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Reports on research with four focus groups of 17-year-old girls of different education levels, about their need, expectations, and attitudes concerning contraceptives. Determined: (1) the school physician is not the person they want to seek help from; (2) peer influence is very important; and (3) girls expect confidentiality from their family physician. Discusses obstacles to obtaining contraceptive care. (Author/JDM)

Abstract Background One-tenth of France's population is prescribed at least one antidepressant, primarily by General Practitioners. The reasons for this high prescription rate remain unclear. One-third of these prescriptions may not comply with clinical practice guidelines, and 20% are potentially unrelated to any psychiatric condition. Our aim was to explore how GPs declare they use antidepressants in daily practice and understand their reasons for prescribing them. Method Six focus groups including a total of 56 rural and urban GPs, with four interviews were performed. The topic guide focused on reasons for prescribing antidepressants in various primary care situations. Phenomenological analysis was performed by four researchers. Results Antidepressants were seen as useful and not harmful. Personal assessment based on experience and feeling determined the GPs' decisions rather than the use of scales. Twenty-four "non-psychiatric" conditions possibly leading to prescription of antidepressants in primary care were found. Conclusions The GPs reported prescribing antidepressants for a wide range of conditions other than depression. The GPs' decision making process is difficult and complex. They seemed to prefer to focus on their difficulties in diagnosing depression rather than on useless overtreatment. Instead of using the guidelines criteria to detect potential cases of useful prescription, physicians tend to use their own tools based on gut feelings, knowledge of the patient and contextual issues.

Abstract Background STI surveillance systems are subject to qualitative and quantitative underreporting. General practitioners (GPs), who are key subjects in case reporting, explain their underreporting partly by their observation that taking a sexual history is embarrassing for patients, and that patients are reluctant to disclose information on their sexual practices. In this study we examine patients' willingness to provide data for STI surveillance. Methods A questionnaire-based survey in a stratified population sample of 300 patients aged 18–60 years. Results The large majority of respondents stated to be willing to give information on their sexual practices for the purpose of STI surveillance. They preferred to answer sexual history questions to their GP; filling in a form on the internet was the second best option. Conclusion Based on these results, it is unlikely that the cooperation of patients would be a weak link in STI surveillance strategies. This observation, together with the fact that the majority of patients at risk for STIs have regular access to general practice services, justify renewed efforts to enliven primary care-based STI surveillance strategies.

OBJECTIVE: The introduction of human papillomavirus (HPV) detection in cervical screening will make it necessary to provide appropriate information to the general public. Only 3% of Flemish women could name HPV as the viral agent involved in cervical cancer development. The aim of this study was to investigate whether general practitioners (GPs) have appropriate knowledge of the relationship between HPV and cervical cancer to be able to inform women. METHODS: A questionnaire was developed to measure perception of 20 risk factors for cervical cancer development, on a scale of 1 (unimportant) to 5 (very important). Respondents were also asked to give an estimate of the chances of survival for women, diagnosed with cervical cancer detected by screening. RESULTS: Sixty GPs and 28 trainees filled in the questionnaire. The five most important risk factors in the perception of the respondents were, in order of decreasing importance, viral infection, number of sex partners, sexual behaviour of the partner, unsafe sex, and early start of sexual activity. Fifty-six percent of the GPs expected the chance of survival to be between 80 and 100%, compared to only 31% of the trainees. CONCLUSION: Most GPs are well aware of sexual habits as risk factors for cervical cancer development, including the role of HPV as the viral agent in the etiology. However, they seem to underestimate the role of smoking and are unable to identify the correct chance of survival for women in whom cervical cancer is detected within the frame of the cervical smear program. PRACTICE IMPLICATIONS: Attention should be given to education of medical students and practitioners, in order to allow them to supply patients with sufficient background information to make an informed choice on participating in cervical cancer screening. [ABSTRACT FROM AUTHOR]

