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Hajdarevic, S., Norberg, A., Lundman, B. & Hörnsten, Å. (2024). Becoming whole again-Caring for the self in chronic illness-A narrative review of qualitative empirical studies. Journal of Clinical Nursing
Open this publication in new window or tab >>Becoming whole again-Caring for the self in chronic illness-A narrative review of qualitative empirical studies
2024 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702Article in journal (Refereed) Epub ahead of print
Abstract [en]

AIM AND OBJECTIVES: To explore how chronic illness transforms the self when living with and managing chronic illness and what this means for their self and identity. We also discuss how people with chronic conditions could be supported by healthcare professionals to manage illness in daily life.

BACKGROUND: Self-management recommendations from health care are commonly based on a biomedical understanding of the disease. People's experiences of how a condition affects them and adequate support are crucial for their outcomes in daily self-management.

DESIGN: A narrative review.

METHODS: A systematic search was undertaken during January 2021 across the databases MEDLINE, CINAHL, PsycINFO, Soc INDEX and Philosopher's Index. A quality appraisal of articles was performed. Our analysis was inspired by qualitative content analysis. The PRISMA Checklist 2020/EQUATOR guidelines was used to report the study.

RESULTS: Twenty-eight peer-reviewed qualitative empirical articles focusing on self in a variety of chronic illnesses with relevance to nursing published from January 2010 to December 2020 were included. The main theme, Developing from an uncertain existence to meaning and wholeness, was built up by the five themes: Walking on an unstable ground; Being stalemated; Being involved with others for better or worse; Searching for meaning; and lastly, Modifying self and integrating a new way of living.

CONCLUSIONS: The results illuminate experiences that seldom are prioritized but need to be addressed by health professionals. Such experiences are oriented more towards the existential self rather than medical issues, why it is important to go beyond the medical lens.

RELEVANCE TO CLINICAL PRACTICE: This is important knowledge for nurses aiming to support people with chronic illnesses. Nurses supporting people in self-management need to be aware that by teaching and encouraging people to revise their daily habits, they also work on the boundaries of their self-concept.

PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Place, publisher, year, edition, pages
John Wiley & Sons, 2024
Keywords
chronic illness, nursing, review, self, self‐management
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-226794 (URN)10.1111/jocn.17332 (DOI)38886987 (PubMedID)
Available from: 2024-06-20 Created: 2024-06-20 Last updated: 2024-06-20
Backman Lönn, B., Hörnsten, Å., Styrke, J. & Hajdarevic, S. (2024). Clinical research nurses perceive their role as being like the hub of a wheel without real power: Empirical qualitative research. Nursing Open, 11(5), Article ID e2183.
Open this publication in new window or tab >>Clinical research nurses perceive their role as being like the hub of a wheel without real power: Empirical qualitative research
2024 (English)In: Nursing Open, E-ISSN 2054-1058, Vol. 11, no 5, article id e2183Article in journal (Refereed) Published
Abstract [en]

Aim: This study aimed to explore the experiences of being a clinical research nurse (CRN), in Sweden.

Design: A qualitative study analysing individual interview data.

Methods: Interviews with 10 participants were conducted in April 2017 and repeated with five participants in May 2022. A semi-structured interview guide was used to cover topics such as experiences of working in a new role and professional challenges related to the role. The transcribed interviews were analysed inductively using qualitative content analysis.

Results: The main theme revealed that the CRNs experienced their work role as being like a hub in a wheel, using an ethical compass, but without real power. The six themes identified showed that CRNs worked independently and relied on clinical experiences as nurses but needed more education. They not only had a sense of duty but also too large responsibilities. Furthermore, they viewed their work as valuable and important. However, they needed an accentuated ethical compass and were also affected by power relations that negatively impacted work.

Conclusion: Working as a CRN means being in a central position and working independently, which requires diverse skills and competencies. CRNs, however, face and manage complex ethical and practical challenges without real power. They experience huge responsibilities but need education and acknowledgement, indicating a need for improvement. This is an important message to stakeholders and managers about the necessity of taking adequate action to support CRNs who are crucial resources in clinical research.

Patient or Public Contribution: No patient or public contribution.

