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Background: Over the past decades, reorganizations and structural changes in Swedish primary care have affected time utilization among health care professionals. Consequently, increases in administrative tasks have substantially reduced the time available for face-to-face consultations. This study examined how work-time was utilized and the association between work time utilization and the perceived psychosocial work environment in Swedish primary care settings. Methods: This descriptive, multicentre, cross-sectional study was performed in 2014-2015. Data collection began with questionnaire. In the first section, respondents were asked to estimate how their workload was distributed between patients (direct and indirect patient work) and other work tasks. The questionnaire also comprised the Copenhagen Psychosocial Questionnaire, which assessed the psychosocial work environment. Next a time study was conducted where the participants reported their work-time based on three main categories: direct patient-related work, indirect patient-related work, and other work tasks. Each main category had a number of subcategories. The participants recorded the time spent (minutes) on each work task per hour, every day, for two separate weeks. Eleven primary care centres located in southeast Sweden participated. All professionals were asked to participate (n = 441), including registered nurses, primary care physicians, care administrators, nurse assistants, and allied professionals. Response rates were 75% and 79% for the questionnaires and the time study, respectively. Results: All health professionals allocated between 30.9% - 37.2% of their work-time to each main category: direct patient work, indirect patient work, and other work. All professionals estimated a higher proportion of time spent in direct patient work than they reported in the time study. Physicians scored highest on the psychosocial scales of quantitative demands, stress, and role conflicts. Among allied professionals, the proportion of work-time spent on administrative tasks was associated with more role conflicts. Younger staff perceived more adverse working conditions than older staff. Conclusions: This study indicated that Swedish primary care staff spent a limited proportion of their work time directly with patients. PCPs seemed to perceive their work environment in negative terms to a greater extent than other staff members. This study showed that work task allocations influenced the perceived psychosocial work environment. ; Funding Agencies|Medical Research Council of Southeast Sweden; Sodertorn University Sweden

Background In primary care, the diagnosis of pneumonia is often based on history and clinical examination alone. However, a previous study showed that the general practitioners degree of suspicion correlates well with findings on chest X-ray, when the C-reactive protein (CRP) value is known. Objectives The present study aimed to investigate to what extent the physicians degree of suspicion is affected by the CRP level when community-acquired pneumonia is suspected in primary care. Methods A prospective observational study was conducted at five primary health care centres in Sweden between October 2015 and December 2017. Adult patients (n = 266) consulting their health care centre with symptoms of lower respiratory tract infection, where the physician suspected pneumonia, were included consecutively. Anamnestic information and findings from clinical examination were documented in a case report form. All patients were tested for CRP. The physicians rated their degree of suspicion as unsure, quite sure, and sure before and after the CRP result. Results The degree of suspicion of pneumonia changed in 69% of the cases; most often to a lower degree (40%). In 28% of the cases, there was no longer any suspicion of pneumonia after CRP. Conclusion Our results indicate that CRP testing highly influences the physicians degree of suspicion of pneumonia in primary care and that it seems to be of most value when not sure of the diagnosis. ; Funding Agencies|Medical Research Council of Southeast Sweden

Background Health care in many countries entails long waiting times. Avoidable healthcare visits by young adults have been identified as one probable cause. Objective The aim of this study was to explore healthcare providers experiences and opinions about young adults healthcare utilisation in the first line of care. Method This study used latent qualitative conventional content analysis with focus groups. Four healthcare units participated: two primary healthcare centres and two emergency departments. This study included 36 participants, with 4-7 participants in each group, and a total of 21 registered nurses and 15 doctors. All interviews followed an interview guide. Results Data were divided into eight categories, which all contained the implicit theme of distribution of responsibility between the healthcare provider and the healthcare user. Young adult healthcare consumers were considered to be highly influenced by external resources, often greatly concerned with small/vague symptoms they had difficulty explaining and unable to wait with. The healthcare providers role was much perceived as being part of a healthcare structure-a large organisation with multiple units-and having to meet different priorities while also considering ethical dilemmas, though feeling supported by experience. Conclusion Healthcare personnel view young adults as transferring too much of the responsibility of staying healthy to the healthcare system. The results of this study show that the discussion of young adults unnecessarily seeking health care includes an underlying discussion of scarcity of resources. Patient or Public Contribution The conduct of this study is based on interviews with young adult patients about their experiences of seeking healthcare. ; Funding Agencies|Region Ostergotland [LIO-720671]; Forskningsradet i Sydostra Sverige [FORSS-749601]