Primary Human Papillomavirus (HPV) screening on samples collected by women themselves has proven to be an effective strategy for cervical cancer screening (CCS) and may increase participation rates in women who do not partake (regularly) in screening. The aim of this study is to investigate reasons for non-participation and perceptions of CCS using self-sampling methods among under-screened women in Flanders. Individual interviews with 15 underscreened women aged 30-64 years were conducted. During the interviews, participants were given the opportunity to try out a urine and vaginal self-sampling kit. Thematic analysis was based on Ajzen's model of the Theory of Planned Behavior. The results showed that 14 out of 15 participants were more likely to participate in CCS if they had the option to self-sample. One of the main findings was a lack of knowledge on different aspects of cervical cancer. Most women had a positive attitude toward cancer screening and primary prevention such as HPV vaccination. Subjective norms were influenced by healthcare professionals, peers, and organized government initiatives. Informational, organizational, contextual, and emotional factors were mentioned as barriers as well as facilitators for participation. Additionally, high self-efficacy was considered to make self-sampling more convenient. All women showed the intention to use at least one method of self-sampling. We can conclude that women who do not participate in CCS would be more motivated to participate using self-sampling methods. Adequate education and guidance should be provided.

Background: The clinical general practitioner (GP) workforce is decreasing. Many studies have analysed the negative aspects of the profession but, few examine the positive aspects and job satisfaction. A European collaborative group including 8 participating countries recently conducted a qualitative study to analyse the positive factors and found 31 job satisfaction factors., Objectives: To determine which of these 31 factors are important and applicable to future policies to improve family medicine attractiveness, recruitment, and retention in France., Method: The Delphi consensus method was chosen. Two Delphi rounds were conducted in March-April 2017 and retained satisfaction factors with at least 70% of scores ≥7. The Nominal Group Technique (NGT) was used to rank these retained factors. Participants assigned 5 points to the factor they considered most important, 3 points to the second, and 1 point to the third. Factors receiving at least 5% (10 points) of the total points (198 points) were included in the final list. The expert panel included GPs and non-GPs., Results: Twenty-nine experts began the procedure and 22 completed it. Thirty factors were retained after the 2 Delphi rounds. The NGT resulted in 8 factors: (i) Engage in family medicine to take care of the patients; (ii) Care coordination, patient advocacy; (iii) Flexibility in work; (iv) Trying to be a person-centred doctor; (v) Involvement in healthcare organization; (vi) Benefiting from a well-managed practice; (vii) Being a teacher, a trainer; (viii) Efficient professional collaboration., Conclusion: These 8 job satisfaction factors are important to consider and apply to future policy development., (© The Author(s) 2022. Published by Oxford University Press.)

Childhood-onset Takayasu arteritis (TA) is a rare, heterogeneous disease with limited diagnostic markers. Our objective was to identify and classify all candidates for biomarkers of TA diagnosis in children reported in the literature. A systematic literature review (PRISMA) of MEDLINE, EMBASE, Wiley Cochrane Library, ClinicalTrias.gov, and WHO ICTRP for articles related to TA in the pediatric age group between January 2000 and August 2023 was performed. Data on demographics, clinical features, laboratory measurements, diagnostic imaging, and genetic analysis were extracted. We identified 2026 potential articles, of which 52 studies (81% case series) met inclusion criteria. A total of 1067 TA patients were included with a peak onset between 10 and 15 years. Childhood-onset TA predominantly presented with cardiovascular, constitutional, and neurological symptoms. Laboratory parameters exhibited a low sensitivity and specificity. Imaging predominantly revealed involvement of the abdominal aorta and renal arteries, with magnetic resonance angiography (MRA) being the preferred imaging modality. Our review confirms the heterogeneous presentation of childhood-onset TA, posing significant challenges to recognition and timely diagnosis. Collaborative, multinational efforts are essential to better understand the natural course of childhood-onset TA and to identify accurate biomarkers to enhance diagnosis and disease management, ultimately improving patient outcomes.

