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  • 301.
    Nguyen, Huong Thu
    Nordic Council of Ministers, Nordic School of Public Health NHV. Research Institute for Child Health, National Hospital of Pediatrics, 18/879 La Thanh road, Hanoi, Dong Da district, Vietnam..
    Birth weight and growth during the first two years of life: a study in urban and rural Vietnam2014Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Differences in health and living conditions between urban and rural settings can be seen as an important example of gaps between population groups. Birth weight and child growth are important predictors for the future health of a person and at aggregate level, for the public health of a population.The general aim of this thesis is to describe and discuss birth weight, physical growth and breastfeeding of children, as well as associated factors, from birth to 24 months of age in urban and rural areas of Vietnam, thus contributing to the evidence base for health strategy and policy.

    Methods: Two Health and Demographic Surveillance Sites in Hanoi were used; urban Dodalab and FilaBavi in the rural part. To study rural birth weight 1999 to 2010 information was obtained for 10,114 newborn in FilaBavi. To study urban rural growth disparities 2008-2010, 1,466 children were followed for two years after birth with measurements of weight and length. A study of breastfeeding included 2,572 mothers followed for one year after delivery. Background information about households and mothers was taken from routine surveys in the two sites.

    Results: The mean birth weight in FilaBavi remained stable at about 3,100 grams, over the 12 years studied despite rapid economic and technological development. At the individual level we found birth weight to be associated with household economy and the education of mothers. In the urban rural comparison, the mean birth weight for urban boys and girls were 3,298 and 3,203 g as compared with 3,105 and 3,057 g for the rural infants. Children in the urban area grew faster than those in the rural area. There were markedly higher frequencies of stunting in the rural area compared with the urban. The initiation of breastfeeding during the first hour of life was more frequent in the urban area. Exclusive breastfeeding during the first three months of age was more commonly reported in the rural than in the urban area. Both birth weight and child growth were statistically significantly and positively associated with economic conditions and mother’s education.

    Conclusion: The results of the studies presented in this thesis show that there are large and important differences in child birth weight, child growth and infant breastfeeding between urban and rural areas. There are also major differences between the areas with respect to education and economic resources. All predictors of child birth weight and growth discussed are directly or indirectly associated with the social and economic conditions. Globalization and urbanization means obvious risks for increasing gaps between as well as within the rural and urban areas. Large discrepancies in a society will lead to serious public health problems in all segments of the population, not only the underprivileged.

  • 302.
    Nguyen, Huong Thu
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Research Institute for Child Health, National Hospital of Pediatrics, 18/879 La Thanh road, Hanoi, Dong Da district, Vietnam..
    Eriksson, Bo
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Nguyen, Liem Thanh
    Nguyen, Chuc Thi Kim
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Petzold, Max
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Bondjers, Göran
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Ascher, Henry
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Physical growth during the first year of life.: A longitudinal study in rural and urban areas of Hanoi, Vietnam.2012In: BMC pediatrics, ISSN 1471-2431, Vol. 12, p. 26-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Good infant growth is important for future health. Assessing growth is common in pediatric care all over the world, both at the population and individual level. There are few studies of birth weight and growth studies comparing urban and rural communities in Vietnam. The first aim is to describe and compare the birth weight distributions and physical growth (weight and length) of children during their first year in one rural and one urban area of Hanoi Vietnam. The second aim is to study associations between the anthropometric outcomes and indicators of the economic and educational situations.

    METHODS: Totally 1,466 children, born from 1st March, 2009 to June 2010, were followed monthly from birth to 12 months of age in two Health and Demographic Surveillance Sites; one rural and one urban. In all, 14,199 measurements each of weight and length were made. Birth weight was recorded separately. Information about demographic conditions, education, occupation and economic conditions of persons and households was obtained from household surveys. Fractional Polynomial models and standard statistical methods were used for description and analysis.

    RESULTS: Urban infants have higher birth weight and gain weight faster than rural infants. The mean birth weight for urban boys and girls were 3,298 grams and 3,203 grams as compared to 3,105 grams and 3,057 grams for rural children. At 90 days, the urban boys were estimated to be 4.1% heavier than rural boys. This difference increased to 7.2% at 360 days. The corresponding difference for girls was 3.4% and 10.5%. The differences for length were comparatively smaller. Both birth weight and growth were statistically significantly and positively associated with economic conditions and mother education.

    CONCLUSION: Birth weight was lower and the growth, weight and length, considerably slower in the rural area, for boys as well as for girls. The results support the hypothesis that the rather drastic differences in maternal education and economic conditions lead to poor nutrition for mothers and children in turn causing inferior birth weight and growth.

  • 303.
    Nguyen, Huong Thu
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Research Institute for Child Health, National Hospital of Pediatrics, 18/879 La Thanh road, Hanoi, Dong Da district, Vietnam..
    Eriksson, Bo
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Petzold, Max
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Bondjers, Göran
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Tran, Toan Khanh
    Nordic Council of Ministers, Nordic School of Public Health NHV. Family Medicine Department, Hanoi Medical University, Vietnam.
    Nguyen, Liem Thanh
    Ascher, Henry
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Factors associated with physical growth of children during the first two years of life in rural and urban areas of Vietnam.2013In: BMC pediatrics, ISSN 1471-2431, Vol. 13, p. 149-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Differences between urban and rural settings can be seen as a very important example of gaps between groups in a population. The aim of this paper is to compare an urban and a rural area regarding child growth during the first two years of life as related to mother's use of antenatal care (ANC), breastfeeding and reported symptoms of illness.

    METHODS: The studies were conducted in two Health and Demographic Surveillance Sites, one rural and one urban in Hanoi, Vietnam.

    RESULTS: We found that children in the urban area grow faster than those in the rural area. There were statistical associations between growth and the education of the mother as well as household resources. There were positive correlations between the number of ANC visits and child growth. We also saw a positive association between growth and early initiation (first hour of life) of breastfeeding but the reported duration of exclusive breastfeeding was not statistically significantly related to growth. Reporting symptoms of illness was negatively correlated to growth, i.e. morbidity is hampering growth.

    CONCLUSIONS: All predictors of growth discussed in this article, ANC, breastfeeding and illness, are associated with social and economic conditions. To improve and maintain good conditions for child growth it is important to strengthen education of mothers and household resources particularly in the rural areas. Globalization and urbanization means obvious risks for increasing gaps not least between urban and rural areas. Improvement of the quality of programs for antenatal care, breastfeeding and integrated management of childhood illness are also needed in Vietnam.

  • 304.
    Nguyen, Huong Thu
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Research Institute for Child Health, National Hospital of Pediatrics, 18/879 La Thanh road, Hanoi, Dong Da district, Vietnam..
    Eriksson, Bo
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Tran, Toan Khanh
    Nordic Council of Ministers, Nordic School of Public Health NHV. Family Medicine Department, Hanoi Medical University, Vietnam.
    Nguyen, Chuc Thi Kim
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Ascher, Henry
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Birth weight and delivery practice in a Vietnamese rural district during 12 year of rapid economic development.2013In: BMC pregnancy and childbirth, ISSN 1471-2393, Vol. 13, p. 41-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Since the Doi Moi reform 1986 economic conditions in Vietnam have changed significantly and positive health and health care developments have been observed. International experience shows that improved economic conditions in a country can reduce the risk of perinatal mortality, decrease the risk of low birth weight and increase the mean birth weight in newborns. The Health and Demographic Surveillance Site (HDSS) FilaBavi in Bavi district outside Hanoi city has been operational since 1999. An open cohort of more than 12,000 households (52,000 persons) has been followed primarily with respect to demography, economy and education. The aim of this research is to study trends in birth weight as well as birth and delivery practices over the time period 1999-2010 in FilaBavi in relation to the social and economic development.

    METHODS: Information about birth weight, sex, place and method of delivery, mother's age and education as well as household economy of 10,114 children, born from 1999 to 2010, was obtained from the routine data collection in the HDSS.

    RESULTS: Over the study period the mean birth weight remained at the same level, about 3,100 g, in spite of increased economic resources and technology development. At the individual child level we found associations between birth weight and household economy as well as the education of the mother. Hospital delivery increased from about 35% to 65% and the use of Caesarian section increased from 2.6% to 10.1%.

    CONCLUSION: During the twelve years studied, household income as well as the use of modern technology increased rapidly. In spite of that, the mean and variation of birth weight did not change systematically. It is suggested that increasing gaps in economic conditions and misallocation of resources, possibly to overuse of technology, are partly responsible.

  • 305.
    Nguyen, Huong Thu
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV. Research Institute for Child Health, National Hospital of Pediatrics, 18/879 La Thanh road, Hanoi, Dong Da district, Vietnam..
    Eriksson, Bo
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Tran, Toan Khanh
    Nordic Council of Ministers, Nordic School of Public Health NHV. Family Medicine Department, Hanoi Medical University, Vietnam.
    Petzold, Max
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Bondjers, Göran
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Nguyen, Chuc Thi Kim
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Thanh, Liem Nguyen
    Ascher, Henry
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Breastfeeding practices in urban and rural Vietnam.2012In: BMC public health, ISSN 1471-2458, Vol. 12, p. 964-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to describe and compare breastfeeding practices in rural and urban areas of Vietnam and to study associations with possibly influencing person and household factors. This type of study has not been conducted in Vietnam before.

    METHODS: Totally 2,690 children, born from 1st March 2008 to 30th June 2010 in one rural and one urban Health and Demographic Surveillance Site, were followed from birth to the age of 12 months. Information about demography, economy and education for persons and households was obtained from household surveys. Standard statistical methods including survival and regression analyses were used.

    RESULTS: Initiation of breastfeeding during the first hour of life was more frequent in the urban area compared to the rural (boys 40% vs. 35%, girls 49% vs. 40%). High birth weight and living in households with large number of assets significantly increased the probability for early initiation of breastfeeding. Exclusive breastfeeding at three months of age was more commonly reported in the rural than in the urban area (boys 58% vs. 46%, girls 65% vs. 53%). The duration of exclusive breastfeeding as well as of any breastfeeding was longer in the rural area than in the urban area (medians for boys 97 days vs. 81 days, for girls 102 days vs. 91 days). The percentages of children with exclusive breastfeeding lasting at least 6 months, as recommended by WHO, were low in both areas. The duration of exclusive breastfeeding was significantly shorter for mothers with three or more antenatal care visits or Caesarean section in both areas. High education level of mothers was associated with longer duration of exclusive breastfeeding in the rural area. No significant associations were found between duration of exclusive breastfeeding and mother's age, household economy indicators or household size.

    CONCLUSION: Intervention programs with the aim to promote breastfeeding are needed. Mothers should particularly be informed about the importance of starting breastfeeding early and to prolong exclusive breastfeeding. In order to reach the WHO recommendation of six months exclusive breastfeeding, we propose an extended maternity leave legislation to at least six months.

  • 306.
    Niclasen, Birgit
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Folkesundhed i børnehøjde: indikatorer for børns sundhed og velbefindende i Grønland2009Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Aim: Based on a broad examination of child health in Greenland and in depth analyses in fields of special relevance, the aim is to identify a set of core indica-tors of children’s health and well-being seen in a social context at the national and municipal level, and present empirical data about them.

