positively associated with universalism is only partially true. Equality is positively associated (B = .301, p < .001), while generalized trust is negatively associated with universalism (B = -.052, p < .001). Not only do Americans show lower levels of support for income equality and universalism than Europeans, but the effect of being American holds even after controlling for socio-demographic and religious variables (B = .044, p < .01). When the model tests the association of equality and trust on universalism in each region, it explains approximately 17 percent of the variance of universalism for the United States, and approximately 13 percent in Europe and Canada.

Les services reproductifs transfrontaliers (SRT) réfèrent au déplacement d'une juridiction à une autre, de personnes ou de matériel reproductif dans le cadre d'un projet de procréation assistée (PA). Ce phénomène a été observé dans de nombreux pays, mais le système de PA mondialisé canadien, ou reproscape, demeure sous-étudié. Ce manque de connaissances nuit au développement normatif en matière de PA. En adoptant un cadre conceptuel issu de l'anthropologie médicale, l'objectif général de cette thèse était de décrire et comprendre le reproscape canadien. Pour alimenter la réflexion éthique et juridique et la prestation des services de PA, nous avons réalisé une enquête ethnographique clinique multisite combinant : (1) une revue de la littérature, (2) l'observation participante et non participante de deux cliniques de fertilité (Québec et Ontario), d'une agence d'importation de gamètes et d'une dizaine de congrès scientifiques, ainsi que (3) des entrevues semi-dirigées avec 45 actrices et acteurs des SRT : personnes utilisatrices, personnel médical et intermédiaires. Les données ont fait l'objet d'une analyse qualitative inductive, assistée du logiciel NVivo 11. Trois dimensions émergent de nos résultats. (1) Le Canada se caractérise par une mosaïque de lois et de règlements locaux, fédéraux et provinciaux qui influencent de façon paradoxale les SRT. L'obligation de don altruiste, établie par la Loi sur la procréation assistée (LPA), joue un rôle prédominant sur le reproscape canadien. (2) Au niveau de l'expérience des SRT, la simplicité de certains SRT intégrés à la pratique clinique, comme l'importation de sperme ou d'ovocytes, contraste avec la complexité des voyages vers l'étranger auxquels les personnes utilisatrices se sentent souvent contraintes. (3) Interrogées sur leurs perspectives éthiques, quatre positions principales ressortent des entrevues: (a) le respect de leur autonomie reproductive, (b) les risques individuels et (c) sociaux des SRT, dont celui d'exploitation des gestatrices et des donneuses d'ovules, ainsi que (d) les incohérences de la LPA quant à sa capacité d'atténuer ces risques. En conclusion, le reproscape canadien se caractérise, entre autres, par une situation de " sous-traitance reproductive " : une reconnaissance institutionnelle des SRT, combinée à une délocalisation des risques moraux et médicaux hors des frontières nationales. Les conclusions de notre étude mettent en évidence le caractère inextricable du local et du global en PA et comment le reproscape mondial fonctionne par vases communicants.
Abstract : Cross-border reproductive care (CBRC) refers to the movement from one jurisdiction to another of persons or reproductive material as part of assisted reproductive technology (ART) treatment. This phenomenon has been observed in many countries, but the Canadian globalized ART system (or "reproscape") remains understudied empirically. This lack of data undermines the normative development in terms of ART. The aim of this dissertation is to describe and understand the Canadian reproscape in order to support ethical and legal reflection. To achieve this goal, we conducted a multi-site clinical ethnography combining (1) literature reviews, (2) participant and non-participant observation in two fertility clinics (Quebec and Ontario), a gamete importation and distribution agency and a dozen scientific congresses, (3) as well as semi-directed interviews with 45 actors of CBRC: users, medical professionals and intermediaries. The data were analyzed by inductive qualitative analysis assisted by NVivo 11 software. Three dimensions emerge from our results. (1) Regarding the legal and clinical contexts of ART, Canada is characterized by a local mosaic of laws and regulations that paradoxically influence CBRC. The altruistic obligation established by the Assisted Human Reproduction Act (AHRA) plays a predominant role on the reproscape. (2) In terms of the experience of the main actors, the simplicity of CBRC integrated to the clinic, such as the import of semen or oocytes, contrasts with the complexity of journeys abroad for which users often feel constrained. (3) When asked about their ethical perspectives, the actors mentioned four main positions: (a) the respect for their reproductive autonomy, (b) the individual and (c) social risks of CBRC, including the exploitation of egg donors as well as gestational surrogates, and (d) AHRA inconsistencies in its ability to mitigate these risks. Our conclusion is that the Canadian reproscape is characterized, inter alia, by a situation of "reproductive outsourcing." This concept is characterized by an institutional recognition of CBRC combined with a relocation of moral and medical risks outside national borders. The results of our study underline the inextricable local and global nature of ART and how CBRC works as communicating vessels.

