To neutrally offer or strongly recommend? General practitioners' perspectives on screening for gestational diabetes according to the national guideline in Norway.

OBJECTIVE: To explore general practitioners' experiences and reflections on how the current Norwegian guideline for screening for gestational diabetes affects their clinical practice. DESIGN: A qualitive study in which data were collected through semi-structured focus group interviews and analyzed thematically. SETTING AND SUBJECTS: Five focus groups conducted in 2020 among GPs in Norway; three interviews took place face-to-face and two were held digitally. The total number of participants was 31. RESULTS: GPs acknowledged the potential benefits of more extensive screening, but had concerns about the medicalization of pregnancy, stating that some women experienced considerable anxiety. The GPs expressed doubts about the guideline's evidence base but differed in how they interpreted what the guideline was asking them to do. Some offered eligible women the opportunity to be screened, while other set up a screening appointment without consulting the women first. For some, fear of incrimination made them recommend screening without being convinced that it was the right thing for the patient. CONCLUSIONS: It is unclear whether the guideline for gestational diabetes requires GPs to recommend screening to pregnant women or if they should provide neutral information about the availability of screening. This ambiguity should be addressed, and the guideline evaluated against the core principles of general practice.

The Norwegian guideline for gestational diabetes (2017) increased the proportion of pregnant women eligible for screening and spurred considerable debate.The GPs in this study expressed concerns about the lack of evidence and the consequences of screening more women for gestational diabetes.It is unclear to GPs whether they are required to recommend screening to pregnant women or just inform them of its availability.The guideline should be evaluated to better account for the benefits, burdens and costs of screening and any subsequent treatment.

Effect of an Intervention in General Practice to Increase the Participation of Immigrants in Cervical Cancer Screening: A Cluster Randomized Clinical Trial.

Importance: Immigrant women have lower participation in cervical cancer screening (CCS) programs. At the same time, some groups of immigrants have higher prevalence of cervical cancer. Targeted interventions are therefore necessary. Objective: To determine whether an intervention among general practitioners (GPs) could influence immigrant women's participation in the Norwegian CCS program. Design, Setting, and Participants: Cluster-randomized clinical trial using the 20 subdistricts of the Bergen, Norway, municipality as clusters. The clusters were matched in 10 pairs according to the number of immigrant women living in them and randomized thereafter. The intervention was implemented between January and June 2017 among urban, primary care, general practices in Bergen. Follow-up ended in January 2018. General practices belonging to the control areas continued treatment as usual. A total of 10 360 women who attended 73 general practices in the 20 subdistricts were included as participants. Intervention: The intervention consisted of 3 elements: an educational session for GPs at lunch describing the importance of CCS among immigrants and giving advice about how to invite them to participate, a mouse pad as a reminder, and a poster placed in waiting rooms. In the educational session, we elaborated the need for GPs to ask every immigrant woman about CCS, regardless of their reason for contacting their GP. Main Outcomes and Measures: The main outcome, screening status of immigrant women by January 1, 2018, was obtained from the Norwegian Cancer Registry. The effect of the intervention was measured as odds ratio (OR) for CCS status as of January 1, 2018, for the intervention group vs the control group, with 3 levels of adjustments: baseline CCS status at January 1, 2017 (model 1), additional adjustment for women's age, marital status, income level, and region of origin (model 2), and further adjustment for the GP's sex, age, and region of origin (model 3). Two subgroup analyses, screening status at baseline and women's country of origin, were conducted to assess whether these factors had any influence on the effect of the intervention. Data were analyzed as intention to treat. Results: A total of 10 360 immigrant women, 5227 (50.4%; mean [SD] age, 44.0 [12.0] years) in the intervention group and 5133 (49.6%; mean [SD] age, 44.5 [11.6] years) in the control group, belonging to 39 general practices in the intervention area and 34 in the control area, were included in the study. The proportion of immigrant women screened increased by 2.6% in the intervention group and 0.6% in the control group. After adjustment for screening status at baseline, women in the intervention group were more likely to have participated in CCS (OR, 1.24 [95% CI, 1.11-1.38]). This statistically significant effect remained unchanged after adjustment for women's characteristics (OR, 1.24 [95% CI, 1.11-1.38]) and was reduced, but still significant, after further adjustment for GP characteristics (OR, 1.19 [95% CI, 1.06-1.34]). In subgroup analyses, the intervention particularly increased participation among women who were not previously screened at baseline (OR, 1.35 [95% CI, 1.16-1.56]), and those from Poland, Pakistan, and Somalia (OR, 1.74 [95% CI, 1.17-2.61]) when adjusting for baseline screening status. Conclusions and Relevance: Our intervention targeting general practices significantly increased CCS participation among immigrants, although the absolute effect size of 2% in the fully adjusted model was small. Engaging other primary health professionals such as midwives to perform CCS could further contribute to increasing participation. Trial Registration: ClinicalTrials.gov Identifier: NCT03155581.