    Methods: Investigation I is a literature review on child health in its social con-text in Greenland. Investigation II analyzes the development in BMI in a retro-spective cohort of schoolchildren in Nuuk (the capital) from 1972 to 2002. The prevalence of overweight and obesity among children at school start and at graduation age was analysed, and for children followed from school start to graduation age the positive and negative predictive value of early-acquired overweight were analyzed. Investigation III analyzes with low birth weight as an example if an internationally used indicator can be used in Greenland. In Investigation IV and V indicators, their background, and their selection are ana-lyzed. The indicators were proposed based on the UN Convention on the Rights of the Child, international and national public health programmes, and Greenland’s municipal child policies. Indicators were searched for in the litera-ture, databases, and international homepages. They were together with material on child health, health care delivery, present surveillance, data sources, and data availability collected in a database structured in four domains: demographic and socio-economic conditions; health status and well-being; determinants of health, risk, and protective factors; and health systems and health policy. Based on proposed criteria, 28 indicators from conception to age 18 at the national level were identified for immediate use, and 25 indicators for later implementation. At the municipal level, 24 indicators modified according to the small popula-tions and lack of data in the municipalities was proposed.

    Results: Today, chronic diseases dominate in children, even if serious infec-tious diseases are not fully controlled and mortality during childhood is still high compared to the other Nordic countries. Overweight at school entry in-creased from 9.6% to 22.5% and at age 15 from 13.0% to 19.3% during the 30 years from 1972 to 2002. In more than half of the children the early-acquired overweight remained. Low birth weight was found to be as good an indicator as in other developed countries. The most important modifiable determinants of low birth weight, are smoking and antenatal care. Large subgroups of children are vulnerable because of their socio-economic and demographic conditions. Important part of the morbidity was higher among children in remote municipalities, while the capital and municipalities with lar-ger cities had better access to health care facilities. A consequence is that the health care system contributes to the health gap between privileged and less privileged children.

    Conclusion: The selected indicators are a powerful tool in monitoring core issues in children’s health and the factors influencing it. If equal opportunities for health are to be given to all children in Greenland, a strategy is needed, which goes beyond the proposals of the present public health program, and which includes a coordinated effort from all structural levels and sectors in so-ciety. Of value for the future work is that the few, well documented indicators that are proposed are based on systematic evidence and are seen from a public health perspective, and adapted to Greenlandic conditions. They also build on routinely collected data as well as on data from a nationwide and internationally based survey on schoolchildren health and well-being that is repeated every four years. Trend analyses are therefore possible. The indicators make it possible to gain easy and inexpensive access essential knowledge on child health, including potentials to make comparisons over time and between countries and munici-palities.Nevertheless, further development was found necessary regarding data access, data quality, and data collection.

  • 307.
    Niclasen, Birgit
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Low birthweight as an indicator of child health in Greenland - use, knowledge and implications.2007In: International Journal of Circumpolar Health, ISSN 1239-9736, E-ISSN 2242-3982, Vol. 66, no 3, p. 215-25Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The aim of this study was to analyse if low birthweight is a valuable indicator of child health in Greenland.

    STUDY DESIGN: A case study focusing on "low birthweight as an indicator in Greenland" with 3 units and 5 subunits of analyses.

    METHODS: Literature reviews, interviews with health care professionals and an analysis of the National Birth Register.

    RESULTS: Low birthweight was a well-known and yearly surveyed indicator, but not used by clinicians or by policymakers. Research was sparse, but the major risk factor observed was smoking. The rate of low birthweight in 1997-2005 was on average 5.0%. Of the low birthweight cases, 67.0% infants were born prematurely but only 44.8% of these births had a low birthweight. The known risk factors for a low birthweight in Greenland included abnormal delivery, low Apgar score at 5 minutes, female gender, multiple birth, being a single mother and less than complete prenatal care by a midwife. For preterm birth, associations were found with a not normal delivery, perinatal mortality, low Apgar score at 5 minutes, multiple birth, single mothers, mothers born in Greenland, young mothers, mothers living in a village and in nulliparae.

    CONCLUSIONS: Low birthweight is as valuable an indicator of child health at the national level in Greenland as it is in other developed countries. If interventions are to be aimed at known, quantitatively important, modifiable determinants of low birthweight, the results suggest that cigarette smoking and antenatal care are the most important to address.

  • 308.
    Niclasen, Birgit
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Bjerregaard, Peter
    Centre for Health Research in Greenland, National Institute of Public Health, Denmark.
    Child health in Greenland.2007In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 35, no 3, p. 313-22Article in journal (Refereed)
    Abstract [en]

    AIM: To review the knowledge on child health and child health problems in Greenland.

    METHOD: The review was based on theses, national statistics, national and international reports, and a search in Pub Med, PsycINFO, Web of Science, and WHOLIB databases from 1985 to 2005. The resulting articles were sorted by topic, type, quality of study, and relevance for child health today, providing 47 articles.

    RESULTS: Children in Greenland have become taller and have improved their general health. The morbidity found in Greenlandic children is similar to that found elsewhere even though the magnitude of problems might differ. The child mortality is relatively high and unevenly distributed. The acute disease pattern is dominated by infections, mostly airway infections. Otitis and its sequelae is a problem. An increase in chronic conditions such as atopy, asthma, obesity, and disabilities has taken place. Overweight and obesity have tripled in 20 years and are a health threat as well as constituting negative health behaviour. Social ill health, socioeconomic inequity, and sociocultural changes also influence health but their consequences are not well investigated in children.

    CONCLUSIONS: A relatively high child mortality but the same morbidity pattern as in other Western societies was found. Negative health behaviour is frequent in schoolchildren. The influence of rapid cultural changes, and familial and societal factors related to social ill health, together with socioeconomic inequity, are of major importance to the health of children in Greenland. More accurate data on child health are necessary in the future to secure better prioritization. It is suggested to construct a set of reliable indicators of child health in Greenland to monitor the health of children on a national and regional basis.

  • 309.
    Niclasen, Birgit
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Köhler, Lennart
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Core Indicators of Children’s Health and Well-Beingat the Municipal Level in Greenland2009In: Child Indicators Research, ISSN 1874-897X, E-ISSN 1874-8988, Vol. 2, no 2, p. 221-244Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to expose the background for proposing core indicators for children’s health and well-being at the municipal level in Greenland; to define criteria for relevant and scientifically sound indicators; to propose a set of such indicators; to give data on their distribution, and compare the outcomes between different types of municipalities. The indicators were drawn from actual knowledge of children’s health and experiences reported in international studies. They were based on goals from the National Public Health strategy and the UN Convention on the Rights of the Child. A set of 24 indicators were identified in 4 domains (demographic and socio-economic conditions; health status and well-being; determinants of health, risk, and protective factors; and health systems and health policy). Additional indicators were proposed for later implementation, most of these lack available data. Data revealed large differences between municipalities. In general, remote communities have the most unfavourable socio-demographic and health conditions. At the same time, larger communities’ access to health care services is more favourable. A consequence is that the health care system unintentionally contributes to the increasing health gap between privileged and less privileged children. A comprehensive strategy is need to guarantee equitable health standards for all Greenlandic children and that reaches far beyond the aims stated in the present national public health programme.

  • 310.
    Niclasen, Birgit
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Köhler, Lennart
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    National indicators of child health and well-being in Greenland.2009In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 37, no 4, p. 347-56Article in journal (Refereed)
    Abstract [en]

    AIMS: The aim of the study was to identify core indicators of children's health and well-being at the national level, adapt them to the needs of children in Greenland, and present empirical data about them.

    METHODS: The indicators were based on the actual knowledge about the health of children in Greenland, on the goals identified in the National Public Health Strategy and in the UN Convention on the Rights of the Child, as well as on experiences from international studies. Criteria to determine quality and relevance were identified.

    RESULTS: It is proposed that the 28 core indicators of child health that fulfilled the selected criteria be implemented immediately and that another 25 indicators be implemented later. Data showed that large subgroups of children are vulnerable because of their socioeconomic and demographic conditions, that morbidity associated with health behaviour and mortality was high, and that at-risk health behaviour was frequent compared to children in the other Nordic countries.

    CONCLUSIONS: The carefully selected indicators could be powerful tools in monitoring core issues in children's health and the factors influencing it. They are also a necessary starting point for determining the outcomes of the country's health and welfare policies. Although relevant indicators were identified, a lack of both validated data sources and routine data collections was obvious. Data on the proposed indicators showed many affected children in Greenland.

  • 311.
    Niclasen, Birgit
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Petzold, Max
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Schnohr, Christina
    University of Copenhagen, Denmark.
    Overweight and obesity at school entry as predictor of overweight in adolescence in an Arctic child population.2007In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 17, no 1, p. 17-20Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to analyse the changes in the prevalence of overweight, obesity, and in mean body mass index (BMI) among school children, and to analyse the predictive value of overweight and obesity at school entry to overweight and obesity in adolescence in an Arctic child population.

    METHODS: Retrospective cohort study. A database was created on the basis of files from health examinations. Data on children aged 5-7 years and 13-17 years and the subsample of children followed from school entry to adolescence was analysed.

    RESULTS: During the years 1972-2002 the prevalence of overweight and obesity increased significantly, and mean BMI rose by 5.6% at school entry and by 4.7% in adolescence. Sensitivity and specificity: Of the children being obese in adolescence, 56.3% were already obese at school entry; for the overweight children, 50.6% were also overweight or obese at school entry. Of the children with normal weight in adolescence, 91.9% were also normal weight at school entry. The positive predictive value of being overweight or obese combined at school entry was 59.5%, i.e. more than every second retained their overweight or obesity in adolescence. Only 10% of the obese school entry children had gained normal weight in adolescence. The negative predictive value for normal weight children at school entry was 91.3%.

    CONCLUSION: The study showed that during 30 years from 1972, overweight and obesity among school children in Greenland have increased dramatically. Overweight and obesity at school entry were shown to be a good predictor of overweight or obesity in adolescence.

  • 312.
    Nissen Biong, Stian
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    "–mellom døden som befrielse og drømmen om et liv": Personlige narrativer om noen opiatavhengige menns selvmordsadferd2005Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    The aim of the present study was to illuminate the experiences of suicidal behaviour in someNorwegian males with long-term drug addiction, and interpret their personal narratives inregards of meaning and communication. Open-ended, in-depth interviews were chosen forcollecting data. A phenomenological-hermeneutic approach, based on the ideas of Ricoeurin combination with Labovs structural perspective on personal narratives was used toanalyse the data.This study suggests that the suicidal behaviour is a result of a complex interrelationshipbetween the person himself, the group he is a part of and the society at large. Analysis of thepersonal narratives resulted in six sub-categories. Three main categories were identified: 1)The meaning of being confirmed and attached, 2) The meaning of wishing changes in lifecircumstances and 3) The meaning of choosing between possible solutions”. The analysis asa whole formed a theme: “Between death as a solution and dreaming of a life”.The suicidal behaviour can be viewed as a speech about the individuals’s emotional relationto themselves. How masculinity is constructed has had a great impact on the participant’ssuicidal behaviour, specially their relationship with their father. The participants ownrecourses in life have been associated with a sense of coherence. Non-judgemental attitudesin professional helpers and easy access to acute psychosocial care are of importance from apreventing public health perspective

  • 313.
    Nordblad, Brita
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Finns en läkande vårdatmosfär?: En kvalitativ studie om betydelsen av vårdmiljö och bemötande för patienter.2012Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    Background: Medical treatment, care, and rehabilitation offered to patients in primary care settings are established and mostly evidence-based. Patients can receive diagnose, treatment and, quite often, cure. A dimension that receives less attention involves the effects of a carefully planned physical environment. Combined with a carefully planned environment, respectful interaction between patients and health professionals enhancesthe atmosphere of care settings.

