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Background: The aim of this study was to explore correlation between health locus of control (HLOC) and clinical outcomes in patients with diabetes mellitus type 2 (DMT2). Subject and methods: Cross-sectional study. A multistage, stratified proportional sampling was used to draw a random sample of 46 GPs and, systematic sampling of the first 6 DMT2 patients visiting the chosen GPs with recently registered blood pressure, lipid and glycaemic profile. The patients completed Croatian version of HLOC (ZKL-90-2) and socio-demographic data questionnaires after signing informed consent. Results: DMT2 patients mostly displayed internal HLOC, followed by circumstances, powerful others and chance. Almost all observed objective clinical outcomes, except fasting blood glucose and LDL cholesterol, are in correlation with internal HLOC scale. Correlations were mostly negative. The patients considering themselves to be in command over diabetes obtained the lower scores at total cholesterol (p=0.014), triglycerides (p=0.037), systolic (p=0.003) and diastolic blood pressure (p=0.025). Positive correlation with Es and Eo scales measuring external HLOC was found regarding levels of LDL cholesterol (p=0.032), triglycerides (p=0.009) and systolic (p=0.001) blood pressure. HbA1c (p=0.001). Fasting blood glucose (p=0.002) was higher in patients believing in external circumstances. Conclusion: DMT2 patients who believed they had control over their disease obtained better disease outcomes than those believing in external circumstances., Pozadina: Cilj ovog istraživanja bio je istražiti postoji li povezanost između zdravstvenog lokusa kontrole (ZLK) i kliničkih ishoda u bolesnika sa šećernom bolešću tip 2 (ŠBT2). Ispitanici i metode: Presječno istraživanje. Stratificiranim reprezentativnim slučajnim uzorakovanjem odabrano je 46 liječnika opće/obiteljske medicine koji su potom odabrali prvih 6 bolesnika koji su ih posjetili tijekom perioda istraživanja, a koji su imali nedavno zabilježenu vrijednost arterijskog tlaka, lipidni profil te kratkoročnu i dugoročnu vrijednost vrijednost glukoze. Po davanju informiranog pristanka bolesnici sa ŠBT2 ispunili su hrvatsku verziju upitnika za procjenu zdravstvenog lokusa kontrole (ZKL-90-2) i upitnik o sociodemografskim podacima. Rezultati: U bolesnika sa ŠBT2 većinom je bio izražen unutarnji lokus kontrole, potom je slijedila vjera u okolnosti, moćne druge i utjecaj slučaja. Većina proučavanih objektivnih kliničkih ishoda DMT2, osim glukoze na tašte i LDL kolesterola u korelaciji su sa skalom koja mjeri unutarnji ZLK. Korelacije su većinom negativne, bolesnici koji su imali izražen unutarnji ZLK imali su niže vrijednosti ukupnog kolesterola (p=0.014), triglicerida (p=0.037), sistoličkog (p=0,003) i dijastoličkog (p=0,025) arterijskog tlaka. Utvrđene su pozitivne korelacije skala Es i Eo (koje mjere vanjski ZLK) s razinama: LDL kolesterola (p=0,032), triglicerida (p=0,009) i sistoličkog arterijskog tlaka (p=0,001). Utvrđene su više vrijednosti HbA1c (p=0,001) i glukoze na tašte (p=0,002) u bolesnika koji su imali izreženo vjerovanje u utjecaj okolnosti (vanjski ZLK). Zaključak: Bolesnici sa ŠBT2 koji su imali izražen unutarnji lokus kontrole imali postignute bolje vrijednosti kliničkih ishoda liječenja ŠBT2 u odnosu na bolesnike koji su imali izražen vanjski lokus kontrole.

The specialization in family medicine (FM) was introduced in the academic year 1960/61, but there was an almost 12-year gap in its implementation. Specialized training (ST) was reintroduced in 2003 through the project "Harmonization of family medicine with EU standards introducing a FM specialization". The aim of this paper is not to present all of the developmental phases of the ST curriculum, but to provide accounts of some of the challenging experiences which might be of help to the readers. Experience in several areas is examined: experience in educational need assessment using focus group method; introduction of a new specialist exam; development of the Study Guide, the Trainee Manual, and the Trainer Manual; selection procedure and training of trainers; and skill-lab training and peer-group learning. Systematic evaluation was planned for the next year, when the current project finishes and is to be replaced by another one. The general impression is that ST in FM is perceived as quite challenging, both for the trainees and for the teachers.

