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  • 1.
    Ahlborg, Tone
    Nordic Council of Ministers, Nordic School of Public Health NHV. Nordic School of Public Health NHV.
    Experienced quality of the intimate relationship in first-time parents: Qualitative and quantitative studies2004Doctoral thesis, comprehensive summary (Other academic)
  • 2.
    Ahlborg, Tone
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Nordic School of Public Health NHV.
    Dahlöf, Lars-Gösta
    Nordic School of Public Health NHV.
    Hallberg, Lillemor R-M
    Nordic School of Public Health NHV.
    Quality of intimate and sexual relationship in first-time parents six months after delivery.2005In: Journal of Sex Research, ISSN 0022-4499, E-ISSN 1559-8519, Vol. 42, no 2, p. 167-74Article in journal (Refereed)
    Abstract [en]

    This study aimed to describe the quality of the intimate relationship among parents six months after the birth of their first child. The Dyadic Adjustment Scale (DAS) has been modified and used on 820 responding first-time parents, of which 768 were couples. The results reveal that most parents were happy in their relationship, but both mothers and fathers were discontented with the dyadic sexuality. "Being too tired for sexual activity" was a problem, especially for the mothers, and the most common frequency of intercourse was once or twice per month. The result does not support the assumption that the couples compensate the lacking sexuality with sensuality. Good communication within the couple was associated with higher levels of several dimensions of the intimate relationship, especially dyadic consensus and satisfaction. Thus, one way to stabilize and strengthen a relationship when dyadic sexual activity is low would be to emphasize dyadic communication and sexual activity.

  • 3.
    Ahlborg, Tone
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Nordic School of Public Health NHV.
    Persson, Lars-Olof
    Nordic School of Public Health NHV.
    Hallberg, Lillemor R-M
    Nordic School of Public Health NHV.
    Assessing the quality of the dyadic relationship in first-time parents: development of a new instrument.2005In: Journal of Family Nursing, ISSN 1074-8407, E-ISSN 1552-549X, Vol. 11, no 1, p. 19-37Article in journal (Refereed)
    Abstract [en]

    The purpose of this research was to psychometrically evaluate the Dyadic Adjustment Scale (DAS), modified for use with new, first-time parents by extending the items of communication, sensuality, and sexuality. A total of 820 Swedish respondents, 6 months after the birth of their first child, participated in the study. Psychometric evaluation was conducted with factor analysis. The obtained factor structure was tested with multitrait analysis program. Thirty-three items were found to fit into a five-factor solution, explaining 50% of the total variance. Descriptive data revealed that most new parents were satisfied with their intimate relationship in general, but dissatisfied with their sexual lives. The modified DAS, now called the Quality of Dyadic Relationship Instrument includes 33 items and seems to be a useful, updated measurement for assessing quality of the intimate relationship in new first-time parents.

  • 4.
    Ahlborg, Tone
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Nordic School of Public Health NHV.
    Strandmark, Margareta
    Nordic School of Public Health NHV.
    The baby was the focus of attention - first-time parents' experiences of their intimate relationship.2001In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 15, no 4, p. 318-25Article in journal (Refereed)
    Abstract [en]

    The baby was the focus of attention - first-time parents' experience of their intimate relationship. The purpose of this study was to describe the phenomenon of 'first-time parents' intimate relationship', to focus on their mental health, and the ability to support them professionally. Ten Swedish parents (five couples) were interviewed on two occasions, when the first baby was 6 and 18 months old, respectively. A descriptive phenomenological method was used. The findings show that the essence of the phenomenon is 'The baby was the focus of attention'. This had different meanings for the couples, putting them in two categories. For the first category, the essence was that the baby was the focus of mutual concern, which implied a fostered relationship. The strain of parenthood in this category was mild. In the second category, the baby was focused on at the expense of the father, who felt rejected emotionally. This impaired the relationship and parenthood involved a severe strain. The way the spouses communicated differed between the two categories. This study shows that mental health can be affected, especially among first-time fathers, and this could jeopardize the relationship and family health. An awareness of this fact is needed among the health professionals giving care to first-time parents.

  • 5.
    Ahlborg, Tone
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Nordic School of Public Health NHV.
    Strandmark, Margaretha
    Nordic School of Public Health NHV.
    Factors influencing the quality of intimate relationships six months after delivery--first-time parents' own views and coping strategies.2006In: Journal of Psychosomatic Obstetrics and Gynaecology, ISSN 0167-482X, E-ISSN 1743-8942, Vol. 27, no 3, p. 163-72Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to describe and analyze first-time parents' experiences of factors that affect the quality of their intimate relationship and the way they cope with their situation six months after delivery. The method used was inductive qualitative content analysis of two open questions in a larger questionnaire. The data is based on 535 respondents' statements. The factors affecting the quality of the intimate relationship were available or missing and could be classified into four categories. 1. 'Coping by adjustment to parental role', e.g., mutual support as new parents, 2. 'The couple's 'intimacy', i.e., togetherness and love, 3. 'Coping by communication', i.e., verbal and non-verbal mutual confirmation, and 4. 'Coping with external conditions', e.g., by seeking social support. The results are described in a model, which could constitute a basis for the promotion of health in family health care, with the aim, if possible, of preventing unnecessary separations/divorces after couples become parents.

  • 6.
    Ahlborg, Tone
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Strandmark,, Margaretha
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Dahlöf, L-G
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    First-time parents' sexual relationships.2000In: Scandinavian Journal of Sexology, ISSN 1398-2966, Vol. 3, no 4, p. 127-139Article in journal (Refereed)
    Abstract [en]

    Describes the phenomenon termed, "First-time parents' sexual relationship". The qualitative descriptive phenomenological method was applied for the material from the interviews. Ten couples (aged 24–42 yrs) were interviewed separately and undisturbed on a single occasion, when the first baby was nine-months-old. The results indicated that the essence of the phenomenon described in this study pertained to sexual desire. The significance of the concept differed among parents. Some couples lacked the time and energy for each other due to the presence of the baby but compensated for their desires with reciprocal tenderness alternating with that shown to the baby. Some couples assigned time actively for each other which enabled them to enjoy their sexual desire. One couple was forced to control their sexual desires due to severe mucus infection. However, this couple compensated with caressing and thereby confirmed each other emotionally and sexually. Certain mothers longed for desire or emotional confirmation. These couples lacked the ability to assign time and show interest reciprocally, as well as an ineffective communication. Their relationships were characterized by misunderstandings and unarticulated demands.

  • 7.
    Andersen, Anders Johan W
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    I ALL FORTROLIGHET: En undersøkelse av meldinger ompsykisk helse på internett i Norge og Sverige2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    This thesis draws attention to the field of “e-mental health” and offers an analysis of messages about mental health on the Internet. The aim is to examine how mental health was presented on Internet-based mental health services in Norway and Sweden and to discuss challenges for community mental health services in a public health perspective. The study relies on qualitative methodology with exploratory, descriptive, and analytic objectives. In 2009 atotal of 60 Internet-based mental health services were identified and mapped and they revealed similarities of origin, target-groups, content, and respondents. Communications on publicly accessible question-and-answer services were examined using qualitative content analysis. Service users’ concerns and expectations of services were analyzed as well as the services’ responses. The study showed variations in the service profiles, expectations of service users, and the message contents. Mental health was portrayed overall as a relationalconcern in messages from applicants while individualinterpretations dominated the answers from the services. Given that service users had great confidence in the services’ expertise, and services rather consistently recommended them to seek help from healthcare providers, the study creates the impression that online services contribute to individualizing questions about mental health in Norway and Sweden. The variations that emerged in the analysis challenge the public health field to respect the ambiguous complexity of issues surrounding mental health. It provides support for a broad understanding of public health, and makes it particularly important to bring together different disciplines in efforts to promote mental health and prevent illness. The study challenges public health actors to refrain from visions of individual human perfection, and suggests the possibility of developing a community mental health focus grounded on the recognition of human vulnerability and dependency. The study challenges the public health field to recognize online services not only as extensions of existing services, but also as independent communication channels for mental health “consumers” and an opportunity for them to test the waters of community mental health services. The thesis stresses the obligations incumbent upon services to bring people’s experiences back to the community by making anonymous messages available in the public sphere. In this way the services might work as society’s “listening posts,” helping to provide strength to the marginalized voices of the Scandinavian welfare states

  • 8.
    Andersen, Anders Johan W
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Svensson, Tommy
    Nordic Council of Ministers, Nordic School of Public Health NHV. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden .
    Internet-based mental health services in Norway and Sweden: characteristics and consequences.2013In: Administration and Policy in Mental Health, ISSN 0894-587X, E-ISSN 1573-3289, Vol. 40, no 2, p. 145-53Article in journal (Refereed)
    Abstract [en]

    Internet-based mental health services increase rapidly. However, national surveys are incomplete and the consequences for such services are poorly discussed. This study describes characteristics of 60 Internet-based mental health services in Norway and Sweden and discusses their social consequences. More than half of the services were offered by voluntary organisations and targeted towards young people. Professionals answered service users' questions in 60% of the services. Eight major themes were identified. These characteristics may indicate a shift in the delivery of mental health services in both countries, and imply changes in the understanding of mental health.

  • 9.
    Andersen, Anders Johan W
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Svensson, Tommy
    Nordic Council of Ministers, Nordic School of Public Health NHV. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden .
    Reaching out to people struggling with their lives: a discourse analysis of answers from Internet-based services in Norway and Sweden.2012In: Psychology research and behavior management, ISSN 1179-1578, Vol. 5, p. 113-21Article in journal (Refereed)
    Abstract [en]

    The Internet has enlarged the scope of human communication, opening new avenues for connecting with people who are struggling with their lives. This article presents a discourse analysis of 101 responses to 98 questions that were posted on 14 different Internet-based mental health services in Norway and Sweden. We aimed to examine and describe the dominant understandings and favored recommendations in the services' answers, and we reflected upon the social consequences of those answers. The services generally understood life struggles as an abnormal state of mind, life rhythms, or self-reinforcing loops. Internet-based mental health services primarily counsel service users to seek help, talk to health care professionals face-to-face, and discuss their life struggles openly and honestly. They also urge service users to take better care of themselves and socialize with other people. However, such answers might enhance the individualization of life problems, masking social origin and construction. Consequently, the services are challenged to include social explanations in their answers and strengthen their responsibility to amplify peoples' messages at a societal level. Potentially, such answers could strengthen democratic structures and put pressure on social equity.