    Aim: This study aimed to investigate how patients experience the atmosphere they encounter when visiting a rehabilitation unit within a primary care unit.

    Method: Qualitative research interviews and qualitative content analysisResults: The atmosphere in care settings encompasses three domains: physical environment, interaction between patients and health professionals, and the organization. Within these domains, categories include sense of control, physical conditionsfor to attract attention, subjective experience, knowledge of the effects of the environment, attention to and confirmation of the patient, communication, holistic view of the patient, patient in focus, participation, empathy, equality in the meeting, To do ―the little more‖, healthcare content, accessibility, continuity, cooperation, equal care, patient rights, spirit of interaction between patient and health professional, and spirit of improvement and development. The major themes that emerged were the patient’s need to be noticed and valued.

    Conclusion: Our results suggest that the organization should be added to the concepts of atmosphere in care settings. The organization can create and obstruct careconditions. The overarching theme of these categories is the patient’s need to be noticed and valued

  • 314.
    Nordling, Elisabeth
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Jämförande analys av lättare psykisk ohälsa hos kvinnor och män före och efter skattereformen 1990/912008Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    BACKGROUND:  Tax policy can contribute to the improvement or deteroriation of citizens'  conditions. This has rarely been the object of investigation in public health science.

    The tax reform of 1990/91 was financed partly by the increasing of indirect tax. Those dynamic effects of the reform, promised before its introduction, did not occur. Soon after the introduction of the reform, an investigation carried out by the Council for Official Statistics´ (SCB) reported that anxiety amongst families had increased in the matter of home economics.

    AIMS: An analysis comparing prior to and following the tax reform of mental health problems describing the effects on a number of family types and the effects on a civic level.

    METHOD: Literature study and statistics from SCB.

    RESULT: During the 1990ties the mental health problems of younger and middle-aged people have increased. Families with children, which have substantial basic requirements have received an extremely low positive result of the tax reform, while families without children, whose basic requirements are less substantial have received a considerably high result. As a result of the tightening, there has been increased unemployment, which has resulted in decreased expenditure particularly in the public sector.

    CONCLUSIONS: This investigation indicates that a functioning civic economy with low unemployment needs the basic requirements of all groups to be met. This is achieved by continuing shaping of the tax system. Otherwise economic growth decreases, unemployment increases, which in turn leads to mental health problems. Tax policy and its consequences should be included in a public health plan, in which tax percentage on the surplus are presented, when the basic requirements for all socio-groups are covered. Furthermore there is a need for further research of the basic requirements of socio-groups and their effect on a civic level. A further measure would be to include health impact assessment before the introduction of major tax reforms.

  • 315.
    Norman, Christina
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Strategier för rehabiliteringoch återkomst till arbete: Samverkan mellan myndigheter och organisering i frivilliga former2010Licentiate thesis, monograph (Other academic)
    Abstract [en]

    The thesis is a contemporary analysis of parts of the Swedish welfare system. Co-operation between agencieswithin the welfare system and provision of welfare services by organizations within the voluntary sector are two contemporary tendencies. Both studies are focusing on the rehabilitation process for individuals who have been excluded from the labour market for a longer time period. The first study describes and analyzes co-operation in a three year project as a strategy for provision of complex welfare services (the ReSam project). The second study describes and analyzes the club house model of rehabilitation (the Fountain House movement).The first study is based on a process evaluation, where different kinds of data were collected through interviews, focus groups and diaries. These data were subsequently analyzed with qualitative methods. The second study isparticipant oriented, which means that a group of members conducted the study in co-operation with the re-searcher. The study isexplorative and research data were collected in a variety of ways including detailed notes, taped interviews and cognitive maps.The results of the first study show that it was possible to co-operate across the organizational boundaries of the different agencies involved, but there were obstacles related to organizational and cultural differences between the agencies, divided loyalties of the officials involved, and limited resources available to deal with the complex needs of the clients. The most important factor was that the officials learnt more about each other and the agencies involved. The result of the second study reveals that daily work tasks forms, deepens and reinvents both relationships as well as the supportive environment. Supportive mechanisms were an explicit ideology, plain structure of the meetings, frequent held working groups and thecertification process. Furthermore, it was important that the taskswere considered as necessaryand made a dif-ference. On the other hand, the members described the clubhouse environment as restricting for some. In the discussion, trust is used as a concept which spans over individual, interpersonal and organizational levels and becomes a useful tool as a theoretical concept binding the two studies to-gether. Trust was revealed as the most important ingredient as it comes to establishing sustainable relationships on a group level. Finally, some possible future scenarios are drawn up and discussed concerning the roles and relations between the welfare system and contemporary new forms of orga-nizing welfare services.

  • 316.
    Nygaard, Bjørn
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    WHO CC Affiliate Safe Community Support Centres og deres rolle i Safe-Community bevegelsen: En studie av organisering, utvikling og framtid2007Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    The international Safe-Community (SC) movement is steadily growing. This study highlights the so-called Affiliate Safe Community Support Centres (ASC) and their role in the movement. The concept of SC is treated as an innovation and an organisational model diffusing according to the theories of Rogers and Røvik. The ASCs are looked upon as ”change agencies” according to these theories. This is a case-study according to Yin of 9 out of 15 ASCs. Three of them have lost their status as ASC, six still have their status. The following five propositions are examined: 1.There are no differences in how the ASCs have executed their role that can explain why some have lost their status and some not. 2.The reason why some have lost their status can be explained by internal organisational, personal or economic conditions. 3.The ASCs and their tasks are not well known by the ”users”. 4.The ASCs have a weak or little conscious relations to the theoretical and scientific foundation of diffusion processes. 5.The SC-concept is to a very little degree considered as an organisational model. Data was collected from surveys and interviews with people at all ”levels” of the SC-movement as well as written material. All five propositions were strengthened by the material. The study leads to the following conclusions and recommendations which hopefully can improve the reputation and efficiency of the SC-movement and ease the work of the ASCs: The ASCs have an important role in the movement, but they are too few to serve an increasing number of SCs. The development of new ASCs should go on simultaneously with the increase of SCs. It is also necessary with a geographical distribution corresponding with the distribution of the SCs. The economy of the ASC-work has a very weak foundation, and this should be taken more seriously. There are conflicts between ASC-work and other tasks. There are no indications that certain models of internal organisation or company construction are more functional than others. Organisational matters are not considered sufficiently important. This is alarming, and may threaten the existence of the whole movement if not taken more seriously. It must be a responsibility of the WHO Collaborating Centre to bring these matters to discussion. There are few other arenas for these discussions than the regional and world-wide conferences. But in addition the institutions teaching SC-issues have a responsibility for taking up these topics in their education programmes. Women have a very strong position in the ASC. But it is not possible from this material to draw conclusions as to whether their position has influenced the priorities or choice of topics in the ASC-work.

  • 317.
    Nåvik, Marit
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    ”Fortsett sånn!” Samhandling ved utskrivning fra alderspsykiatrisk spesialisthelsetjeneste: Undersøkelse av dagens praksis2011Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    Aim: This study aimed to examine the opinions of physicians and nurses in the municipalities in Telemark, Norway regarding information given in written reports from the old age psychiatri unit and to examine the usefulness of collaboration when patients leave the hospital.

    Methods: This study used a cross-sectional survey. A questionnaire was developed and sent to 497 health professionals. The data were analyzed by both qualitative and quantitative methods.

    Results: Physicians and nurses in the municipalities have different knowledge and experiences regarding the services offered by the old-age psychiatry hospital. They described the reports from the hospital as informative and useful for further treatment of the patient. Collaboration practices were also evaluated as useful. Ambulant examination of patients and participation in meetings, education and guidance were evaluated as positive approaches.

    Conclusions: Physicians and nurses in the municipalities in Telemark county expressed satisfaction with the information in the reports and the existing collaboration practice when old age psychiatry patients leave the hospital. They want more of the services offered today.

  • 318.
    Odegård, Synnöve
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Andersson, Dan K G
    Insulin treatment as a tracer for identifying latent patient safety risks in home-based diabetes care.2006In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 14, no 2, p. 116-27Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore whether attitudes and opinions in areas of importance to patient safety expressed by nurses with medical responsibility were related to the knowledge of diabetes among home care personnel.

    DESIGN: A questionnaire survey was used to evaluate the knowledge of diabetes among 3144 nurses' aides' and assistant nurses working in 15 municipalities in Sweden. In each municipality a nurse with medical responsibility answered another questionnaire dealing with patient safety matters in general and diabetes in particular.

    RESULTS: There were large differences in the knowledge of diabetes among home care personnel on the municipality level. Attitudes and opinions of the nurses with medical responsibility in the areas of leadership, guidance and continuing education were significantly related to the knowledge of diabetes among nurses' aides' and assistant nurses.

    CONCLUSIONS: Our study shows that factors that are related to attitudes and opinions about patient safety among nurses with medical responsibility can increase the risk of home care personnel to make mistakes in the direct care of patients with diabetes.

  • 319.
    Oja, Ivika
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Guidelines for type 2 diabetes in Estonia:: knowledge, attitudes and self-reported behaviour among general practitioners.2005Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    Introduction: The aim of this study was to assess the patient, practice and practice management related factors contributing to non-adherence of type 2 diabetes mellitus clinical practice guideline in Estonia.Methods: Descriptive postal survey using a self-administered questionnaire. Results: Of the 354 doctors who received the questionnaire 46% (n=163) responded. 76% of them have type 2 diabetes guidelines. Low awareness of diabetes and its complications among patients as well as their low motivation to change their lifestyle were considered to be the biggest difficulties in managing individual patients. In addition to the most often listed problems, non-compliance with medical regimen, patients’ financial problems and their non-attendance were mentioned. The greatest health care systems related barriers to practices providing desirable care wereinadequate number of patients` educational materials, the lack of special diabetes education for nurses and underfunding. The patient related issues were regarded as problems in 96% of the cases and health care system related factors were mentioned in 79% of the cases.

  • 320.
    Ojala-Seppänen, Outi
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    EVALUATION OF REPORTING ON PROJECTS FINANCED THROUGH THE EUROPEAN COMMISSION AIDS BUDGET LINE2005Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    The AIDS epidemic affects the whole world, as there is no region of the world that has been spared.Approximately 34-46 million people are infected with HIV and more than 24 million people havealready died since the first cases were identified in 1981. The pandemic is no longer just a healthproblem but a serious threat to human development. Significant efforts have been made to halt the transmission of the disease. As early as 1987, the European Union established a HIV/AIDSProgramme in Developing Countries. From 1994 to 2001 the EC spent an average of 625 million Euros everyyear on health, HIV/AIDS and population in more than 100 developing countries. The EC support is mainly implemented through projects financed through Community grants. The main objective of this study is to contribute to improving the quality of project reporting. The purpose is to evaluate the reporting on projects financed through the European Commission AIDSbudget line both in terms of structure and content through analyzing the final project reports. The targets and the amount of moneyinvested in the fight against HIV/AIDS are high, but are wereaching the targets and getting value for the moneyinvested? The spread of HIV/AIDS continues despite increased efforts in recent years. Nearly 5 million people became newly infected in 2003. This is more than in any previous year. The effectiveness of HIV/AIDS projects, in terms of changing attitudes and behavioural change, has been criticized. According to this study,changes canbe identified at several levels – the individual, the community and the international. It was shown in some case studies in the assessed reports thatthe projects could have significant impact on the individuals. This study shows that the strength ofthese projects was the diversityof them and the new innovative approaches. They targeted different vulnerable populations like children, IDUs, truckers etc. Further they used many strategies on addressing many areas related to AIDS as human rights, capacity building, advocacy, clinicalpractice etc. This studysuggests more systematic evaluations of the EC funded AIDS prevention projects and the application of a unified format for reporting in order to be able to compare results and effectiveness of interventions.

