# Innovative Technologies and Methods in General Practice: Selected Abstracts from the 97th EGPRN Meeting, Prague, Czech Republic, 12–15 October 2023: All abstracts of the conference can be found at the EGPRN website https://www.egprn.org/page/conference-abstracts

## TL;DR

The paper discusses how modern technologies are transforming general practice, focusing on innovations like point-of-care diagnostics, digital communication, and AI-based systems to improve care delivery and address challenges in primary healthcare.

## Contribution

The paper introduces new approaches in general practice, including the use of AI, digital triage systems, and biomarker tests, while highlighting the need for research on their clinical validity and impact.

## Key findings

- Point-of-care ultrasound and IT applications are increasingly used in primary care.
- AI-based decision support systems and biomarker tests show promise but require clinical validation.
- Primary care in the Czech Republic is growing, but research and multidisciplinary teamwork remain underdeveloped.

## Abstract

The theme reflects the advent of modern technologies into general practice, which to a large extent change diagnostic procedures, the way of working and communicating, both with patients and within the health care system. For example, the Czech Republic has become a European leader in using Point-of-care Technologies (POCT) in Primary Care. The arsenal of instrumental diagnostic technology is developing. In addition to cardiovascular and pulmonary diagnostics, sonographic examination has been recently performed in the Point-of-Care Ultrasound (POCUS) regime. Various solutions in IT applications and communication systems, both with patients and within the healthcare system, are also gaining importance. Remote medicine is emerging. These changes are coming very quickly now, and they are not all evaluated in terms of their actual contribution to improving patients’ and doctors´ satisfaction and safety, quality of care, or cost-effectiveness. In this area, there is both space and need for research in primary care. Innovative methods include new ways doctors organise their practice and approaches managing their patients´ problems. Benefits or risks of a team/shared practice vs. single practice can be the field of research focus. The Czech Republic is characterised by a predominance of single practices in which independent doctors operate. The Europe-wide trend towards the development of team practices is difficult to apply here. There is a shortage of non-medical staff, and it is more difficult to set up multidisciplinary teams. One example of an inspiring innovation in the competence of a Czech GP is the reimbursement of a psychosomatic intervention provided by GPs with psychosomatic training, including self-reflection and supervision. Its cost-effectiveness needs to be evaluated. General Practice in the Czech Republic is developing successfully. Its importance has grown even more after the COVID-19 pandemic, and it is one of the most frequent career choices for medical students. Both professional and scientific organisations have a strong position and academic workplaces of general practice are also developing. However, primary care research still needs to be strengthened. Tradition, experience, methodological background and institutional support are lacking., The situation has improved in recent years, thanks to international and interdisciplinary cooperation and some successful local projects. We believe that the ERGPRN conference in Prague will hasten further development of research in primary care in the Czech Republic.

Healthcare systems around the world are under pressure. Due to the ageing of the population, societal changes and increasing socio-economic inequity, the demand for health care steadily increases. As a result, health expenditures are rising and the healthcare workforce is getting more and more under pressure. Primary care is needed now more than ever. However, primary care is also under pressure because of the ever-increasing demand. In many countries GPs can hardly cope and waiting times for primary care consultation are increasing. As in other healthcare sectors, primary care will not manage to respond to future challenges with the available workforce. Fundamental changes are needed to keep general practice future-proof. Better patient information about when to see their GP. Delegation of tasks to nurses and practice assistants for low complex problems. Possibilities for direct specialist consultation in primary care. In addition, technical innovations in practice organisation and care delivery are needed to balance demand better and available resources in primary care. These technical solutions cover a broad field. Online patient information websites and platforms can adequately answer health questions of the patient, making consultation unnecessary. Discriminating websites with high-quality health information from those of commercially inspired providers proves very difficult for the average patient. Licencing by the government or endorsing by professional primary care organisations may be the solution. Technical innovations in practice organisation may improve the efficiency of primary care delivery. Digital or app-based triage systems positioned as a first response in the practice may better guide the patient to the appropriate primary care deliverer. AI-based digital systems may in future even replace the GP in case of low-risk problems. Web-based platforms can facilitate digital patient consultation and create and provide efficient routeing for low-threshold specialist consultation. Newly developed biomarker tests may improve the quality of primary care by more effectively diagnosing or excluding disease. Calprotectin for IBD, CRP for infectious disease, biomarkers for cardiac ischaemia, and possibly tests for circulating free DNA for early cancer detection. The key challenge is that though many tests may effectively diagnose disease in the lab, the true clinical value is determined by the false positive and negative test result rate. Unfortunately, this balance is unknown for many tests, and less favourable for many others. Artificial intelligence algorithms are being developed that improve identification of patient groups at high risk or facilitate early detection. Routine care data-based algorithms are used to determine elderly patients with an increased risk of frailty. Natural language processing-based analysis of routine primary care text data is being developed for early cancer detection or to demonstrate an increased cancer risk at an earlier stage. Once their validity is demonstrated, these algorithms are translated into decision support systems and integrated into primary care records. The GP can be alerted to an increased cancer or cardiovascular risk during the consultation. Clinical application of these systems faces major practical and ethical challenges. In summary, technical solutions answer the challenges that general practice faces. They should be used to support the GP, not to replace him. High-quality digital information provision is probably one of the most effective innovations to reduce workloads. Promising future in-practice innovations, such as biomarkers and AI-based decision support systems need careful clinical validation before large-scale implementation.