  • 10.
    Andersen, Anders Johan W
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Svensson, Tommy
    Nordic Council of Ministers, Nordic School of Public Health NHV. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden .
    Struggles for recognition: a content analysis of messages posted on the Internet.2012In: Journal of multidisciplinary healthcare, ISSN 1178-2390, Vol. 5, p. 153-62Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The Internet has enlarged the possibilities of human communication and opened new ways of exploring perceptions of mental health. This study is part of a research project aiming to explore, describe, and analyze different discourses of mental health in Norway and Sweden, using material from Internet-based services.

    AIM: To examine messages posed by users of publicly available question-and-answer services and to describe their content.

    METHODS: A Web search was used to identify Norwegian and Swedish Websites offering mental health services by email or posted messages. A total of 601 messages from 20 services, 10 Norwegian and 10 Swedish, were analyzed by means of qualitative content analysis and further interpreted in light of the social theory of recognition by Honneth.

    RESULTS: EIGHT CATEGORIES EMERGED FROM THE ANALYSIS: family life, couples, others, violence, the ungovernable, self-image, negotiating normality, and life struggles. These categories were then grouped into three themes: (1) relationship to significant others, (2) relationship to self, and (3) relationship to the social community. The themes promoted an understanding of mental health as closely connected to political and social factors.

    CONCLUSIONS: The results showed a variety of concerns from various parts of life and empowered the view that mental health should be understood broadly, at a conceptual level. Mental health emerged as a deeply relational concept that emphasized the equal distribution of chances in life. It strengthened the moral grammar of social inclusion and the acceptance of plurality in social life.

  • 11.
    Andersen, Anders Johan W
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Svensson, Tommy
    Nordic Council of Ministers, Nordic School of Public Health NHV. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden .
    The dialogical bricoleur?: Expectations towards internet-based services in Norway and Sweden2012In: Nordic Social Work Research, ISSN 2156-857X, E-ISSN 2156-8588, Vol. 2, no 2, p. 137-152Article in journal (Refereed)
    Abstract [en]

    Mental health is a multifaceted concept that has been described and understood differently throughout history. The emergence of internet-based services has signalled changes in both the delivery of services and the understanding of mental health that could alter expectations towards professionals. This study explores the implicit images of answerers online culled from messages by individuals who use internet-based mental health services (henceforth, submitters) and discusses the possible implications of the answerers. An internet search identified Norwegian and Swedish websites, and 444 messages from 13 of those services were included in our study and analysed via qualitative content analysis. Ten images of the answerers were constructed in this process and they were gathered into four main images named ‘the specialist’, ‘the counsellor’, ‘the therapist’ and ‘the master of discourse’. These four images form the structural element in our presentation of the empirical interpretations and serve as the main expectations towards the services. This article discusses these empirical interpretations in the context of both the scientific ‘bricoleur’ and the Open Dialogue Approach. Our results suggest that the ‘dialogical bricoleur’ is a unifying image in submitters’ expectations towards answerers online. Our study argues for strengthening sensitivity towards submitters and increasing the capacity to encompass human variation on the internet.

  • 12. Arbelaez, Maria Patricia
    et al.
    Gaviria, Marta Beatriz
    Franco, Alvaro
    Restrepo, Roman
    Hincapié, Doracelly
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Tuberculosis control and managed competition in Colombia.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S25-43Article in journal (Refereed)
    Abstract [en]

    Law 100 introduced the Health Sector Reform in Colombia, a model of managed competition. This article addresses the effects of this model in terms of output and outcomes of TB control. Trends in main TB control indicators were analysed using secondary data sources, and 25 interviews were done with key informants from public and private insurers and provider institutions, and from the health directorate level. We found a deterioration in the performance of TB control: a decreasing number of BCG vaccine doses applied, a reduction in case finding and contacts identification, low cure rates and an increasing loss of follow up, which mainly affects poor people. Fragmentation occurred as the atomization and discontinuity of the technical processes took place, there was a lack of coordination, as well as a breakdown between individual and collective interventions, and the health information system began to disintegrate. The introduction of the Managed Competition (MC) in Colombia appeared to have adverse effects on TB control due to the dominance of the economic rationality in the health system and the weak state stewardship. Our recommendations are to restructure the reform's public health component, strengthen the technical capacity in public health of the state, mainly at the local and departmental levels, and to improve the health information system by reorienting its objectives to public health goals.

  • 13.
    Augustsson, Hanna
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Hagquist, Curt
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Kartläggning av studier om nordiska ungdomars psykiska hälsa2011Report (Other academic)
    Abstract [sv]

    I denna forskningsrapport redovisas en kartläggning av studier om nordiska ungdomars psykiska hälsa.Kartläggningen har genomförts av Centrum för forskning om barns och ungdomars psykiska hälsa vid Karlstads universitet på uppdrag av Nordiska högskolan för folkhälsovetenskap (NHV). Kartläggningen har finansierats av Nordiska ministerrådet och ingår som ett delprojekt inom ramen för ministerrådets handlingsplan för psykisk hälsa. Samtliga projekt som ingår i handlingsplanen har initierats av Nordiska Akademin för forskning om psykisk hälsa vid NHV under ledning av docent Lars Fredén.Barns och ungdomars psykiska hälsa är en viktig folkhälsofråga, såväl i de nordiska länderna som i de vidare internationella sammanhangen. Under senare år har området fått en ökad uppmärksamhet. Nordiska ministerrådets handlingsplan för psykisk hälsa är ett uttryck för detta. Ett annat exempel kan hämtas från Sverige. Inspirerade av ett projekt i Kungl. Vetenskapsakademiens regi har de statliga forskningsfinansiärerna riktat totalt 300 miljoner kronor under sex år till forskning om barns och ungdomars psykiska hälsa.Kartläggningen i denna forskningsrapport är gjord med ett systematiskt och vetenskapligt arbetssätt, men kan inte likställas med de systematiska kunskapsöversikter som Kungl. Vetenskapsakademien producerade i tidigare nämnda projekt, eller med de rapporter som Statens beredning för medicinsk utvärdering utarbetar. Föreliggande rapport är gjord med väsentligt mindre resurser och med förenklade arbetsmetoder. En preliminär version av rapporten presenterades vid konferensen Ung och utsatt som den 5-6 maj 2011 anordnades vid NHV

  • 14.
    Beillon, Lena Marie
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Att värdera vårdbehov- ett kliniskt dilemma: En studie av nyttjandet av ambulanssjukvård i olika geografiska områden2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The health care system in the Nordic countries’ are based on that those individuals who have urgent need of health care should have access to it without unnecessary delay. But regarded to limited resources prioritisation has to be made. The reason for prioritising is to deliver an appropriate and rapid response to those with the most urgent needs and to guarantee the public a qualitative good and effective health care. The health care system has an important role for creating safety, especially the emergency medical service. When someone become acute ill or injured, there are expectations for immediately rapid response from the health care system. The prioritisation and allocation of the ambulance service is performed from an emergency medical centre by the emergency number 112. Several Emergency Medical Systems use a criteria based prioritizing system for ambulance response. In such a system the operators at the medical emergency dispatch centres have to assess patients’ symptoms and needs for ambulance response. The prioritizing of the ambulance response is based on the seriousness of the patient’s symptoms, on the patient’s current condition and in the case of trauma, on the trauma mechanism. The priority system is supposed to optimize the use of the ambulance service and to match up and meet the patients’ needs with adequate responses of the ambulances. The aim of this thesis is to evaluate if the prioritising of patients medical status leads to appropriate use of the health care service and the emergency medical service. The thesis is based on five parts, including six studies (I-VI) and the methods used have a quantitative approach. Part 1 (study I-II), evaluates the settings of priorities and patients need for prehospital care. Part 2 (study III), describes how patients with chest pain in different geographical areas uses the ambulance service. Part 3 (study IV), analyses the differences in use of the ambulance service between densely and sparsely populated areas. Part 4 (study IV), describes the use of the ambulance service in Finland. Part 5 (study IV), reviews the ambulance patients and the need of care at emergency department or similar level of care. The results show that the initial priority of ambulance response from the dispatch centre was consistent with patients' current status as assessed by ambulance staff in half of the missions, and as assessed retrospectively by an expert panel at one third of cases. According to the assessment of the ambulance personnel and the review from an expert panel there was extensive use of both ”overtriage” and ”undertriage” in the emergency medical dispatching of ambulance missions. The result also shows that decisions lead to sub optimal use of the ambulance service and other health care resources. One of the major findings is the occurrence of undertriage. A triage system has to identify those patients with the most urgent health needs, and give these patients access to care in order to avoid unnecessary deterioration in health status. At the same time must safety margins be maintained and overuse of resources minimised. Another major finding is that a high safety margins and high amount of overtriage leads to that a big part of the ambulance missions are transportation of patients with no need of today’s high tech ambulances or the professional competence of ambulance nurses

  • 15.
    Beillon, Lena Marie
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Suserud, Björn-Ove
    Karlberg, Ingvar
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Herlitz, Johan
    Does ambulance use differ between geographic areas? A survey of ambulance use in sparsely and densely populated areas.2009In: American Journal of Emergency Medicine, ISSN 0735-6757, E-ISSN 1532-8171, Vol. 27, no 2, p. 202-11Article in journal (Refereed)
    Abstract [en]

    AIM: The aim of this study was to analyze possible differences in the use of ambulance service between densely and sparsely populated areas.

    METHODS: This study was designed as a 2-step consecutive study that included the ambulance service in 4 different areas with different geographical characteristics. A specific questionnaire was distributed to the enrolled ambulance services. Completion of one questionnaire was required for each ambulance mission, that is, 1 per patient, during the study periods. For calculations of P values, geographic area was treated as a 4-graded ordered variable, from the most densely populated to the most sparsely populated (ie, urban-suburban-rural-remote rural area). Statistical tests used were Mann-Whitney U test and Spearman rank statistic, when appropriate. All P values are 2 tailed and considered significant if below .01.

    RESULTS: The medical status of the patients in the prehospital care situation was more often severe in the sparsely populated areas. In addition, drugs were more often used in the ambulances in these areas. In the sparsely populated areas, ambulance use was more frequently judged as the appropriate mode of transportation compared with the more densely populated areas.

