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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Genomförande

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

• dokument studie inklusive litteraturgenomgång

• självvärdering genomförd av enhetens båda medarbetare

• individuella intervjuer

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

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

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

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

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

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

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

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

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

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

Aim: The overall aim is to assess the appropriateness of Lay Health Worker (LHW)programmes as a public health intervention in South Africa by considering the effectivenessof LHW programmes across the world and the experience of LHW programmeimplementation and policy making in South Africa.

Methods: This thesis comprises 4 papers that explore the issue of LHWs: (I) A systematicreview of randomised controlled trials (RCTs) of LHW interventions in primary andcommunity health care for maternal and child health and the management of infectiousdiseases; (II) A study of the experiences of farm dwellers trained to be LHWs, as exploredthrough focus group discussions; (III) A study of three LHW supervisors who worked on anintervention to support infant feeding mothers, as explored through individual interviews;and (IV) A study of the process of LHW policy development from the perspective of 11 keyinformants who were individually interviewed.

Findings: LHWs were found to be effective in promoting breastfeeding and in improvingpulmonary TB cure rates (I). There was also some indication that LHWs could be effective inreducing child morbidity and child and neonatal mortality, and in increasing the likelihood ofcaregivers seeking care for childhood illness (I). The experience of LHWs and LHWsupervisors suggests that LHW programmes need adequate support and supervision,especially in protecting the LHWs themselves (II, III). The care and protection of LHWs wasconsidered by policy makers (IV), but policy redevelopment processes did not link the needto ensure that LHWs were not exploited to concerns about gender exploitation.

Conclusions: LHW interventions can be effective but implementing them in developingcountries such as South Africa needs to be approached with caution

Pandemiplaneringen inklusive vaccinationsprogrammet för att möta den nya influ-ensan var unikt till sin omfattning genom att den avsåg hela befolkningen. Något sådant har inte tidigare genomförts i Sverige. Det ger möjlighet att lära för framti-den. Hälso- och sjukvårdsutskottet i Västra Götalandsregionen (VGR) har beställt en utvärdering. En viktig tanke bakom denna utvärdering var att genomföra data-insamlingen medan vaccinationsprogrammet fortfarande var i färskt minne och således dokumentera viktiga skeenden i nära anslutning till att de ägt rum. Den huvudsakliga datainsamlingen skedde under januari 2010. Pandemiorganisationen i sin helhet har vaccinerat drygt 923 000 individer i Västra Götaland. Totalt har mer än 1 080 000 doser registrerats i journalsystemet Svevac. Sjukhusen har vaccinerat cirka 5 procent, primärvården 55 procent, kommunerna 30 procent (skolhälsovården står för 22 procent), företagshälsovården 7 procent samt övriga 3 procent. Antalet personer med rätt att registrera vaccinationer i Svevac har beräknats till 12 000 personer, de flesta av dem är vaccinatörer. Totala antalet vaccinatörer har beräknats till mellan 10 000 – 12 000. De kommer från drygt 600 enheter (Svevac 28 maj 2010).

Utvärderingen har två fokusar – organisering samt epidemiologiskt utfall. Det för-sta handlar om hur den samlade pandemiorganisationen i VGR förbereder sig för att möta den nya influensan inklusive genomförandet av vaccinationsprogrammet. Den andra handlar om att försöka beräkna samhällsnyttan av vaccinationen. Här redovisas den första delen av uppdraget. Den andra redovisas separat. Uppdraget är forskarstyrt och har genomförts av Nordic Centre for Health and Social Assess-ment vid Nordiska högskolan för folkhälsovetenskap i Göteborg. Föreliggande rap-port bygger på en dokumentstudie (cirka 800 sidor planer, riktlinjer, rekommenda-tioner samt minnesanteckningar från möten). Vidare har information hämtats från vetenskaplig litteratur, informationsbroschyrer, artiklar i dagspress och relevanta webbplatser. Den empiriska studien omfattar 44 individuella intervjuer (450 A4-sidor intervjuprotokoll) samt en direkt observation. Utvärderingen lyfter fram både kvalitativa och kvantitativa aspekter. Det ger en rikare bild av händelseförlop-pet och en möjlighet att uttala sig om helheten.