Aim: Our aim was to evaluate the implementation process of a comprehensive cardiovascular disease prevention program in general practice, to enhance understanding of influencing factors to implementation success and sustainability, and to learn how to overcome barriers., Background: Cardiovascular disease and its risk factors are the world's leading cause of mortality, yet can be prevented by addressing unhealthy lifestyle behavior. Nevertheless, the transition toward a prevention-oriented primary health care remains limited. A better understanding of factors facilitating or hindering implementation success and sustainability of prevention programs, and how barriers may be addressed, is needed. This work is part of Horizon 2020 project 'SPICES', which aims to implement validated preventive interventions in vulnerable populations., Methods: We conducted a qualitative process evaluation with participatory action research approach of implementation in five general practices. Data were collected through 38 semi-structured individual and small group interviews with seven physicians, 11 nurses, one manager and one nursing assistant, conducted before, during, and after the implementation period. We applied adaptive framework analysis guided by RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) and Consolidated Framework for Implementation Research (CFIR)., Findings: Multiple facilitators and barriers affected reach of vulnerable target populations: adoption by primary health care providers, implementation and fidelity and intention to maintain the program into routine practice. In addition, our study revealed concrete actions, linked to implementation strategies, that can be undertaken to address identified barriers. Prioritization of prevention in general practice vision, ownership, and shared responsibility of all team members, compatibility with existing work processes and systems, expanding nurse's roles and upskilling competence profiles, supportive financial and regulatory frameworks, and a strong community - health care link are crucial to increase implementation success and long-term maintenance of prevention programs. COVID-19 was a major barrier to the implementation. RE-AIM QuEST, CFIR, and participatory strategies are useful to guide implementation of prevention programs in primary health care.

Background: Recent evidence shows that young people started their first alcohol initiation when they were early adolescents (10-14 years of age), while there is still very little scientific understanding concerning the process of alcohol use of this age group. This study examined how adolescents in Thailand emerge to become drinkers. Method: The semi-structured interview with 10-14-year-olds ( n  = 61) in Chonburi, province of Thailand. Data were collected, and analysis followed the method of content analysis. Results: Our analyzes revealed three steps of alcohol initiation among early adolescents: (a) the pre-stage; (b) the initiation; and (c) the self-adjustment stage. Parent, peer, and the taste of alcohol were noteworthy as the factors that promote young people to accept alcohol sipping and consumption as part of their life. Nevertheless, law, social norms, culture, parents, and health consequences discouraged young people from emerging alcohol initiation. Conclusion: The preliminary evidence from this study recommends the interventions that address both individual-level and interpersonal circumstances as potentially being effective solutions to the provision of precautionary measures against underage alcohol use.

Cardiovascular diseases are the world's leading cause of mortality, with a high burden especially among vulnerable populations. Interventions for primary prevention need to be further implemented in community and primary health care settings. Context is critically important to understand potential implementation determinants. Therefore, we explored stakeholders' views on the evidence-based SPICES program (EBSP); a multicomponent intervention for the primary prevention of cardiovascular disease, to inform its implementation. In this qualitative study, we conducted interviews and focus groups with 24 key stakeholders, 10 general practitioners, 9 practice nurses, and 13 lay community partners. We used adaptive framework analysis. The Consolidated Framework for Implementation Research guided our data collection, analysis, and reporting. The EBSP was valued as an opportunity to improve risk awareness and health behavior, especially in vulnerable populations. Its relative advantage, evidence-based design, adaptability to the needs and resources of target communities, and the alignment with policy evolutions and local mission and vision, were seen as important facilitators for its implementation. Concerns remain around legal and structural characteristics and intervention complexity. Our results highlight context dimensions that need to be considered and tailored to primary care and community needs and capacities when planning EBSP implementation in real life settings.