Syfte: Det övergripande syftet med denna licentiatavhandling är att beskriva resultat från en kartläggning av hälsosituationen hos nyanlända flyktingar som genomgår SFI studier samt att belysa den självskattade hälsorelaterade livskvalitet som arabisktalande deltagare i en specifik hälsofrämjande gruppaktivitet (Hälsoskola) beskriver före, efter samt vid en sexmånaders uppföljning av aktiviteten. Design, metod, urval: Urvalet deltagare i delstudie I var nyanlända arabisktalande flyktingar bosatta i Fosie stadsdel i Malmö och som deltog i SFI utbildning. Undersökningsgruppen bestod av sammanlagt 67 personer, 52 procent män och 48 procent kvinnor. Datainsamlingen genomfördes med hjälp av frågeformulär innehållande frågor om familj och anhöriga, nätverk och service, svenskundervisning och delaktighet, introduktion och hjälpbehov samt om sömn och återhämtning. I delstudie II bestod urvalet av arabisktalande nyanlända flyktingar som genomgick en sju veckors Hälsoskola som en del i sin introduktionsplanering. Dataunderlag bestod av kvalitativa data inhämtat vid deltagande observationer och muntliga grupputvärderingar med 65 kursdeltagare. Därutöver besvarades ett frågeformulär för självskattning av hälsorelaterad livskvalitet samt om sömn och återhämtning. Frågeformuläret besvarades vid kursstart, kursavslutning samt sex månader efter kursens slut. Respondenter i denna del var 39 kursdeltagare som besvarat samtliga tre frågeformulärsomgångar. Därutöver innehåller avhandlingen en artikel vars syfte är att beskriva kursen/metoden Hälsoskola, dess bakgrund och teoretiska kopplingar samt den samverkansprocess som utvecklats mellan professionella aktörer och brukare. Resultat: I delstudie I rapporterade respondenterna hög förekomst av sömn- och trötthetsbesvär. Sextioåtta procent av respondenterna hade sömnproblem motsvarande hälften av veckans dagar. Något färre 43 % rapporterade regelbundna besvär med sömnighet, till exempel att man nickade till under dagen. Fyrtioen procent (män 36 %, kvinnor 50 %) uppfyllde kraven för klinisk insomni baserat på att respondenterna hade både sömnbesvär och trötthetsbesvär under minst hälften av veckans dagar. Därutöver upplevde drygt 80 % av samtliga stor oro över sin familj eller andra anhöriga i hemlandet. Många kände sig isolerade och ensamma, hade svårt att få kontakter med föreningsliv, få tillgång till platser för kulturella aktiviteter, för religionsutövning och för sportaktivitet. Många upplevde också svårighet att få tillgång till hälso- och sjukvård samt tandvård. I utbildningssituationen upplevde drygt hälften stora svårigheter att förstå vad läraren sade och 68 % hade svårt att hinna med i tempot på lektioner. Drygt 64 % rapporterade koncentrationssvårigheter, de hade problem att förstå hemuppgifter liksom att kunna göra hemuppgifter i lugn miljö. För många respondenter rådde oklarhet om introduktionsplanen och cirka hälften av dem hade velat få mera hjälp av sin introduktionshandläggare med läkar- och sjukvårdskontakter samt med sin bostadssituation. I den kvalitativa delen av delstudie II vars syfte var att belysa de viktigaste frågorna från deltagarnas synvinkel, utkristalliserade sig fyra kategorier: 1) Fördjupningsfrågor beträffande innehåll i kursen/Hälsoskolan. 2) Kommentarer angående form och struktur på kursen/Hälsoskolan. 3) Vilka av kursdeltagarnas ”behovsområden” som kursen/Hälsoskolan täcker in och vilka områden som saknas? 4) Vad kursdeltagarna önskar få framfört till administratörer, beslutsfattare och politiker. I den kvantitativa uppföljningsstudien framkom att deltagarna upplevde en hög grad av sömn och koncentrationsproblematik vid kursstart. Denna problematik var betydligt mindre vid kursens avslutning och förändringen kvarstod vid uppföljning sex månader senare. Det framkom även att sömnproblematik var relaterad till de fem variablerna av hälsorelaterad livskvalitet;( rörlighet, aktivitet, egenvård, smärta och oro/depression) och till upplevelsen av det allmänna hälsotillståndet. Angående variablerna smärta och oro/depression kvarstod en signifikant förändring både vid uppföljning ett och vid uppföljning två sex månader efter kursavslut. Både män och kvinnor bedömde sitt allmänna hälsotillstånd som signifikant bättre vid båda uppföljningarna jämfört med vid kursstart, men förändringen var störst beträffande