  • 321.
    Olafsdottir, Helga Sol
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Nordic and Infertile: A study of options and decisions2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Aim: The aim of this thesis was to obtain an overview over the options of Nordic infertile couples regarding assisted reproduction treatment, and to follow couples’ arguments and decision-making process to make relevant decisions about these options.

    Methods: Quantitative and qualitative methods were used. The study design was inspired by Ecological systems theory, where data was gathered from laws and regulations (macro-level), fertility clinics (meso-level) and the couples using these options (micro-level). Study I consists of results from a review of the legislations in the five Nordic countries and results from a questionnaire that was sent to all fertility clinics to gather information about available options. Papers II and III present the findings of the interviews with 22 Nordic couples, after their first appointment with a specialist at the fertility clinic. The couples came from Denmark (3), Finland (6), Iceland (3), Norway (4) and Sweden (6). Study IV presents the findings of follow-up interviews with the same couples approximately three years later. For the qualitative study the tools of Grounded Theory were used.

    Findings: In Study I it was found that Nordic couples generally have good access to assisted reproductive technology treatments (ART), although it is not evenly distributed and there are restrictions related to certain criteria, such as age. There are national differences in the legislations, especially regarding gamete donation. These differences open up for cross-border reproductive care, andmore than one third of the fertility clinics offered treatment to people from other countries. Study II describes the decision-making process of the couples when determining the “right time” to try for a child. The couples mention the need to feel prepared for parenthood; such as a stable social situation, and once they felt prepared they became more susceptible to decision-making catalysts, such as influence from friends and family. Fear of infertility made the couple accelerate their decision regardless of preparation. In Study III the decision-making process of seeking medical help is illustrated. The core category was “negotiation and re-negotiation”. The process of decision-making is first to accept that they have a problem in common, secondly that they need knowledge and finally to take action and get help. Study IV deals with the decision-making process during treatments. Of 22 couples, 17 had succeeded at becoming parents after approximately three years, three couples were still trying and two had not decided how to continue. The core category was “maintaining control in an uncertain situation”. The couples tried to keep focus on the goal and to learn to deal with the new world with various methods.

    Conclusions:The structure of and the access to service for infertile couples differ between the Nordic countries. Some of the differences, e.g. regarding subsidy systems and waiting time, affected the decision making process since they could mean a delay in the treatment process or whether a private or public clinic was chosen. Additionally, a couple consists of two individuals with independent decision-making processes, which makes joint decision-making difficult and time-consuming. The couples have to negotiate their way to a consensus and are constantly confronted with new choices they need to re-negotiate on. The decision-making process, when dealing with infertility, is not a straight line, but rather a chain of small decisions affected by feelings, context and situation

  • 322.
    Olafsdottir, Helga Sol
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Wikland, Matts
    Fertility Center Scandinavia , Gothenburg , Sweden.
    Möller, Anders
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Access to artificial reproduction technology in the Nordic countries in 2004.2009In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 88, no 3, p. 301-7Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To survey access to Artificial Reproduction Technology (ART) treatments in 2004 with regard to legislation, geographical location, financing and the kind of ART treatments provided in the Nordic countries.

    DESIGN: Retrospective descriptive survey of practice at ART clinics and legislation.

    SETTING: Denmark, Finland, Iceland, Norway and Sweden.

    SAMPLE: Sixty-six ART clinics registered with the Nordic Fertility Society in autumn 2005.

    METHODS: A questionnaire was sent to all ART clinics and a survey of legislation concerning ART treatments and public statistics was performed. The response rate was 79%.

    MAIN OUTCOME MEASURES: Access to ART treatments.

    RESULTS: The differences in legislation among the countries mainly concerns gamete donation. Couples living in larger cities or densely populated areas have best access to ART treatments. With regard to subsidizing of treatment costs, Finland and Denmark seem to be the best of the Nordic countries.

    CONCLUSIONS: The main differences among the countries concern the legislation, the cost of the treatments and how those are subsidized.

  • 323.
    Olafsdottir, Helga Sol
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Wikland, Matts
    Fertility Center Scandinavia , Gothenburg , Sweden.
    Möller, Anders
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Nordic couples' decision-making processes during assisted reproduction treatments.2013In: Sexual & reproductive healthcare : official journal of the Swedish Association of Midwives, ISSN 1877-5764, Vol. 4, no 2, p. 49-55Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To study couples' perceptions of their decision-making process during the first three years of infertility treatments.

    STUDY DESIGN: This study is a part of a larger project studying the decision-making processes of 22 infertile heterosexual couples, recruited from fertility clinics in all five Nordic countries, over a three year period. A descriptive qualitative method was used.

    MAIN OUTCOME MEASURES: Process of decision-making during assisted reproduction treatments.

    RESULTS: Seventeen couples had succeeded in becoming parents after approximately three years. Our study suggests that the decision-making process during fertility treatments has three phases: (i) recognizing the decisions to be made, with subcategories; the driving force, mutual project, (ii) gathering knowledge and experience about the options, with subcategories; trust, patient competence, personalized support, and (iii) adapting decisions to possible options, with subcategories; strategic planning, adaption. The core category was "maintaining control in a situation of uncertainty."

    CONCLUSIONS: Two parallel processes affect couples' decision-making process, one within themselves and their relationship, and the other in their contact with the fertility clinic. Couples struggle to make decisions, trusting clinic personnel for guidance, knowledge, and understanding. Nevertheless, couples expressed disappointment with the clinics' reactions to their requests for shared decision-making.

  • 324.
    Olafsdottir, Helga Sol
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Wikland, Matts
    Fertility Center Scandinavia , Gothenburg , Sweden.
    Möller, Anders
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Nordic couples’ decision-making processes in anticipation of contacting a fertility clinic2010In: Journal of Reproductive and Infant Psychology, ISSN 0264-6838, E-ISSN 1469-672X, Vol. 30, no 2Article in journal (Refereed)
    Abstract [en]

    Objective: To explore the decision-making processes of Nordic couples in anticipation of contacting a fertility clinic after experiencing difficulties in conceiving. Method: A retrospective descriptive qualitative study of 22 heterosexual infertile couples recruited from fertility clinics in all five Nordic countries. Results: The process comprises three decisions: (i) accepting that they have a shared problem, (ii) acknowledging the need for more knowledge and (iii) taking action to get help. Subcategories were: (i) infertile or not, maintain the balance in the relationship; (ii) information from social networks and information from the health care system; (iii) having an alternative plan and fear of a wrong decision. The core category was ‘negotiation and re-negotiation’. Differences between the countries were found with regard to the time couples waited before contacting a fertility clinic, and in the utilisation of private vs. public clinics. Conclusion: It requires a process of negotiation and re-negotiation for couples to reach a compromise. Furthermore, the decision-making process is influenced by the structure of health care services in respective countries.

  • 325.
    Olafsdottir, Helga Sol
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Wikland, Matts
    Fertility Center Scandinavia , Gothenburg , Sweden.
    Möller, Anders
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Reasoning about timing of wanting a child:: A qualitative study of Nordic couples from fertility clinics2011In: Journal of Reproductive and Infant Psychology, ISSN 0264-6838, E-ISSN 1469-672X, Vol. 29, no 5Article in journal (Refereed)
    Abstract [en]

    Objective: To explore the reasoning of Nordic couples recruited through fertility clinics in deciding ‘the right time’ to attempt conception and whether nationality impacts on this reasoning. Background: Although previous studies have explored the motivation for childbearing, few investigations have focused on how couples determine the ‘right time’ for parenting. Methods: A qualitative study, including 22 couples recruited from fertility clinics in the 5 Nordic countries. Results: Two main categories were identified: ‘prepared for parenthood’ with four subcategories – stable social conditions, stable relationships, appropriate age, mutual desire for children; and ‘decision-making catalysts’ with three subcategories – social balance, duty to family and fear of infertility. Conclusions: Preparation comes first and clears the way for influences from other factors, although fear of infertility caused couples to accelerate their decision-making processes. Nationality did not affect the categories, although this could be related to the fact that Nordic countries have similar social structures. Reasoning regarding ‘the right time’ depended on situation rather than nationality.

  • 326.
    Olafsdottir, Steingerdur
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    The role of organizational culture in employees´ work-life balance as an aspect of health2008Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    Organizational culture defines how employees should behave in a given set of circumstances. The purpose of this study involved analyzing the organizational culture of an Icelandic software consultancy company in relation to employees´ work-life balance as an aspect of health, and explaining the process for creating and sustaining a supportive work-life culture. Achieving this purpose required answers to several research questions, What are the components of the existing organizational culture? What is the managers´ role in creating and sustaining this organizational culture? What are the challenges in sustaining this organizational culture?

    This case study used both quantitative and qualitative methods, and four data sources for triangulation purposes. The methodological approaches included a questionnaire-based survey, completed by 72 employees (90%); semi-structured interviews with eight employees; observations conducted during two separate weeks; and document analysis of various documents dating back a maximum of two years.

    The results suggest that the case organization´s culture was work-life supportive, i.e., the organization supported and valued employees´ integration of work and private life. The components of the existing organizational culture were defined as: fun, ambition, flexibility, international character, openness, cooperation, informality, flat organizational structure, responsibility, trust, understanding, support, and pride. The managers´ role in creating and sustaining this culture involved availability, supportiveness, understanding, trusting, and giving feedback. Among the main challenges in sustaining the culture was the growth of the organization, which could affect considerably the informal culture. Description of the components of the case organization’s existing culture includes description of the culture’s enablers, according to the purpose of explaining how a supportive work-life culture can be created and sustained.

  • 327.
    Olafsson, Gunnar Alexander
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Merging Hospitals: Motives, methods and outcomes.2008Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    This thesis reviewed recent hospital mergers in Gothenburg, Sweden, and Reykjavik, Iceland, and describes, analyzes, compares, and assesses those mergers. The study focused on the underlying reasons for the mergers, examining both the methods used in the merging process and the merger outcomes. Background information includes organizational theory regarding mergers, hospitals as professional bureaucracies, organizational change and communication, and quality and efficiency in organizations. The study is based on secondary data derived mainly from official documents, evaluations, and research reports. While the study determined similar reasons—mainly economic—underpinning both mergers, the processes differed. The Swedish merger was much better prepared, more radical, and invested more time and money in its process compared to the Icelandic merger, which was less radical and characterized by decisions from the top. Interestingly, the Icelandic merger, which sought to curtail the growth of expenditures but did not demand savings, achieved outcomes that reflected its main goals. Conversely, the Swedish merger sought unrealistic savings in its goals and the savings demands made it impossible for the management team to gain other objectives of the merger, like better service, quality and more competent institution.