In 2014-2015, we conducted a randomized controlled trial (RCT) assessing the effect of an advertising campaign for influenza vaccination using posters and pamphlets in general practitioner (GP) waiting rooms. No effect of the intervention could be demonstrated, but the immunization uptake increased in both arms of the study. In 2019, we deepened the investigations explaining the increased uptake conducting a registry-based 4/2/1 cluster RCT designed by Zelen with two extra years of follow-up of the study cohort. The study population included 23,024 patients eligible to be vaccinated who were registered with 175 GPs. The main outcome remained the number of vaccination units delivered per study group. Data were extracted from the SNIIRAM warehouse claim database for the Lille-Douai district (northern France). No difference in vaccination uptake was found in the Zelen versus the control group of the initial RCT. Overall, the proportion of vaccinated patients increased in the cohort from 51.4% to 70.4% over the three years. Being vaccinated the previous year was a strong predictor of being vaccinated in a subsequent year. The increase in vaccination uptake, especially among people older than 65, can be explained by a cohort effect. Health promotion and the promotion of primary health care may play an important role in this increase.

Electrolyte disturbances are common in patients with cystic fibrosis (CF). Current guidelines on monitoring sodium status are based on research in a small group of infants and require blood sampling. The aim of this study was to evaluate urinary salt parameters as a surrogate for sodium-status in different age-groups. Blood and urine samples for electrolytes were collected from 222 patients followed at the Ghent University Hospital CF-center. Fractional sodium excretion (FENa) and several urinary parameters were calculated. Clinical characteristics did not differ according to sodium status, defined as FENa <0.5%. ROC analysis demonstrated that sodium/creatinine ratio (UNa/Creat) predicted the sodium status most accurately with high sensitivity and specificity (97 and 91% respectively). The UNa/Creat cut-off predicting a FENa <0.5% differed significantly according to age. The UNa/Creat is an excellent marker for the sodium status defined as a FENa <0.5%. However, different cut-offs according to age category should be applied., Competing Interests: Conflict of interest None of the authors have a conflict of interest., (Copyright © 2021 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Objective: This study aimed to explore the positive factors related to working in general practice in France, from a student studying medicine, trainee general practitioner (GP) and GP point of view., Setting: Primary care, France., Design: Nine different qualitative studies involving medical students, trainees and GPs., Participants: Sixty-seven medical students, 22 trainees in general practice and 71 GPs., Results: The final codebook contained 66 interpretative codes and 8 positive themes. The themes were general practice as a commitment, doctor-patient care and relationships, skills and competencies in general practice, practice organisation and work-life balance, relationship with the professional community, GPs and university, GPs in the social community and private life, relatives and family. Positive feelings about being a GP are similar throughout the different age groups, from young students to older professionals., Discussion and Conclusion: This study provided a comprehensive picture of the satisfied GP across different ages. This picture describes GPs as patient-centred professionals who need to have the freedom to choose an efficient working environment, organise their practice, have opportunities for professional development and acquire specific competencies. Both younger and older GPs believe in the future of general practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A cross-sectional study was applied to obtain factors associated with alcohol consumption since information among early adolescents in Thailand is limited. Data was collected from December 2016 to March 2017. A questionnaire was developed through a literature review and tested for validation and reliability. Multi-stage random sampling was used to recruit youths aged 10-14 years from Chonburi Province, Thailand. Descriptive statistics (mean and standard deviation), Chi-squared test, and multivariable logistic regression were used for data analysis. The mean and standard deviation (SD) for the age of participants was 12.07 years (1.42) with 50.23% being male. In total, 10.94% reported drinking alcohol in the past 12 months. Current drinking in the past year was positively associated with older youths of 14 years of age (AOR = 5.34, 95% CI = 2.91-9.81) having a positive attitude toward alcohol consumption behavior (AOR = 4.18 95% CI = 3.36-5.21), direct observation of friends' drinking (AOR = 4.21, 95% CI = 3.32-5.32), direct observation of villagers/community members' drinking (AOR = 1.99, 95% CI = 1.15- 3.48), adolescents whose parents stored alcohol at home (AOR = 1.35, 95% CI = 1.06-1.55), and being exposed to alcohol advertising (AOR = 1.60, 95% CI =1.16-2.23). The factor most inversely associated with current drinking appears to be male gender (AOR = 0.78, 95% CI =0.64-0.94). Strategies for delaying and reducing drinking among early adolescents should accompany these risk factors into any preventive programs.