Den fråga forskarna umgåtts med är hur en modell, ett logiskt sammanhängande system för att möta en influensapandemi kan se ut med utgångspunkt i nuvarande kunskap och vägledande policydokument. Här bortser forskarna från hur systemet fungerar idag för att istället försöka skapa en måttstock eller referenspunkt mot vilken verksamheten kan bedömas – en referenspunkt i form av den ”optimala praktiken”. Gapet mellan optimal praktik och det händelseförlopp som dokumen-teras och granskas i utvärderingen bildar forskarnas helhetsbedömning.

I redovisningen granskas bl.a. epidemiplan, systemets aktörer, ansvarsfördelning, arbetets uppläggning och styrning på regional nivå och fältnivå. Organisationen för pandemiledning och Smittskyddsenhetens (SME) centrala roll gås igenom. Här ingår bl.a. logistik för inköp, lagerhållning och transporter. Extern och intern in-formation samt kommunikationen med massmedia granskas. Slutligen granskas belastningen på den reguljära vården.

Slutsatser

Utvärderingen har bedömt pandemiledningens arbete i nio dimensioner som gene-rerats från den idealbild eller ”optimala praktik” som presenteras i de teoretiska utgångspunkterna. 1)Att prioritera- Utvärderingen visar att hälso- och sjukvården i VGR planerat väl för att möta ett scenario innebärande en första pandemivåg utan vaccin. - Utvärderingen visar att pandemiledningen snabbt växlade över till att för-bereda för massvaccination.- Utvärderingen visar att det fanns oklarheter i anvisningarna beträffande risk-grupper vilket gjort dem svåra att avgränsa. 2)Att agera under osäkerhet- Utvärderingen visar att framför allt SME som hållit i trådarna behållit initiativ-et under planering och genomförande och gjort detta väl.3)Att agera under stress- Utvärderingen visar att systemet som helhet levererat trots de oklara påfrestande omständigheterna. 4)Att kommunicera under osäkerhet- Utvärderingen visar att den valda kommunikationsstrategin, baserad på öppen kommunikation, varit lyckad även om den varit tidskrävande för ledningen på SME.- Utvärderingen visar att den regionala informationen varit för detaljerad beträffande annonskampanjen gentemot allmänheten. 5)Att styra viktiga flöden- Utvärderingen visar på tydliga svårigheter att få till ett fungerande arbetsflöde för vaccinering beroende på försenade vaccinleveranser. 6)Att anpassa den reguljära vården- Utvärderingen visar att den strategi man valt för att anpassa den reguljära vården har varit att försöka minska den totala arbetsmängden under pandemin. Strategin fungerade denna gång.7)Att visa prov på flexibilitet- Utvärderingen visar att där man planerat väl och i tid, där var man redo att ställa om den ursprungliga planeringen. 8)Att balansera regional styrning med lokalt handlingsutrymme- Utvärderingen visar att styrningen har fungerat – det tog initialt lite tid innan den hann hitta sina praktiska former lokalt. 9)Att ha koll på kostnaderna- Utvärderingen visar att flera kostnadsposter ännu inte är tillgängliga varför forskarna saknar underlag för att bedöma pandemiledningens kostnadskontroll.Några lärdomar- De privata utförarna i primärvården behöver involveras i pandemiarbetet via en gemensam representation. - Ett välfungerande 1177 (Sjukvårdsrådgivningen) är viktigt för att avlasta sjuk-husens/primärvårdens akutmottagningar.- De informatörer som engageras på regionnivå i VGR behöver arbeta mer själv-ständigt som experter mot media samtidigt som de koordinerar sitt budskap med den lokala nivån. - Vården överöstes initialt med icke selekterad information. Samma information spreds från nationell, regional och lokal nivå. Varför inte marknadsföra vaccina-tionsmanualen som vaccinationsenheternas primära informationskälla.- Undvik andra organisatoriska påfrestningar under en vaccinationskampanj, t.ex. vårdvalsreform eller större organisationsförändringar.- Hälso- och sjukvården har ingen personal att tillgå för extraordinära händelser. Det har varit svårt att utnyttja personalstrategiska funktionen på ett gott sätt. Ett bra instrument för att mäta aktuell sjuklighet bland personalen saknas vilket försvårar personalplaneringen. För att stärka SME föreslås en regional resurs-grupp hos HSA (Hälso- och sjukvårdens adressregister) som vid behov kan diri-geras till funktioner som behöver resurstillskott. - Pandemiplanen behöver revideras, vilket påbörjats. - Den valda strategin för massvaccination föreslås bli omprövad. Jämförelser med strategier i andra landsting är viktig men svår då förutsättningarna är olika samt att man registrerar sina vaccinationer på olika sätt. - Pandemiledningen har tagits på sängen av de oregelbundna vaccinleverans-erna. Att vaccinet inte levererades som planerat är den enskilt mest betydelse-fulla frågan att lära för framtiden.- Samarbetet med kommunerna var avgörande för att genomföra vaccinations-uppdraget.SlutordPandemiarbetet blev en allas angelägenhet. Häri ligger magin att i det osäkra och i den upplevda stressen var alla funktioner i samhället som hade med pandemin att göra inriktade på att bidra. Därför har systemet levererat.