kvinnorna. Konklusion: De sammantagna resultaten visar att det finns en hög fysisk och psykisk ohälsoproblematik i den undersökta populationen med avseende på deras självskattade hälsa. Denna problematik har ett nära samband med sömn och koncentrationsproblem och får även konsekvenser för de nyanländas dagliga aktiviteter och etablering i det nya samhället. Det framkommer ett stort behov av hjälp från hälso- och sjukvården men också en brist på tillit till detsamma, bland annat beroende på svårtillgänglighet och brist på professionella tolkar. Å andra sidan visar resultaten i denna licentiatavhandling att mottagningssystemet med noga överlagda insatser kan åstadkomma betydande positiva förändringar för gruppen nyanlända flyktingar. Den självupplevda hälsorelaterade livskvaliteten för deltagare i kursen Hälsoskola visade på signifikanta förändringar inom de undersökta aspekterna för gruppen som helhet vid kursslut och vid senare uppföljning. De reella faktiska kunskaperna inom egenvård och om det svenska hälso- och sjukvårdssystemet hade ökat betydligt vid kursavslut. Nämnda effekter kan även få positiva följdverkningar för nästa generation och andra personer i kursdeltagarnas nära omgivning.
Aim: The overall aim of this thesis is to describe the results of a survey of the health situation of newly-arrived refugees attending a course in Swedish for Immigrants (SFI) (study I) and elucidate the self-rated health-related quality of life that Arabic-speaking participants in a spe-cific health-promoting group activity (Health School) report before, immediately after and at a six-month follow-up of that activity (study II). Design, method, sample: The sample in study I comprised newly-arrived Arabic-speaking refugees living in the Malmö district of Fosie who were attending a SFI course. A total of 67 persons participated, 52 per cent men, 48 per cent women. Data were collected with the aid of a questionnaire with both open-ended and closed alternative responses about family and relatives, networks and services, Swedish language lessons and participation, introduction and needs, sleep and recovery. In study II the sample comprised newly-arrived Arabic-speaking refu-gees who attended a seven-week Health School as a part of their intro-ductory planning. The study was based on qualitative data obtained by participatory observation and oral group evaluations with 65 course participants. In addition, we used a questionnaire with closed response alternatives for self-rating health-related quality of life, including sleep and recovery. The questionnaire was administered at the beginning and end of the group activity as well as six months after the end. This sam-ple comprised 39 participants in the group activity who responded to the questionnaire on all three occasions. Furthermore, the thesis contains an article describing the Health School group activity/method, its background and theoretical links, as well as the collaborative process that developed between professionals and re-cipients. Results: The respondents in study I reported a high frequency of sleep- and fatigue-related complaints. Sleep disturbances on the equivalent of every other day were reported by 68 per cent and somewhat fewer, 43 per cent, reported regular problems with drowsiness, for instance drop-ping off during the day. Criteria for clinical insomnia were met by 41 per cent (36 per cent of the men, 50 per cent of the women), based on the combination of sleep disturbance and complaints of fatigue at least every other day. In addition, over 80 per cent of the sample experienced great anxiety about their family or other relatives in their home country. Many felt isolated and lonely, found it hard to get in touch with associations, have access to places for cultural activities, practicing religion and participating in sports. Many also experienced difficulties in gaining access to health care and dental care. In the educational situation (SFI), more than half had great difficulty in understanding what the teacher said and 68 per cent found it hard to keep up with the pace of the lessons. More than 64 per cent reported difficulties with concentration, problems with understanding homework and being able to do homework in a calm environment. Many respondents were uncertain about the introductory plan and roughly half had wanted