Trustworthy guidelines need reliable methods. The state-of-the-art methods for developing trustworthy guidelines in 2023 are based on the methodology developed by the Grading of Recommendations Assessment, Development and Evaluation (short GRADE) working group (WG). GRADE WG started in the year 2000 as an informal collaboration of people interested in addressing the shortcomings of grading systems in healthcare. GRADE WG is evolving and cultivating GRADE methodology as there are to date 35 GRADE guidance papers and more than 60 GRADE-related publications developed by members of GRADE WG. The lecture will introduce some innovative methods developed in recent years within the guidelines field.

Ukraine lacks state breast and cervical cancer screening programmes, which can contribute to the underestimation and overlooked of cancer screening. The ongoing war has led both doctors and population to prioritise managing acute and chronic diseases rather than screening. In 2022, the detection of breast cancer through screening methods decreased from 36.9% to 28.8%, and cervical cancer from 37.9% to 24.2%, according to the Ukrainian national cancer registry.

How much does GPs’ provision of personalised information about cervical and breast cancer screening affect internally displaced women’s (IDPW) intentions to be screened?

A validated questionnaire will assess readiness for breast and cervical cancer screening of IDPW (aged 21–74). Participants will be randomly assigned to 2 groups: 1. Group A (receive motivation consulting sessions from GPs and personal intended screening plan developed by designed web-based program ‘Screening Advisor’); 2. Group B (receive standard GP consultation sessions and screening educational materials). Both groups’ screening readiness will be reassessed, allowing for comparison and evaluation of the interventions’ impact. After one month, the performance rate will be estimated: number of participants who have undergone suggested screening.

We seek to investigate if personalised screening recommendations suggested by ‘Screening Advisor’ have a different effect on readiness and performance than handling screening educational materials after the GP’s consultation about screening.

Finding ways to increase readiness and performance of breast and cervical cancer screening is crucial for Ukrainian IDPW to prevent late diagnosis, treatment delays, and mortality during war crisis.

Practice-based research networks (PBRNs) are research infrastructures established to overcome hurdles associated with clinical studies in primary care. PBRNs have been successfully set up in the UK, Netherlands, USA, Ireland, Canada and Australia. In Norway, 5.5 million inhabitants have access to a GP through a patient list system, and 70% visit their GP at least once a year. We have established a nationwide PBRN based on research-oriented GP practices and an innovative IT solution.

We aim to describe the establishment, organisation, function and outcomes of PraksisNett - The Norwegian Primary Care Research Network.

We briefly describe the conception, institutional cooperation and funding process that enabled us to set up the network. We then focus on how the projects are conducted, including evaluation and approval by the PBRN staff and practical implementation in the GPs’ offices. Finally, we present the network outcomes so far.

Our PBRN comprises two parts: a human infrastructure (employees, including academic GPs) organised as four regional nodes and a coordinating node, and an IT infrastructure based on a secure multiparty computation protocol. This enables computing on distributed data without ever exposing or moving it. For a given research Project, the system can easily calculate the number of eligible patients and generate recruitment lists at each GP site. The core of the infrastructure is 90 general practices contractually linked to PraksisNett. These include almost 500 GPs, serving around 500,000 patients. Twenty studies are either completed or ongoing, and 80 have expressed an interest in using the network since its conception.