  • 328.
    Olsson, Jeanette
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Ungdomar och stress: en undersökning av förekomsten av stress och psykosomatiska besvär bland gymnasieelever2006Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    BACKGROUND: Stress and psychosomatic symptoms is one of the major public health problems in Sweden. Psychological disease accounts for 20% of the burden of disease in Sweden. Also young people show an increasing degree of stress and psychosomatic symptoms.

    OBJECTIVES: The objective of the study was to investigate the prevalence of self-rated stress and psychosomatic symptoms among secondary school students.

    MATERIAL AND METHODS: A questionnaire was distributed. 970 students filled it out (75%). The questionnaire had 16 questions on self-rated stress and psychosomatic symptoms. The background variables were sex, grade and program.

    RESULTS: The majority of the students often felt happy, a sense of mastering and had a positive view of their future, but a high proportion of the students felt stress, the level of school related stress was very high. Psychosomatic symptoms such as problems with sleep, feeling anxious, irritable and low was common. There was a clear gender difference. The girls had a higher degree of stress and psychosomatic symptoms and lower degree of happiness, sense of mastering and positive view of their future. A majority of the students had an adult to talk to, which in 90% of the cases was a parent. Those students who didn’t have such an adult had twice as high degree of psychosomatic symptoms.

    CONCLUSIONS AND RECOMMENDATIONS: The study showed an association between stress and psychosomatic symptoms. It is important that the school, both on local and national level, take measures to decrease the level of school related stress. The society should increase its support to families, so more young people can have an open and trusting relationship to their parents. Further research is needed about the high level of stress and psychosomatic symptoms among girls, so the increasing burden of disease among women can be reversed.

  • 329.
    Olsson, Linda
    Nordic Council of Ministers, Nordic School of Public Health NHV. Västra Götalandsregionen.
    Utvärdering av Program Sexuell hälsa.          Västra Götalandsregionen: SLUTRAPPORT – 17 februari 20102010Report (Other academic)
    Abstract [sv]

    NCHSA har fått i uppdrag av Enheten för hivprevention i Västra Götaland att utvärdera Program Sexuell hälsa. Programmet startade 1999 och har inte tidigare varit föremål för extern utvärdering. Programmet vänder sig till medarbetare inom hälso- och sjukvård som arbetar inom fältet sexuell hälsa. Dess övergripande mål är att finna effektiva strategier och metoder i arbetet med prevention av STI/hiv och oönskade graviditeter och många insatser har genomförts av programmet för att infria detta mål.GenomförandeSyftet med utvärderingen är att beskriva och utvärdera programmet med avseende på verksamhetsinriktning, arbets- och organisationsform och resultat. Den teo-retiska plattformen utgörs av samverkansteori och nätverksteori med fokus på inter-organisatoriska nätverk.Utvärderingen genomfördes med hjälp av dokumentstudie, direkt observation, självvärdering samt individuella intervjuer. Resultatet har analyserats utifrån åtta bedömningskriterier; programmets inriktning, organisering, samverkan mellan be-rörda parter, räckvidd, utveckling, engagemang, nytänkande och inverkan på slut-målgruppen.Resultat• Utvärderingen visar att programmet har många nätverk, projekt och utbildningar under sitt paraply vilket haft stor betydelse för programmets primära målgrupp – professionen. Beträffande slutmålgruppen – allmänheten – föreslås ett ökat fokus på primärprevention.• Programmets organisering fungerar samtidigt som det är svårt att definiera pro-grammet i sig.• Samverkan mellan de deltagande aktörerna har möjliggjorts tack vare program-met. De främsta effekterna har varit kortare kontaktvägar och praktiska fördelar i det vardagliga arbetet med slutmålgruppen. • Information och kunskap når den primära målgruppen – medarbetare inom olika verksamheter som arbetar med sexuell hälsa – men det återstår arbete innan pro-grammet når ut i hela VGR. • Programmet har både höjt kunskapen och förändrat arbetssättet hos den primära målgruppen.• Att skapa engagemang är en av programmets styrkor. Känsla av sammanhang och ökad kunskapsnivå bidrar till arbetstslust. org.• Det finns tydliga sekundära vinster för slutmålgruppen med programmet men an-satsen är långsiktig och resultaten är för närvarande svåra att mäta. Strategiska frågeställningar inför framtiden1. Är det tid för referensgruppen att välja spår? På vilket sätt gör gruppen mest nyt-ta? Som utvecklingsgrupp? Problemlösningsgrupp? Förankringsgrupp? Referens-grupp?2. Hur blir programmet och dess aktiviteter i större utsträckning en hela regionens angelägenhet? 3. Hur stärks programmets länk till närsamhället för att möta de specifikt lokala behoven?4. Hur kan programmet bidra till att primärprevention ges ökad status hos program-mets medverkande aktörer?5. Hur mäts sexuell hälsa hos slutmålgruppen? Kan en samling indikatorer över gruppens kunskaper, attityder, uppfattningar och kanske riskbeteende som används över hela regionen vara en framkomlig väg?

  • 330.
    Ostlie, Ingrid L
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Dale, Oystein
    Möller, Anders
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    From childhood to adult life with juvenile idiopathic arthritis (JIA): a pilot study.2007In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 29, no 6, p. 445-52Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To explore the experiences of the health service provision in the transition process from childhood to adult life from the perspective of young patients with juvenile idiopathic arthritis (JIA) and health professionals working in this field.

    METHOD: Two groups of young persons with JIA and two groups of health professionals were interviewed in focus groups. The data were analysed according to approved guidelines for qualitative analysis.

    RESULTS: 'Capability to lead a meaningful adult life' emerged as a core category; capability as a consequence of 'being enabled' from the youths' point of view, and 'enabling the young patients' from the health professionals' perspective. Preparation for the transition and transfer process was perceived as inadequate and seemed dependent on enthusiastic health professionals both in the children's and adult wards. Suggestions for formal improvements were required in four main areas.

    CONCLUSION: This pilot study has identified inadequacies in the transition management provided for young people with JIA. Acceptance of the young persons as active participants in their own transition process might strengthen these young persons' experience of an autonomous identity and enable participation socially and in society, thus enhancing the ability to achieve a meaningful adult life. Further investigations should focus on adults living with JIA, how they lead their lives physically and psychosocially.

  • 331.
    Ostlie, Ingrid Landgraff
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Living with Juvenile Idiopathic Arthritis from childhood to adult life: An 18 year follow-up study from the perspective of young adults2009Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background and aim: As an experienced paediatric nurse I have recognised that adolescents with persistent chronic childhood diseases fall between two chairs. International studies support this recognition. Norwegian adolescents with juvenile idiopathic arthritis are no exception. Chronic arthritis from childhood might have far-reaching consequences for the growth and development of the child, and for the family and community. The fact that a considerable proportion of children with JIA continue to have active disease and disease residua through adolescence into adulthood underlines the importance of illuminating the situation in a public-health perspective. Through this study I aim at exploring physical and psychosocial health among young adults with JIA in a life-span perspective from childhood and adolescence into adult life.

    Methods: The thesis has a qualitative and a quantitative approach. Study I had an abductive explorative design. The experiences and perceptions of health-care transition were explored by focus-group interviews with young people with JIA and related health professionals respectively. Qualitative content analysis was utilised. Study II had an abductive explorative design with qualitative interviews to explore young adults’ experiences of living with JIA in a life-span perspective. Qualitative content analysis was utilised. Study III had a longitudinal deductive design. The standardised questionnaires of Health Assessment Questionnaire, General Health Questionnaire version 30, and Visual Analogue Scales of pain, fatigue, and illness were utilised to explore physical ability, psychosocial health, pain, fatigue, and illness in a cohort of patients with JIA 18.3 years after symptom-onset. Comparisons with baseline and first follow-up were performed. Data were analysed by descriptive statistics and non parametric tests. Study IV had a cross-sectional deductive design. In addition to the questionnaires utilised in study III, the questionnaire of SF-36 Health Survey and data on education, employment, need of assistive equipment at work, and use of health services the previous year were employed. Comparisons with Norwegian population- based data were performed. Data were analysed by descriptive statistics, and parametric and non parametric tests.

    Findings: In study I, ability to live a meaningful and responsible adult life seemed to be a common goal. Obstacles for the young people were the nature of the disease, a lack of focus on transition processes, and overprotective parents and health professionals. Obstacles for the health professionals were lack of inter-professional and inter-institutional formal co-operation and agreed practice, and lack of competence on adolescent development and health. Study II demonstrates that living with JIA implies a constant oscillation between struggle and adjustment to an insecure everyday life and an unpredictable life course. This was expressed as bodily experiences of limitation and freedom, interpersonal experiences of being included or set on the sidelines, and intrapersonal perceptions of insecurity and confidence. Of the 55 young adults with JIA in study III, 21 reported physical disability, and 12 reported psychiatric distress within the clinical range. Furthermore, 26 patients reported illness, 27 pain, and 33 fatigue above 10 on the VAS scale (0-100). Significant correlations were found between physical disability, pain, illness and fatigue, and between psychiatric distress, pain, and fatigue. Comparisons from first to second follow-up of the cohort showed no significant changes in physical or psychosocial functioning, pain, or fatigue. In study IV, physical ability and pain were significant predictors of the average variation of physical health while psychiatric distress and female gender were significant predictors of the average variation of mental health. Impaired physical health was associated with low rates of psychiatric distress. As compared to the general Norwegian population, impaired HRQL in the physical domain was found, but not in the mental domain, and a higher level of education, but similar employment rate.

    Conclusion: The four studies demonstrate complementary findings. Discrepancies between interviews and inquiries indicate that the interviews illuminate a depth and breadth of life with JIA in a life-span perspective that not is possible to unveil solely by standardised inquiries. Although persistent favourable outcomes are found physically and psychosocially from first to second follow-up, young adults with JIA reveal that life with JIA encompasses struggle and adjustment to an insecure life situation physically, psychologically, and socially.

  • 332.
    Ostlie, Ingrid Landgraff
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Aasland, A
    Department of Child and Adolescent Psychiatry, and 4 Department of Rheumatology, Rikshospitalet Medical Center, Oslo, Norway.
    Johansson, I
    Department of Nursing, Gj ö vik University College, Norway, Department of Nursing, Karlstad University, Sweden.
    Flatö, B
    Department of Rheumatology, Rikshospitalet Medical Center, Oslo, Norway.
    Möller, Anders
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    A longitudinal follow-up study of physical and psychosocial health in young adults with chronic childhood arthritis.2009In: Clinical and Experimental Rheumatology, ISSN 0392-856X, E-ISSN 1593-098X, Vol. 27, no 6, p. 1039-46Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The aim was to describe physical and psychosocial health status in a second follow-up of a cohort of patients with chronic childhood arthritis, to compare results from the present study with the first follow-up, and to explore the course of physical and psychosocial functioning from baseline.

    METHODS: At a median of 18.3 years after symptom onset 55 patients answered the self-administered questionnaires Health Assessment Questionnaire Disability Index (HAQ-DI), Visual Analogue Scales (VAS) of pain, fatigue and illness, and General Health Questionnaire (GHQ) 30-item version. Results from the current study were compared to first follow-up median 8.7 years after symptom onset, and the course of physical and psychosocial function from baseline was discussed.