their introductory officer to be more helpful in contacts with health care, including doctors, and housing matters. The qualitative part of study II, which aimed to elucidate the most im-portant issues according to the participants, gave rise to four categories: 1) More in-depth issues concerning the content of the group activi-ty/Health School, 2) Comments on the form and structure of the group activity/Health School, 3) Which of the participants’ “needs” were cov-ered by and which were missing, and 4) What the participants wanted to convey to administrators, decision-makers and politicians. The quantitative follow-up study showed that when the group activity started, the participants experienced a high degree of problems with sleep and concentration. Such problems were considerably less frequent at the end of the activity and this change persisted six months later. Moreover, the sleep disturbances were related both to the five variables of the health-related quality of life (mobility, activity, self-care, pain and anxiety/depression) and to the perception of general health. The variables pain and anxiety/depression showed significant improvements at the end of the activity as well as six months later. Men as well as women rated their general health as significantly improved at both follow-ups compared with baseline; the change was greatest for women. Conclusions: Taken together, the results show that in terms of self-rated health, the studied population has a high degree of problems with physical and mental ill-health. These problems are closely related to problems with sleep and concentration, besides having consequences for the newly-arrived persons’ daily activities and for settling in the host country. A great need of assistance from health care emerges, as well as a lack of trust in this, partly due to difficulty of access and a lack of professional interpreters. At the same time, the findings in this thesis show that the reception sys-tem with evidence-based inputs can achieve considerable positive changes for newly-arrived refugees. The self-rated health-related quality of life for participants in the group activity/Health School showed that for the group as a whole, the studied aspects had improved significantly both by the end of the activity and at the six-month follow-up. Proper actual knowledge about self-care and the Swedish health care system had increased significantly by the end of the activity. These effects can also have positive consequences for the next generation and others close to the participant. The group activity needs to be tested with other language groups of newly-arrived in order to warrant general conclusions.

Sedan flera hundra år tillbaka har människor immigrerat till Sverige. Efterhand har denna invandring mer och mer reglerats genom olika lagar och samarbeten. I Sverige har det så uppstått en grupp av personer som inte är asylsökande och som av olika skäl lever i landet utan uppehållstillstånd. En del av dessa har tidigare sökt asyl men fått avslag, medan andra aldrig sökt asyl. Dessa personer kan inte åtnjuta hälso- och sjukvård på samma villkor som den svenska befolkningen eller ens på de villkor som staten beslutat att asylsökande ska ha rätt till. Den vård gömda flyktingar har rätt till är den vård som klassas som omedelbar. Många gömda flyktingar är dessutom rädda för att söka vård och deras vårdbehov täcks till stor del av ideella organisationers insatser. Som sjuksköterska kan man komma att möta denna patientgrupp i stort sett var man än arbetar och det är då av största vikt att man funderat över sina etiska ställningstaganden och satt sig in i de lagar som är aktuella. I denna uppsats granskas och sammanställes den litteratur som finns att tillgå kring gömda flyktingar och sjukvård. Det sammanställda materialet diskuteras sedan ur en vårdvetenskaplig synvinkel och med hjälp av begreppen livsvärld, hälsa och lidande. Man kan i det valda materialet konstatera att det saknas litteratur skriven med vårdvetenskaplig ansats. I de åtta texterna som granskats har tre fokus hittats; Barns situation, Att leva som gömd flykting samt Hinder och möjligheter för tillgång till vård. Slutligen diskuteras vikten av vårdvetenskaplig forskning på området med mål att underlätta för kliniskt verksamma sjuksköterskor i mötet med denna patientgrupp.