Our PBRN may serve as a model for other countries wanting to strengthen primary care research. This will benefit both patients, GPs and society in terms of improved quality of care.

Telemedicine, which involves delivering medical care from a distance, has experienced rapid growth due to technological advancements. Physicians’ acceptance of telemedicine plays a crucial role in its long-term adoption. Rogers’ theory of ‘diffusion of innovations’ explains the slow progress of telemedicine. Yet, the COVID-19 pandemic accelerated telemedicine usage pushed Rogers’ curve of innovation adoption to the right (innovators, early adopters, early majority, late majority and laggards). Retail telemedicine, primarily focusing on minor conditions, has gained traction in Swedish primary care since 2016. Furthermore, Sweden is implementing a national digital text platform for asynchronous contacts in 2023.

This study aims to examine the status of telemedicine in primary care and present a conceptual framework for its understanding.

A classic grounded theory approach was employed for data analysis, adhering to the ‘all is data’ principle. The study drew on diverse sources, including primarily secondary literature analysis and multiple interviews with telemedicine caregivers, users and stakeholders, with a specific emphasis on the Swedish context.

Telemedicine is defined as remotely delivered care assisted by digital technology. It offers substantial ‘convenience capital’ to patients, saving working hours, travel costs, and leisure time. However, primary care providers exhibit hesitancy towards telemedicine, perceiving it as having low value with few personal contacts hindering integration into blended care models. After the COVID-19 pandemic surge, telemedicine has lost in volume. To overcome this inertia, technical improvements, regulatory adjustments, and remuneration changes are necessary to integrate telemedicine seamlessly into primary care. Adequate training for primary care providers in telemedicine is crucial to recognise its limitations and advantages, including telework opportunities.

Telemedicine, providing cost and time-saving benefits, is well-received by patients. Nonetheless, its growth has been impeded by primary care providers’ hesitancy. Addressing the mismatch between caregivers and patients is pivotal to ensuring the future success of telemedicine.

Addictive disorders substantially contribute to the global burden of disease. Early detection in primary care is recommended, and numerous screening tests are available. However, barriers to addictive disorder screening exist and the feasibility of using these tests in primary care is unclear.

This study aims to identify available addictive disorder screening tests whose feasibility has been evaluated in primary care

This systematic literature review was performed using Pubmed, PsycINFO, and the Cochrane Library databases. The search strategy included four research topics: addictive disorders, screening, primary care, and feasibility. Selection criteria included published studies evaluating the feasibility of an addictive disorder screening test in primary care. Data were extracted for each included article and each analysed screening test.

Of the 4,911 articles selected, 20 were included and 16 screening tests were studied. Physician feasibility was evaluated with satisfaction questionnaires or qualitative studies, mainly measuring test administration time. Patient feasibility was measured using criteria including ‘ease of use,’ comprehension or format preference. Self-administered formats were preferred, especially electronic versions. Overall, the TAPS (Tobacco, Alcohol, Prescription medication, and other Substance use) tool provides a good balance between ease of use, brevity of administration and more extensive screening for substance use disorders.

Feasibility appears to be a set of heterogeneous criteria relating to users, including comprehension or satisfaction, and practical aspects, including administration time or format preference. Given the absence of feasibility study guidelines, the criteria synthesised in this review could serve as a basis for screening test feasibility studies in primary care.

General practitioners (GPs) often struggle with the diagnostic uncertainty of distinguishing functional gastrointestinal disorders (FGID) from organic disorders in children with chronic gastrointestinal symptoms. It is essential to limit referrals of children with FGID while not missing organic disorders such as inflammatory bowel disease (IBD). Faecal calprotectin (FCal) testing may be useful as it can safely rule out IBD.

This study evaluates whether FCal testing can reduce referral rates to paediatric specialist care.

Dutch GP practices were randomly assigned to an intervention or control group in a pragmatic clustered randomised controlled trial. The intervention group received online training about the indication, interpretation, follow-up and communication of FCal testing and used it at their discretion. The control group followed Dutch GP guidelines that do not recommend the test. The primary outcome was the referral rate to paediatric care within six months. GPs enrolled children aged 4–18 with chronic abdominal pain and/or diarrhoea, aiming to recruit 406 children. Participants were not blinded to the intervention but researchers were blinded during statistical analysis. We used multilevel logistic regression on both an intention-to-treat and per-protocol basis.