Background: Information about health in the population and interventions to improve public health can be assembled directly through the National Public Health Survey and indirectly from health care. However, there are no generally applied routines for collection, analysis, and reporting of information from health care for public health interventions. In addition there are no routines for collection and feed-back of public health measures in health care.

Aims: To analyse the role of health care and its methods of information about population health, and to support the development of health informatics and methods on follow up on public health interventions in health care.

Methods: This project started by implementation and assessment of the Minimum Data Set instrument for public health nurses (PHN-MDS) in Örebro County (I). Next, clinical notes from public health nurses were analysed by a triangulation process and core elements identified, to be used in the information model (II). The Hospital Discharge Register is often used as a proxy for disease and disability in the population. In order to test its validity, data were collected for each individual who used an official care provider in a well defined geographical area (III). The final work (IV) uses data from a Public Health Survey in order to assess how and to whom health care professionals present questions and advice on health related life style and what factors influence this.

Results: The PHN-MDS makes it possible to assess health problems in the population (I). Analyses of clinical notes from public health nurses showed a broad spectrum of interventions ranging from health promotion to diagnostic, therapeutic, rehabilitation and palliative actions (II). The comparisons of data on ischemic heart disease and its risk factors on an individual level indicated that less than half of the cases were identified in the Hospital Discharge Register (III). Smoking and physical activity are the most common themes for questions and counselling by professionals in health care. The probability to be asked decreases with age, and women are less often given questions and advice. Persons with obvious needs of counselling e.g. with diabetes, obesity and high blood pressure were more likely to receive counselling (IV).

Conclusions: Development of health informatics makes it possible to collect and analyse data from health care in order to broaden the knowledge on health in the population, as well as on individual counselling within health care. Unfortunately, routines based on developed health informatics systems are insufficient

Aim: This thesis aims to describe and analyse the concept of health-promoting leadership, including criticalconditions for implementation and evaluation of such leadership.

Methods: Three case studies and one conceptual analysis were conducted using qualitative methods, including interviews, observations and document analysis. The qualitative data material in study III was supplementedwith quantitative material from a leadership survey. Study I was a qualitative case study of a Swedish industrial company characterized by a low sickness rate, a structure of self-managed teams and an organisational culturethat aimed to develop employee skills and influence. Study II was a phenomenograpic study of health-promoting leadership, as described by 20 individuals employed in Swedish municipalities. Study III was a case study of anintervention programme for the development of health-promoting leadership conducted in four city districts of Gothenburg, Sweden. Study IV was a case study on collaboration in workplace health promotion between municipalities in a Swedish region.

Results: Study I illustrates how a company leader developed and influenced organisational culture, including the employees’ control over their work situation, participation and personal development. The results of this study emphasise the importance of considering contextual factors when evaluating the role of leadership in promotinghealth at work. Study II describes health-promoting leadership in three different ways: organising health promoting activities, supportive leadership style, and developing a health-promoting workplace. Interviewees frequently linked good leadership in general with good employee health. Study III shows the importance ofregarding the development of health-promoting leadership as a contribution to building organisational capacityfor a health-promoting workplace. The intervention programme was implemented in an existing managementgroup already producing action plans for workplace health promotion. Such integration is an important part ofbuilding organisational capacity for creating and sustaining a health-promoting workplace. Study IV shows thatcollaborative health-promoting leadership is viewed as a strategy to reduce the sickness rate amongmunicipalities in a region. The study implies that collaborative workplace health promotion should be organisedinitially on a small scale, giving participants the time and opportunities to develop mutual trust. Moreover, StudyIV demonstrates the importance of including participants with differing levels of knowledge and experienceabout workplace health promotion.