Purpose: The purpose of this study was to describe experiences of childhood brain tumor survivors (CBTS) and key figures in their environment after returning to school, using the International Classification of Functioning, Disability and Health - Children and Youth framework., Methods: We conducted semi-structured interviews with five children, nine parents, 28 teachers, and 14 health professionals at three predetermined times over a two-year period. A qualitative content analysis was performed by linking meaningful units from transcribed interviews to ICF codes., Results: Children experienced diverse body dysfunctions that could impede school participation, mostly related to knowledge acquisition and application, executive functioning and social life. Support at school and professional aftercare were essential to alleviate the child's difficulties. The teacher's attitude, parental involvement, and practices of collaboration belonging to the child's supportive network further influenced the reintegration process. Also, child-specific factors including emotional reactions to illness, age, and balance between school life and leisure time were considered to affect school readjustment., Conclusions: The International Classification of Functioning, Disability and Health framework is a useful instrument to systematically describe experiences of CBTS and key figures regarding school life, providing a common language to communicate for stakeholders in education and healthcare following the child's return.IMPLICATIONS FOR REHABILITATIONThe International Classification of Functioning, Disability and Health - Children and Youth framework is a useful instrument to describe experiences regarding school life of childhood brain tumor survivors (CBTS) and key figures in their environment.The ICF-CY model can be combined with a standardized assessment of neurocognition or performance to achieve a comprehensive view of the child's participation at school, by exploring both personal and environmental factors.Childhood brain tumor survivors mostly show impairments in acquiring and applying knowledge, executive functioning and social life, which may require increased support at school and professional aftercare.A positive attitude of school staff, high parental involvement in school life and adequate collaboration between parents, education and healthcare are important to prioritize in the context of reintegration into school of CBTS.

Background: General practitioners (GPs) should regularly review patients' medications and, if necessary, deprescribe, as inappropriate polypharmacy may harm patients' health. However, deprescribing can be challenging for physicians. This study investigates GPs' deprescribing decisions in 31 countries., Methods: In this case vignette study, GPs were invited to participate in an online survey containing three clinical cases of oldest-old multimorbid patients with potentially inappropriate polypharmacy. Patients differed in terms of dependency in activities of daily living (ADL) and were presented with and without history of cardiovascular disease (CVD). For each case, we asked GPs if they would deprescribe in their usual practice. We calculated proportions of GPs who reported they would deprescribe and performed a multilevel logistic regression to examine the association between history of CVD and level of dependency on GPs' deprescribing decisions., Results: Of 3,175 invited GPs, 54% responded (N = 1,706). The mean age was 50 years and 60% of respondents were female. Despite differences across GP characteristics, such as age (with older GPs being more likely to take deprescribing decisions), and across countries, overall more than 80% of GPs reported they would deprescribe the dosage of at least one medication in oldest-old patients (> 80 years) with polypharmacy irrespective of history of CVD. The odds of deprescribing was higher in patients with a higher level of dependency in ADL (OR =1.5, 95%CI 1.25 to 1.80) and absence of CVD (OR =3.04, 95%CI 2.58 to 3.57)., Interpretation: The majority of GPs in this study were willing to deprescribe one or more medications in oldest-old multimorbid patients with polypharmacy. Willingness was higher in patients with increased dependency in ADL and lower in patients with CVD.