It is well known that countries with strong primary care achieve better health outcomes at lower costs. Therefore, the effort of World Health Organization in promoting primary care as a basic principal of successful health care system is an ongoing process. Although Croatia was recognized as a country with primary care orientation due to the development of health centers and introduction of specialist training of general practitioners, it seems that many health care reforms aimed at better organization of health institutions and decreasing of health care costs did not result with higher primary care orientation. By application of the Primary Care Score instrument in 2014 (Croatia received 11.2 out of 20 possible points), and international comparison performed in 2002, it was concluded that among the eighteen OECD countries Croatia could be categorized as an "intermediate primary care country", obtaining the scores just a bit above the average.

Interes za probleme seksualnog zdravlja uvećala je spoznaja da je učestalost te vrste problema daleko veća no što se pretpostavljalo, zapažanje da se bolesne osobe teško odlučuju otvoreno progovoriti o svojim seksualnim tegobama i napredak na planu liječenja seksualnih tegoba. Temeljna podjela seksualnih problema oslonjena je na tijek seksualnog akta i dijeli probleme na one uzrokovane seksualnom željom/motivacijom, te na probleme uzbuđenja i probleme orgazma. Podjela usmjerena na partnere dijeli probleme na one osobne prirode (mogu biti tjelesni i psihički), probleme veza (kontakta i komunikacije), te na probleme proizašle iz pritiska okoline. U dijagnostici seksualnih problema postoje specifičnosti koje su usmjerene na pitanja spolnog identiteta i uloge, hormonalnog funkcioniranja pacijenta, seksualnog iskustava pacijenta, seksualnih navika i znakova zlostavljanja. Paleta terapijskih intervencija u rješavanju seksualnih problema uključujje kirurške, psihološke, medikamentozne i ostale intervencije. Napredak u liječenju erekcijske disfunkcije u muškaraca na medikamentoznom planu privlači posebnu pozornost. U primjeni modernih lijekova za liječenje erekcijske disfunkcije potrebna je dobra upućenost stručnjaka kako bi adekvatno indicirali upotrebu tih lijekova i adekvatno savjetovali pacijente kao lijekove koristiti. Rekreativna upotreba te vrste lijekove nije poželjna niti među ženama niti među muškarcima.

Aims were to explore Health locus of control (LOC)of diabetes mellitus type 2 (DMT2) patients, also in relation to patinets` sociodemographic characteristics (sex, education, working status, and family status), context (place of birth, experience with chronic diseases in family, economy status) and quality of life. Cross sectional study was carried out in 77 DMT2 patients in two Croatian family medicine practices. Patients filled two questionnaires: on patients` general data and questionnaire for evaluation of LOC (ZLK-90-2). Statistic analysis was done using Statistika, version 7.1 statistic program, and values P>0, 05 were considered statistically significant. The patients` average age was 63.4 years +/-13, 1 (M+/-SD), and average duration of DMT2 was 10.3+/-8.2 years(M+/-SD). In patients was mostly expressed believe in internal LOC. On second place was believe in dependence of health on circumstances, than believe in influence of chance, destiny or God, and finally influence of powerful others. Highliy educated patients had statistically significantly less expressed internal LOC and believe in influence of chance, destiny or God. Patients who underestimated their quality of life statistically significantly less believed in dependence of health on circumstances. Statistic significance between other investigated characteristics was not found. Understanding LOC of DMT2 patients are base for developing more effective educative and intervention medical programs for caring those patients, since it could help in making the right access in caring for every single patinet or group of patinets who has the same LOC.