    CONCLUSIONS: Our study suggests that the appropriateness of the use of ambulance is not optimal. Furthermore, our data suggest that geographical factors, that is, population density, is related to inappropriate use. Thus, strategies to improve the appropriateness of ambulance use should probably take geographical aspects into consideration.

  • 16.
    Berg, Geir V
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Å fremme den eldre sykehuspasientens helse i lys av et folkehelse- og et holistisk-eksistensielt sykepleieperspektiv2007Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background and aim: The number of elderly hospital patients is increasing in line with tidisciplinary eriatric approach reduces illness, re-hospitalization and costs as well as improving dge about health and health erly hospital patients from a public health and nursing erspective. ploys a combination between different data collection methods, data urces and analytical techniques in order to investigate health and health promotion . Study three illustrated and explored the life world of empowerment, health and health promotion were introduced to nurses in the advancing age of the population. Old people are a heterogeneous group when itcomes to health status and sickness. Research findings suggest that a mulgsurvival rates and functional level. The aim of this thesis was to describe and develop knowlepromotion related to eldpData sources and methods: The thesis, which comprises four studies, has a qualitative approach that emsoamong elderly hospital patients. Study one was conducted as a theoretical conceptual analysis and synthesis of the concepts of man, health, nursing and illness/disease based on description of the concepts in three nursing theories. Study two described and explored health and health promotion from the perspectives of ten elderly hospital patients using qualitative interviewsfive nurses and their understanding of health promotive nursing related to the elderly hospital patient by means of participant observation. Study four was an explorative study. The conceptsorder to give a mutual theoretical platform before participating in reflection group dialogues. Two groups of nurses participated in three dialogues that were conducted by a moderator and an assistant. The dialogues were tape-recorded and transcribed verbatim. Each dialogue was analysed with qualitative content analysis. Findings: The thesis proposes a stipulative definition of health promotive nursing with a holistic-existential approach based on five necessary preconditions. The definition and preconditions may serve as a theoretical basis for health promotion in nursing. The elderly hospital patients reported that health was being able to be the person I am, to do what I want, to feel well and have strength. Health promotion was described as being enabled by being seen as the person I am, through information and knowledge as well as hope and motivation. The nurses’ attitude to health and health promotion was influenced by two different views; the biomedical and the holistic nursing view, between which they moved. In their work the nurses were masters at balancing on a tightrope and interacting with a professional competence that makes it possible to manage a constantly changing work situation. Reflection group dialogues revealed a dual relation among the about participating nurses to empowerment and power. The nurses highlighted the importance of using an individualised approach in order to promote the health of elderly hospital patients with focus on respect for the individual and normalization of the situation. Conclusion: The thesis proposes a stipulative definition of health promotion as well as five preconditions that may serve as guidance and offer a health promotive nursing approach for elderly hospital patients. How health promotion and health are understood depends on one’s scientific and professional background as well as the experience of caring for the individuals in one’s charge. The understanding of health promotion on the part of both nurses and elderly hospital patients was somewhat vague, but improved as a result of dialogue and discussions. Empowerment may be a suitable strategy, as it helps both nurses and elderly patients to acknowledge the necessity of controlling and influencing their situation. However, empowerment implies a consciousness of one’s own power. According to the elderly hospital patients in this study, health is promoted when they are seen as a person, when they receive adequate information and knowledge their condition and when they feel motivated. Reflection group dialogues may be a strategy to increase the professional consciousness of nurses to implement research findings and to focus on promoting the health of elderly hospital patients.

  • 17.
    Berg, Geir V
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Hedelin, Birgitta
    Sarvimäki, Anneli
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    A holistic approach to the promotion of older hospital patients' health.2005In: International Nursing Review, ISSN 0020-8132, E-ISSN 1466-7657, Vol. 52, no 1, p. 73-80Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To describe how nurses interpreted health promotion related to older patients in a medical hospital ward and the presuppositions for this work.

    METHODS: The study had a descriptive and explorative design. Data were created through participant observation of five nurses and informal dialogues with four nurses working in an infection unit in a small hospital in Norway. The nurses where followed during a period of 6 months. The observations and dialogues were interpreted and transformed into text. This text was analysed with qualitative content analysis and interpreted hermeneutically on three levels: (1) reading the text to get an overview of the themes; (2) systematically separating central patterns; and (3) highlighting the patterns with examples.

    FINDINGS: The nurses' interpretation of health promotion was closely connected to their interpretation of health and holistic nursing. Two main aspects were uncovered in the informal dialogues: a biomedically oriented nursing view and a holistically oriented nursing view. The observations showed that presuppositions, such as waiting for something or somebody, constantly changing situations, complexity and diversity in patient cases, influenced the nurses' work in general and also their focus on health promotion. The nurses balanced between the biomedical and the holistic approach. It seemed to be important for the nurses to be the masters of walking on a tightrope and to have professional clinical competence.

    CONCLUSION: It was difficult to find a clear focus on health promotion. The most visible focus was on diagnosis and treatment, while the more complex and comprehensive situations related to health promotion of older patients seemed to be underprioritized. The phenomenon of 'waiting' may be an important issue for further research.

  • 18.
    Berg, Geir V
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Sarvimäki, Anneli
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    A holistic-existential approach to health promotion.2003In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 17, no 4, p. 384-91Article in journal (Refereed)
    Abstract [en]

    Health promotion seems to be implicit in many nursing theories, but the theoretical and philosophical basis of health promotion in nursing is not always explicitly stated. The interpretation of health promotion is closely related to the interpretation of man, health, illness and nursing. There is a need to clarify, refine and redefine health promotion in nursing because the concept is partly nonspecific and has not been used to identify a distinctive nursing focus. The aim of this study was to formulate a stipulative definition of health promotive nursing with a holistic-existential approach. A philosophical frame of reference in combination with conceptual analysis and theoretical synthesis were used as the methodological approach. The philosophical framework served as a basis in selecting the nursing theories and influenced the analysis. Two nursing theories and one nursing model were selected due to their influence on Norwegian nursing and because of their philosophical basis. Through analysis and synthesis of the selected nursing theories, the concepts man, health, illness/disease and nursing were analysed. The paper proposes a stipulative definition of health promotion in nursing based on a holistic-existential approach, supported by five necessary conditions. The definition and conditions needs to be further investigated by both empirical studies and by comparing with other relevant nursing theories, in order to formulate theoretical statements. The proposed definition may be the first step in a process of developing a theoretical framework of health promotive nursing with a holistic-existential approach.

  • 19.
    Berg, Geir V
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Sarvimäki, Anneli
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Hedelin, Birgitta
    Hospitalized older peoples' views of health and health promotion.2006In: International Journal of Older People Nursing, ISSN 1748-3735, E-ISSN 1748-3743, Vol. 1, no 1, p. 25-33Article in journal (Refereed)
    Abstract [en]

    Older peoples' health varies considerably and the number of older people who need hospital care will increase in the future. Traditionally, the focus of nursing care in hospitals is oriented towards diagnosis and treatment of disease, although health and health promotion are inherent in theories and definitions of nursing. This is an important issue in health politics, in new laws and regulations in Norway. However, it was difficult to find research-based knowledge about how nurses work with health promotion and health related to older hospitalized patients. This study aimed at describing older hospitalized patients' experiences of health and health promotion. The study used a descriptive and explorative qualitative design, with an interpretative-phenomenological approach. Ten older hospitalized patients, recruited through purposeful sampling, were interviewed during their hospital stay. The informants described health as Being able to be the person I am, to do what I want to do, and feel well and have strength. Health promotion was described as Being enabled through being the person I am, through information and knowledge and through hope and motivation. The findings may be applied to nursing practice in order to focus on promotion of health as an individual process built upon the unique person's life and situation, supported by nursing care and medical treatment.

  • 20. Bian, Ying
    et al.
    Sun, Qiang
    Zhao, Zhengyan
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Market reform: a challenge to public health--the case of schistosomiasis control in China.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S79-94Article in journal (Refereed)
    Abstract [en]

    This study examines how the provision of schistosomiasis control has adapted to increased exposure to market forces which has occurred in China over the past decades with the main emphasis on contemporary performance of the services. Financial and service data were collected and analysed from ten schistosomiasis stations in the Hunan province. A document and literature review, key informant interviews, as well as two focus group discussions were conducted to establish their context. The study found that the schistosomiasis control stations had shifted their emphasis from prevention to clinical services and that 62% of the stations' total income now comes from charging for individual clinical services, while 90% of the total costs was related to providing these services. The study found that revenue generation had become the primary motive, and that over-treatment and prescription had become an accepted practice for all the stations. The study concludes that a combination of lax supervision and accountability, and a greater reliance on user-payment and market mechanisms has severely compromised the provision of the public goods elements of the schistosomiasis control programme.

  • 21.
    Biong, Stian
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Between death as escape and the dream of life: Psychosocial dimensions of health in young menliving with substance abuse and suicidal behaviour2008Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Substance abuse and suicidal behaviour are major challenges to public health. These phenomena are mainly studied by quantitative designs. This qualitative thesis aims at gaining a deeper understanding of substance abuse and suicidal behaviour, as experienced by young men in different types of treatment. By describing, exploring and interpreting lived experiences, in this thesis I try to give a more nuanced language of both substance abuse and suicidal behaviour, also in young migrating men. I also focus on the system of services related to the prevention and follow-up of life-threatening overdoses by describing and exploring how this phenomenon is experienced by individuals and professionals in Oslo. By researching the lived experiences of substance abuse and suicidal behaviour, combined with researching the phenomenon of life-threatening overdoses, a deeper insight is gained and this can be an important source to both prevention and health promotion for the group in question. The first three papers are based on descriptive, explorative and interpretative studies. How meaning is constructed is the core research question. In the fourth study I describe and explore life-threatening overdoses as a contemporary phenomenon in its context. The research questions are on a descriptive level. In the first three papers, the research object is the personal narratives from in-depth interviews, which are analysed using a phenomenological hermeneutic method. The case study is composed of data collected from different sources, and analysed by triangulation. The main finding in the first paper is that substance abuse and suicidal behaviour can be understood as goal-oriented, communicative and meaning-making activities about the individuals’ balance between death as an escape from pain and the hope of a life. In the second study, metaphorical expressions about a shifting sense of self is understood as balancing being an agent or a victim. In migrating young men these phenomena are interpreted as goal-oriented, communicative and meanig-making activities about existing in a maze that is perceived as closed. The findings of the case study show that different forms of life-threatening overdoses in Oslo are experienced in a state of existential and material stress. A wish of follow-up might not be expressed by the individual. Due to structural problems, such as lack of goals, professionals do not prevent such events in a planned way, nor do they cooperate between different levels. Professionals decide what is good quality in prevention and follow-up of life-threatening overdoses

  • 22.
    Biong, Stian
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Karlsson, Bengt
    Svensson, Tommy
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Metaphors of a shifting sense of self in men recovering from substance abuse and suicidal behavior.2008In: Journal of Psychosocial Nursing and Mental Health Services, ISSN 0279-3695, E-ISSN 1938-2413, Vol. 46, no 4, p. 35-41Article in journal (Refereed)
    Abstract [en]

    The purpose of this descriptive study was to explore and interpret men's experience of sense of self within the context of recovery from substance abuse and suicidal behavior. A secondary analysis of data from a previous study of four young Norwegian men revealed how a shifting sense of self was constructed through the use of metaphors. The analysis identified three themes related to the participants' sense of self: The Meaning of Being Isolated, The Meaning of Being Close to the Point of No Return, and The Meaning of Still Being on the Edge. By acknowledging metaphorical expressions as a source of important knowledge, this study reflects on how mental health professionals can use metaphors in the recovery process. As part of the' treatment alliance and therapeutic communication, we suggest that metaphors may aid the assessment of suicidal ideation, promote a sense of a more active self, and signal acceptance and recognition of subjectivity.