Conclusions: Health-promoting leadership can be defined as leadership that works to create a culture for healthpromotingworkplaces and values, to inspire and motivate employee participation in such a development. Healthpromotingleadership can also be viewed as a critical part of organisational capacity for health promotion,including managerial knowledge and skills as well as organisational policies and structures that support a healthpromotingworkplace. Therefore, leadership involvement in the systematic development of both the physical andpsychosocial work environment is important.

Background Mental health problems among older adults are a central public health problem. Depressive disorders are among the most prevalent mental disorders in later life. Maintaining good health and experiencing well-being in later life are important for the growing population of older adults, enabling them to enjoy life and participate in society for longer.

Aims The overall aim of the thesis is to examine how mental health and mental well-being can be promoted and how the incidence and prevalence of depressive symptoms and disorders can be prevented among older adults. The specific aims of the included studies are to examine the associations between mental ill-health (depression and psychological distress) and social capital among older adults, as well as to collect and evaluate the effect of psychosocial interventions for the primary prevention of depressive disorders. Another specific aim is to provide a better understanding of how social capital influences the experienced mental well-being among older adults.

Methods Population-based survey data collected in Finland and Sweden in 2008 and 2010 were used and logistic regression analyses were conducted to examine the associations between depression and psychological distress among older adults (65+) and various social capital components. A systematic review and meta-analysis were conducted to evaluate the effect of psychosocial interventions on depressive symptoms, functional level and quality of life. Furthermore, two independent sets of qualitative data material – collected through two focus group interviews and an open-ended question included in a Finnish population-based survey from 2008 – were used in order to identify views on the causal mechanisms between mental well-being and social capital in later life (60+).

Results Restricted social networks with regard to both quantity and quality aspects were found to associate with depression and psychological distress in later life as defined in this thesis. Low structural and cognitive social capital are both significant depression covariates in older adults, although the findings were somewhat inconclusive from the association studies. Low frequency of social contacts with friends and neighbours and experienced mistrust in friends were all significantly related to depression, while no statistically significant connection was found between depression and experienced mistrust in neighbours. Further, restricted access to instrumental social support was statistically significantly associated with depression, while other cognitive components of social capital, such as experienced general mistrust, as well as having a limited number of people to count on or who are concerned about you were significantly associated with psychological distress. In addition, based on both quantitative and qualitative data the findings of this thesis highlight the effectiveness and subjective importance of social activities for the maintenance of mental health and well-being among older adults. The social activities are an important mental health resource among older adults because of the accompanied sense of belonging to a social group, as well as feelings of purpose with regard to everyday life and hope for the future. The social activities evaluated in the systematic review and meta-analysis significantly reduced depressive symptoms when compared to no-intervention controls. However, the systematic review also revealed the scarce research base of psychosocial interventions, as only a small number of studies were included and many were characterised by a small or no effect.

Conclusions The findings illustrate the need to actively maintain the social networks and interactions of older people in order to promote mental health and prevent mental ill-health. Older people experiencing low-level social capital are more likely to suffer from mental ill-health and this risk group should have access to initiatives that empower social networking and a maintained rich social life. In addition, the findings highlight the significant potential of psychosocial interventions as they support active and healthy ageing when appropriately implemented

Background and purpose: Acute/critically ill patients have had their life-conditions severely altered from awell-functioning everyday situation to a situation in which they struggle to survive. Traditionally the knowledgeparadigmfrom natural sciences together with medical expertise constitutes the framework for treatment. To beacute/critically ill involves experiences and events and phenomena typical to the situation. The patients’embodied knowledge is not limited to the personal and private sphere, it refers to highly relevant preconditionsfor visibility and reception, also on an existential level; it represents knowledge which needs to be researchedand discussed openly within the public health and nursing sciences. This knowledge represents a differentontology and epistemology from the natural sciences and thus a different perspective, also with regards toclinical tutoring. The dissertation’s primary target is to increase the knowledge about how critical illness isexperienced and how experience based knowledge is significant to teaching in an intensive care context.

Data and methods: The dissertation is based on qualitative methods. Sub-study I includes reviews ofarticles on stress in a perspective of body, space and relationship. Sub-study II contains interviews with formerICU patients relating to their experience of body, strength and movement during critical illness. Sub-study III isbased on former ICU patients’ experience of the physical presence of their significant others during criticalillness. Sub-study IV contains observations and interviews of ICU nurses on how they teach experience basedand interpretation based knowledge in clinical tutoring. Phenomenological-hermeneutic analysis method isapplied to all four sub-studies.