Cilj ovog istraživanja bio je povećanje razumijevanja procesa prilagodbe bolesnika na kroničnu bolest, temeljem istraživanja i opisivanja iskustva bolesnika oboljelih od ŠBT2 ili IM u procesu suočavanja, upoznavanja, prihvaćanja i življenja s ovim kroničnim bolestima, u kontekstu svakodnevnog rada obiteljskog liječnika. Ovo kombinirano kvalitativno i kvantitativno istraživanje (engl. mixed-method research) konceptualizirano je i dizajnirano kao primarno kvalitativno, proceduralne sheme: QUAL+quant, te su i kvalitativni i kvantitativni podaci prikupljeni paralelno u isto vrijeme, sa manjim naglaskom na kvantitativnom dijelu, s ciljem utvrđivanja, konvergiraju li rezultati oba istraživanja u smjeru jednog, zajedničkog razumjevanja istraživanog fenomena. Bolesnici su odabrani metodom namjernog uzorkovanja baziranoj na teoriji (engl. theoretical sampling) koje podrazumijeva tri tipa namjernog uzorkovanja: početno otvoreno, potom aksijalno i završno selektivno, u kojima se fokus uzorkovanja mijenjao prema tipu kodiranja. Uzorkovanje je provedeno paralelno s analizom podataka, do zasićenja kategorija. Istraživanjem je obuhvaćeno 64 bolesnika od kojih 32 bolesnika s registriranom šećernom bolešću tipa 2 (MKB X revizija - E11), i 32 bolesnika s registriranim infarktom miokarda (MKB X revizija - I 21, I22, I23, I24.1 i I25.2). Uzorak ispitanika prikupljen je preko 16 liječnika odabranih slučajnim odabirom iz osnovnog skupa od ukupno 424 liječnika zaposlenih u djelatnosti opće/obiteljske medicine Grada Zagreba, u sva tri Doma zdravlja Grada Zagreba (DZ Zagreb Centar, DZ Zagreb Istok i DZ Zagreb Zapad) (103). U kvalitativnom dijelu istraživanja, metodom problemskog usmjerenog (dubinskog) polustrukturiranog intervjua, prikupljeni su podaci od 64 bolesnika (32 koji boluju od šećerne bolesti tip 2 (ŠBT2) i 32 bolesnika koji su preboljeli infarkt miokarda (IM). Paraleleno s intervjuiranjem, provođena je analiza intervjua vodeći se principima „utemeljene“ teorije (engl. „grounded theory“). U kvantitativnom dijelu istraživanja, kod tih istih bolesnika, standardiziranim upitnicima prikupljeni su podaci o doživljaju bolesti, zdravstvenom lokusu kontrole, zadovoljstvu životom i socijalnoj podršci. U obradi podataka korišteni su: kompjuterski softver Atlas.ti (kvalitativna analiza podataka) i statistički program Statistica, ver. 7.1 (obrada kvantitativnih podataka). Kvalitativnom analizom podataka na principima utemeljene teorije, koji su prikupljeni intervjuiranjem bolesnika oboljelih od ŠBT2 ili IM problemskim, polustrukturiranim dubinskim intervjuom, proizašle su četiri teme vezane uz iskustva bolesnika: 1) bolesnikovo iskustvo prilikom saznanja dijagnoze ili spoznaje da ima ŠBT2 ili IM; 2) bolesnikovo iskustvo s prihvaćanjem ŠBT2 ili IM; 3) bolesnikovo iskustvo sa životnim promjenama uslijed ŠBT2 ili IM; i 4) bolesnikovo iskustvo s čimbenicima koji su utjecali na proces prihvaćanja i tijek življenja sa ŠBT2 ili IM. Utjecaj liječnika pokazao se važnim faktorom olakšanja bolesnikova nošenja s bolešću u svakoj od ovih tema: adekvatnom komunikacijom liječnika (korištenje za bolesnike razumljiva jezika, svjesnost verbalne i neverbalne komunikacije), odnosom liječnika prema bolesniku (uzajamno poštovanje i povjerenje, briga za bolesnika i emocionalna podrška), odnos liječnika prema bolesti (stavom liječnika koji naglašava ozbiljnost bolesti) te pružanje dozirane, strukturirane informacije i edukacije na kontinuiranoj bazi u vremenu po postavljanju dijagnoze, uključujući čest kontakt i postupno proširenje dotadašnjeg fonda bolesnikova znanja o bolesti i liječenju. Kvantitativni rezultati upućuju da je zadovoljstvo života za obje skupine bolesnika (na Thurstonovoj skali od 1-10) prosječno unutar «normale» subjektivne kvalitete života [(bolesnici od IM 6,3±3,0 (M±SD), bolesnici od ŠBT2 6,5±2,4 (M±SD)]. Socijalna podrška za obje skupine bolesnika (na Thurstonovoj skali od 1-10) bila je visoka [1. pitanje: (bolesnici od IM 9,6±1,4 (M±SD), bolesnici od ŠBT2 9,0±2,6 (M±SD)], [2. pitanje: (bolesnici od IM 9,6±1,4 (M±SD), bolesnici od ŠBT2 9,0±2,6 (M±SD)]. Većina bolesnika iz našeg istraživanja imala je izražen unutarnji lokus kontrole zdravlja: (skala I: bolesnici od IM 28,2±2,7 (M±SD), bolesnici od ŠBT2 28,9±2,9 (M±SD). Potom je podjednako bilo izraženo vjerovanje u utjecaj okolnosti i važnih drugih (bolesnici od IM: Eo skala 21,6±3,5 (M±SD), te Evd skala 19,5±2,6 (M±SD); bolesnici od ŠBT2; Evd skala 20,0±4,6 (M±SD), te Eo skala 20,0±3,6 (M±SD). Najmanje je bilo izraženo vjerovanje u utjecaj slučaja, sudbine ili loše sreće (skala Es: bolesnici od IM 14,2±3,4 (M±SD); bolesnici oboljeli od ŠBT2 14,1±4,0 (M±SD). Nije utvrđena statistički značajna razlika između dviju skupina bolesnika u zdravstvenom lokusu kontrole. Procjena doživljaja bolesti, određivanjem prosječnih vrijednosti odgovora bolesnika na linearnoj skali Thurstonova tipa od 0-10, pokazala je visoki skor za skale: trajanje bolesti [bolesnici od IM: 9,4±1,5 (M±SD), bolesnici od ŠBT2: 8,2±3,4 (M±SD)]; kontrola bolesti terapijom [bolesnici od IM: 8,6±1,4 (M±SD), bolesnici od ŠBT2: 8,1±1,9 (M±SD)] i razumijevanje bolesti [bolesnici od IM: 7,5±3,0 (M±SD), bolesnici od ŠBT2: 7,5±2,6 (M±SD)]; a umjereno visokim skale: osobna kontrola nad bolešću [bolesnici od IM 6,6±2,6 (M±SD), bolesnici od ŠBT2: 6,9±2,6 (M±SD) ]; utjecaj na život [bolesnici od IM 6,0±2,8 (M±SD) ], te u bolesnika od IM: zabrinutost za bolest 4,4±3,5 (M±SD), emotivna pogođenost bolešću 5,0±3,1 (M±SD), te jakost simptoma 5,1±3,1 (M±SD). Bolesnici od ŠBT2 procijenili su niskim skale: utjecaj na život 3,7±2,9 (M±SD), zabrinutost za bolest 3,2±3,2 (M±SD), emotivna pogođenost bolešću 3,1±3,5 (M±SD), te identitet bolesti 2,7±2,8 (M±SD). Utvrđena je statistički značajna razlika na skalama utjecaj na život (p=0,004), jakost simptoma (p=0,006) i emotivna pogođenost bolešću (p=0,025) u smjeru doživljaja većeg utjecaja bolesti na život, veće jakosti simptoma i veće emotivne pogođenosti bolešću u bolesnika oboljelih od IM. Bolesnici od IM su u procesu suočavanja, upoznavanja, prihvaćanja i življenja s kroničnom bolešću bili suočeni s većom potrebom za promjenama u dotadašnjem životu, jače pogođeni bolešću, te su se brže prilagođavali na bolest od bolesnika od ŠBT2. Iako su obje bolesti imale kompleksno psihološko značenje i za bolesnike predstavljale psihološki teret tijekom procesa suočavanja, upoznavanja, prihvaćanja i življenja, IM doživljen je kao poštenija „fer bolest“ jer je odmah pokazao svoje simptome, dok je ŠBT2 doživljena kao više „nefer, podmukla bolest“, koja u početku “nema simptoma, a onda te zaskoči s komplikacijama“. Rezultati ovog kombiniranog kvalitativnog i kvantitativnog istraživanja još jednom potvrđuju važnost nalaza literature da osobni, psihološki (emotivni i kognitivni), socijalni i kontekstualni elementi bolesnika igraju važnu ulogu u njegovu zdravstvenom ponašanju, te podržavajući principe bolesniku usmjerene skrbi, potiču zdravstvene profesionalce na istraživanje bolesnikove predodžbe (doživljaja) bolesti kao početne točke za daljnje intervencije ostvarenja preporučenog zdravstvenog ponašanja i optimizacije ishoda liječenja kroničnih bolesnika., The aim of this study was to gain insight into the process of adaptation to chronic illness, based on the investigation and description of diabetes mellitus type 2 (DMT2) patients or myocardial infarction (MI) patients experience, in the process of confrontation, getting acquainted with, accepting and living with those two diseases, in the general practitioner everyday working context. The present mixed-method study was conceptualized and designed as a dominantly qualitative, which is indicated by the following procedural notation: QUAL+quant. That is, both qualitative and quantitative data were collected at the same time, and the primary methodology was qualitative, with a lesser emphasis on the quantitative portion, to determine if the two converge upon a single understanding of the research problem being investigated. The sample was purposeful, based on the method of theoretical sampling, which consisted of three sampling types: initial open coding, than axial coding and final selective coding, with changing of the sampling focus according to the coding type. Sampling process was parallel to data analysis, until the saturation of all categories. 