Program: Sjuksköterskeutbildning

Uppsatsnivå: C

AbstractThe Arab World has sadly witnessed protracted conflict affecting several of its regions in recent years. Conflict-affected populations have been significantly impacted by chronic deficiencies in medical care including unprecedented numbers of refugees and migrants requiring ongoing support in neighbouring countries. Humanitarian response to crisis has historically focused on the supply of nutrition, water, and emergent trauma relief, followed by control and prevention of infections. Prevention and management of non-communicable diseases, specifically cancer, have been relatively neglected; however, with regional conflicts lasting for many years, cancer care has become an increasingly urgent issue to be addressed. The humanitarian community has stressed the need for situational assessment regarding disease prevalence and available resources, with identification of specific regional challenges. Lack of infrastructure, important diagnostic and treatment modalities, clinical experts and regulatory bodies are the main obstacles to cancer care at all stages from screening and prevention to therapeutics and palliation. The initial step to improving cancer care provision should be implementing needs-based priority assessment and policies within the context of governing bodies that control and monitor performance. Collaboration and coordination among national and international organizations and stakeholders are essential to improve data collection on which to base resource allocation and address growing disparities in cancer outcomes.

AbstractThis chapter chronicles the organizing efforts of a group of Swedish medical professionals who volunteered on an ad hoc basis to provide health care for refugees in the fall of 2015. We show how different types of resources both enabled and constrained the autonomy of the professionals as they moved under the aegis of established civil society organizations and, as such, became bureaucratized. In the autonomous organizational setting, material resources were central, and professionals negotiated among themselves to establish working norms and guidelines for the acquisition and usage of resources. In the bureaucratized setting, with little to no room for negotiation, human resources were central, and regulations were imposed on the volunteering professionals by the civil society organizations.

While the forced displacement of people from their homes has been described since ancient times, the past half-century has witnessed an expansion in the size of refugee populations of extraordinary numbers. In 1970, for example, there were only 2.5 million refugees receiving international protection, primarily through the United Nations High Commission for Refugees (UNHCR). By 2006, UNHCR was legally responsible for 8.4 million refugees. In addition, it is conservatively estimated that an additional 23.7 million people are displaced within the borders of their own countries. Although similar in characteristics to refugees who have crossed international borders, internally displaced persons do not receive the same protection of international law. Adding all refugee-type persons together, the world is forced to acknowledge the reality that over the past decade more than 10 000 people per day became refugees or internally displaced persons. The sheer magnitude of the global refugee crisis, the resettlement of large numbers of refugees in modern industrial nations such as Canada, the United States, Europe, and Australia, and the increased media attention to civil and ethnic conflict throughout the world has contributed to the medical and mental health issues of refugees becoming an issue of global concern. This chapter will focus on a comprehensive overview of the psychiatric evaluation and treatment of refugees and refugee communities. Although this mental health specialty is in its infancy, many scientific advances have been made that can facilitate the successful psychiatric care of refugee patients.

This chapter examines the ethical issues related to the practice of health care in an environment where human rights are absent, specifically relating to the conditions for refugees and asylum seekers who arrive by sea in Australian territory. The ethical considerations of working within the offshore detention environment are discussed. Health-care workers in these harsh environments often have divided loyalties, when duties to their patients conflict with duties to their employer or to the state. The author draws on published accounts and interviews with health-care providers who have worked on Manus Island and Nauru and Christmas Island, the sites used by Australia for offshore detention of asylum seekers.