Between 01-10-2019 and 01-07-2021, 40 GP practices were assigned to the intervention group and 44 to the control group enrolling 203 and 202 children, respectively. Alarm symptoms were more frequently documented in the intervention (26.6%) than in the control group (8.9%), while the referral rates were similar (22.8 vs 21.9%, adjusted OR 0.94; 95% CI 0.57–1.54). In the per-protocol analysis,a we found a reduction in referral rates (5.8 vs 20.3%, adjusted OR 0.21; 95% CI 0.09–0.50).

Our results do not support the routine use of faecal calprotectin in primary care until the reasons why GPs did not adhere to the recommendations given in the online training are known.

Lifestyle receives increasing attention in primary care of cancer survivors. However, little is known about how to implement lifestyle programmes in general practice and the related barriers and facilitators successfully.

What are the barriers and facilitators to implementing a physical activity (PA) programme for cancer survivors in general practice from the perspective of general practitioners (GPs) and practice nurses?

A qualitative study using data from multiple sources collected during the implementation of the PA programme: field notes, interviews with GPs, and a focus-group with participating practice nurses. We used thematic analyses proposed by Braun & Clarke and two researchers performed inductive coding. All data was collected in Atlas.ti.

We collected field notes of all GP practices that initially participated (n = 20), and interviewed three GPs and seven practice nurses from six GP practices who continued participation, and two GPs and two practice nurses from three GP practices who quit participation. Barriers to implementation were organisational issues, low commitment of the GP and practice nurse, negative experiences with participating patients, and an undefined patient group. Facilitators were collaboration within the team, a motivated practice nurse and experienced patient benefits. Strategies to address the barriers included embedding consultations within regular clinical practice, combining consultations, enabling practice nurses to share their experiences with peers, defining patient group and technical support for digital problems.

The most important barriers and facilitators from GPs’ and practice nurses’ perspectives on the implementation of a PA programme for cancer survivors in GP practice relate to the organisation domain and patient experiences. This qualitative study results can be used to improve future implementation of lifestyle programmes in primary care.

Maternal and child health is a priority for the health system of Tajikistan. However, significant challenges remain, such as limited access to quality antenatal and intranatal care, family planning, and emergency obstetric care. In addition, there is a high rate of premature births and iron and nutrient deficiencies.

To assess the effectiveness of Quality Committees as an innovative technology in improving the quality and availability of services at the PHC level.

A comparative assessment of the main indicators on maternal and child health was conducted before and after 5 years of activity of the QCs in 12 pilot districts of Khatlon region with a population of about 1 million people.

The analysis showed that the QCs effectively improved the quality of services. The proportion of women who made four or more antenatal visits during the last pregnancy increased significantly from 56% in 2016 to 86% in 2019. The number of pregnant women receiving nutrition counselling also increased, from 16.3 thousand in 2016 to 51.5 thousand in 2019. The proportion of children aged 6–23 months who are not breastfed and receiving minimally acceptable nutrition significantly increased between 2016 and 2019, from 16% to 53%. The proportion of women who have reached a minimum level of dietary diversity reached 90% compared to 71% in control communities that are not pilot districts.

The activities of the Quality Committees at the level of PHC institutions in the districts have improved the indicators of antenatal care and early childhood nutrition through internal monitoring, continuous education of doctors and nurses at the District and Rural Health Centres, as well as Health Houses on maternal and child health issues.

Online symptom checkers and digital triage tools are part of a current effort to better assist patients in their healthcare-seeking behaviour. Compliance, in particular, requires a more solid evidence-based approach, with limited evidence currently focusing on intention to comply, rather than quantifying the direct impact on patients’ decision-making.

RQ1: How compliant are people with the advice given by a digital self-triage tool? RQ1.1: How do patient, urgency, disease, and triage characteristics influence compliance?RQ2: To what degree do intention to comply and compliance correlate?

A prospective longitudinal observational study was designed as a proof of concept in which an online triage tool was integrated into a GPC website. Routine registration data of the triage system was linked to a second dataset from ICAREdata, containing anonymous patient data from unplannable care systems. Algorithmic data-matching visualised the patient flow through the healthcare system (n = 398). A structured questionnaire gaged the patient’s intention pre- and post-advice, the impact of triage on care-seeking behaviour and underlying motivational drivers (n = 99). These results were matched to compare intention to subsequent action.