60 subjects were enrolled in study, 30 DMT2 patients and 30 MI patients. In qualitative part of the study, using method of the structured depth interviewing, data on 60 patients experience with their chronic illness were gathered (30 DMT2 and 30 MI patients). In the quantitative part of the study, using standardized questionnaires, data on illness perception, health locus of control, life satisfaction and social support were gathered. The qualitative results were analyzed, parallel to interviewing and based on the principles of grounded theory, using the qualitative data analysis and research software ATLAS.ti, while the quantitative results were analyzed using descriptive nonparametric statistical procedures due to the fact that distributions of all relevant quantitative variables showed a significant decline from normal distribution (Kruskal-Wallis test, Wilcoxson-Mann- Whitney test) Four themes emerged from the qualitative data: patients experience while confronting the diagnosis of DMT2 or MI; patients experience during process of accepting DMT2 or MI; patients experience with DMT2 or MI related life changes; and patients experience with factors influencing process of accepting and life with DMT2 or MI. Quantitative results showed that, for both groups of patients, quality of life was average within an “normal” of subjective quality of life [(MI patients 6.3±3.0 (M±SD), DMT2 patients 6.5±2.4 (M±SD)], while social support was high (MI patients 9.6±1.4 (M±SD), DMT2 patients 9.0±2.6 (M±SD)]. In both groups of patients was mostly expressed believe in internal LOC [(I scale: MI patients 28.2±2.7 (M±SD); DMT2 patients 28.9±2.9 (M±SD)]. Than it was equally expressed believe in dependence of health on circumstances [(Eo scale: MI patients 21.6±3.5 (M±SD); DMT2 patients 20.0±3.6 (M±SD)], and influence of powerful others [(Evd scale IM patients 19.5±2.6 (M±SD); DMT2 patients 20.0±4.6 (M±SD)]. Least of all patients believe in influence of chance, destiny or god [(Es scale: MI patients 14.2±3.4 (M±SD); DMT2 patients 14.1±4.0 (M±SD)]. The patients’ illness perception assessment on an 11-point (0 to10) scale showed the highest median scores±standard deviation: “timeline” (MI patients: 9.4±1.5, DMT2 patients: 8.2±3.4), “treatment control” (MI patients: 8.6±1.4, DMT2 patients: 8.1±1.9), and for “understanding” (MI patients: 7.5±3.0 DMT2 patients: 7.5±2.6), followed by: “personal control” (MI patients 6.6±2.6, DMT2 patients: 6.9±2.6), “consequences” (MI patients 6.0±2.8), and for MI patients: “concern” (4.4±3.5), “emotional response”(5.0±3.1), and “identity” (5.1±3.1). DMT2 patients assessed following scales low: “consequences” (3.7±2.9), “concern” (3.2±3.2), “emotional response”(3.1±3.5), “identity” (2.7±2.8). MI patients assessed significantly higher scales “consequences” (p=0.004), “identity” (p=0.006) and “concern” (p=0.025) than DMT2 patients. MI patients were in the process of confrontation, getting acquainted with, accepting and living with chronic illness faced with need for greater changes in their life (qualitative results), more affected with illness [qualitative results + quantitative results (identity, consequences, concern)], and adjusted faster to their illness than DMT2 patients [qualitative results + quantitative results (identity, consequences, concern)]. Although, both illnesses had complex psychological meaning and for both groups of patients played psychological burden during processes of confronting, getting acquainted with, accepting and living with those two illnesses, MI was perceived as more „fair“ illness since it instantly shows its symptoms, while DMT2 was perceived more „unfair, perfidious“illness, which in the beginning doesn’t show its symptoms, but after some time “it ambush patient with complications“. Results of this mixed/method research once again confirm the importance of the literature finding that patient personal, psychological (emotive and cognitive), social and contextual factors play important role in patients health behavior, and supporting the principles of patient centered care, encourage the health professionals on the investigation of patient illness perception as a starting point for further intervention in order to accomplish recommended heath behavior and optimization of chronic patients treatment outcomes.