    RESULTS: At second follow-up, 38% reported HAQ-DI above 0 indicating physical disability, 22% had a GHQ-30 score in the clinical range indicating psychiatric distress, and fatigue seemed to be an overarching aspect of the health status. Pain was an important correlate of physical disability at first and second follow-up. At second follow-up psychiatric distress was a significant correlate of pain and fatigue, indicating a relation to disease severity. The association between psychosocial functioning and chronic family difficulties observed at first follow-up is not evident at second follow-up.

    CONCLUSIONS: The favourable physical and psychosocial outcome reported at first follow-up seems to persist. However, arthritis-related ill-health is still evident in a considerable proportion of the patients, indicating a constant impact of the disease on every-day life of the individual.

  • 333.
    Ostlie, Ingrid Landgraff
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Johansson, Inger
    Department of Nursing, Gjövik University College, Gjövik, Norway, Department of Nursing, Karlstad University, Karlstad, Sweden .
    Aasland, A
    Department of Child and Adolescent Psychiatry, and 4 Department of Rheumatology, Rikshospitalet Medical Center, Oslo, Norway.
    Flatö, B
    Department of Rheumatology, Rikshospitalet Medical Center, Oslo, Norway.
    Möller, Anders
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Self-rated physical and psychosocial health in a cohort of young adults with juvenile idiopathic arthritis.2010In: Scandinavian Journal of Rheumatology, ISSN 0300-9742, E-ISSN 1502-7732, Vol. 39, no 4, p. 318-25Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore self-rated physical and psychosocial health in a cohort of young adults with juvenile idiopathic arthritis (JIA) 18.3 years after symptom onset, make comparisons with population-based data, and illuminate possible predictors of self-rated health.

    METHODS: Of a baseline cohort of 84 patients with JIA, 55 (65.5%) answered the self-administered questionnaires of the Health Assessment Questionnaire (HAQ), the Visual Analogue Scale (VAS) of pain, fatigue, and illness, the Medical Outcomes Study 36-item Short Form Health Survey (SF-36), and the General Health Questionnaire (GHQ-30). Telephone interviews were conducted with 51/55 patients. Population-based norm-data of SF-36 were used for comparison.

    RESULTS: Significantly impaired physical health but no difference in psychosocial health was found as compared to the general Norwegian population. The level of education was significantly higher whereas no difference was found in employment status as compared to norm-data. Pain was a significant correlate of the education level. Predictors of physical impairment were physical disability and pain, whereas psychiatric distress and female sex were predictors of mental ill-health.

    CONCLUSION: Physical disability does not seem to have a negative influence on the patients' functioning psychosocially.

  • 334.
    Ostlie, Ingrid Landgraff
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Johansson, Inger
    Department of Nursing, Gjövik University College, Gjövik, Norway, Department of Nursing, Karlstad University, Karlstad, Sweden .
    Möller, Anders
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Struggle and adjustment to an insecure everyday life and an unpredictable life course. Living with juvenile idiopathic arthritis from childhood to adult life - an interview study.2009In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 31, no 8, p. 666-74Article in journal (Refereed)
    Abstract [en]

    PURPOSE: . To obtain a deeper understanding of the meaning of living with juvenile idiopathic arthritis (JIA) through childhood and adolescence into adult life as described by young adults with JIA themselves.

    METHOD: Based on a qualitative study design, 15 young adults were interviewed individually. The data were analysed using a qualitative content analysis approach.

    RESULTS: Living with JIA involves struggle and adjustment to an insecure everyday life and an unpredictable life course. The informants' experiences emerged as dichotomies on a continuum describing the dynamics in life experiences individually and over time. The categories include bodily experiences of limitations or freedom, being acknowledged or set aside in interpersonal relationships, and intrapersonal experiences of insecurity or confidence. The findings indicate a change to greater acceptance and adjustment to the disease over time.

    CONCLUSION: The impact of JIA on life in a time of transition from childhood to adult life involves complex challenges on coping strategies and adjustment processes. Understanding this complexity is urgent for health professionals to contribute to both normal developmental task achievements and overall well-being for young people with JIA. Further investigations should focus on coping and adjustment processes when facing disease fluctuations and unpredictability in a life-span perspective.

  • 335.
    Palm, Marianne
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Helsefremmende lederskap: en utforskende studie blant førstelinjeledere ved et norsk helseforetak2010Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    Intention: This study aimed to explore the perceptions of first-line managers regarding the reasons they practice leadership, and to determine whether health-promoting aspects are essential to personnel management skills.

    Method: The study was conducted as a single case study that triangulated both data and methods. Data were collected from a multi-site health trust in Norway. I sent questionnaires to 15 first-line managers, whose responses provided the basis for interviews with three first-line managers. I also collected and examined documents such as action plans and work instructions. I used content analysis to analyze interviews.

    Results: Arrangements for health-supporting leadership were a major focus in the leaders’ daily work. They also focused on arrangements that could figure importantly in attaining good physical and psychosocial working environments. The leaders considered themselves role models, and they thought that their way of practicing leadership could influence the well-being of their employers as well as worker productivity and goal attainment. While their options for practicing leadership were based primarily on knowledge and experience, demands concerning activity and effectiveness were also important elements of their leadership. Results from the questionnaires showed that almost all first-line managers met regularly with their employers, and all respondents indicated that they involved their employers in the determination of plans and goals. However, making independent decisions did not come easily for all first-line managers.

    Examination of work instructions showed that their superiors expected first-line managers to emphasize arrangements that would lead to good working environments, thus ensuring good working conditions, and securing professional competence and high quality service provision.

    Conclusion: Findings indicate that first-line managers want to include a health-promoting aspect in their leadership skills. Interestingly first-line managers feel they -“sit between the devil and the deep sea”-.

  • 336. Paphassarang, C
    et al.
    Philavong, K
    Boupha, B
    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.
    Equity, privatization and cost recovery in urban health care: the case of Lao PDR.2002In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 17 Suppl, p. 72-84Article in journal (Refereed)
    Abstract [en]

    Along with the shift from a planned to market-oriented economy, as in many other developing countries, Lao PDR has promoted health care partnerships with the private sector, and cost recovery in public hospitals, to increase resources in the public sector, while at the same time attempting to ensure appropriate access to health care for those without means to pay. In a multi-case design, this study compares two neighbourhoods of different socioeconomic status comprising 10 households, representing urban districts in three provinces. In-depth interviews were conducted over a 1-year period with three visits to each household. Members of the households were interviewed on their perceptions and utilization of health care services. Focus group discussions of public providers and individual interviews of private providers, leaders of the villages and hospital administrators provided complementary perspectives. The study found that both socioeconomic groups utilized private health services as their first choice, including private clinics and treatment abroad for those with high socioeconomic status, while the low socioeconomic group preferred private pharmacies. The unwelcoming attitudes of health staff and procedural barriers have led both groups to meet their health care needs in the private sector. Here the health care they receive is strictly limited to what they can pay for. For the poor, in most cases, this means drugs alone, i.e. no examination, no diagnosis and only limited advice. Limited financial resources often means receiving inappropriate and insufficient medication. Equity in health care remains theoretical rather than practical and the social goals of the reform have not been achieved.

  • 337.
    Polluste, Kaja
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Kalda, Ruth
    Lember, Margus
    Evaluation of primary health care reform in Estonia from patients' perspective: acceptability and satisfaction.2004In: Croatian Medical Journal, ISSN 0353-9504, E-ISSN 1332-8166, Vol. 45, no 5, p. 582-7Article in journal (Refereed)
    Abstract [en]

    AIM: To analyze the population's view of the primary health care reform five years after the formal implementation of the reform investigating the acceptability of the primary health care system, patients' preferences, and satisfaction with their family doctors.

    METHODS: Face-to-face interviews using structured questionnaires were preformed with a random sample of the Estonian residents aged 15-74 years (n=999).

    RESULTS: Out of 999 respondents, 35% prefer to first see their family doctor and if necessary to get a referral or a recommendation to see a specialist. The referral to the specialist by the family doctor is more preferred by older respondents, rural people, by the respondents with a lower level of education and income as well as by people who were more satisfied with their family doctor. The people who were more satisfied with their family doctor found that the whole health care system was functioning better than the previous primary health care system. Out of all the respondents who have had a contact with their family doctor during the last 12 months 87% (n=585) were satisfied with his work. The overall satisfaction with the family doctor depended on 1) perceived competence of the physician (OR=0.624, 95% confidence interval (CI)=0.419-0.933); 2) understanding the patient's problem (OR=0.699, 95%CI=0.496-0.984); 3) punctuality of the physician (OR=1.533, 95%CI=1.075-2.186); and 4) the location of the primary health care center/clinic (OR=0.751, 95%CI=0.574-0.983).

    CONCLUSION: During the five-year-period most of the Estonian population has accepted the new primary health care system and the satisfaction rate has increased. Family doctors are in the center of the primary health care systems and their professional competence plays a great role in making the system acceptable for the patients.

  • 338.
    Ponsford, Anna-Stina
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Mobility Services for Drivers with Medical Conditions: Lessons learned from a study of the change in mobility services provided in Sweden in 1998 compared to 20072008Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    Background. The Swedish government states that participation and influence are among the most fundamental prerequisites of public health. Mobility services provide professional and high quality information, advice, and assessment to individuals with a medical condition or recovering from an accident or injury that may affect their ability to drive, access, or egress a motor vehicle. Although Swedish physicians must report drivers with medical conditions, rehabilitative training for driving licenses following injury or severe medical conditions does not exist within contemporary Swedish healthcare systems.

    Aim. This study aimed primarily to describe and compare two driving assessment models, i.e., the model used by Traffic Medicine Center (TRMC) Stockholm in 1998 and the model provided by Mobilitetscenter.se (MC.se) Gothenburg in 2007. The study also sought to determine the context of the changed provision of driving assessments and identify the significant components of this change.

    Method A literature review, synthesised with the author’s research and complemented by practice-based evidence, provided the knowledge base and starting point of this essay. Action research paired with intervention propelled the changes in the provision of mobility services in Sweden between 1998 and 2007. The author used John Ovretveit’s identification of significant change components to illuminate the complex change process that occurred.  Selection of an appropriate list of variables to compare the two assessment models derived from FORUM of Mobility Centres, the umbrella organization of British Mobility Centres that developed national guidelines for driving ability assessments in the UK; the QEF Mobility Centre was a member of that organization. The author used a questionnaire and a semi-structured interview to gather relevant data from the compared centers.

    Results TRMC aims primarily to provide services for society through its contributions to road safety. A Mobility Center focuses on providing assessment and rehabilitation services, optimizing impaired drivers’ mobility potential and minimizing collision risks. Cognitive assessment at TRMC accounted for a large part of this study’s time allotment. MC.se’s practical driving test in a suitably modified car provides the most significant difference between the two models.  In addition, MC.se has replaced physicians and psychologists with occupational therapists.

    Conclusion TRMC aims to ensure that current drivers comply with medical driving laws and regulations. MC.se provides assessments that maximize mobility potential and also ensure low collision rates. Thus, safety is balanced against the right to mobility. The study also explores coping strategies, training, adaptations, and choice of vehicle.