Although palliative care nurses are identified as key players in supporting couples during advanced illness, there is a lack of evidence about their knowledge and experiences with this particular role. The aim of the study was to explore palliative care nurses' attitudes, roles, and experiences in addressing relationship functioning of couples in daily practice. A qualitative study was conducted using in-depth interviews, observational research, and peer debriefing groups with palliative care nurses in Flanders, Belgium. Nurses support relationship functioning by creating a couple-positive care environment, by being present/acknowledging feelings, and by rectifying imbalances between couples. They do so in a proactive way, backed up by team support. Nurses hesitate toward explicitly unraveling and intervening in relationship problems, in favor of providing comfort or offering a strengths-based approach. The findings offer an urgent call to enhance the educational programs for palliative care nurses by integrating the theories and practice frameworks that guide relational assessment and intervention, which are being used in family nursing.

Aims and Objectives: To explore the views of general practitioners, practice nurses and patients on interprofessional collaboration in general practice and to understand to what extent the nurse-doctor relationship meets their needs and expectations., Background: To address future challenges of primary health care, there is a need for integrated interprofessional collaboration care systems with a patient-centred focus. Worldwide, there is an integration of nurses in general practice. However, in a transitioning Belgian context little is known about the perspectives of three key stakeholder groups., Design: The results of four qualitative descriptive primary studies were triangulated and a secondary analysis resulted in a thematic synthesis within a pragmatic research paradigm., Methods: Primary data were collected through individual, semi-structured interviews with 7 general practitioners, 19 practice nurses and 21 patients living with chronic illness in 26 primary care centres with different nurse integration levels. We conducted a secondary analysis for the thematic synthesis of the different stakeholders' perspectives. This study was reported in accordance with the COREQ checklist., Results: Four overarching themes were found as follows: vision and mission at general practice level, patient-centred care, practice nurse role development and interprofessional collaboration. Interprofessional collaboration within general practice ensures better response to patient needs. Evolution of the practice nurse role to autonomous decision-making can be facilitated by clear vision and mission, team communication, complementarity of responsibilities and trust-based professional relationships., Conclusions: The key for patient-centred care in a well-organised practice is a clear vision and mission and well-defined task description for interprofessional collaboration. General practice is urging for systematic guidance for the sustainable integration of a practice nurse., Relevance to Clinical Practice: Our study highlights opportunities and challenges to nurse integration in general practice from key stakeholders' perspectives, which can inform other transitioning contexts., (© 2019 John Wiley & Sons Ltd.)

Reintegration into school is a milestone for childhood brain tumor survivors, as well as for their parents, teachers, and healthcare providers. We explored their experiences following the school re-entry by conducting semi-structured interviews. Thematic analysis resulted in four main themes: "school performance," "psychosocial well-being," "support and approach," and "communication and collaboration." Children were pleased to return to school despite confrontation with adverse outcomes. Parents, teachers, and healthcare providers identified current and future concerns and challenges, as well as opportunities for academic and personal development. Their experiences highlight the importance of coordinated and systematic follow-up in close collaboration with healthcare providers.

This multiple case study investigated perspectives of childhood brain tumor survivors on reintegration into school over a 2-year period. Semistructured interviews were conducted with 5 children at 3 times to obtain an extensive view of their overall school experience. Thematic analysis of data resulted in 4 themes: "school life and participation," "peer relations and friendships," "performance and difficulties," and "support and follow-up." Childhood brain tumor survivors consider school attendance as part of a normal disease-free life. Social contact and friendships represent their main motivating factors for returning to school. Attitudes and feelings regarding performance, difficulties, and support vary among survivors and change over time. In conclusion, continuity in learning and social contact established before the return facilitate the reintegration process. A comprehensive assessment of their academic and psychosocial functioning should be organized on reentry. Systematic follow-up by parents, school staff, and health professionals throughout the child's school career is required., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective : To discover short-term changes in perspectives of parents and teachers of childhood brain tumour survivors on school reintegration, in order to reveal similarities and differences between them over time. Methods : Semi-structured interviews were conducted with parents and teachers of five children at the start and the end of a 1-year period following the child's school re-entry. Results : Thematic analysis of data resulted in three main themes: 'the child's performance and wellbeing', 'the school's attitude and approach' and 'communication and working together'. Parental concerns about child-specific changes and the school's approach to the child could either decrease or increase over time. Teachers remained focused on assessing their pupil's learning potential and finding ways of appropriate support. Their different perspectives on communication and working together became more pronounced. Conclusions : This study emphasizes the importance of clear communication and collaboration, coordinated follow-up and availability of healthcare professionals during the child's school reintegration.

