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1.  Patient Expectations from Consultation with Family Physician 
Croatian medical journal  2006;47(1):148-154.
To assess patient expectations from a consultation with a family physician and determine the level and area of patient involvement in the communication process.
We videotaped 403 consecutive patient-physician consultations in the offices of 27 Estonian family physicians. All videotaped patients completed a questionnaire about their expectations before and after the consultation. Patient assessment of expected and obtained psychosocial support and biomedical information during the consultation with physician were compared. Two investigators independently assessed patient involvement in the consultation process on the basis of videotaped consultations, using a 5-point scale.
Receiving an explanation of biomedical information and discussing psychosocial aspects was assessed as important by 57.4-66.8% and 17.8-36.1% patients, respectively. The physicians did not meet patient expectations in the case of three biomedical aspects of consultation: cause of symptoms, severity of symptoms, and test results. Younger patients evaluated the importance of discussing psychological problems higher than older patients. The involvement of the patients was high in the problem defining process, in the physicians' overall responsiveness to the patients, and in their picking up of the patient's cues. The patients were involved less in the decision making process.
Discussing biomedical issues was more important for the patients than discussing psychological issues. The patients wanted to hear more about the cause and seriousness of their symptoms and about test results. The family physicians provided more psychosocial care than the patients had expected. Considering high patient involvement in the consultation process and the overall responsiveness of the family physicians to the patients during the consultation, Estonian physicians provide patient-centered consultations.
PMCID: PMC2080363  PMID: 16489708
2.  Physical activity of Estonian family doctors and their counselling for a healthy lifestyle: a cross-sectional study 
BMC Family Practice  2010;11:48.
Physical activity offers major health benefits and counselling for it should be integrated into the medical consultation. Based on the literature, the personal health behaviour of the physician (including physical activity) is associated with his/her approach to counselling patients. Our hypothesis is that family doctors (FD) in Estonia are physically active and their recommendation to counsel patients with chronic diseases to use physical activity is high. The study was also interested in how FDs value physical activity among other important determinants of a healthy lifestyle, e.g. nutrition, non-consumption of alcohol, and non-smoking.
Physicians on the electronic list were contacted by e-mail and sent a questionnaire. The first part assessed physical activity by the International Physical Activity Questionnaire (IPAQ) short form. Self-reported physical activity during one week was calculated as total physical activity in minutes per week (MET min/week). The second part of the questionnaire included questions about the counselling of patients with chronic disease concerning their physical activity and a healthy lifestyle. The study focused on female FDs because 95% of the FDs in Estonia are women and to avoid bias related to gender.
198 female FDs completed the questionnaire. 92% reported that they exercised over the past 7 days to a moderate or high level of physical activity. Analysis revealed no statistically significant relationship between the level of physical activity and general characteristics (age, living area, body mass index [BMI], time spent sitting). FDs reported that patients with heart problems, diabetes, and obesity seek their advice on physical activity more often than patients with depression. Over 94% of the FDs claimed that they counsel their patients with chronic diseases about exercising. According to the FDs' reports, the most important topic in counselling patients for a healthy lifestyle was physical activity.
This study showed that female FDs are physically active. The level of physical activity is not related to their age, BMI, living area, or time spent sitting. Also, FDs reported that promotion of physical activity is part of their everyday work.
PMCID: PMC2909965  PMID: 20565892
3.  Patients with depressive disorder, their co-morbidity, visiting rate and disability in relation to self-evaluation of physical and mental health: a cross-sectional study in family practice 
BMC Family Practice  2009;10:38.
High prevalence of depression among primary care patients has increased the need for more research in this field. The objectives of our study were to analyse how depressed patients evaluate their health; which co-morbid diseases are associated with depression; how depression influences the patients' consultation rate in family practice (FP); how disability is associated with depression; and how depression influences the patients' working ability.
A cross-sectional study, part of the PREDICT study. The study group was formed of 1094 consecutive patients from 23 FPs across Estonia, aged 18–75 years, attending a FP to consult the family doctor (FD). Occurrence of major depression during six months was estimated using the Depression Section of the Composite International Diagnostic Interview. The medical records of all patients were analysed concerning co-morbid diseases, number of visits to the FD, and disability. Every patient filled in questionnaires to assess health-related risk factors for depression, and the SF-12 Health Survey to assess functioning and the perception of health.