Overall, 67.3% complied with the advice given, which increased to 77% for those receiving non-urgent triage advice (U5). Compliance was associated with utilisation in the weekend v. weeknight (OR 2.9 95% CI 1.3–3.9, p < 0.002). 97% of survey respondents believed they required a doctor prior to triage. After utilisation, 88.9% indicated they intended to comply, yet in 26.8% of cases observed, behaviour differed from their stated intention.

Patient adherence to triage advice is generally high for the studied tool and in line with current evidence. There is considerable discrepancy between patient behaviour and their declared intention, warranting caution when using the latter as a proximal outcome. Future research on compliance should be of relevant scale and scope and be performed within the tools’ intended setting.

The inverse care law, proposed by Julian Tudor Hart in 1971, states ‘the availability of good medical care tends to vary inversely with the need for it in the population served.’ Tudor Hart held that this law operates in both socioeconomically deprived and/or geographically remote settings. Modern computing methods facilitate analysis and mapping of large datasets, which can be used to test such hypotheses.

This study examines the inverse care law and resilience of differing areas in Ireland’s Midwest to GP clinic closure.

All GP clinic locations in Ireland’s Midwest counties Limerick and Clare, were identified. Administrative boundaries (Small Areas (SAs)) were identified from open data resources and divided into six levels of rurality. The direct linear distance from the centre of each SA to its respective closest GP clinic was measured. Simulated ‘closing’ of each GP clinic was done using a computer programme, which removed practices sequentially from the overall dataset before re-calculating all distances.

GP clinics (n = 112) were mapped across 1,287 SAs. As expected, GP clinics cluster in more urban areas. Most SAs in Co. Clare (63%) and Co. Limerick (66%) are rural. Rural SAs had significantly longer travel distances to GP clinics than urban SAs, and these distances increase further as distance from an urban centre increases. Due to the sparseness of GP clinics in rural locations, simulated closure of GP clinics revealed increasing travel distance to the next closest clinic with increasing level of rurality, in a stepwise fashion (r2 = 0.31).

Due to a lack of alternative GP clinic supply, rural communities are more adversely affected by local GP clinic closure. Our methods are replicable and may encourage policymakers to focus on ensuring rural general practice is supported.Keywords Rural medicine; healthcare access; health equity; rural and remote; primary care; general practitioner; health informatics

Population-based studies on reasons for non-participation in diabetes self-management education (DSME) are scarce in the literature.

1) What socio-demographic and disease-related factors are associated with participation in DSME? 2) What are the reasons contributing to the decision to decline participation in DSME?

We analysed data from the ‘Disease knowledge and information needs – Diabetes Mellitus 2017’ survey, a nationwide population-based survey. In the last 12 months, 1,396 participants reported having diabetes mellitus (DM). Of these, 394 had never attended DSME, while 1,002 had participated in a DSME at some point. To address the research questions, we performed weighted logistic or multinominal regression analyses, using both bivariate and multivariable approaches. Furthermore, we considered beliefs and information about diabetes of participants as well as socio-economic variables as confounding variables, using subscales from the Risk Perception Survey-Diabetes Mellitus, the IPQ-R, and the DAWN-2 questionnaire.

Study participants were significantly more likely to attend DSME if they had a medium to high level of education versus low educational level (OR 1.82 [95% 1.21–2.73], OR 2.04 [95%CI 1.30–3.21], respectively), had type 1 DM versus type 2 DM (OR 2.46 [95% 1.24–4.90]), and insulin treatment compared with non-insulin treatment (OR 1.96 [95%CI 1.33–2.90]). Study participants were significantly less likely to attend DSME if they lived in eastern Germany (OR 0.57 [95% CI 0.39–0.83]), disagreed that DM was a lifelong disease (OR 0.30 [95% CI [0.15–0.62]), had never been encouraged by their physician to attend a DSME (OR 0.19 [95% CI 0.13–0.27]). The main reasons for not attending DSME was a lack of information or advice (48.6%), followed by personal perception that DSME was not necessary (26.6%).

Hypertension is a major public health problem and its proper diagnosis and treatment are crucial to reduce cardiovascular morbidity and mortality.