Medical errors are a significant public health concern that affects patient care and safety. Highlighted as a substantial problem in the 1999 Institute of Medicine report, medical errors have become the third leading cause of death in the United States of America. Failure to inform the patient of adverse events caused by a medical error compromises patient autonomy. Disclosure of adverse events to patients and families is critical in managing the consequences of a medical error and essential for maintaining patient trust. When errors occur, healthcare practitioners are faced with the ethical and moral dilemmas of if and to whom to disclose the error. Healthcare providers face these disclosure dilemmas across all disciplines, locations, and generations and have far-reaching implications on healthcare quality and the progress of medicine. We have previously reported the Canadian provincial initiatives encouraging open disclosure of adverse events and have suggested its integration into a 'no-fault' model. Though similar in content, the Canadian provincial initiatives remain isolated because of their non-mandatory nature and absence of federal or provincial laws on disclosure. The purpose of this study was to review and compare the disclosure policies implemented by individual health care regions/authorities in various parts of Canada to identify quality issues related to medical error disclosure based on several ethical and professional principles. The complexities of medical error disclosure to patients present ideal opportunities for medical educators to probe how learners balance the moral complexities involved in error disclosure. Effective communication between health care providers, patients, and their families throughout the disclosure process is integral in sustaining and developing the physician-patient relationship. We believe that the disclosure policies can provide a framework and guidelines for appropriate disclosure, leading to more transparent practices. We suggest that disclosure practice can be improved by creating a uniform policy centered on addressing errors in a non-punitive manner and respecting the patient's right to an honest disclosure and be implemented as part of the standard of care.

This project emerges from the need to counteract a scenario of risk and unpredictability in the care provided to patients in illness situations, which stems from a poor or non-existent health record system (HRS). The direct contact in the year of 2017 with an emergency medical Non-Governmental Organization (NGO), working in context of humanitarian crises, demonstrated the precarious and yet scarce presence of such a system. The lack of practicality, easy understanding and access to other health partners proved to compromise the quality of care.Since a functional HRS (via paper or electronic means) is a core component for the management, delivery, and safety of quality in healthcare, the identification of a simple and yet effective system, capable of maintaining a history of care provided, is imperative. This need increases exponentially when the focus is on a humanitarian crisis context, in which populations have been forced into displacement and the health system is disrupted, of which the Internal Displaced Persons in Iraq are an example (commonly referred as refugees). The constraint of resources and the clash of different cultures and experiences between professionals, can hinder or even compromise the provision and quality of care, as well as the experience and perception of patients themselves regarding the services provided.With this study I propose the mapping of a HRS within an emergency medical field hospital, in a refugee camp in Iraq, to ensure the quality of emergency management and delivery of care, in a scenario of instability and political uncertainty. This system, which functions as a systematically collected database, presents specific health characteristics of a given patient when receiving differentiated care essential to guarantee high standards of care.A service design methodology to test the hypothesis will be used through a service blueprint development, capable of mapping the activities, processes and systems involved in a patient's health experience. Design research methods such as service safari and user shadowing with informal ethnographic interviews will be implemented, as well as workshops with national and international health professionals involved with NGO work.Thus, it is expected to re-design a robust monitoring and patient track, with faster access of the patient’s history to health professionals, a better prevention of medication errors and duplication, and a greater transparency in the management and delivery of care. The easy implementation of the system will also allow an easier communication of patient’s needs and care, between different health stakeholders.