Findings: Sub-study I describes how patients experience stress in a perspective of body, space andrelation. The body is influenced by sleep deprivation, pain and anxiety. Patients experience loss of control withtheir bodies as well as with the situation. The room mirrors the situation patients are in, creating stress by itsrepresentation of life as well as fear of dying. The patient’s horizontal position reflects disproportionate powerinducing a sense of disempowerment. Relational stress situations usually appear in contexts involvingobservation, care or treatment. The organizational structure and activity on the ward affects stress levels. In substudyII the ICU patients experience how power and movement is affected by a sense of loss of body, how theymanage to respond to the situation and how they eventually reclaim the body, power and movement. Theyexperience disempowerment and limitations to movement. This causes dependency and creates conflicts withtheir significant others, especially with regards to proximity and distance. The patients address their loss of bodyby drawing on resources from their significant others, yet refrain from allowing themselves involvement infamily matters. The struggle for survival is characterised by gallows humour and the cry for help as their finalcry. Reclaiming the body happens stepwise with the aid of staff combined with a need to achieve. Sub-study IIIdescribes problems related to proximity to, and distance from, the significant others. A sense of exclusion iscontradicted by being showered with gifts. It is unsettling for patients to have their situation compared to theirsignificant others’. They fear the loss of community with loved ones, yet they need to limit visits fromsignificant others. The lack of ability to communicate when others are physically present is unsettling. Sub-studyIV describes how ICU nurses tutor students in practise by demonstrating knowledge in meaningful actions. Theyconvey their impressions of situations to provide an overview, convey knowledge of observable phenomena, andteach skills to assist the body’s own processes. They also assess and evaluate physical expressions in the patientand how these can be read and addressed. Nurses are also concerned with conveying embodied knowledge totheir students.

Conclusion: In four sub-studies this dissertation highlights a form of knowledge which clearly contraststhat of the natural sciences. During acute critical illness patients experience severe stress and disempowermentcaused by a lack of response and action from nurses who are unable to interpret the body’s own knowledge inthe situation. Patients are often facing life and death questions characterised by marginality and existentiality.Patients demonstrate ability to cope with the situation, but are rarely assisted with coping. Intensive care nursesdisseminate a variety of professional skills and knowledge to their students in order to provide comprehensionand understanding of situations. Experience based knowledge from an intensive care context thus becomes asignificant supplementary factor in the public health perspective

Objective: The general scientific objective of this thesis is to reach a greater understanding of processes of collaboration.

Design and methods: The study was conducted through participatory action research within the health services of Hässleholm, Sweden. The people involved, who were participants of different activities related to health care, aimed at developing their collaboration in a collective attempt to facilitate the development of an integrated local health care. Based on local circumstances and perspectives, the research has generated knowledge on which future decisions on how to implement practical changes can be made. A combination of various methods was used to generate empirical material, where the main method was participant observation withdialogue. In addition, interviews and document reviews were conducted as well as the use of collaborative inquiry,which is a specific method within participatory action research. The study was conducted according to a hermeneutic approach and interpretations were supported by various theoretical perspectives and models. Kurt Lewin's field theory constituted a general theoretical frame of reference for the study.

Results: By describing and interpreting the course of events that were presumed to have an impact on the development of collaboration, a greater understanding of the observed collaboration process was achieved. The process was described in terms of vertical as well as horizontal integration within and between organisations. This description included components that were present in work processes as well as social processes. The observed collaboration process was divided into sub-processes, each of them containing a certain type of activity that was performed in support of the development of collaboration. Strategies for development of collaboration were identified and illustrated by different models: the linear hierarchical model and the dynamic model. The latter was developed through action research.