  • 23.
    Biong, Stian
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Ravndal, Edle
    National Institute of Alcohol and Drug Research, Oslo, Norway.
    Living in a maze: Health, well-being and coping in young non-western men in Scandinavia experiencing substance abuse and suicidal behaviour2008In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 4, no 1, p. 4-16Article in journal (Refereed)
    Abstract [en]

    The aim of the study was to illuminate and interpret the lived experiences of emigration, substance abuse and suicidal behaviour in young non-western men in Scandinavia. The research questions were formulated as: (1) How is meaning constructed in the narratives? (2) What impact do these experiences have on health, well-being and coping? Data were collected using open-ended in-depth interviews. A phenomenological-hermeneutic approach, inspired by the philosophy of Ricoeur, was used to analyse the data. The naïve reading involved awareness of the participants’ perceived sense of insecurity in life. The structural analysis identified three themes: (1) the meaning of getting in a tight spot, (2) the meaning of being in a fog and (3) the meaning of the burning bed. A comprehensive understanding of the data was formulated as “living in a maze”. Ill health involved having a sense of liminality, which impaired one's possibilities to define and re-define goals. Substance abuse and suicidal behaviour were explicit expressions of not being well, when living in a maze that was perceived as closed. Both problem-focused and emotion-focused coping were used by the participants. These provided the motivation for substance abuse and suicidal behaviour.

  • 24.
    Biong, Stian
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Ravndal, Edle
    National Institute of Alcohol and Drug Research, Oslo, Norway.
    Young men's experiences of living with substance abuse and suicidal behaviour: Between death as an escape from pain and the hope of a life2007In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 2, no 4, p. 246-259Article in journal (Refereed)
    Abstract [en]

    The aim of the study was to illuminate the experiences of suicidal behaviour in young Norwegian men with long-term substance abuse and to interpret their narratives with regard to meaning. Data were collected using open-ended, in-depth interviews. A phenomenological hermeneutic approach, inspired by the philosophy of Ricoeur, was used to analyse the data. The naïve reading involved awareness of the perceived sense of pain and hope in the participants. In the structural analysis, three themes were identified: (1) the meaning of relating, (2) the meaning of reflecting and (3) the meaning of acting. A comprehensive understanding of data indicated that the meaning of living with suicidal behaviour could be understood as a movement between different positions of wanting death as an escape from pain and hope for a better life. Our conclusion is that suicidal behaviour in men with substance abuse is a communicative activity about the individual's lived experience of pain and hope. How the participants experienced and constructed masculinity influenced the suicidal behaviour. To reduce pain and create hope by being seen and confirmed in social relationships, and being helped to verbalize existential thoughts and openly discuss possible solutions, are of importance.

  • 25.
    Björklund, Margereth
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    LIVING WITH HEAD AND NECK CANCER: AHEALTH PROMOTION PERSPECTIVE: A Qualitative Study2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background and aim: In society there is a growing awareness that a vital factor for patientswith chronic diseases, such as head and neck cancer (HNC), is how well they are able tofunction in their everyday lives – a common, but often overlooked, public health issue. Theoverall aim of this thesis is to reach a deeper understanding of living with HNC and toidentify the experiences that patients felt promoted their health and well-being. It alsoexplores the patients’ experiences of contact and care from health professionals and whetherthese encounters could increase their feelings of health and well-being; salutogenic approach.

    Methods: This thesis engages a qualitative data design. On three occasions, 35 purposivelyselected patients were interviewed (31 from Sweden and one from Denmark, Finland, Island,and Norway). The first study was conducted in the Nordic counties (I), and the remainingstudies were conducted in Sweden (II, III, IV). Interviews were performed on a single basis(I, II, III) and then repeated (IV). The individual, semi-structured qualitative interviews usedopen-ended questions (n=53). Three different forms of analyses were used: critical incidenttechnique (I), thematic content analysis (II), latent content analysis (III), and interpretativedescriptive analysis (paper IV).

    Findings: Living with head and neck cancer was expressed as living in captivity, in the sensethat patients’ sometimes life-threatening symptoms were constant reminders of the disease.The patients experienced a threat against identity and existence. Patients struggled to findpower and control over everyday life, and if successful this appeared to offer them better health and well-being along with spiritual growth. The general understanding was that these patients had strong beliefs in the future despite living on a virtual rollercoaster. The patients went through a process of interplay of internal and external enabling that helped them acquire strength and feelings of better health and well-being. Consequently, they found power and control from inner strength and other health resources, e.g. social networks, nature, hobbies,activity, and health professionals. However, the findings also revealed the opposite; that somepatients were more vulnerable and felt powerless and faced everyday life with emotional andexistential loneliness. They were dependent on next of kin and health professionals. Having good interpersonal relationships and emotional support 24 hours a day from next of kin were crucial, as were health promoting contacts and care from health professionals. This healthpromoting contact and care built on working relationships with competent healthprofessionals that were available, engaged, respectful, validating, and, above all experiencedin the treatment phase. But many patients experienced not health promoting contact and care –and a sense of not being respected, or even believed. Added were the patients’ experiences ofinadequate coordination between phases of their lengthy illness trajectory. They felt lost andabandoned by health services, especially before and after treatment.

    Conclusions: Inner strength, good relationships with next of kin, nature, hobbies, andactivities could create strength and a sense of better health and well-being. Patientsexperienced a mutual working relationship during dialoguing and sensed co-operation andequality in encounters with competent health professionals. This could lead to enhancedpower and control i.e. empowerment in a patient’s everyday life. The findings highlightpsychosocial rehabilitation in a patient-centred organisation when health professionals supportpatients’ inner strength and health resources, and also offer long-term support to next of kin.Finally, this research suggests that if health professionals could gain a deeper understandingof the psychosocial, existential, social, and economic questions on patients’ minds, they couldbetter sense how patients feel and would be better equipped not only to offer greater support,but to raise their voices to improve health policy and health care for these patients.

  • 26.
    Björklund, Margereth
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Fridlund, B
    Centre for Health Promotion Research, Halmstad University, Halmstad, Sweden .
    Cancer patients' experiences of nurses' behaviour and health promotion activities: a critical incident analysis.1999In: European Journal of Cancer Care, ISSN 0961-5423, E-ISSN 1365-2354, Vol. 8, no 4, p. 204-12Article in journal (Refereed)
    Abstract [en]

    Patients with head and neck cancer report several disease- and health-related problems before, during and a long time after completed treatment. Nurses have an important role in educating/supporting these patients about/through the disease and treatment so that they can attain well-being. This study describes the cancer patients' experiences of nurses' behaviour in terms of critical incidents after nurses had given them care to promote health. The study had a qualitative, descriptive design and the method used was the critical incident technique. Twenty-one informants from the Nordic countries diagnosed with head and neck cancer were strategically selected. It was explained to the informants what a critical incident implies before the interviews took place; this was defined as a major event of great importance, an incident, which the informants still remember, due to its great importance for the outcome of their health and well-being. The nurses' behaviour was examined, and critical incidents were involved in 208 cases-150 positive and 58 negative ones-the number of incidents varying between three and 20 per informant. The nurses' health promotion activities or lack of such activities based on the patients' disease, treatment and symptoms, consisted of informing and instructing the patients as well as enabling their participation. Personal consideration and the nurses' cognisance, knowledge, competence, solicitude, demeanour and statements of understanding were found to be important. Continuous health promotion nursing interventions were of considerable value for the majority of this group of cancer patients. Oncology nurses could reconfirm and update the care of head and neck cancer patients by including health promotion activities in individual care plans. By more frequent use of health promotion models, such as the empowerment model, the nurses could identify and focus on those individuals who needed to alter their life-style as well as tailor their approach towards these patient by setting goals for well-being and a healthy life-style.

  • 27.
    Björklund, Margereth
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Sarvimäki, Anneli
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Berg, Agneta
    Kristianstad University College, Kristianstad, Sweden.
    Health promoting contacts as encountered by individuals with head and neck cance2009In: Journal of Nursing and Healthcare of Chronic Illness, ISSN 1752-9816, E-ISSN 1752-9824, Vol. 1, no 3, p. 261-268Article in journal (Refereed)
    Abstract [en]

    Aim.  To describe the characteristics of health promoting contacts with health professionals as encountered by individuals with head and neck cancer.

    Background.  Head and neck cancer has a profound and chronic impact on the individual’s everyday life, e.g. physical problems that hinder speaking, breathing, eating and drinking. Furthermore, fear and uncertainty can lead to long-term psychological and psychosocial problems. The National Institute of Public Health in Sweden advocates that all care contacts should improve the quality of the individual’s health.

    Design.  A qualitative descriptive and explorative design was used. Eight participants were interviewed in the year 2005 and a qualitative thematic content analysis of the data was performed.

    Findings.  Health promoting contacts were defined as contacts where health care professionals contribute positively to the well-being of individual patients. Characteristics include being available, engaged, respectful and validating. Three themes were identified: being believed in one’s illness story; having a working relationship with health professionals and receiving individualised, tailored care.