Place, publisher, year, edition, pages
John Wiley & Sons, 2024
Keywords
clinical research nurse, clinical study coordinator, interviews, nurse, professional development, qualitative, role
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-225539 (URN)10.1002/nop2.2183 (DOI)001232953100001 ()38805659 (PubMedID)2-s2.0-85194839660 (Scopus ID)
Funder
Region Västernorrland
Available from: 2024-06-03 Created: 2024-06-03 Last updated: 2024-06-10Bibliographically approved
Hawranek, C., Rosén, A. & Hajdarevic, S. (2024). How hereditary cancer risk disclosure to relatives is handled in practice: patient perspectives from a Swedish cancer genetics clinic. Patient Education and Counseling, 126, Article ID 108319.
Open this publication in new window or tab >>How hereditary cancer risk disclosure to relatives is handled in practice: patient perspectives from a Swedish cancer genetics clinic
2024 (English)In: Patient Education and Counseling, ISSN 0738-3991, E-ISSN 1873-5134, Vol. 126, article id 108319Article in journal (Refereed) Published
Abstract [en]

Objectives: Hereditary cancer risks can be effectively managed if at-risk relatives enroll in surveillance and preventive care. Family-mediated risk disclosure has internationally been shown to be incomplete, selective and leave over a third of eligible at-risk individuals without access to genetic counseling. We explored patients handling of cancer risk information in practice. 

Methods: We conducted twelve semi-structured interviews with patients who had completed their genetic counseling and been asked to disclose risk information to relatives. Questions were designed to investigate lived experiences of communicating hereditary risk and focused on disclosure strategies, intrafamilial interactions and emotional responses. 

Results: Qualitative content analysis yielded five categories. These span personal fears, shared responsibilities, feeling of empowerment, innovative solutions and unmet needs. Patients put high value on collaboration with their genetic healthcare professionals but also solicited better overview of the counseling process and more personalized, case-tailored information. 

Conclusions: Our results add novel insights about the practical strategies employed by genetic counselees and their motivations behind disclosing hereditary risk information to relatives. 

Practice implications: A patient-centered cancer genetics care would clarify roles and responsibilities around risk disclosure, inform counselees about the process upfront and tailor information to offer case-specific data with the family’s inheritance pattern explained.

Place, publisher, year, edition, pages
Elsevier, 2024
Keywords
Hereditary cancer, Genetic counseling, Patient experiences, Risk disclosure, Risk perception, Health behavior, Cancer prevention
National Category
Nursing Cancer and Oncology
Identifiers
urn:nbn:se:umu:diva-225092 (URN)10.1016/j.pec.2024.108319 (DOI)2-s2.0-85193717890 (Scopus ID)
Funder
Cancerforskningsfonden i NorrlandForte, Swedish Research Council for Health, Working Life and Welfare, 2018-00964Region VästerbottenSwedish Cancer Society
Available from: 2024-05-27 Created: 2024-05-27 Last updated: 2024-05-30Bibliographically approved
Lundell, S., Isaksson, U., Coe, A.-B., Harrison, S. L. & Hajdarevic, S. (2024). Swedish translation and psychometric testing of the self-conscious emotions in COPD questionnaire. Respiratory Medicine, 226, Article ID 107624.
Open this publication in new window or tab >>Swedish translation and psychometric testing of the self-conscious emotions in COPD questionnaire
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2024 (English)In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 226, article id 107624Article in journal (Refereed) Published
Abstract [en]

Assessment of self-conscious emotions is important to develop tailored interventions for people with chronic obstructive pulmonary disease (COPD). Previous instruments have largely been developed for mental health populations. The Self-Conscious Emotions in COPD Questionnaire was the first instrument to assess self-conscious emotions in people with COPD, but it was only available in English.

The aim was to translate the Self-Conscious Emotions in COPD Questionnaire into Swedish and to evaluate its psychometric properties and internal structure in a Swedish context.

The translation process included forward and backward translation, a multidisciplinary meeting, assessment of content validity, and cognitive interviews. The translated instrument was tested in a sample of 173 people with COPD between September 2021 and September 2022. Parallel analysis (PA), exploratory factor analysis (EFA), and test-retest reliability was performed.

The content validity index (CVI) for the instrument was 0.88. Based on the PA, an EFA with a two-factor solution was conducted, with a high Cronbach's alpha (0.786-0.821), and one item about self-blame was excluded. The two factors were labelled: The burden of living with a disability and The desire to hide vulnerability. Test-retest reliability showed no difference between scale scores on factor or item level, except for one item.

The Swedish Self-Conscious Emotions in COPD showed good validity and reliability. One item was excluded from the two subscales, indicating that the instrument needs to be further developed to cover the concept of self-blame. The instrument is expected to be a valuable tool for assessing self-conscious emotions in people with COPD.