Cervical cancer screening among immigrant women in Norway- The healthcare providers' perspectives.

OBJECTIVE: To explore health care providers' (HCPs) experiences regarding cervical cancer screening (CCS) among immigrant women, their strategies to facilitate these consultations and their need for further information. DESIGN: Exploratory qualitative design. SETTING: HCPs who perform CCS: general practitioners, midwives and private gynaecologists, working in Oslo, Norway. SUBJECTS: We interviewed 26 general practitioners, 3 midwives and 3 gynaecologists. METHOD: Both focus groups and personal in depth semi structured interviews. Interview transcripts were analysed using a thematic analysis approach. RESULTS: Some of the HCPs' experiences related to CCS were common for all women regardless of their immigrant background, such as the understanding of routines and responsibilities for prevention. Aspects specific for immigrant women were mainly related to organization, language, health literacy levels, culture and gender. Several strategies targeting organizational (longer consultations), language (using interpreters), health literacy (using anatomy models to explain) and culture (dealing with the expression of pain) were reported. Most HCPs had not previously reflected upon specific challenges linked to CCS among immigrant women, thus the interviews were an eye-opener to some extent. HCPs acknowledged that they need more knowledge on immigrant women's' reproductive health. CONCLUSION: HCPs' biases, stereotypes and assumptions could be a key provider-level barrier to low uptake of CCS test among immigrants if they remained unexplored and unchallenged. HCPs need more information on reproductive health of immigrant women in addition to cultural awareness. Key Points The participation rate of immigrant women to cervical cancer screening in Norway is low, compared to non-immigrants. This might be partly attributed to health care system and provider, and not only due to the women's preferences. Our focus groups and interviews among health care providers show, that in addition to cultural competence and awareness, they need knowledge on reproductive health of immigrants. We recommend an intervention targeting health care providers to close the gap in cervical cancer screening.

Primary healthcare usage and morbidity among immigrant children compared with non-immigrant children: a population-based study in Norway.

OBJECTIVES: Health status, disease spectrum and use of healthcare have been reported to vary across groups of migrants and according to the different phases of migration. However, most studies are conducted among adults. This study assesses usage of primary healthcare (PHC) by children with immigrant background compared with non-immigrant children in Norway and describes their relative morbidity burden. DESIGN: Population-based retrospective cohort study. SETTING: This study used 3 linked population-based registers in Norway for children under 18 years of age in 2008. MAIN EXPOSURE AND OUTCOME MEASURES: Immigrants were defined as children with both parents born abroad, and further classified into first and second generation, and according to the World Bank income categories of their parents' country of origin. Usage and morbidity were assessed with negative binomial regression and logistic regression analyses, respectively. Further, population-attributable fraction analyses on PHC visits were conducted to estimate the impact on the primary health system. PARTICIPANTS: 1 168 365 children including 119 251 with immigrant background. RESULTS: The mean number of visits to PHC for non-immigrant children was 1.40 compared with 1.19 for immigrants from high-income countries (HIC) and 1.76 for immigrants from low-income countries (LIC). Compared with non-immigrants, first generation immigrants used PHC significantly less after adjusting for age and sex (incidence risk ratio (IRR) 0.70 (HIC) to 0.93 (LIC)) while second generation immigrant children generally used PHC more (IRR 1.03 (HIC) to 1.43 (LIC)); however, the median number of visits were similar between all groups. The morbidity spectrum also varied between the groups. CONCLUSIONS: Compared with non-immigrants, the excess number of consultations attributable to immigrant groups corresponds to around 1.3% of PHC visits among children.