    Conclusions.  Health promoting contacts were experienced mainly during the treatment phase, when patients had daily contact with specific, qualified health professionals. Although the interview questions focused on health promoting contacts, nearly half of the contacts were experienced as not health promoting. Feelings of abandonment were particularly manifested before and after treatment. The starting point for achieving health promoting contact lies in understanding the patient’s lifeworld in relation to health, illness and suffering and focusing on the individual’s personal strengths and health resources.

    Relevance to clinical practice.  The findings highlighted the importance of ensuring that patient interests and concerns are core considerations in health care. The participants viewed continuing individualised, tailored care and access to ear, nose and throat healthcare professionals as highly important.

  • 28.
    Björklund, Margereth
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Sarvimäki, Anneli
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Berg, Agneta
    Kristianstad University College, Kristianstad, Sweden.
    Health promotion and empowerment from the perspective of individuals living with head and neck cancer.2008In: European Journal of Oncology Nursing, ISSN 1462-3889, E-ISSN 1532-2122, Vol. 12, no 1, p. 26-34Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to shed light on health promotion from the perspective of individuals living with head and neck cancer. Eight informants were interviewed and latent content analysis was used. Individuals living with head and neck cancer experienced many problems that had a negative impact on their health. One overarching main theme was demonstrated; the ability to regain control and empower oneself. Three themes emerged: (1) Being enabled by dialogue with one's inner self, including three sub-themes: transformed and improved self-esteem, recognising and embracing existentiality, and increased self-determination. (2) Being enabled by means of contact with a social network, including two sub-themes: emotional support and practical support. (3) Being enabled by means of contact with and a passion for the environment, including two sub-themes: nature, hobbies and activities. Empowerment, the goal of health promotion, was understood as an ongoing process, and the ability to promote health varied and was dependent on internal and external enabling of acting and doing. The interpretation of this ongoing process demonstrates interplay assisted by a dialogue with one's inner self, contact with a social network and a passion for the environment. Altogether, these findings may inspire nurses and other health care professionals to support the individual's empowerment process and pose non-pathology-oriented questions such as "what improves your health?" or "what makes you feel good?"

  • 29.
    Björklund, Margereth
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Sarvimäki, Anneli
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Berg, Agneta
    Kristianstad University College, Kristianstad, Sweden.
    Living with head and neck cancer:: a profile of captivity2010In: Journal of Nursing and Healthcare of Chronic Illness, ISSN 1752-9816, E-ISSN 1752-9824, Vol. 2, no 1, p. 22-31Article in journal (Refereed)
    Abstract [en]

    Aim.  To illuminate what it means to live with head and neck cancer.

    Background.  Patients could experience head and neck cancer as more emotionally traumatic than other cancers because of visible disfigurement and its life-threatening impact on vital functions. This long-term illness often leads to lifestyle changes such as to physical function, work and everyday tasks, interpersonal relationships and social functioning.

    Design.  This study used a qualitative and explorative longitudinal and prospective design with semi-structured interviews and open-ended questions. Twenty-one interviews were conducted with six participants with newly diagnosed or newly recurrent head and neck cancer. The analysis was descriptive and interpretive.

    Findings.  The participants were living ‘in captivity’ in the sense that their symptoms were constant reminders of the disease. Our findings also revealed existential loneliness and spiritual growth, as interpreted within six themes: altered sense of affiliation; hostage of health care; locked up in a broken body, but with a free spirit; confined in a rogue body, forced dependency on others, and caught up in a permanent illness trajectory.

    Conclusions.  Living with head and neck cancer involves emotional and existential vulnerability. The participants and their next of kin experienced insufficient support from health services and inadequate coordination between phases of their lengthy illness trajectory. These findings call for changes in oncological rehabilitation and management. Patient care must take a holistic view of everyone involved, centring on the individual and the promotion of health. A care coordinator could navigate between the individual patient needs and appropriate health services, hopefully with results that lessen the individual’s emotional and existential confinement.

  • 30.
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    1990 - 2000: A Decade of Health Sector Reformin Developing Countries: Why, and What Did We Learn?2005Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Objective: The overall aim of the work is to contribute to a better understanding of the dynamics between health sector reform policies and practices as well as the factors that determine and shape the thinking about global public health; and to try out a framework for understanding the inter-linkages and interactions between the determinants for and the elements of health sector reforms and their implementation.

    Methods: The object of study was a contemporary phenomenon, consisting of a diverse array of interventions in many different directions and fields within a complex political, social and economic environment. It is difficult to attribute the effects of the reforms to any single intervention or to establish exact boundaries between the phenomenon and the context. Therefore, a multi-stage case study research strategy, based on the work of R.K.Yin, was chosen. The study involved two major sub-units of analysis, i.e., the macro and the micro level. Each of these involved several sub-units of analysis. The analysis of the micro level further comprised a cross-case analysis of 10 individual case studies conducted in six developing countries.

    Results: Clear linkages were found between the greater societal processes and the shape and results of reforms during the decade. The reforms had not been completed in any of the countries studied, but appeared to be stuck with undesired effects, lacking energy to move forward. Contributing to this was the diminishing role of the state, which bordered abdication from public health in most of the countries, leaving the drive to the market and individual demands and interests. The net effect could well be a reversal of some of the public health achievements of the past - however, it was also found that reverting to dedicated disease control programmes would not be the answer, as these were found unsustainable and undermining the health systems.

    Conclusion: There is a divide between libertarian and utilitarian values on the one side and communitarian and egalitarian values on the other. Thus, it is not just about public health practitioners not being good enough to implement, it is more so about what we want to achieve and what it acceptable respectively not acceptable and reaching compromises. This place the societal processes at centre-stage for public health. However, it is also about implementation, it is about how public health policy-makers and reformers can effectively dialogue and facilitate achieving consensus and translate the societal 'wants' and 'want nots' into managerial bites. Implementation becomes a process of constant adjustment and readjustment oscillating between political and technocratic levels

  • 31.
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    The proof of the reform is in the implementation.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S3-23Article in journal (Refereed)
    Abstract [en]

    In 2000, TDR funded a series of studies to examine the opportunities and threats of health sector reform to the control of tropical diseases. This article is a cross-case analysis of ten of those studies, exploring the similarities in patterns across the countries covered: Colombia, China, Nigeria, the Philippines, Sudan, Tanzania and Uganda. The implementation experiences across countries were strikingly similar despite very different socio-economic and epidemiological situations. The reform implementation was neither complete nor clean and had in all the countries found some sort of least-energy equilibrium where the processes had stopped at a sub-optimal stage needing considerable renewed 'change-energy' to achieve its objectives. The role of the state had, in several cases, been reduced to a situation where it neither pursued the interest of the public nor protected the individual against harm caused by the behaviours of others. Whether one should follow a dedicated disease control programme or a systems approach is not a relevant question. Effective disease control cannot be implemented without strong and functioning health systems and health system performance cannot be improved without considering which purpose the system is to serve.

  • 32.
    Blas, Erik
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Limbambala, M
    The challenge of hospitals in health sector reform: the case of Zambia.2001In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 16 Suppl 2, p. 29-43Article in journal (Refereed)
    Abstract [en]

    Zambia underwent a period of health sector reform from 1993 to 1998. The reform attracted substantial support from the World Bank and bilateral donors. While significant achievements were made with respect to decentralization, increased accountability and donor collaboration, the reform stalled in 1998 without having achieved its objectives, largely because of the handling of hospital reform and the civil servants in the health sector. This study was an attempt to analyze this experience with the hospital issue. Service and infrastructure information was collected from all 88 hospitals in the country. Further, information was collected about the social, economic, and political context of the reform. The results show that an historical legacy from the colonial and post-colonial eras has left the country with an expensive and skewed hospital structure that is rapidly deteriorating and very difficult to reform. The referral system is not functioning: higher-level hospitals provide a higher level of care to their immediate catchment populations than is available to the population in general. The reality is thus far from the vision of equity of access to cost-effective quality care. Zambian doctors have either left the country or are concentrated at the highest referral levels in two provinces, leaving the lower levels and most of the country in the hands of expatriate doctors. There are no resources in the government or the private systems to maintain the current hospital infrastructure and things will likely deteriorate unless radical decisions are taken and implemented. The study further shows that the question of hospital reform is a political high-risk zone. If the problems are to be dealt with, the Zambian planners must, together with the politicians, work to create a broad national consensus for understanding the situation, its urgency, and the limited options for forward action.

  • 33.
    Blas, Erik
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Limbambala, M
    User-payment, decentralization and health service utilization in Zambia.2001In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 16 Suppl 2, p. 19-28Article in journal (Refereed)
    Abstract [en]

    The study was undertaken to assess the impact of health sector reform from 1993 to 1997 in Zambia in respect of health care service utilization and the shift of caseload from hospitals to health centres. Four key indicators were chosen: general attendance, measles vaccinations, general admissions, and deliveries. Complete sets of district data were analyzed, covering 4.5 million people out of the total population in 1997 of 9.7 million. The results show, on the one hand, a dramatic decrease of about one-third in general attendance for both hospitals and health centres over a 2-year period, followed by a period with a continued but slower decrease. On the other hand, the results also show increases at health centres in measles vaccinations (up 40%), in admissions (up 25%) and in deliveries (up 60%). The study further documents a shift of caseload from hospitals to health centres for some key services. The health centre share increased from 72.2% to 79.8% for measles vaccinations, from 23.9% to 31.0% for general admissions, and from 22.9% to 32.4% for deliveries. However, the intended overall shift in outpatient caseload from hospitals to health centres did not materialize. The main lessons are: utilization patterns can be influenced by policies such as user-payment and decentralization; user payment in poor populations leads to dramatic declines in utilization of services; and decentralization with local control of resources could be an alternative to the traditional vertical disease programme approach for priority interventions.

  • 34.
    Blix, Ellen
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    INNKOMST-CTG. En vurdering av testens prediktive verdier, reliabilitet og effekt: Betydning for jordmødre i deres daglige arbeid2006Doctoral thesis, comprehensive summary (Other academic)
  • 35.
    Blix, Ellen
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Nordic School of Public Health NHV.
    Ohlund, Lennart S
    Norwegian midwives' perception of the labour admission test.2007In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 23, no 1, p. 48-58Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore what information and knowledge the labour admission test is perceived to provide and what meaning the test carries in the daily work of practising midwives.