Place, publisher, year, edition, pages
Elsevier, 2024
Keywords
Chronic obstructive pulmonary disease, Emotions, Psychometry, Reliability, Self-consciousness, Validity.
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-223353 (URN)10.1016/j.rmed.2024.107624 (DOI)2-s2.0-85189985496 (Scopus ID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2020-01129
Available from: 2024-04-15 Created: 2024-04-15 Last updated: 2024-04-23Bibliographically approved
Fjällström, P., Coe, A.-B., Lilja, M. & Hajdarevic, S. (2023). Adopting standardized cancer patient pathways as a policy at different organizational levels in the Swedish health system. Health Research Policy and Systems, 21(1), Article ID 122.
Open this publication in new window or tab >>Adopting standardized cancer patient pathways as a policy at different organizational levels in the Swedish health system
2023 (English)In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 21, no 1, article id 122Article in journal (Refereed) Published
Abstract [en]

Background: Standardized cancer patient pathways as a new policy has been adopted in healthcare to improve the quality of cancer care. Within the health systems, actors at different levels manage the adoption of new policies to develop healthcare. The various actors on different levels play an important role and influence the policy adoption process. Thus, knowledge about how these actors use strategies when adopting cancer patient pathways as a policy in the health system becomes central.

Method: The study's aim was to explore how actors at different organizational levels in the health system adopted cancer patient pathways. Our overarching case was the Swedish health system at the national, regional, and local levels. Constructivist Grounded Theory Method was used to collect and analyze qualitative interviews with persons working in organizations directly involved in adopting cancer patient pathways at each level. Twelve individual and nine group interviews were conducted including 53 participants.

Results: Organizational actors at three different levels used distinct strategies during the adoption of cancer patient pathways: acting as-missionaries, fixers, and doers. Acting as missionaries consisted of preaching the idea of cancer patient pathways and framing it with a common purpose to agree upon. Acting as fixers entailed creating a space to put cancer patient pathways into practice and overcome challenges to this. Acting as doers comprised balancing breadth and speed in healthcare provision with not being involved in the development of cancer patient pathways for the local context. These strategies were not developed in isolation from the other organizational levels but rather, each level interacted with one another.

Conclusions: When adopting new policies, it is important to be aware of the different strategies and actors at various organizational levels in health systems. Even when actors on different levels developed separate strategies, if these contribute to fulfilling the four domains of inter-organizational collaboration, they can work well together to adopt new policies. Our study highlighted that the application of two domains was lacking, which meant that local actors were not sufficiently involved in collaboration, thus constricting the local use and optimization of cancer patient pathways in practice.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2023
Keywords
Collaboration, Grounded theory method, Health systems, Organizational levels, Organizational policy, Primary health care, Strategies
National Category
Nursing Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-217363 (URN)10.1186/s12961-023-01073-8 (DOI)38012670 (PubMedID)2-s2.0-85177861191 (Scopus ID)
Funder
The Kempe FoundationsRegion Västerbotten, RV-731891Region Västerbotten, RV-744851Region Västerbotten, RV-855211Region Västerbotten, RV-931881Region Västerbotten, RV-939898Visare Norr, 939897Visare Norr, 929986Visare Norr, 838121Cancerforskningsfonden i Norrland, LP-18–2193
Available from: 2023-11-30 Created: 2023-11-30 Last updated: 2023-12-14Bibliographically approved
Hajdarevic, S., Högberg, C., Marzo-Castillejo, M., Siliņa, V., Sawicka-Powierza, J., Esteva, M., . . . Harris, M. (2023). Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis: a qualitative study. BJGP Open, 7(4), Article ID BJGPO.2023.0029.
Open this publication in new window or tab >>Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis: a qualitative study
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2023 (English)In: BJGP Open, E-ISSN 2398-3795, Vol. 7, no 4, article id BJGPO.2023.0029Article in journal (Refereed) Published
Abstract [en]

Background: While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral.

Aim: To explore European PCPs’ experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.

Design & setting: A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.

Method: Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.

Results: A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients’ descriptions did not suggest cancer; distracting factors reduced PCPs’ cancer suspicions; patients’ hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.

Conclusion: The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The ‘Swiss cheese’ model of accident causation showed how the themes related to each other.

Place, publisher, year, edition, pages
Royal College of General Practitioners, 2023
Keywords
Primary health care, physicians, primary care, cancer, Europe, diagnostic errors, qualitative research
National Category
Nursing Cancer and Oncology
Identifiers
urn:nbn:se:umu:diva-214654 (URN)10.3399/bjgpo.2023.0029 (DOI)37380218 (PubMedID)2-s2.0-85180193308 (Scopus ID)
Available from: 2023-09-22 Created: 2023-09-22 Last updated: 2024-02-19Bibliographically approved
Fjällström, P., Hörnsten, C., Lilja, M., Hultstrand, C., Coe, A.-B. & Hajdarevic, S. (2023). Reduction in the diagnostic interval after the introduction of cancer patient pathways for colorectal cancer in northern Sweden. Scandinavian Journal of Primary Health Care, 41(3), 287-296
Open this publication in new window or tab >>Reduction in the diagnostic interval after the introduction of cancer patient pathways for colorectal cancer in northern Sweden
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2023 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 41, no 3, p. 287-296Article in journal (Refereed) Published
Abstract [en]

Objective: To compare the diagnostic interval for patients with colorectal cancer before and after the introduction of cancer patient pathways in northern Sweden.