Background: Recreational cannabis legalization has become more prevalent over the past decade, with recreational cannabis now legal in 13 U.S. states and nationally in Uruguay, Canada, and Malta. At the same time, there is evidence for increasing rates of cannabis use and consequences from use (i.e., crime and motor vehicle accidents) among some age groups, particularly in North America. Thus, it is crucial to understand the role of recreational legalization on person-level outcomes, such as cannabis consumption and health-outcomes. Previous reviews have focused on outcomes in the U.S., but there remains a need for a broader international evaluation of the effect of legalization. Additionally, there is a dearth of reviews examining recreational cannabis legalization as past literature has focused more attention on medical cannabis legalization. The current review examined the role of recreational cannabis legalization on a variety of person-centered outcomes to understand if the consequences of legalization. Method: A comprehensive systematic review was conducted in accordance with PRISMA guidelines. Inclusion criteria involved: empirical quantitative research, article available in English, a research design evaluating the impact of recreational cannabis legalization (e.g., pre vs. post), and person-level cannabis use, and/or clinical outcomes included as dependent variables (opposed to outcomes such as changes in the price or potency of cannabis). Two individuals independently coded studies for eligibility and extracted information. The search revealed 69 studies that met criteria for inclusion. Results: Our search revealed five main categories of outcomes associated with recreational cannabis legalization: cannabis and substance use behaviors, health-care impacts, attitudes surrounding cannabis, crime-related outcomes, and driving-related outcomes. The studies were predominantly cross-sectional designs and most took place within the U.S. The extant literature revealed inconsistencies surrounding the role of recreational legalization. In the case of cannabis use behaviours, there was mixed evidence for different subpopulations. For example, legalization was associated with increased cannabis use for college samples, but there were inconsistent findings for adolescents. Additionally, some studies pointed towards negative consequences associated with legalization, such as increased cannabis use in clinical populations and increased cannabis-related healthcare visits. Other studies suggested no impact of legalization through either no change in examined outcomes or heterogenous conclusions (e.g., cannabis-related attitudes). Finally, there was also evidence of positive consequences for recreational legalization, such as decreased drug-related arrests and cigarette use. Conclusions: Overall, the balance of research suggests there is no clear support for any large magnitude person-level impact of recreational cannabis legalization. This review indicates that more conclusive evidence regarding the impact of recreational legalization is still required and reveals a need for more longitudinal study designs with longer-term follow-ups as well as studies from a broader range of geographic jurisdictions. As recreational cannabis legalization becomes implemented globally, a systematic evaluation of the outcomes associated with enactment is of increasing relevance.

Overview Skin cancer prevention is a component of the new Cancer Plan 2022–27, which guides the work of the Cancer Institute NSW. To lessen the impact of skin cancer on the community, the Cancer Institute NSW works closely with the NSW Skin Cancer Prevention Advisory Committee, comprising governmental and non-governmental organisation representatives, to develop and implement the NSW Skin Cancer Prevention Strategy. Primary Health Networks and primary care providers are seen as important stakeholders in this work. To guide improvements in skin cancer prevention and inform the development of the next NSW Skin Cancer Prevention Strategy, an up-to-date review of the evidence on the effectiveness and feasibility of skin cancer prevention activities in primary care is required. A research team led by the Daffodil Centre, a joint venture between the University of Sydney and Cancer Council NSW, was contracted to undertake an Evidence Check review to address the questions below. Evidence Check questions This Evidence Check aimed to address the following questions: Question 1: What skin cancer primary prevention activities can be effectively administered in primary care settings? As part of this, identify the key components of such messages, strategies, programs or initiatives that have been effectively implemented and their feasibility in the NSW/Australian context. Question 2: What are the main barriers and enablers for primary care providers in delivering skin cancer primary prevention activities within their setting? Summary of methods The research team conducted a detailed analysis of the published and grey literature, based on a comprehensive search. We developed the search strategy in consultation with a medical librarian at the University of Sydney and the Cancer Institute NSW team, and implemented it across the databases Embase, MEDLINE, PsycInfo, Scopus, Cochrane Central and CINAHL. Results were exported and uploaded to Covidence for screening and further selection. The search strategy was designed according to the SPIDER tool for Qualitative and Mixed-Methods Evidence Synthesis, which is a systematic strategy for searching