    DESIGN: In-depth interviews transcribed verbatim and analysed using the grounded theory technique.

    SETTING: Four different labour wards in Norway.

    PARTICIPANTS: A theoretical sample of 12 practising midwives.

    FINDINGS: The core category "experiencing contradictions" was identified during the analyses, indicating that the midwives found conflicting interests within themselves, or between themselves and others when using the labour admission test. They experienced contradictions between professional identity and the increasing use of technology, between feeling safe and feeling unsafe and between having power and being powerless.

    KEY CONCLUSIONS: The labour admission traces could be difficult to interpret, especially for newly qualified midwives. Some midwives thought that a labour admission trace could protect them in case of litigation. The hierarchy of power in the labour ward influences the use and interpretation of the labour admission test. Some midwives felt their professional identity threatened and that midwives in general are losing their traditional skills because of the increasing use of obstetric technology.

    IMPLICATIONS FOR PRACTICE: The findings of the present study should be taken into consideration when changing practice to not routinely perform the labour admission test. There is also a need for further research on what effect the increasing use of obstetric technology has on traditional midwifery skills.

  • 36.
    Blix, Ellen
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Nordic School of Public Health NHV.
    Reiner, Liv M
    Klovning, Atle
    Oian, Pal
    Prognostic value of the labour admission test and its effectiveness compared with auscultation only: a systematic review.2005In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 112, no 12, p. 1595-604Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To assess the effectiveness of the labour admission test in preventing adverse outcomes, compared with auscultation only, and to assess the test's prognostic value in predicting adverse outcomes.

    DESIGN: Systematic review.

    SETTING: Labour wards in hospitals.

    POPULATION: Pregnant women in labour. Three randomised controlled trials including 11,259 women and 11 observational studies including 5831 women.

    METHODS: Literature searches in Medline, EMBASE, CINAHL, SweMed, The Cochrane Central Register of Controlled Trials, reference lists from identified studies and contact with experts.

    MAIN OUTCOME MEASURES: Obstetric interventions (augmentation of labour, continuous electronic fetal monitoring, epidural analgesia, fetal blood sampling and operative deliveries) and neonatal outcomes (perinatal mortality, Apgar score, seizures, resuscitation and admission to neonatal unit).

    RESULTS: Meta-analyses of the controlled trials found that women randomised to the labour admission test were more likely to have minor obstetric interventions like epidural analgesia [relative risk (RR) 1.2, 95% confidence interval (95% CI) 1.1-1.4], continuous electronic fetal monitoring (RR 1.3, 95% CI 1.2-1.5) and fetal blood sampling (RR 1.3, 95% CI 1.1-1.5) compared with women randomised to auscultation on admission. There were no significant differences in any of the other outcomes. From the observational studies, prognostic value for various outcomes was found to be generally poor. Likelihood ratio (LR) for a positive test was above 10 in 2 of 28 single outcomes and between 5 and 10 in six outcomes.

    CONCLUSIONS: There is no evidence supporting that the labour admission test is beneficial in low risk women.

  • 37.
    Blix, Ellen
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Sviggum, Oddvar
    Koss, Karen Sofie
    Øian, Pål
    Inter-observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts.2003In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 110, no 1, p. 1-5Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To assess the inter-observer agreement in assessment of the labour admission test between midwives and obstetricians in the clinical setting and two experts in the non-clinical setting, the inter-observer agreement between two experts in the non-clinical setting and to what degree fetal distress in labour could be predicted by the two experts.

    DESIGN: Observational study.

    SETTING: The maternity unit of Hammerfest Hospital, Norway.

    POPULATION: Eight hundred and forty-five high and low risk women.

    METHOD: The labour admission test was first assessed by the midwife or obstetrician in the clinical setting, and was later assessed by two experts. The traces were assessed as normal, equivocal or ominous. Weighted kappa (kappaw), proportion of agreement (Pa) and predictive values were calculated.

    MAIN OUTCOME MEASURES: Weighted kappa, proportion of agreement, sensitivity, positive predictive value and likelihood ratios.

    RESULTS: Inter-observer agreement between Expert 1 and Expert 2: kappaw 0.38 (CI 0.31-0.46), Pa for reactive labour admission test 0.86 (CI 0.83-0.88) and Pa for equivocal/ominous test 0.33 (CI 0.26-0.40). Agreement between Expert 1 and midwives/obstetricians: kappaw 0.25 (CI 0.15-0.36), Pa for reactive labour admission test 0.89 (CI 0.87-0.91) and Pa for equivocal/ominous labour admission test 0.18 (CI 0.11-0.25). Agreement between Expert 2 and midwives/obstetricians: kappaw 0.28 (CI 0.20-0.37), Pa for reactive labour admission test 0.85 (CI 0.82-0.88) and Pa for equivocal/ominous test 0.20 (CI 0.14-0.26). Totally 5.9% of the newborns had fetal distress. At cutoff equivocal test, sensitivity was 0.22 and 0.31 in the two observers. Positive predictive values were 0.13 and 0.11. Likelihood ratio for a positive test was 2.30 and 1.92 and likelihood ratio for a negative test 0.86 and 0.83.

    CONCLUSION: A labour admission test is still routine practice in most obstetric units in the Western world when there is little evidence on its benefits. The results from this study may provide some reconsideration for such practice, and for more research.

  • 38.
    Blix, Ellen
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Nordic School of Public Health NHV.
    Øian, Pål
    Labor admission test: an assessment of the test's value as screening for fetal distress in labor.2001In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 80, no 8, p. 738-43Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To determine if the labor admission test (LAT) can predict fetal distress in a population of laboring women, and in subgroups of low- or high-risk women, who delivered within six hours or between six and 24 hours after LAT.

    METHODS: The data charts of all women who delivered at Hammerfest Hospital in 1996, 1997 and 1998 were retrospectively read. If the woman was admitted to the hospital because of onset of labor, was in the first stage of labor and delivered within 24 hours after admission, she was included. In the study period, 1639 gave birth and 932 were included in the study. A descriptive analysis of the population and assessment of LAT's sensitivity, positive predictive value, specificity and negative predictive value at different cut-off values was done.

    RESULTS: In the study population 5.8% had fetal distress, and 5.3% had an operative delivery because of fetal distress. LAT's sensitivity in the whole population was 0.15 and positive predictive value was 0.16. Specificity was 0.95 and positive predictive value was 0.95. In the subgroups of low- and high-risk women, who delivered within six hours or between six and 24 hours after LAT, sensitivity varied between 0 and 0.36, and positive predictive value varied between 0 and 0.27. Specificity varied between 0.92 and 0.96, and negative predictive value varied between 0.89 and 0.97.

    CONCLUSIONS: According to these results, LAT cannot be recommended as a screening test for fetal distress in labor in low-risk women. Sensitivity is too low, and there are too many false-positive tests. It is unclear if LAT has benefits among high-risk women.

  • 39.
    Cabrera, Claudia
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Socio-economic Status and Health in Women: Population-based studies with emphasis on lifestyle and cardiovascular disease2005Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The aim of this thesis was to investigate socio-economic status in relation to morbidity and mortality, in particular cardiovascular disease among women using data from two population based studies from Sweden. The secondary aim was to explore mechanisms potentially linking socio-economic status to health, assessing for example dental, dietary, and lifestyle factors. Samples: The Population Study of Women in Gothenburg Sweden was begun in 1968-69. A representative random sample of 1,622 women was selected according to date of birth and within the strata 38, 46, 50, 54, and 60 years of age; the participation rate was 90 percent. The Gerontological and Geriatric Population Studies in Gothenburg (H-70) are based on representative samples of 70-year olds from Göteborg, Sweden who participated in a series of cross sectional and longitudinal studies between1971 and 2000. Participation rates ranged from 86 percent for men and 83 percent for women in the 1901/2 birth cohort to 65 percent for men and 69 percent for women in the 1930 birth cohort. Main results: High socio-economic status was associated with a decreased risk for cardiovascular disease [RR 0.49; CI 0.24 – 0.99] in middle aged women independently of risk factors such as smoking and obesity;moreover opposing monotonic trends were seen for mortality from cancer and cardiovascular disease in relation to socio-economic status. Tooth loss, a proxy for cumulative lifetime oral infection was also associated with an increased risk for cardiovascular disease in women independently of socio-economic factors such as the husband’s occupational category, income, and educational level. Among 70-year old cohorts, later-born women were heavier and had higher body mass index than earlier-born women within the high education group only. However, secular increases in waist-hip ratio were seen in both educational groups. Compared to earlier-born cohorts of 70-year old men, later-born cohorts had higher body mass index and cholesterol levels across social strata, and heart disease and diabetes mellitus became more prevalent. Among the elderly, secular trends indicated greater improvements in cardiovascular risk factors among women than men, with exception to smoking and alcohol consumption. Diet quality and food selection were assessed in relation to socio-economic status in the youngest cohort of 70-year olds born in 1930. Socio-economic disparities in diet quality were detected in men but not in women. Conclusions: From a public health perspective, it is suggested that risk factor patterns should be investigated in association with socio-economic status in order to expose health inequalities, and to develop more equitable interventions for cardiovascular disease prevention.

  • 40.
    Cabrera, Claudia
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Hakeberg, Magnus
    Ahlqwist, Margareta
    Wedel, Hans
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Björkelund, Cecilia
    Bengtsson, Calle
    Lissner, Lauren
    Can the relation between tooth loss and chronic disease be explained by socio-economic status? A 24-year follow-up from the population study of women in Gothenburg, Sweden.2005In: European Journal of Epidemiology, ISSN 0393-2990, E-ISSN 1573-7284, Vol. 20, no 3, p. 229-36Article in journal (Refereed)
    Abstract [en]

    The objective of this study was to evaluate the association between number of missing teeth and all cause, cardiovascular, and cancer mortality as well as morbidity and to explore whether socio-economic factors mediate this association. An ongoing prospective cohort study of 1462 Swedish women included a dental survey in 1968/69 with follow-up until 1992/93. The dental examination included a panoramic radiographic survey and a questionnaire. Number of missing teeth at baseline was analysed in a Cox proportional hazards model to estimate time to mortality and morbidity. Number of missing teeth, independently of socio-economic status variables (the husband's occupational category, combined income, and education) was associated with increased all cause mortality and cardiovascular disease mortality respectively (relative risk (RR): 1.36; 95% confidence interval (95% CI): 1.18-1.58) and (RR: 1.46; 95% CI: 1.15-1.85 per 10 missing teeth), but no associations were found for cancer mortality (RR: 1.18; 95% CI: 0.91-1.52). The relation between poor oral health and future cardiovascular disease could not be explained by measures of socio-economic status in this study.