The new Hungarian Hypertension Registry aimed to evaluate the features of blood pressure measurement practice of family physicians and hypertension care specialists and to register the blood pressure values measured during everyday practice.

Omron M3 IT devices were distributed for four months to family physician practices and hypertension outpatient clinics between October 2018 and April 2023. Blood pressure data was transmitted online from the cuff of the monitors to the central database using the Medistance system of Omron.

Family physicians (n = 2,385), internists (n = 988) and cardiologists (n = 232) participated in the study. During 10 four-month long evaluation periods altogether, 4.804821 blood pressure measurements were registered. The daily average number of measurements in the ten periods was between 3.0 and 5.6. Following the ESH diagnostic criteria, the proportion of subjects in optimal, normal and high-normal blood pressure categories were 14%, 13.4% and 16.7%, respectively. Altogether 56% of the measurements belonged to stage 1, 2 and 3 hypertension categories (31.6%, 17.1% and 7.4%, respectively). The average systolic blood pressure values in family physician practices with more than 2,500 patients were higher than those with less than 1,500 patients (141.8 mmHg versus 139.84 mmHg, respectively).

The low daily average number of blood pressure measurements refers to the limited blood pressure screening capacity of the Hungarian family physicians. In practices with more patients, the blood pressure is generally less controlled. These results suggest the need to reconsider the blood pressure measurement guidelines and further promote home blood pressure measurements.

A multifactorial intervention programme was tested to reduce hip fracture risk in a high-risk group of Swedish women.

Could reduced hip fracture incidence and mortality be observed during 20 years after a fracture prevention programme?

A total of 295 women, selected from a population-based cohort of 1,248 women aged 70–100, were recruited for a controlled intervention study in 2001 with follow-up in 2004. The 295 women had high hip fracture risk with at least two of the following risk factors: age ≥ 80 years, body weight ≤ 60 kg, prior fragility fracture, and fall the previous year. The intervention group of 103 women were offered exercise at home and in the group, home hazard reduction and pharmacological treatment. A control group of 192 women received treatment as usual. Risk factors including up-rise ability were assessed 2001 and 2004 and incident hip fractures were derived from radiology records 2002–2021. Survival analyses and standard statistics were performed.

Between 2001 and 2004, there was a decline in up-rise ability among controls compared to the intervention group (136 to 117 out of 192 vs. 67 to 69 out of 103, p < 0.001). By 2004, improved up-rise ability was more common in intervention group than in controls among those with impaired up-rise ability in 2001 (12 out of 36 vs. 5 out of 56, p < 0.001). Up-rise ability at baseline was associated with a longer time to first hip fracture or death only for the intervention group (Kaplan-Meier, log-rank 4.0, p < 0.05; adjusted Cox regression analysis HR = 0.4; CI 0.1–0.9, p < 0.05).

Self-reported up-rise ability decreased in controls compared to the intervention group, in a multifactorial intervention for 295 women at high hip fracture risk between 2001 and 2004. Only women in the intervention group with up-rise ability at baseline 2001 had a longer time to first hip fracture or death at follow-up 2021.

Adolescence is the transition from childhood to adulthood, with significant changes in all spheres of life. This period is characterised by concerns such as school performance, low self-esteem, sexuality, self-image, social relationships with great repercussions on emotions and behaviours.

To detect the main emotional and behavioural problems in adolescents.

The cross-sectional study was conducted in adolescents aged 16–18 from the Mos Secondary School (Galicia, Spain). Emotional and behavioural problems were measured with the validated questionnaire Child and Adolescent Assessment System (SENA), a self-administered scale (scale 1= ‘never’ to 5 =’always’), voluntary and anonymous.This scale includes socio-demographic variables and other subscales: scales of control (inconsistency, negative impression and positive impression), scales of internalised problems (depression, anxiety, social anxiety, somatic complaints, post-traumatic symptomatology, obsession-compulsion), scales of externalised problems (attention problems, hyperactivity-impulsivity, anger control problem, aggression, defiant behaviour, antisocial behaviour), scales of other types of specific problems (eating behaviour problems, schizotypy, substance use), scales of contextual problems (family problems, problems with school, problems with peers), scales of vulnerabilities (emotional regulation problems, sensation seeking) and scales of personal resource problems (self-esteem, social integration and competence, awareness of problems) that identify different indicators of each of the emotional or behavioural disorders.