Design: A retrospective study comparing two cohorts (2012 and 2018) of patients diagnosed with colorectal cancer before and after the introduction of cancer patient pathways in 2016.

Setting: Three counties in northern Sweden with large sparsely populated areas and some cities (637143 residents ∼5.1 residents/km2).

Subjects: Patients were included from the Swedish Cancer Register. Electronic health records reviews were performed and linked to socioeconomic data from Statistics Sweden.

Main outcome measures: Differences in the diagnostic intervals, the patient intervals and the characteristics associated with the longest diagnostic intervals and investigations starting at the emergency department.

Results: The two cohorts included 411 patients in 2012 and 445 patients in 2018. The median diagnostic interval was reduced from 47 days (IQI 18–99) to 29 days (IQI 9–74) (p < 0.001) after the introduction of cancer patient pathways in general. Though for the cases of cancer in the right-side (ascended) colon, the reduction of the diagnostic interval was not observed and it remained associated with investigations starting at the emergency department.

Conclusion: Our results indicate that cancer patient pathways contributed to an improvement in the diagnostic interval for patients with colorectal cancer in general, yet not for patients with cancer in the right-side colon.

Implication: In general, cancer patient pathways seem to reduce the diagnostic interval for colorectal cancer but it is not a sufficient solution for all colorectal cancer localisations.

Place, publisher, year, edition, pages
Taylor & Francis, 2023
Keywords
cancer patient pathways, Colorectal cancer, diagnostic interval, primary healthcare, socioeconomic factors, symptoms, time to diagnosis
National Category
Cancer and Oncology Nursing
Identifiers
urn:nbn:se:umu:diva-212509 (URN)10.1080/02813432.2023.2234003 (DOI)001025227600001 ()37450480 (PubMedID)2-s2.0-85165303497 (Scopus ID)
Available from: 2023-08-01 Created: 2023-08-01 Last updated: 2023-09-04Bibliographically approved
Sjöström, A. E., Hajdarevic, S., Hörnsten, Å., Kristjánsdóttir, Ó., Castor, C. & Isaksson, U. (2023). The Swedish version of the eHealth literacy questionnaire: Translation, cultural adaptation, and validation study. Journal of Medical Internet Research, 25, Article ID e43267.
Open this publication in new window or tab >>The Swedish version of the eHealth literacy questionnaire: Translation, cultural adaptation, and validation study
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2023 (English)In: Journal of Medical Internet Research, E-ISSN 1438-8871, Vol. 25, article id e43267Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: With the increasing digitalization in health care, an effective instrument is necessary to assess health care consumers' digital competencies-their "eHealth literacy." The 7-scale eHealth Literacy Questionnaire (eHLQ), based on the theoretically robust eHealth Literacy Framework, has shown strong psychometric properties in Denmark and Australia.

OBJECTIVE: The aim of this study was to translate, culturally adapt, and evaluate the psychometric properties of the Swedish version of the eHLQ.

METHODS: We followed the Translation Integrity Procedure guidelines to translate and culturally adapt the questionnaire to Swedish using forward and backward translations, review by an expert panel, and cognitive interviewing. The psychometric properties of the Swedish eHLQ were investigated by evaluating its internal consistency (Cronbach α) and a priori-defined factor structure (confirmatory factor analysis).

RESULTS: A total of 236 primary health care patients and parents of hospitalized children were included in the validation analysis. The mean age was 48.5 years, and 129 (55%) were women. All 7 eHLQ scales showed good internal consistency, with the Cronbach α ranging from .82 to .92. Single-factor and 7-factor confirmatory factor analysis showed satisfactory model-fit values. With one exception, all items demonstrated satisfactory loadings on their respective factors.

CONCLUSIONS: The Swedish eHLQ demonstrated strong psychometric properties. It has the potential as a useful tool for a variety of purposes, including population surveys, intervention evaluations, and eHealth service implementations.