Introduction: In many low- and middle-income countries emergency care is provided anywhere in the health system; however, no studies to date have looked at which providers are chosen by patients with perceived emergencies. Ecuador has universal health coverage that includes emergency care. However, earlier research indicates that patients with emergencies tend to seek private care. Our primary research questions were these: What is the scope of perceived emergencies?; What is their nature?; and What is the related healthcare-seeking behavior? Secondary objectives were to study determinants of healthcare-seeking behavior, compare health expenditure with expenditure from the past ordinary illness, and measure the prevalence of catastrophic health expenditure related to perceived emergencies. Methods: We conducted a cross-sectional survey of 210 households in a rural region of northwestern Ecuador. The households were sampled with two-stage cluster sampling and represent an estimated 20% of the households in the region. We used two structured, pretested questionnaires. The first questionnaire collected demographic and economic household data, expenditure data on the past ordinary illness, and presented our definition of perceived emergency. The second recorded the number of emergency events, symptoms, further case description, healthcare-seeking behavior, and health expenditure, which was defined as being catastrophic when it exceeded 40% of a household´s ability to pay. Results: The response rate was 85% with a total of 74 reported emergency events during the past year (90/1,000 inhabitants). We further analyzed the most recent event in each household (n=54). Private, for-profit providers, including traditional healers, were chosen by 57.4% (95% confidence interval [CI] [44-71%]). Public providers treated one third of the cases. The mean health expenditure per event was $305.30 United States dollars (USD), compared to $135.80 USD for the past ordinary illnesses. Catastrophic health expenditure was found in 24.4% of households. Conclusion: Our findings suggest that the provision of free health services may not be sufficient to reach universal health coverage for patients with perceived emergencies. Changes in the organization of public emergency departments and improved financial protection for emergency patients may improve the situation.

Background: Non-governmental organizations (NGOs) have a key role in improving health in low-and middle-income countries. Their work needs to be synergistic, complementary to public services, and rooted in community mobilization and collective action. The study explores how an NGO and its health services are perceived by the population that it serves, and how it can contribute to reducing barriers to care. Design: A qualitative exploratory study was conducted in remote Ecuador, characterized by its widespread poverty and lack of official governance. An international NGO collaborated closely with the public services to deliver preventative and curative health services. Data were collected using focus group discussions and semistructured interviews with purposively sampled community members, healthcare personnel, and community health workers based on their links to the health services. Conventional qualitative content analysis was used, focusing on manifest content. Results: Emerging themes relate to the public private partnership (PPP), the NGO and its services, and community participation. The population perceives the NGO positively, linking it to healthcare improvements. Their priority is to get services, irrespective of the providers structure. The presence of an NGO in the operation may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively. Conclusions: To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the populations trust in the organization, an NGO should operate in a manner that is as integrated as possible within the existing structure. The NGO should work close to the population it serves, with services anchored in the community. PPP parties should develop a common platform with joint messages to the target population on the providers structure, and regarding partners roles and responsibilities. Interaction between the population and the providers on service content and their expectations is key to positive outcomes of PPP operations. ; Funding Agencies|Karolinska Institutet; Linkoping University; Ecuador

In 2008, Ecuador underwent a major health reform with the aim of universal coverage. Little is known about the implementation of the reform and its perceived effects in rural parts of the country. The aim of this study was to explore the perceived effects of the 2008 health reform implementation, on rural primary health care services and financial access of the rural poor. A qualitative study using focus group discussions was conducted in a rural region in Ecuador, involving health staff, local health committee members, village leaders, and community health workers. Qualitative content analysis focusing on the manifest content was applied. Three categories emerged from the texts: (1) the prereform situation, which was described as difficult in terms of financial access and quality of care; (2) the reform process, which was perceived as top-down and lacking in communication by the involved actors; lack of interest among the population was reported; (3) the effects of the reform, which were mainly perceived as positive. However, testimonies about understaffing, drug shortages, and access problems for those living furthest away from the health units show that the reform has not fully achieved its intended effects. New problems are a challenging health information system and people without genuine care needs overusing the health services. The results indicate that the Ecuadorean reform has improved rural primary health care services. Still, the reform faces challenges that need continued attention to secure its current achievements and advance the health system further. ; Funding Agencies|Centre for General Practice and Primary Health Care, County Council of Ostergotland, Sweden; County Council of Ostergotland, Sweden

High-redox potential laccases are powerful biocatalysts with a wide range of applications in biotechnology. We have converted a thermostable laccase from a white-rot fungus into a blood tolerant laccase. Adapting the fitness of this laccase to the specific composition of human blood (above neutral pH, high chloride concentration) required several generations of directed evolution in a surrogate complex blood medium. Our evolved laccase was tested in both human plasma and blood, displaying catalytic activity while retaining a high redox potential at the T1 copper site. Mutations introduced in the second coordination sphere of the T1 site shifted the pH activity profile and drastically reduced the inhibitory effect of chloride. This proof of concept that laccases can be adapted to function in extreme conditions opens an array of opportunities for implantable nanobiodevices, chemical syntheses, and detoxification. ; This study was based upon work funded by EU Projects (NMP4-SL-2009-229255-3D-Nanobiodevice, FP7-KBBE-2010-4-26537-Peroxicats and COST Action CM0701) and a project from the Spanish Government (BIO2010-19697). D.M.M. was supported by a JAE grant and D.G.P. was supported by a Peroxicats contract. M.P. received support from the 2009 Ramón y Cajal programme of the Spanish MINECO. ; Peer reviewed