Background: Health promotion is part of GPs' commitments. Some waiting rooms have therefore been implemented with audiovisual aids (posters, pamphlets or screens) for health promotion purposes. Few studies have assessed the effect of audiovisual aids in primary care., Objectives: To identify, describe and appraise studies that have investigated the effects of audiovisual aids on health promotion in primary healthcare waiting rooms. To determine which factors influence this impact through literature review., Methods: Systematic review. Two independent researchers using predefined keywords searched databases. Additional publications were extracted from the reference lists of the selected articles. The selection of the articles was performed on the title and abstract, followed by complete reading and assessment. Bias and level of evidence were analysed., Results: A total of 909 articles were collected. Most of them were not in primary care settings. Fourteen peer-reviewed articles fully meeting inclusion criteria were included and analysed. Good quality studies were scarce. Eight of these articles using videos or slideshows on TV screens or tablets indicated effects: three of them were significant on patient knowledge with acceptable evidence and three on health behaviour on surrogate endpoints. Audiovisual aids seem to be used or noticed by patients and can induce conversations with physicians. The relevant factors that might influence these effects (duration of exposure, conception quality, theme, target population and time spent in the waiting room) are insufficiently investigated., Conclusion: Audiovisual aids broadcasting messages using screens (TVs, computers, tablets, and smartphones with Bluetooth ® pairing) probably enhance patients' knowledge. A change in health behaviour remains controversial.

In the process of continuing developments and contemporary working conditions, this study provides an in depth exploration of proactive behavior in midwifery. Exploring 55 midwifery students' perceptions on facilitators and/or barriers of proactive behavior in midwifery practice, this study uncloses additional insights of proactive behavior in midwifery and aims to confirm and/or supplement previous results. Four key themes were identified: 1) Nature-nurture, supported by good communication and lifelong learning. 2) Willingness, regulated by the midwife's norms and values and the organizational culture of the midwifery team. 3) The impact of awareness and feedback on the reflective tendencies to strengthen the midwife's beliefs and convictions to behave proactively. 4) Time was identified as something gained in the presence of proactive behavior as well as a barrier if time was limited. Providing midwives with knowledge of the key factors required to successfully effect proactive behavior in midwifery, this study has merit for future midwifery education, policy and practice. Strengthening intrinsic motivation of midwives integrated into midwifery education, focus on feedback as part of the daily routine of the midwife and the gaining of time as an effect of proactive behavior, needs clear attention in midwifery practice., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Aim: To explore palliative care nurses' attitudes, roles and concrete experience with regard to addressing sexual issues in their daily practice., Background: Patients and their partners in palliative care might experience dramatic changes in their sexuality and want nurses to provide the opportunity to address them. Moreover, it is argued that the holistic philosophy of palliative care encourages nurses working in this area to include sexual issues in their daily care. It is, however, unknown how palliative care nurses address sexual issues., Design: A generic qualitative study was performed., Methods: In total, 21 in-depth interviews were done with nurses from different facilities of palliative care networks in Flanders. Data were collected between September 2014 - September 2016 and thematic analysis was used to analyse the data., Results: It was found that the way palliative care nurses addressed sexual issues was clearly influenced by their own interpretation of the philosophical principles underlying palliative care. The different interpretations of these basic principles create tensions for nurses about how to address sexual issues in the daily practice of palliative care and nurses vary in their reactions to these tensions. The present findings show that palliative care nurses - when they were able to overcome these tensions - use a "sex-positive approach" that fits with their tendency to focus on quality of life., Conclusion: Out of the results of this study, we made a list of good practices for palliative care nurses addressing sexual issues. This list can be used in nursing educational programs., (© 2018 John Wiley & Sons Ltd.)