Place, publisher, year, edition, pages
JMIR publications, 2023
Keywords
cultural adaptation, digital health, eHLQ, eHealth, eHealth literacy, health literacy, validation
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-206994 (URN)10.2196/43267 (DOI)37043268 (PubMedID)2-s2.0-85152474327 (Scopus ID)
Funder
Swedish Diabetes AssociationForte, Swedish Research Council for Health, Working Life and Welfare
Available from: 2023-04-24 Created: 2023-04-24 Last updated: 2024-01-17Bibliographically approved
Koskela, T. H., Esteva, M., Mangione, M., Contreras Martos, S., Hajdarevic, S., Högberg, C., . . . Petek, D. (2023). What would primary care practitioners do differently after a delayed cancer diagnosis?: Learning lessons from their experiences. Scandinavian Journal of Primary Health Care, 42(1), 123-131
Open this publication in new window or tab >>What would primary care practitioners do differently after a delayed cancer diagnosis?: Learning lessons from their experiences
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2023 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, National Library of Medicine, 2024 Mar;42(1): 123-131, Vol. 42, no 1, p. 123-131Article in journal (Refereed) Published
Abstract [en]

Objective: Diagnosis of cancer is challenging in primary care due to the low incidence of cancer cases in primary care practice. A prolonged diagnostic interval may be due to doctor, patient or system factors, or may be due to the characteristics of the cancer itself. The objective of this study was to learn from Primary Care Physicians’ (PCP) experiences of incidents when they had failed to think of, or act on, a cancer diagnosis.

Design: A qualitative, online survey eliciting PCP narratives. Thematic analysis was used to analyse the data.

Setting and subjects: A primary care study, with narratives from 159 PCPs in 23 European countries.

Main outcome measures: PCPs’ narratives on the question ‘If you saw this patient with cancer presenting in the same way today, what would you do differently?

Results: The main themes identified were: thinking broadly; improvement in communication and clinical management; use of other available resources and ‘I wouldn’t do anything differently’.

Conclusion (Implications): To achieve more timely cancer diagnosis, PCPs need to provide a long-term, holistic and active approach with effective communication, and to ensure shared decision-making, follow-up and continuing re-assessment of the patients’ clinical conditions.

Keywords
Cancer, diagnostic erroors, Europe, primary care physicians, primary health care, qualitative research
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-218702 (URN)10.1080/02813432.2023.2296117 (DOI)38116949 (PubMedID)2-s2.0-85180175382 (Scopus ID)
Available from: 2023-12-27 Created: 2023-12-27 Last updated: 2024-02-09
Hawranek, C., Maxon, J., Andersson, A., van Guelpen, B., Hajdarevic, S., Numan Hellquist, B. & Rosén, A. (2022). Cancer worry distribution and willingness to undergo colonoscopy at three levels of hypothetical cancer risk - a population-based survey in Sweden. Cancers, 14(4), Article ID 918.
Open this publication in new window or tab >>Cancer worry distribution and willingness to undergo colonoscopy at three levels of hypothetical cancer risk - a population-based survey in Sweden
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2022 (English)In: Cancers, ISSN 2072-6694, Vol. 14, no 4, article id 918Article in journal (Refereed) Published
Abstract [en]

Purpose: We describe levels of cancer worry in the general population as measured with the Cancer Worry Scale (CWS) and investigate the association with colonoscopy screening intentions in three colorectal cancer risk scenarios. 

Methods: The data were sourced through a population-based survey. Respondents (n = 943) completed an eight-item CWS and questions on colonoscopy screening interest at three hypothetical risk levels. 

Results: Respondents without a personal cancer history (n = 853) scored 9.46 on the six-item CWS (mean, SD 2.72). Mean scores were significantly higher in women (9.91, SD 2.89) as compared to men (9.06, SD 2.49, p < 0.001). Linear regression showed higher cancer worry in women and those with children when controlling for education, age group, and country of birth. High cancer worry (six-item CWS mean >12) was identified in 25% of women and in 17% of men. Among those, 71% would attend a colonoscopy screening compared to 52% of those with low cancer worry (p < 0.001, 5% CRC-risk). 

Conclusions: The distribution of cancer worry in a general population sample showed higher mean scores in women, and levels overlapped with earlier findings in cancer-affected samples. Respondents with high cancer worry were more inclined to undergo a colonoscopy screening, and intention increased with higher levels of hypothetical risk.

Place, publisher, year, edition, pages
MDPI, 2022
Keywords
cancer, oncology, cancer worry, cancer worry scale, colonoscopy, colorectal cancer, early detection of cancer, patient reported outcome measures
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-192473 (URN)10.3390/cancers14040918 (DOI)000766443100001 ()35205668 (PubMedID)2-s2.0-85124360606 (Scopus ID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2018-00964
Available from: 2022-02-14 Created: 2022-02-14 Last updated: 2023-03-24Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0003-0661-8269

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