Depression was found in 230 (21%) of the patients. Depressed patients reported less accomplishment owing to emotional problems (OR 1.80; 95% CI 1.18–2.72), being less careful as usual (OR 1.81; 95% CI 1.26–2.60), and having pain that extremely interfered with their normal work (OR 2.50; 95% CI 1.33–4.70) in comparison with non-depressed patients. Also depressed patients were more days on sick-leave (OR 1.00; 95% CI 1.00–1.01) than non-depressed patients. However, analysis of the medical records did not indicate that depressed patients consulted the FD more or had more co-morbid diagnoses than the non-depressed patients.
Depressed patients may have low self-reported functioning due to emotional problems, pain, and their working ability may have decreased; however, the patients of both groups have an equal number of co-morbid diagnoses and their consultation rate is similar.
PMCID: PMC2696418  PMID: 19486534
4.  Family doctors' problems and motivating factors in management of depression 
BMC Family Practice  2006;7:64.
Depression is a frequent psychiatric disorder, and depressive patient may be more problematic for the family doctors (FD) than a patient suffering from a somatic disease. Treatment of patients with depressive disorders is a relatively new task for Estonian FDs. The aim of our study was to find out the family doctors' attitudes to depression related problems, their readiness, motivating factors and problems in the treatment of depressive patients as well as the existence of relevant knowledge.
In 2002, altogether 500 FDs in Estonia were invited to take part in a tailor-made questionnaire survey, of which 205 agreed to participate.
Of the respondents 185(90%) considered management of depressive patients and their treatment to be the task of FDs. One hundred and eighty FDs (88%) were themselves ready to deal with depressed patients, and 200(98%) of them actually treated such patients. Commitment to the interests of the patients, better cooperation with successfully treated patients, the patients' higher confidence in FDs and disappearance of somatic complaints during the treatment of depression were the motivating factors for FDs. FDs listed several important problems interfering with their work with depressive patients: limited time for one patient, patients' attitudes towards the diagnosis of depression, doctors' difficulties to change the underlying causes of depression, discontinuation of the treatment due to high expenses and length. Although 115(56%) respondents maintained that they had sufficient knowledge for diagnostics and treatment of depression, 181(88%) were of the opinion that they needed additional training.
FDs are ready to manage patients who might suffer from depression and are motivated by good doctor-patient relationship. However, majority of them feel that they need additional training.
PMCID: PMC1635052  PMID: 17074079
5.  Prediction of depression in European general practice attendees: the PREDICT study 
BMC Public Health  2006;6:6.
Prevention of depression must address multiple risk factors. Estimating overall risk across a range of putative risk factors is fundamental to prevention of depression. However, we lack reliable and valid methods of risk estimation. This protocol paper introduces PREDICT, an international research study to address this risk estimation.
This is a prospective study in which consecutive general practice attendees in six European countries are recruited and followed up after six and 12 months. Prevalence of depression is assessed at baseline and each follow-up point. Consecutive attendees between April 2003 and September 2004 who were aged 18 to 75 were asked to take part. The possibility of a depressive episode was assessed using the Depression Section of the Composite International Diagnostic Interview. A selection of presumed risk factors was based on our previous work and a systematic review of the literature. It was necessary to evaluate the test-retest reliability of a number of risk factor questions that were developed specifically, or adapted, for the PREDICT study. In a separate reliability study conducted between January and November 2003, consecutive general practice attendees in the six participating European countries completed the risk factor items on two occasions, two weeks apart. The overall response rate at entry to the study was 69%. We exceeded our expected recruitment rate, achieving a total of 10,048 people in all. Reliability coefficients were generally good to excellent.
Response rate to follow-up in all countries was uniformly high, which suggests that prediction will be based on almost a full cohort. The results of our reliability analysis are encouraging and suggest that data collected during the course of PREDICT will have a satisfactory level of stability. The development of a multi-factor risk score for depression will lay the foundation for future research on risk reduction in primary care. Our data will also provide the necessary evidence base on which to develop and evaluate interventions to reduce the prevalence of depression.
PMCID: PMC1368984  PMID: 16409633
6.  The diagnostic value of endoscopy and Helicobacter pylori tests for peptic ulcer patients in late post-treatment setting 
BMC Gastroenterology  2004;4:27.