In the study, 147 participants (women 64.1%, men 35.9%) were included. Internalised problems were twice as prevalent in females (depression 57%, anxiety 53.8%, social anxiety 44.1%, somatic complaints 65.6%, post-traumatic symptomatology 54.8% and obsessive-compulsive 49.5%). Eating behaviour problems (43%), emotional regulation (49.5%) and self-esteem (52.7%), are more prevalent in general and twice as frequent in the female sex, according to statistical significance (α < 0.05).

Depression and anxiety are identified as the most prevalent problems among the study population. Internalised problems are more prevalent in the female sex. The direct relationship between self-esteem and eating behaviour problems stands out, mainly in the female sex.

Primary care healthcare workers (PCW) have been one of the groups most affected by long COVID-19. Self-perceived disability is critical in assessing the disease burden in terms of its impact on quality of life (QoL) and occupational activity.

How do PCW perceive the impact on their health status and QoL resulting from long COVID-19?

An observational, descriptive, multicentre study was conducted using an ad hoc online questionnaire (cross-sectional survey with self-report questionnaire). Data was collected on quality of life, perceived health status, disabling symptoms, and sick leave of healthcare workers with persistent symptoms at least eight weeks after testing positive for SARS-CoV-2. A 10-point Likert scale (0–10) assessed self-perceived disability and quality of life impairment (0 no impact; 10 maximum impact). A descriptive analysis of the study variables was performed. Confidence intervals (CI) of 95% were calculated.

A total of 573 women (median age 50; IQR 42, 54) and 116 men (median age 46; IQR 40, 51) responded. Participants reported a mean perceived disability value of 7.0 (IQR 5, 8) and QoL of 8 (IQR 7, 9), with no significant differences between men and women. The most frequent disabling symptoms were fatigue (86.2%, CI 83.4 to 88.6%), lack of concentration/attention deficit (69.1%, CI 65.6 to 72.4%), mental fog (63.1%, CI 59.5 to 66.7%), muscle pain (61.8%, CI 58.2 to 65.4%), and mental confusion (60.5%, CI 56.8 to 64.1%). Of the 689 participants, 67.8% (CI 64.2 to 71.2%) reported being or having been on sick leave due to persistent symptoms.

The persistence of symptoms after COVID-19 appears substantially impact the health-related quality of life of PCWs, with a substantial effect on their work productivity.Keywords Healthcare workers; long COVID-19; primary care; quality of life; sick leave.

During the COVID-19 pandemic, the significance of primary health care (PHC) has been assessed using over 40 distinct indicators across Europe. However, a consensus has yet to be reached on the most effective COVID-19 indicators to establish a comprehensive PHC scorecard for European health authorities. This study aims to create a scorecard to enhance policy decision-making in future European health crisis scenarios.

Which PHC indicators are most relevant for assessing the impact of the pandemic in primary care settings?

In an online Delphi study, 168 primary care and public health specialists were invited to answer the following questions. The survey had 86 items, structured in 11 sections to assess 22 PHC indicators. A Likert scale was used to evaluate the results. In the first round, 117 experts participated and 102 in the second round and achieved a high degree of consensus (results). Data collection took place between December 2022 and April 2023. The consensus was defined as 70% of respondents agreeing or strongly agreeing.

In the first round, 117 experts participated and 102 in the second round and achieved a high degree of consensus. In the first round: Four indicators with disaggregation and periodicity information were accepted. Seven indicators were rejected and 11 went to a second round. In the second round, five indicators were accepted and six were clearly rejected with very low punctuation. The panel finally agreed to select nine PHC indicators with a disaggregation at the regional and national level mainly and a weekly periodicity, which may change to daily in pandemic periods. Variability was found in the portfolio of services across countries.

This study contributes to identifying a minimum set of indicators to consider primary care activity for decision-making to epidemic and pandemic situations of COVID-19 and other respiratory infections.

Efforts to control the spread and impact of the COVID-19 pandemic have primarily focused on widespread vaccination campaigns. However, factors beyond vaccine availability are crucial in determining individuals’ willingness to be vaccinated.