  • 339.
    Popa, Cornelia
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    DU90 for the assessmentof drug prescribing in primary care2005Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    Prescribing of drugs is an integral component of health care. In ideal situations drug prescribing constitute safe, effective, and inexpensive treatment alternatives for many conditions. However, poor and inappropriate prescribing is associated with illness and increased costs that can have an important impact at population level. Therefore, evaluation of the quality of drug prescribing is an important part of the process to improve quality in health care delivery. "Drug Utilisation 90%" (DU90) is an innovative approach to assess drug prescribing. Using this approach the drugs that represent 90% of the drug prescription/sales volume are identified. The rationale behind the development of DU90 rests on an assumption that a low number of products prescribed is associated with more rational prescribing practices. Furthermore, the approach can be used to asses what proportion of the drugs that represent 90% of the volume is made up by drugs recommended by local drug committees. In this essay, a feasibility study of DU90 is presented. Furthermore, the usefulness of DU90 as an indicator for quality assessment is discussed. It is concluded that DU90 does not directly reflect the quality of prescribing but it seems to be an useful tool in the quality assessment process through indicating areas that need to be analysed in more depth. The approach can be used for exploring drug prescribing data in a rapid, effective and inexpensive way

  • 340.
    Povlsen, Lene
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Diabetes in children and adolescents from non-western immigrant families: health education, support and collaboration2008Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Aims: The general aims of this thesis were 1) To explore how non-western immigrant families’ different background and factors related to immigration and acculturation may affect the outcome of education and support in paediatric diabetes management; 2) To provide knowledge on how diabetes education and support for immigrant children and their families should be given to ensure them adequate competence in disease management and the children optimum metabolic control. Methods: The thesis comprises five studies carried out 2001-2006. Study I was based on national register data on metabolic control (N=977), questionnaires to all 20 Danish paediatric diabetes centres and structured interviews with 38 immigrant families. Study II was an intervention study including the development of guidelines and adapted educational material, followed by a re-education programme for 37 families. Study III was a case study of 11 Turkish and Kurdish children/families comprising data from medical records, a participant observation and qualitative interviews with the parents, one interpreter and three diabetes team members. Study IV included qualitative interviews with Arabic parents of 12 children, living as immigrants in Denmark and in Cairo/Egypt respectively. Study V comprised data on metabolic control and qualitative interviews with 11 young adult immigrants with type 1 diabetes since childhood or adolescence.Findings: The young immigrants were very unevenly distributed between the Danish paediatric centres. Most teams had little knowledge of and no special educational offers for immigrant families, just as the use of professional interpreters was limited. The immigrant parents had clearly different pre-conditions for diabetes education as compared with ethnic Danish parents, just as most had a low level of acculturation as evaluated by their need for an interpreter. Major differences were identified between the different ethnic groups and between the individual immigrants. The immigrant children and adolescents had different pre-conditions as compared to their parents; most, however, had non-optimum metabolic control. The design of an adapted educational programme could optimise the outcome of diabetes education, but was not sufficient to provide the families with competence in diabetes management and the children/ adolescents with good metabolic control of long duration. Many parents in particular experienced difficulty combining diabetes management with their principles relating to good parenthood. In addition, they appeared to be insecure and doubtful about the competence of the Danish health care professionals.Conclusions: A different ethno-cultural background is likely to create barriers to health education, learning and collaboration. The non-homogeneity of non-western immigrant families requires educational initiatives tailored to the pre-conditions and needs of the individual family members; adapted initiatives such as peer education are suggested. Special support for immigrant children and adolescents should be considered. A close, supportive and trust-filled relationship between the families and health care professionals is needed to facilitate learning, collaboration and good metabolic contro

  • 341.
    Povlsen, Lene
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Karlberg, Ingvar
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Ringsberg, Karin
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Support and education of immigrants with chronically ill children: Identified needs from a case study of Turkish and Kurdish families2008In: Health Education Journal, ISSN 0017-8969, E-ISSN 1748-8176, Vol. 67, no 1, p. 35-44Article in journal (Refereed)
    Abstract [en]

    Objective The aim of the study was to analyse how parents of Turkish and Turkish/Kurdish children with diabetes and health care professionals perceived the education and support provided, and to assess what was required to improve the collaboration between the families and the team in order to optimize selfcare and metabolic control.

    Design A case study including semi-structured interviews, participant observation and information from medical records.

    Setting The study was carried out in Copenhagen, Denmark.

    Method The study included 11 children aged 4—17 years of Turkish and Kurdish origin, their parents, the Turkish interpreter and the paediatric diabetes team.

    Results The study identified the following factors that might contribute to improve the outcome: 1) Adjusted educational initiatives to promote a better understanding of concepts like chronic disease and selfcare, and to ensure that the content of the education is understood, implemented and maintained; 2) special support to enable parents to deal with practical and emotional problems and conflicts related to diabetes management; 3) closer contact and psychosocial support in order to promote learning and motivation for selfcare as well as promoting attendance at the clinics.

    Conclusion Non-western immigrants have a considerable need for special support to help them learn to manage a chronic disease. Health education should aim at bridging the gap between differences related to culture and traditions

  • 342.
    Povlsen, Lene
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Olsen, Birthe
    Ladelund, Steen
    Diabetes in children and adolescents from ethnic minorities: barriers to education, treatment and good metabolic control.2005In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 50, no 6, p. 576-82Article in journal (Refereed)
    Abstract [en]

    AIM: This paper reports an investigation to establish whether metabolic control is different in children and adolescents from ethnic minorities with type 1 diabetes compared with young Danish patients, and to learn about factors affecting their opportunities to achieve good metabolic control.

    BACKGROUND: The prevalence of diabetes in children and adolescents from ethnic minorities in Denmark is increasing. Having a different ethnic background has frequently been described as a risk factor for poor metabolic control, but whether the risk is represented by the ethnicity and immigration itself or in combination with other factors is unclear.

    METHODS: The study included data (gender, age, diabetes duration HbA(1c), number of incidents of severe hypoglycaemia and ketoacidosis) from a national register including 919 Danish and 58 children and adolescents from ethnic minorities, questionnaires to all 20 Danish paediatric diabetes centres and questionnaires to 38 families of other ethnic backgrounds completed by professional interpreters. The study was conducted in 2001-2002.

    RESULTS: HbA(1c) was significantly higher in children and adolescents from ethnic minorities (mean 9.05 +/- 1.4%) compared with Danish patients (mean 8.62 +/- 1.3%; P = 0.018). There was no significant difference in HbA(1c) among the different ethnic groups, nor in the prevalence of severe hypoglycaemia or ketoacidosis. Patients from different ethnic minorities were unevenly distributed throughout the country, and generally the centres provided limited specialized knowledge and support. The questionnaires completed by the parents revealed limited schooling, lack of professional education and a major need for interpreters; these characteristics were especially prevalent among the mothers.

    CONCLUSIONS: Young patients from ethnic minorities have significantly poorer metabolic control compared with Danish patients, and patients with an immigrant background are seen as a vulnerable group with different needs and probably fewer chances of achieving good control. Special education for health care professionals as well as projects to improve methods, quality and knowledge should be encouraged in order to provide tailored support to members of individual ethnic groups. We recommend that the use of professional interpreters should become the gold standard in health care provision to all immigrant families.

  • 343.
    Povlsen, Lene
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Olsen, Birthe
    Ladelund, Steen
    Educating families from ethnic minorities in type 1 diabetes-experiences from a Danish intervention study.2005In: Patient Education and Counseling, ISSN 0738-3991, E-ISSN 1873-5134, Vol. 59, no 2, p. 164-70Article in journal (Refereed)
    Abstract [en]

    Ethnic minorities may constitute vulnerable groups within Western health care systems as their ability to master severe chronic diseases could be affected by barriers such as different culture and health/illness beliefs, communication problems and limited educational background. An intervention focusing on immigrant families with children with type 1 diabetes is described. The intervention included the development of adapted educational material and guidelines, and a subsequent re-education of children, adolescents and parents from 37 families. The study demonstrated that it was possible to improve health outcome. During the study, the knowledge of diabetes increased, but with considerable differences between the families. HbA(1c) also decreased significantly during the intervention, but increased during follow-up. The paper discusses possible explanations and suggestions for optimising education and calls for new projects where ethnic minorities are active participants in the development of appropriate educational programs and material.

  • 344.
    Povlsen, Lene
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Ringsberg, Karin
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Learning to live with type 1 diabetes from the perspective of young non-western immigrants in Denmark2008In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 17, no 11, p. 300-309Article in journal (Refereed)
    Abstract [en]

    Aims and objectives.  To explore how young adults with a non-western immigrant background and type 1 diabetes since childhood/adolescence have perceived learning to live with the disease, with special focus on health education and support.

    Background.  A national Danish study found significantly poorer metabolic control in non-western immigrant children and adolescents as compared with ethnic Danes. Subsequent studies have primarily focused on immigrant parents, whereas little is known about how immigrant children/adolescents have perceived the diagnosis and the diabetes care and support provided.

    Design.  A mixed quantitative and qualitative design was applied. This included data on metabolic control for 2002–2006 and semi-structured interviews in 2006 with eleven strategically selected young immigrants. Data were analysed using qualitative content analysis.

    Findings.  The findings are described in three thematic categories: Perceptions and reactions at the time of diagnosis; Learning to manage the disease; Present and future life with diabetes. Some findings were similar to those in studies describing children and adolescents of western origin, but the participants also shared perceptions which appeared to be related to their immigrant background. Above all, they described their parents as having difficulty coping with the disease and providing them with sufficient support.

    Conclusions.  The diagnosis of diabetes in immigrant children and adolescents requires special pedagogic and psychosocial approaches to bridge the gaps related to culture and traditions and introduce the concept of diabetes management, not least to the parents, in a more optimum way.

    Relevance to clinical practice.  Diabetes care should be a continuous and holistic process, constantly aiming to explore existing knowledge and the need for additional education and support for both the patient and his/her family. Special attention should be paid to the fact that immigrants may have limited pre-knowledge of chronic diseases in childhood, including the concept of selfcare.

  • 345.
    Povlsen, Lene
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Ringsberg, Karin C
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Learning to live with a child with diabetes - problems related to immigration and cross-cultural diabetes care.2009In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 23, no 3, p. 482-9Article in journal (Refereed)
    Abstract [en]

    Diabetes in childhood is a serious chronic disease. Having a different ethnic background is described as a risk factor for poor metabolic control and quality of life. The aim of the study was to explore variations in how parents living as immigrants in Denmark and in their native country had perceived learning to live with a child with diabetes. This was done in order to identify potential problems related to immigration and cross-cultural care which should be considered in the provision of diabetes care to immigrant families. Data were collected by semi-structured interviews with Arabic-speaking immigrant parents of six children with diabetes in Denmark and matched Egyptian parents of six children in Cairo. The children were 7-16 years old and had been diagnosed in 2003-2005. Data were analysed using a phenomenographic approach, focussing on describing variations in the parents' perceptions of the phenomenon 'Learning to live with a child with diabetes'. The findings show that the parents in the two countries shared many reactions and concerns, but that they responded and were affected in different ways. Above all, the immigrant parents experienced their parental role and the life of the child with diabetes, in a more doubtful and negative way. The findings further indicate that the establishment of a trustful relationship between the immigrant families and the health-care professionals should be given high priority. The study concludes that parents with an immigrant background are likely to require special pedagogic, psychological and social support to learn to adapt and come to terms with the diagnosis of a chronic disease in a child.