  • 41.
    Cabrera, Claudia
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Helgesson, Östen
    Wedel, Hans
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Björkelund, Cecilia
    Bengtsson, Calle
    Lissner, Lauren
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Socioeconomic status and mortality in Swedish women: opposing trends for cardiovascular disease and cancer.2001In: Epidemiology (Cambridge, Mass.), ISSN 1044-3983, Vol. 12, no 5, p. 532-6Article in journal (Refereed)
    Abstract [en]

    We examined relations between socioeconomic status and cardiovascular disease, cancer, and diabetes mellitus in a 24-year prospective study of 1,462 Swedish women. Two socioeconomic indicators were used: the husband's occupational category for married women and a composite indicator combining women's educational level with household income for all women. The husband's occupational category was strongly associated with cardiovascular disease and cancer mortality in opposite directions, independent of age and other potential confounders. Women with husbands of lower occupational categories had an increased risk of cardiovascular disease mortality [relative risk (RR) = 1.60; 95% confidence interval (95% CI) = 1.09-2.33] while experiencing lower rates of all-site cancer mortality (RR = 0.69; 95% CI = 0.50-0.96). A similar relation was seen with the composite variable: women with low socioeconomic status had an increased risk of cardiovascular disease (RR = 1.37; 95% CI = 1.01-1.84) but a somewhat lower risk for cancer of all sites (RR = 0.86; 95% CI = 0.66-1.11). Finally, morbidity data (diabetes mellitus, stroke, and breast cancer) yielded results that were consistent with the mortality trends, and breast cancer appeared to account for a major part of the association between total cancer and high socioeconomic status. In summary, higher socioeconomic status was associated with decreased cardiovascular disease mortality and excess cancer mortality, in such a way that only a weak association was seen for all-cause mortality.

  • 42.
    Cabrera, Claudia
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Rothenberg, E
    Eriksson, Bo G
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Wedel, Hans
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Eiben, G
    Steen, B
    Lissner, Lauren
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Socio-economic gradient in food selection and diet quality among 70-year olds.2007In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 11, no 6, p. 466-73Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The aim of this study was to assess social disparities in food choices and diet quality in a population of 70-year old Swedes.

    DESIGN: Cross-sectional study among participants in the 2000 Gerontological and Geriatric Population Studies in Goteborg.

    PARTICIPANTS: A representative population of men (n=233) and women (n=321) from Goteborg, a city on the south western coast of Sweden.

    METHODS: One hour diet history interviews were performed and 35 specific foods and food groups were identified; in addition a diet quality index (DQI) was calculated. Differences in food choices and diet quality scores were tested across educational and socio-economic index categories (SEI).

    RESULTS: Men with higher education and SEI had higher diet quality scores than those with lower socio-economic status, while no differences in DQI were noted in women. Further analysis of women based on their husband's occupational group also yielded no differences in diet quality. When studying individual foods, socio-economic differences were observed in women and men.

    CONCLUSIONS: Selection of food varies by education and occupational status in both sexes although socio-economic disparities in diet quality were observed in men only.

  • 43.
    Cabrera, Claudia
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Wilhelmson, Katarina
    Allebeck, Peter
    Wedel, Hans
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Steen, Bertil
    Lissner, Lauren
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Cohort differences in obesity-related health indicators among 70-year olds with special reference to gender and education.2003In: European Journal of Epidemiology, ISSN 0393-2990, E-ISSN 1573-7284, Vol. 18, no 9, p. 883-90Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to describe cohort differences in health indicators among four birth cohorts of 70-year old men and women from Göteborg, Sweden, born in 1901/2, 1905/6, 1911/12, and 1922. With special reference to gender, education, and obesity, it is hypothesized that changes in health among elderly men and women may not be occurring in a uniform manner. The variables studied were: systolic and diastolic blood pressures, triglycerides, cholesterol, height, weight, body mass index, waist-hip ratio, physical inactivity, current smoking, and alcohol consumption, plus selected prevalent diseases. Logistic and linear regression models were used to test for secular trends and effect modification by gender. Most trends in metabolic and lifestyle indicators varied in relation to gender as well as education. For instance, later-born male cohorts were more overweight than earlier-born groups while the later-born female cohorts had similar relative weights but a more centralized fat patterning. These cohort differences further varied by education where later-born men with less education and later-born women with higher education tended to be more overweight, compared to earlier-born cohorts. Finally, significant cohort differences in previously diagnosed myocardial infarction, stroke, and diabetes mellitus at age 70 were observed in men only. Interaction terms revealed that the gender difference was statistically significant only in the case of diabetes mellitus. In conclusion, secular trends in many obesity-related health indicators among 70-year old Swedish cohorts were dependent on both gender and socio-economic factors.

  • 44.
    Carlsson, Lennart
    Nordic Council of Ministers, Nordic School of Public Health NHV. Västra Götalandsregionen.
    Utvärdering av verksamheten vid Enheten för Asyl- och flyktingfrågor, Västra Götalandsregionen: RAPPORT – 26 Maj 20092010Report (Other academic)
    Abstract [sv]

    Vi inleder med en kort beskrivning av NCHSA, det centrum som fått föreliggande utvärde-ringsuppdrag. Nordic Centre for Health and Social Assessment (NCHSA), verksamt vidNordiska högskolan för folkhälsovetenskap (NHV), har till uppgift att erbjuda nordiska organisationer och institutioner inom välfärdsområdet utvärderingskompetens på uppdragsbasis. NCHSA håller samman ett kunskapsnätverk knutet till NHV som består av en mix av forskare som i sina uppdrag tillämpar vetenskaplig metodik. NCHSA är kopplad till akademiska institutioner vilket innebär att NCHSA endast tar uppdrag vars resultat och erfarenheter får användas i forskningssammanhang. NCHSA har, enligt styrelsens intentioner, under de första verksamhetsåren 2008-2009 koncentrerat uppdragen till Norge och Sverige. För mer utförlig information hänvisas till www.nchsa.se.

    Västra Götalandsregionen (VGR) har, via Regionöverläkare Karin Stenqvist, önskat en utvärdering av Enheten för Asyl- och flyktingfrågor (EAF) vid kanslienheten på hälso- och sjukvårdsavdelningen. EAF bildades 2004 och sägs ha skördat framgång-ar i sitt arbetssätt genom att ha skapat ordning, struktur och rutiner för hälso- och sjukvård till asylsökande och flyktingar. Man vill gå vidare genom att samtidigt som man bevarar sin initiala flexibilitet också utvecklar sin förmåga till förnyelse. Önskan om utvärdering ska ses som ett sätt att dels dokumentera och analysera verksam-hetens framgångsfaktorer, dels ge input till den avsedda förnyelsen. Uppdraget har lämnats till NCHSA. Det har genomförts av fil dr Lennart Carlsson, forskaranknuten till Karolinska Institutet. Lennart Carlsson ingår i NCHSA:s kunskapsnätverk.Uppdraget gäller genomförandet av en utvärdering med lärande ansats, där enhe-tens roll som kunskaps- och kommunikationsnav för hälso- och sjukvårdsfrågor för asylsökande ska beskrivas, analyseras och värderas.

    Genomförande

    Uppläggningen av arbetet har planerats och genomförs i tre faser enligt följande

    • dokument studie inklusive litteraturgenomgång
    • självvärdering genomförd av enhetens båda medarbetare
    • individuella intervjuer

    Dokumentstudien och självvärderingen genomfördes under hösten 2008. Intevjuer och komplettering av uppgifter till dokumentstudien genomfördes i huvudsak under första kvartalet 2009.

    En styrgrupp bestående av tre forskare vid NHV har följt och kommenterat arbetet under dess gång.

    EAF har analyserats ur tre olika aspekter. Den första handlar om enhetens uppdrag och organisering och omfattar: enhetens uppdrag, enhetens organisationsform och organisatoriska placering, rutiner för hälsoundersökning samt de asylsökandes boende- eller vistelseformer. Den andra handlar om information, där uppgiftsflöden mellan organisationsenheter analyseras. Den tredje handlar om relationering, där förmåga till nätverksbyggande analyseras.I analogi med den lärande ansatsen i utvärderingsarbetet avslutas rapporten med tre strategiska frågeställningar som bedöms viktiga att uppmärksamma inför fram-tiden. Dessa redovisas nedan.SlutsatserEAF upplevs av omvärlden som en trygg, tillförlitlig och uppdaterad kunskapskälla inom ett besvärligt verksamhetsfält. Verksamheten är dock sårbar genom sin liten-het beroende på att den bygger på ett nära samarbete mellan två medarbetare med kompletterande kompetenser. Utvärderingen visar att EAF har hög måluppfyllelse vad gäller både antal genomförda hälsoundersökningar och den tidsgräns på två månader som satts som mål för dessa undersökningar. Med detta menas att hälso-undersökning är utförd inom denna tidsgräns efter den asylsökandes ankomst till Sverige. Ett arbete som möjliggör kvalitetssäkring av hälsoundersökningar inklusive hälsosamtal har satts igång. Enhetens framgångsformel re – en sjuksköterska och en ekonom. Medarbetarna har korta beslutsvägar genom sin centrala placering. De har hälso- och sjukvårdsled-ningens förtroende och ges därmed möjlighet att arbeta självständigt. Enhetens re-sultat är mätbart och EAF fungerar idag som ett förtroendeingivande kunskapsnav för frågor om asylsökandes hälso- och sjukvård.