Guidelines for management of peptic ulcer patients after the treatment are largely directed to detection of H. pylori infection using only non-invasive tests. We compared the diagnostic value of non-invasive and endoscopy based H. pylori tests in a late post-treatment setting.
Altogether 34 patients with dyspeptic complaints were referred for gastroscopy 5 years after the treatment of peptic ulcer using a one-week triple therapy scheme. The endoscopic and histologic findings were evaluated according to the Sydney classification. Bacteriological, PCR and cytological investigations and 13C-UBT tests were performed.
Seventeen patients were defined H. pylori positive by 13C-UBT test, PCR and histological examination. On endoscopy, peptic ulcer persisted in 4 H. pylori positive cases. Among the 6 cases with erosions of the gastric mucosa, only two patients were H. pylori positive. Mucosal atrophy and intestinal metaplasia were revealed both in the H. pylori positive and H. pylori negative cases. Bacteriological examination revealed three clarithromycin resistant H. pylori strains. Cytology failed to prove validity for diagnosing H. pylori in a post-treatment setting.
In a late post-treatment setting, patients with dyspepsia should not be monitored only by non-invasive investigation methods; it is also justified to use the classical histological evaluation of H. pylori colonisation, PCR and bacteriology as they have shown good concordance with 13C-UBT. Moreover, endoscopy and histological investigation of a gastric biopsy have proved to be the methods with an additional diagnostic value, providing the physician with information about inflammatory, atrophic and metaplastic lesions of the stomach in dyspeptic H. pylori positive and negative patients. Bacteriological methods are suggested for detecting the putative antimicrobial resistance of H. pylori, aimed at successful eradication of infection in persistent peptic ulcer cases.
PMCID: PMC529255  PMID: 15507141
7.  Family doctors' involvement with families in Estonia 
BMC Family Practice  2004;5:24.
Family doctors should care for individuals in the context of their family. Family has a powerful influence on health and illness and family interventions have been shown to improve health outcomes for a variety of health problems. The aim of the study was to investigate the Estonian family doctors' (FD) attitudes to the patients' family-related issues in their work: to explore the degree of FDs involvement in family matters, their preparedness for management of family-related issues and their self-assessment of the ability to manage different family-related problems.
A random sample (n = 236) of all FDs in Estonia was investigated using a postal questionnaire. Altogether 151 FDs responded to the questionnaire (response rate 64%), while five of them were excluded as they did not actually work as FDs.
Of the respondents, 90% thought that in managing the health problems of patients FDs should communicate and cooperate with family members. Although most of the family doctors agreed that modifying of the health damaging risk factors (smoking, alcohol and drug abuse) of their patients and families is their task, one third of them felt that dealing with these problems is ineffective, or perceived themselves as poorly prepared or having too little time for such activities. Of the respondents, 58% (n = 83) were of the opinion that they could modify also relationship problems.
Estonian family doctors are favourably disposed to involvement in family-related problems, however, they need some additional training, especially in the field of relationship management.
PMCID: PMC526768  PMID: 15504236
8.  Differential Impact of Risk Factors for Women and Men on the Risk of Major Depressive Disorder 
Annals of Epidemiology  2012;22(6):388-396.
Our aim is to examine which risk factors have a greater impact in women than in men on the risk of major depressive disorder (MDD) and whether factors differ between a possible recurrent MDD and a first onset of MDD.
Prospective cohort study of general practice attendees in seven countries, who were followed up at 6 and 12 months (predictD). Absolute risk differences (interaction contrast) across sex for onset of DSM-IV MDD after 6 or 12 months of follow-up were estimated for 35 risk factors from 7101 participants without MDD at baseline.
A total of 599 participants (80% female) had an onset of MDD at 6 or 12 months. Most risk factors had a greater impact in women than in men on the risk of MDD and were not restricted to a specific class of risk factors. After we stratified for a history of depressive symptoms, we found that the impact of risk factors across sex was generally stronger on possible recurrent MDD than on a first onset of MDD.
Our findings may partly account for the observed difference in incidence of MDD between men and women.