This study aims to investigate the knowledge, attitudes, and perceptions in a Greek island community regarding COVID-19 vaccination. Additionally, it seeks to determine the vaccination rate, the rate of vaccine refusal and identify factors influencing vaccination decision-making.

We conducted a cross-sectional study involving 202 adult participants in Crete during September-October 2021. Data collection was carried out through an online questionnaire. The questionnaire covered socio-demographic information and explored participants’ vaccination status, factors influencing acceptance or reluctance, perceptions of vaccine safety, and more.

Among the participants, 73.3% (n = 148) had received the COVID-19 vaccine, while 26.7% (n = 54) remained unvaccinated at the time of the study. Reasons for vaccine refusal included mainly concerns about side effects and doubts regarding vaccine safety. Approximately 42.6% believed vaccines offered protection against COVID-19 infections and 42.2% perceived them safe. Moreover, 59.4% of participants felt well-informed about vaccination. Concerning health risks, 36.6% believed vaccines posed a significant danger to their health and 25.2% thought they posed some risk. Additionally, 49.2% of participants considered doctors to have a large or significant influence on their vaccination decisions. Multivariable analysis revealed that older age groups were significantly associated with better knowledge and lower perceived health risks from vaccination. Negative attitudes and unfavourable perceptions of COVID-19 vaccines were also significantly associated with being unvaccinated against COVID-19.

The study reveals a relatively high willingness to receive the COVID-19 vaccine. However, negative attitudes and unfavourable perceptions were significant factors contributing to vaccine refusal. These findings emphasise the crucial role of physicians in promoting positive attitudes, improving knowledge, and influencing perceptions regarding COVID-19 vaccination uptake in the general population.

COVID-19 vaccination has substantially altered the course of the pandemic, saving tens of millions of lives globally, and the booster doses are crucial in restoring vaccine effectiveness.

What are the challenges of Vlora citizens during the initiation of the vaccination process? What are the factors that affect this process?

This is a cross-sectional study conducted in Vlora, Albania. Participants were interviewed about their perception of the immunisation process, side effects and the impact of vaccines on their chronic diseases.

The prevalence of continuing the vaccination process was 82%. Covid-19 infection is significantly reduced after each vaccination dose. Pain at the injection site (86.4%), muscle pain (8.5%), tiredness (6.3%), headache (4%), fever (2.8%) and others (10%) were the most reported side effects.

Regardless of side effects and the presence of chronic diseases, most individuals are willing to continue the vaccination process up to the second dose. This decision seems to be significantly impacted by the effectiveness of vaccination in preventing COVID-19 infection, type of administered vaccine and perception that the side effects severity lessens in the booster doses. The vaccination process has high rate of acceptance for the first and second doses. This study found that the participants decided to get further doses depending on the severity of previous side effects experienced and level of protection from COVID-19 infection.

Several studies show a high impact on workers’ mental health and burnout during the COVID-19 pandemic but there’s a dearth of studies assessing the current situation after the end of this pandemic.

To assess the levels of burnout among family doctors in Catalonia, at three different times: two during the COVID-19 pandemic, and the last one after the WHO declared the end of COVID-19 as a health emergency.

Cross-sectional study involving members of a general practitioners’ Catalan Society. A self-administered survey was sent via institutional e-mail. The survey was answered by 499 doctors between June-July 2021 (S1), 454 in March-April 2022 (S2) and 386 in May-June 2023 (S3). Probable burnout was assessed through Maslach Burnout Inventory (MBI) test, which has three independent dimensions: emotional exhaustion (EE), depersonalisation (DP) and personal achievement (PA). Demographic variables were also assessed. A descriptive analysis and a comparison between S1, S2 and S3 results with statistical tests and 95% confidence intervals were performed.

Samples are similar in gender (79% female), age (47 years old) and years in the same workplace (12 years). Regarding MBI dimensions, high level of EE was 67,5% in S1, with a statistically significant decrease in S2 and S3 (56,4% and 58,1% respectively); high levels of DP were 42,7% (S1), 37,0% (S2) and 36,7% (S3); low levels of PA were 29,9% (S1), 30,4% (S2) and 24,2% (S3). Gender (female) and age (younger) were significantly related to higher levels of EE. Working in rural areas was related to lower levels of DP.

High prevalence of burnout is consistent during the three periods, with a slight decrease in S2 and S3. Half of our participants have been suffering from high levels of emotional exhaustion for more than a year.