    1. Hur bidrar häslo- och sjukvårdslednigen till att ge EAF fortsatt legimitet?

    2. Hur omprövas uppdraget till EAF? Fokus på vårdens innehåll och kvalitet.

    3. Hur säkerställer EAF att verksamheten fungerar om fem år?

  • 45.
    Chudal, Roshan
    et al.
    Department of Child Psychiatry, University of Turku, Turku, Finland.
    Gissler, Mika
    Nordic Council of Ministers, Nordic School of Public Health NHV. Department of Child Psychiatry, University of Turku, Turku, Finland / National Institute for Health and Welfare, Helsinki, Finland.
    Sucksdorf, Dan
    Department of Child Psychiatry, University of Turku, Turku, Finland.
    Lehti, Venla
    Department of Child Psychiatry, University of Turku, Turku, Finland.
    Suominen, Auli
    Department of Child Psychiatry, University of Turku, Turku, Finland.
    Hinkka- Yli-Salomaki, Susanna
    Department of Child Psychiatry, University of Turku,.
    Brown, Alan S
    Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY, USA, / Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, NY, USA.
    Sourander, Andre
    Department of Child Psychiatry, University of Turku, Turku, Finland / Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY, USA / Regional Centre for Child and Youth Mental Health and Child Welfare, University of Tromsø, Tromsø, Norwa.
    Parental age and the risk of bipolar disorders2014In: Bipolar Disorders, ISSN 1398-5647, E-ISSN 1399-5618, ISSN 1398-5647Article in journal (Refereed)
    Abstract [en]

    Objectives:Studies on the association between parental age and bipolardisorder (BPD) are scarce and with inconsistent findings. The aim of thisstudy was to examine the association of parental age and age differencebetween parents with risk of BPD in offspring.Methods:This nested case–control study identified 1,861 cases ofindividuals with BPD born in Finland during 1983–1998 and diagnosedby the end of 2008, and 3,643 sex- and date of birth-matched controlsfrom nationwide population-based registers. Conditional logisticregression was used to examine the association adjusting for potentialconfounding due to age of the other parent, parental psychiatric history,educational level, and place of birth.Results:A U-shaped association of unadjusted odds ratios (ORs) forBPD risk was seen in different paternal age categories, with the oddsincreasing at both ends of the age spectrum. In the adjusted analyses,offspring of fathers aged≥50 years had a 2.8-fold increased odds[OR=2.84, 95% confidence interval (CI): 1.32–6.12] of BPD ascompared to those with fathers aged 30–34 years. The odds wereincreased 1.3-fold (OR=1.35, CI: 1.06–1.72) in fathers aged 20–24 years. No significant association was found between maternal ageand BPD in the adjusted analyses. Age difference between parents wasnot associated with BPD.Conclusions:The increased risk of BPD in offspring of the youngest andoldest fathers in the study suggests the involvement of differentbiological and psychosocial factors at the two ends of the paternal agespectrum. These findings may be significant in the context of advancingparental age in recent times.

  • 46.
    Clancy, Ann
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    A profession under threat? An exploratory case study of changes in Norwegian public health nursing.2007In: International Nursing Review, ISSN 0020-8132, E-ISSN 1466-7657, Vol. 54, no 2, p. 197-203Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The first courses for public health nurses in Norway were held in the 1920s-1930s. In 1957, the Act regulating public health nursing was passed. Norwegian public health nurses have a primary role in promoting health and preventing illnesses. Their role has changed with a changing society. This article shows some of the challenges the nurses have faced. It focuses on collaboration, tasks, leadership and authority/status.

    AIMS: The study's intentions are exploratory. It looks into how the nurses experience their changing role.

    METHODS: A single case with an embedded design is the method chosen; the case is 'Changes in the role of the Norwegian public health nurse during the period 1984-2005'. Document analysis and interviews are sources of evidence.

    FINDINGS: The findings show that public health nurses' visibility seems to be an important issue. There are some divergences between relevant literature on the nurses' professional status and the views of the nurses in the study. Several other public health professionals have lost tasks and formal positions of authority.

    CONCLUSION: The nurses interviewed still feel that they are a respected and trusted profession despite being less visible. A recent study among parents who frequent local clinics confirms their important role. Can the nurses' lack of visibility have undesired outcomes? A profession that is unassuming, not visible and that fights silent battles may have problems being heard when it tries to promote issues concerning family health. Further studies are indicated.

  • 47.
    Clancy, Ann
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Perceptions of public health nursing practice On borders and boundaries, visibility and voice2009Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Aim: The aim of this comprehensive thesis is to explore different perceptions of public health nursing practice. The intention being to contribute to developing the service, theoretically and practically, in throe with current and future public health needs.

    Methods: The thesis comprises five studies. Public health nurses, young people, parents and decision makers are interviewed and share their perceptions of public health nursing practice (studies I, II, III and IV). Consultations at local child health clinics, clinics for young people and at school health services are observed (study III). A cross sectional study amongst a sample of doctors, public health nurses, midwives and child protection workers is carried out (study V). The first four studies have an explorative, descriptive design. Study V, with its focus on interprofessional collaboration, is based on the results of studies I, II, and IV.

    Findings: Study I, a case study, provides a backdrop for the remaining four studies. It focuses on changes the nurses have faced during the period 1984-2005. The results point to issues of visibility and that respect is more important for the nurses than authority or status. Study II is a philosophical study based on interviews with public health nurses. It gives an introduction to the philosophy of Emmanuel Levinas and develops a novel theoretical and practical understanding of aspects of responsibility in public health nursing. Study III shows the importance of relationships with service users in public health nursing practice; and that not only pleasantness but also honesty and openness are important. This study has contributed to further developing models of public health nursing interventions. Decision makers in study IV point to the challenges public health nurses face regarding collaboration, visibility and boundaries. Study V is a cross sectional questionnaire study that focuses on interprofessional collaboration. The results show that size of municipality can influence frequency of meeting points and views on issues relating to collaboration; and that mental health services are those most missed in collaborative relationships. The findings warrant further research and should be of interest when organising municipal health- and social services in Norway.

    Conclusions: The thesis concludes that service users and decision makers are satisfied with public health nursing services, but that public health nurses face challenges related to collaboration, to boundaries for knowledge and involvement, and in making their health promotive function visible

  • 48.
    Clancy, Ann
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Gressnes, Thomas
    Harstad University College, Harstad, Norway.
    Svensson, Tommy
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Public health nursing and interprofessional collaboration in Norwegian municipalities: a questionnaire study.2013In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 27, no 3, p. 659-68Article in journal (Refereed)
    Abstract [en]

    The purpose of this study was to examine collaboration relating to public health nursing in different sized Norwegian municipalities. It sought to gain insight into factors that are important for successful collaboration, frequency of meeting points for collaborating activities and missing professionals in different sized municipalities. A cross-sectional e-post questionnaire study was carried out on a national sample of public health nurses and their collaborators. A total of 849 public health nurses (43.64%), 113 doctors at clinics and school health services (54.8%), 519 child protection workers (16.34%) and 115 midwives (41.3%) returned the questionnaire. The data were analysed using descriptive and inferential statistics. Analysis of variance (anova), Kruskal-Wallis H and chi-square tests were used to tests differences between groups. Trust, respect and collaborative competence were ranked highest by all the respondents and formalised structures, economy and leadership ranked least important in collaborative activity. The majority of the respondents stated that they do not have fewer meeting points compared with 5 years ago. Collaboration with mental health services was missed most by all respondents. There were associations between frequency of meeting points and statements on collaboration related to municipality size. Norway is in the throes of a major coordination reform. The fact that relational factors were deemed most important for successful collaboration is an important finding at a time when focus is on structural change. The findings indicate the need for further in depth qualitative studies on reasons for 'missing collaborators,' on professional cultures in different sized municipalities and on interpersonal relationships. Qualitative enquiry is necessary to gain a greater understanding of how relational concepts of respect, trust and conflict are understood by municipal public health professionals.

  • 49.
    Clancy, Ann
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Svensson, Tommy
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    'Faced' with responsibility: Levinasian ethics and the challenges of responsibility in Norwegian public health nursing.2007In: Nursing Philosophy, ISSN 1466-7681, E-ISSN 1466-769X, Vol. 8, no 3, p. 158-66Article in journal (Refereed)
    Abstract [en]

    This paper is concerned with aspects of responsibility in Norwegian public health nursing. Public health nursing is an expansive profession with diffuse boundaries. The Norwegian public health nurse does not perform 'hands on' nursing, but focuses on the prevention of illness, injury, or disability, and the promotion of health. What is the essence of ethical responsibility in public health nursing? The aim of this article is to explore the phenomenon based on the ethics of responsibility as reflected upon by the philosopher Emanuel Levinas (1906-1995). From an ethical point of view, responsibility is about our duty towards the Other, a duty we have not always chosen, are prepared for, or can fully explain; but it is nevertheless a demand we have to live with. Interviews with five experienced Norwegian nurses provide the empirical base for reflection and interpretation. The nurses share stories from their practice. In interpreting the nurses' stories, the following themes emerge: personal responsibility; boundaries; temporality; worry, fear, and uncertainty; and a sense of satisfaction. As the themes are developed further, it becomes apparent that, despite their diversity, they are all interrelated aspects of ethical responsibility. Responsibility for the Other cannot be avoided, ignored, or transferred. The nurses' responsibility is personal and infinite. Levinasian ethics can help nurses understand the importance of accepting that being a responsive carer can involve not only contentment in the predictable, but also the fear, worry, and uncertainty of the unpredictable.

  • 50.
    Clancy, Ann
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Svensson, Tommy
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Perceptions of public health nursing consultations:: tacit understanding of the importance of relationships2010In: Primary Health Care Research and Development, ISSN 1463-4236, E-ISSN 1477-1128, Vol. 11, no 4Article in journal (Refereed)
    Abstract [en]

    Aim This study aims to describe and reflect upon how a sample of nurses, parents and young people experience consultations at local clinics and school health services. Central to the concept of health promotion is ensuring that focus is on the empowerment of clients through dialogue and participation. This study aims to explore public health nursing consultations with this in mind.

    Background Norwegian public health nurses are in contact with almost all families at the child health clinic. They meet children and young people at school health services and youth clinics; putting them in an important position to promote health and prevent illnesses.

    Methods Participant observations and in-depth interviews are the methods chosen. The data were analysed using qualitative content analysis.

    Findings The study shows that good relationships are not only sustained by pleasantness but also by honesty and directness, provided that the relationship is based on trust and sincerity. Continuity and trust in services seem paramount to the service users’ satisfaction. Service users were not always able to put the reason for their appreciation into words, just as the nurses had difficulty verbalising their strategies. Words often fall short when attempts are made to capture the essence of caring, trust and other life phenomena. Openness on agenda and focus on feedback from service users are important in order to ensure empowering services. Further studies should address the interconnectedness of the service and the subtleties of public health nursing consultations

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