PMCID: PMC3657146  PMID: 22625996
Depression; Sex; Epidemiology; Interaction Contrast; Cohort; CIDI, Composite International Diagnostic Interview; MDD, Major depressive disorder
9.  Recent life events pose greatest risk for onset of major depressive disorder during mid-life 
Journal of Affective Disorders  2012;136(3):505-513.
The authors examined an additive model for the association of life events and age with onset of major depressive disorder (MDD) and whether the combination of life events and age posed greater risk than the sum of their independent effects.
Data were used from a prospective cohort study of 10,045 general practice attendees (PredictD). We included those without MDD at baseline (N = 8293). We examined age divided into tertiles and into 10 year groups. Life events were assessed at baseline using the List of Threatening Life Experiences Questionnaire and categorized according to type. Main outcome measure was onset of DSM-IV MDD at 6 or 12 months of follow-up. The authors calculated Relative Excess Risks due to Interaction (RERI).
6910 persons (83.3%) had a complete follow-up, of whom 589 (8.5%) had an onset of MDD (166 younger, 254 middle aged and 169 older). The combined effect of personal problems (RERI = 1.30; 95% CI 0.29 to 2.32), events in family or friends (RERI = 1.23; 95% CI 0.28 to 2.19), or problems with law (RERI = 1.57; 95% CI 0.33 to 2.82) and middle age was larger than the sum of individual effects.
Lower response to recruitment in the UK and the Netherlands.
Recent life events carry the largest risk of onset of MDD in mid-life. Understanding the different vulnerability to life events according to age may help to indicate groups at a particular risk and assist in preventive strategies.
PMCID: PMC3657156  PMID: 22119082
Major depression; Age; Stress; Interaction; Cohort
10.  Development and Validation of a Risk Model for Prediction of Hazardous Alcohol Consumption in General Practice Attendees: The PredictAL Study 
PLoS ONE  2011;6(8):e22175.
Little is known about the risk of progression to hazardous alcohol use in people currently drinking at safe limits. We aimed to develop a prediction model (predictAL) for the development of hazardous drinking in safe drinkers.
A prospective cohort study of adult general practice attendees in six European countries and Chile followed up over 6 months. We recruited 10,045 attendees between April 2003 to February 2005. 6193 European and 2462 Chilean attendees recorded AUDIT scores below 8 in men and 5 in women at recruitment and were used in modelling risk. 38 risk factors were measured to construct a risk model for the development of hazardous drinking using stepwise logistic regression. The model was corrected for over fitting and tested in an external population. The main outcome was hazardous drinking defined by an AUDIT score ≥8 in men and ≥5 in women.
69.0% of attendees were recruited, of whom 89.5% participated again after six months. The risk factors in the final predictAL model were sex, age, country, baseline AUDIT score, panic syndrome and lifetime alcohol problem. The predictAL model's average c-index across all six European countries was 0.839 (95% CI 0.805, 0.873). The Hedge's g effect size for the difference in log odds of predicted probability between safe drinkers in Europe who subsequently developed hazardous alcohol use and those who did not was 1.38 (95% CI 1.25, 1.51). External validation of the algorithm in Chilean safe drinkers resulted in a c-index of 0.781 (95% CI 0.717, 0.846) and Hedge's g of 0.68 (95% CI 0.57, 0.78).
The predictAL risk model for development of hazardous consumption in safe drinkers compares favourably with risk algorithms for disorders in other medical settings and can be a useful first step in prevention of alcohol misuse.
PMCID: PMC3154188  PMID: 21853028
11.  Depression and musculoskeletal problems 
PMCID: PMC2605532  PMID: 19105917
12.  Association of cagA and vacA Genotypes of Helicobacter pylori with Gastric Diseases in Estonia 
Journal of Clinical Microbiology  2002;40(1):298-300.
Gastric biopsy specimens from 156 adult patients from southern Estonia suffering from chronic gastritis, peptic ulcer disease, and perforated peptic ulcer were analyzed by PCR. The cagA gene was evenly distributed throughout 87% of the specimens from the patients with the different gastric diseases. The presence of the cagA gene correlated with that of vacA signal sequence type s1a (99%). However, no clear differences were found in the distribution of cagA and vacA genotypes among patients in Estonia with severe perforated peptic ulcer, uncomplicated peptic ulcer, or chronic gastritis.
PMCID: PMC120128  PMID: 11773138

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