  • 346.
    Puskeppeleit, Monika Petra
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Improving telemedicine onboard Norwegian ships and drilling platforms.: A study of intersectoral co-operation in Maritime Medicine2008Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    Background: Using telemedicine to provide health services for seafarers represents a special case of intersectoral co-operation.Since 2006, several North Sea drilling platforms and internationally operating Norwegian merchant ships have usedonboard telemedicine equipment continuously. Experience gained through this new technology has improvedintersectoral co-operation regarding seafarers’ health care.

    Aim: This study aimed to analyze the need for intersectoral co-operation and networking in maritime medicine by usingtelemedicine equipment at sea. Various Norwegian maritime organizations and institutions participated in the study.

    Methods: I conducted a qualitative descriptive survey using a Web-organized interactive interview technique, a new mode ofinteraction based on a semi-structured interview guide for data collection. After conducting exploratory personalinterviews in October 2006, I developed a Web-based questionnaire comprising 53 questions. Participants receivedan e-mail invitation containing an online link to an Internet-based questionnaire. Individuals unable to use the Webbasedlink could return the completed questionnaire as an e-mail attachment. I collected data between April and June2007 and evaluated some questions according to the principles of content analysis and others with simple quantitative analysis, e.g., frequency and distribution.

    Results: Among 33 persons contacted, 31 (94%) agreed to participate in the study. Respondents represented 11 variousmaritime organizations and companies. Fourteen worked as maritime officers, nine as maritime managers, and eightas medical professionals. Importantly, fourteen respondents (45%) had demonstrated practical working experiencewith telemedicine at sea. According to content analysis, the following categories were developed: communicationandevidence-based telemedicine; maritime e-health standardization and knowledge management; improvingtelemedicine quality management; organizational, technical, and medical competences and intersectoral approach;technical standardization and networking; and communication and information. Four main categories illuminated theparticipants’ demands, i.e., information, communication, standardization, and centralization, and led to thedevelopment of national e-health policy and strategy to support the Norwegian maritime e-health society vianetworking and intersectoral co-operation.

    Conclusions: Intersectoral co-operation in maritime telemedicine requires interorganizational networking in order to introduceeffective and compatible international maritime e-health standards for seafarers’ healthcare. The Norwegian Centrefor Maritime Medicine (NCMM), a Centre of Excellence in maritime medical research, will participate importantlyin this process. The study also showed that a Web-based survey in maritime research offers an easily managedresearch tool that quickly yields a very good overview of a special situation.

  • 347.
    Pétursson, Pétur
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Why Non-Pharmacological Prescribing of Antibiotics?: A Phenomenological Investigation into the Rationale behind it from the GP’s perspective2005Independent thesis Advanced level (degree of Master (Two Years))Student thesis
    Abstract [en]

    BACKGROUND: Concern has increased worldwide with regard to the over-prescribing of antibiotics, as well as the fact that more bacteria strains are developing resistance to antibiotics. According to research, a great deal of this use is for what has been called “non-pharmacological” reasons. The reduction of unnecessary antibiotic use and exploration of the reasons for ”irrational prescribing” has become a public health priority.

    OBJECTIVE: To study the reasons cited by Icelandic general practitioners for their “non-pharmacological” prescribing of antibiotics.

    DESIGN: A qualitative interview-study with research dialogues guided by the Vancouver School of doing phenomenology.

    SETTING: General practice. PARTICIPANTS: 16 general practitioners: 11 in the maximum variety sample and 5 in the theoretical sample. RESULTS: The most important reasons for prescribing antibiotics in situations with low pharmacological indications (non-pharmacological prescribing) were an unstable doctor-patient relationship due to lack of continuity of care, patient pressure in a stress-loaded society, the doctor’s personal characteristics, particularly zeal and readiness to serve, and finally, the insecurity and uncertainty of the doctor who falls back upon the prescription as a coping strategy in a difficult situation.

    CONCLUSION:The causes of non-pharmacological prescribing of antibiotics are highly varied, and relational factors in the interplay between the doctor and the patient are often a key factor. Therefore, it is of great importance for the general practitioner to know the patient and to become better equipped to resist patient pressure, in order to avoid the need to use the prescription as a coping strategy. Continuity of medical care and a stable doctor-patient relationship may be seen as the core concepts in this study and the most important task for the GPs is to promote the patients’ trust.

  • 348.
    Põlluste, Kaja
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Health reforms in Estonia: acceptability, satisfaction and impact2007Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Since the early 1990s, the Estonian health sector has been undergoing a number of reforms. At the same time, a number of legislative acts have also been established, forming a new legal basis for the health system. The introduction of a social health insurance in 1992 was the first reform in the Estonian health sector reorganisation, followed by a primary health care (PHC) reform, a hospital reform and a number of public health reforms. The aim of this thesis is to analyse these health sector reforms in Estonia, focusing on the outcomes of the health system from the population’s perspective. Proceeding from this general aim, the specific objectives of the thesis are as follows: 1) To analyse the PHC reform in terms of the access to the health services and the acceptability and satisfaction with these services. 2) To analyse the health insurance reform in terms of the acceptability and satisfaction with the new system. 3) To analyse the public health reforms and their impact on the health of the population. The empirical data were gathered with the following research methods: reviews of official health statistics and population surveys in 1998, 2002 and 2005 based on face-to-face interviews using structured questionnaires. The main results can be summarised in relation to the objectives of the thesis: 1) The primary health care reform has been implemented and most of the objectives have been achieved. In general, people accept the changes in the PHC system and the satisfaction with the family doctors has increased. Access to the PHC services is good. Based on the results of a population study in 2002 and 2005, more than half of the respondents could see the family doctor on the same day they made an appointment. Almost a half of the respondents (49%) were satisfied with the access to the health services. Satisfaction with the PHC services and family doctors were found to have positive effects on satisfaction with access to health services. Although people with chronic conditions were less satisfied with the access to the health services they did not experience organisational barriers in their access to such services. 2) The health insurance reform has been implemented and a high level of financial protection has been maintained. The solidarity principle of the health insurance system guarantees access to health services for all the insured people. About half of the population is satisfied with the present system. Compared to 2002, the percentage of satisfied people has increased in 2005, while the percentage of very dissatisfied persons has decreased. The most important predictor of satisfaction with the health insurance was the satisfaction with the existing PHC system. The satisfaction with the health insurance was higher in 2002 as well as 2005 among those respondents who had visited a family doctor or a specialist or were admitted in a hospital during the last 12 months before the survey, but lower among those who had visited a dentist. A small majority preferred the solidarity principles and comprehensive financing of health service by health insurance. The attitudes regarding financing principles were related to the personal contacts with the health services. The respondents who had used the PHC or ambulance services preferred a more comprehensive financing of health services, while those who had had contacts with a specialists or dentists would prefer less comprehensive financing if the waiting lists were short. More than three quarters of the respondents were informed about their rights concerning the access to the health services. Personal contacts with family doctors and specialists had positive impact on the level of awareness. 3) Some progress has been made in connection with the public health reforms. A number of national programs and projects to prevent the most essential health risks have been initiated. As a result, there is some evidence of a positive impact on the health of the population – positive trends in dietary habits and decreasing infant mortality, number of abortions, and incidences of sexually transmitted infections and tuberculosis. At the same time, however, the proportion of smokers and consumers of strong alcohol has not decreased. Moreover, there has been an explosive increase of new cases of HIV-infections in 2000, which is one of the most serious public health problems today. Greater progress has been achieved in the areas where health promotion and health education activities have been supported by political decisions to make a healthy choice for the population easier. However, a comprehensive national health policy and strategy is still lacking in Estonia. In public health, this is evidenced by a lack of long-term planning and understanding of the significance of intersectoral co-operation. Discussion. Up to now, the major reforms in the Estonian health system have been implemented. However, the environment is changing and the health system has to respond to these changes. The next step should therefore be to reach a public agreement about the common values of the health system and setting long-term health policy goals. To improve the effectiveness of policy implementation and reform, the importance of systematic research and evaluation should also be stressed.

  • 349.
    Põlluste, Kaja
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Kalda, Ruth
    Lember, Margus
    Primary health care system in transition: the patient's experience.2000In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 12, no 6, p. 503-9Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To find out how Estonian people evaluate the changes in primary health care (PHC), how they perceive the acceptability of the new PHC system, and to assess patients' satisfaction with their primary care doctor.

    DESIGN: Face-to-face interviews using structured questionnaires.

    SETTING: Estonia.

    STUDY PARTICIPANTS: A random sample of Estonian residents aged 15-74 years (n = 997).

    MAIN MEASURES: Acceptability of PHC system (accessibility, the patient-practitioner relations, amenities, and patient's preferences) and patients' satisfaction with primary care doctor.

    RESULTS: Of the 997 respondents, 46% were sufficiently informed about the transition to the general practitioner (GP)-based PHC system; however, 45% of respondents had not personally experienced any changes. Of the 997 persons interviewed, 68% were registered on the patient list of a GCP, and 62% of those who had health problems preferred to consult the primary care doctor first. The waiting time for an outpatient appointment was brief (0-2 days). Of the 997 respondents, 68% were satisfied with their primary care doctor. Satisfaction was dependent on: (i) how patients evaluated the competence of the physician; (ii) comprehensibility of doctor's explanations; and (iii) comfort of the clinic. The right of patients to choose their own primary care doctor and having sufficient information about the changes in PHC system had a positive influence on the level of satisfaction.

    CONCLUSIONS: Patients' opinions are important in the evaluation of PHC. To increase the level of satisfaction, people need to understand the nature and intent of the primary care reforms. Personal choice of primary care doctor and good patient-doctor relationships are important factors too.

  • 350.
    Põlluste, Kaja
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Kalda, Ruth
    Lember, Margus
    Satisfaction with the access to the health services of the people with chronic conditions in Estonia.2007In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 82, no 1, p. 51-61Article in journal (Refereed)
    Abstract [en]

    UNLABELLED: After the implementation of the primary health care reform in Estonia, most of chronic conditions are managed by family doctors (FD) in collaboration with specialists. Although the general population has demonstrated the increase in satisfaction with health care after the reform, it has been questioned if people with chronic diseases have been left on a more disadvantaged position in the new system with some restrictions in the access to specialists.

    OBJECTIVE: To investigate the satisfaction of people with chronic conditions with the access to the health services and compare them to those who did not have a chronic illness.

    METHOD: In November 2005, a random sample of Estonian residents aged 15-74 were personally interviewed using structured questionnaires (n=1446), 29% of them reported to have a chronic illness.

    RESULTS: The people with chronic conditions were less satisfied with the access to the health services. They were more satisfied with their family doctors, but less with the health insurance system and they often reported their problems in seeing the specialist. Compared to other respondents, the people with chronic conditions visited their FDs and specialists more often, but no significant differences were found between their waiting times to see the FD or a specialist.

    CONCLUSION: In Estonia, the people with chronic conditions do not have organisational barriers in their access to the health services. As frequent users of health services, they perceive the shortages of the health system more obviously than the rest of the population and it may reflect their satisfaction with the different aspects of the health system as well as the access to the health services.

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