qualitative and mixed-methods research studies. The SPIDER tool facilitates rigour in research by defining key elements of non-quantitative research questions. We included peer-reviewed and grey literature that included skin cancer primary prevention strategies/ interventions/ techniques/ programs within primary care settings, e.g. involving general practitioners and primary care nurses. The literature was limited to publications since 2014, and for studies or programs conducted in Australia, the UK, New Zealand, Canada, Ireland, Western Europe and Scandinavia. We also included relevant systematic reviews and evidence syntheses based on a range of international evidence where also relevant to the Australian context. To address Question 1, about the effectiveness of skin cancer prevention activities in primary care settings, we summarised findings from the Evidence Check according to different skin cancer prevention activities. To address Question 2, about the barriers and enablers of skin cancer prevention activities in primary care settings, we summarised findings according to the Consolidated Framework for Implementation Research (CFIR). The CFIR is a framework for identifying important implementation considerations for novel interventions in healthcare settings and provides a practical guide for systematically assessing potential barriers and facilitators in preparation for implementing a new activity or program. We assessed study quality using the National Health and Medical Research Council (NHMRC) levels of evidence. Key findings We identified 25 peer-reviewed journal articles that met the eligibility criteria and we included these in the Evidence Check. Eight of the studies were conducted in Australia, six in the UK, and the others elsewhere (mainly other European countries). In addition, the grey literature search identified four relevant guidelines, 12 education/training resources, two Cancer Care pathways, two position statements, three reports and five other resources that we included in the Evidence Check. Question 1 (related to effectiveness) We categorised the studies into different types of skin cancer prevention activities: behavioural counselling (n=3); risk assessment and delivering risk-tailored information (n=10); new technologies for early detection and accompanying prevention advice (n=4); and education and training programs for general practitioners (GPs) and primary care nurses regarding skin cancer prevention (n=3). There was good evidence that behavioural counselling interventions can result in a small improvement in sun protection behaviours among adults with fair skin types (defined as ivory or pale skin, light hair and eye colour, freckles, or those who sunburn easily), which would include the majority of Australians. It was found that clinicians play an important role in counselling patients about sun-protective behaviours, and recommended tailoring messages to the age and demographics of target groups (e.g. high-risk groups) to have maximal influence on behaviours. Several web-based melanoma risk prediction tools are now available in Australia, mainly designed for health professionals to identify patients’ risk of a new or subsequent primary melanoma and guide discussions with patients about primary prevention and early detection. Intervention studies have demonstrated that use of these melanoma risk prediction tools is feasible and acceptable to participants in primary care settings, and there is some evidence, including from Australian studies, that using these risk prediction tools to tailor primary prevention and early detection messages can improve sun-related behaviours. Some studies examined novel technologies, such as apps, to support early detection through skin examinations, including a very limited focus on the provision of preventive advice. These novel technologies are still largely in the research domain rather than recommended for routine use but provide a potential future opportunity to incorporate more primary prevention tailored advice. There are a number of online short courses available for primary healthcare professionals specifically focusing on skin cancer prevention. Most education and training programs for GPs and primary care nurses in the field of skin cancer focus on treatment and early detection, though some programs have specifically incorporated primary prevention education and training. A notable example is the Dermoscopy for Victorian General Practice Program, in which 93% of participating GPs reported that they had increased preventive information provided to high-risk patients and during skin examinations. Question 2 (related to barriers and enablers) Key enablers of performing skin cancer prevention activities in primary care settings included: • Easy access and availability of guidelines and point-of-care tools and resources • A fit with existing workflows and systems, so there is minimal disruption to flow of care • Easy-to-understand patient information • Using the waiting room for collection of risk assessment information on an electronic device such as an iPad/tablet where possible • Pairing with early detection activities • Sharing of successful programs across jurisdictions. Key barriers to performing skin cancer prevention activities in primary care settings included: • Unclear requirements and lack of confidence (self-efficacy) about prevention counselling • Limited availability of GP services especially in regional and remote areas • Competing demands, low priority, lack of time • Lack of incentives.