Conclusions: At an initial stage, collaborationamong the participants in the field was supported by a linear hierarchical model, which constitutes a mind map where collaboration is developed in a linear hierarchical process. Politicians make decisions, managers make plans and professionals implement activities. The model emanates from a consensus theoretical perspective, where conflicts are regarded as disruptive elements. In this case, participants from various domains and organisations avoided the different conceptual worlds of one another, which ledto impediments in the developments of the collaboration process. The action research made it possible to intervene in the process by arranging communication arenas with and for participants from the different domains and organisations. Thus, collaborationcame to evolve from a dynamic model, which includes the assumption that collaboration processes are dynamic and is based on a conflict theoretical perspective, where conflicts are regarded as natural aspects of the processes

Background: The goal of social integration is part of the ideological motivation behind the transition from institutionalised to decentralised psychiatric care. Modern community mental health care considers social integration vital for improving mental health. However, reports suggest that efforts to socially integrate people who suffer from mental health problems have not been as successful as anticipated.Aim: The overall aim of the study was to achieve a deeper understanding of the phenomenon of social integration of people with mental health problems in the community. An additional aim was to develop the healthcare professionals’ insight into this phenomenon by means of co-operative inquiry. The specific research questions were: How have people with mental health problems affected their neighbourhood after re-establishing in the community? How do people with mental health problems experience social integration in the community? How does knowledge of social integration promote practical changes in mental health professionals’ practice?Methods: This study, which comprises four papers, has a hermeneutic design. The data collection methods took the form of interviews with 19 neighbours of group homes for people with mental health problems (Paper I) and focus groups in two separate studies of people with mental health problems, one of which comprised 12 participants in three groups (Paper II) and the other 17 participants in three different multistage focus groups (Paper III), i.e. a total of 14 focus groups. Paper IV utilises findings from Papers I-III by means of a co-operative approach. There were two areas of knowledge development in the research process: dialogue-based teaching and focus groups. The main emphasis of the dialogue-based teaching was to facilitate the articulation of practical and tacit knowledge. Twenty-two healthcare professionals and social workers participated in two different multistage focus groups, a total of 6 focus groups (Paper IV). Data-analysis methods included both the constant comparative process and qualitative content analysis.Findings: The first paper begins with the experiences of neighbours of people who suffer from mental health problems. The neighbours reported frightening behaviours as well as complications in their contact with people who had long-term mental health problems, which led to increased insecurity and fear. The reaction of the neighbourhood was exclusion and segregation in the form of distancing or watching. The next two papers employed a user perspective and revealed that, when meeting people, the participants experienced shame and fear of exclusion due to lack of acceptance and loss of autonomy. Integrity proved a necessary quality for the possibility to be treated as an equal. Lack of work or a meaningful occupation and a low income contributed to a sense of worthlessness and loneliness. Those who had a job or took part in club activities seemed to achieve social companionship, which gave them a sense of being more socially integrated. The co-operative research project enabled co-researchers to gain increased professional knowledge and awareness, as well as providing potential for improvements in clinical practice. Systematic reflection on practice leads to an increased awareness of one’s own attitudes and intervention methods, societal conditions and the community’s attitude to the increased social integration of people with mental health problems. The experiential knowledge gained may contribute to health-promotion strategies such as social integration.Conclusions: Integration difficulties are experienced by both individuals with mental health problems and their neighbouring community. In order to achieve social integration, a person with long-term mental health problems needs to develop adequate social competence. Those working in community mental health care must ensure that people suffering from mental health problems experience a sense of belonging in the community, which can enable them to develop a network and achieve social integration in the planning and development of day-time activities and work, thus promoting social integration. The neighbourhood requires, at the very least, general information when a group home is established. Co-operative inquiry can be beneficial in the public sector, although in order to achieve the best possible result, the whole team must be involved and play an active role in all areas of the research project. If the groups are too large, the participants’ level of engagement may suffer. Multistage focus groups proved to be a powerful method for knowledge acquisition and should be further developed as a means of expanding new knowledg

Forskarutbildning bör kontinuerligt utvärderas för att anpassas till de krav som olika intressenter ställer. Syftet med denna undersökning var att be-skriva hur folkhälsodoktorer, som examinerats från Nordiska hälsovårds-högskolan (NHV) mellan åren 1987 – 2000, upplevt sin forskarutbildning och sin fortsatta akademiska karriär. Data samlades in dels genom en post-enkät med 17 frågor och dels genom en bandinspelad intervju med öppna frågor. Elva av 17 examinerade folkhälsodoktorer besvarade den utsända enkäten. Samtliga ställde sig positiva till att delta i den uppföljande inter-vjun. Fyra av folkhälsodoktorerna tycktes vid tidpunkten för studien vara docentkompetenta och flertalet hade anställningar inom universitet och hög-skolor. Flertalet var forskningsaktiva och hade i genomsnitt publicerat fyra artiklar efter disputationen. Av undersökningen framgår att de examinerade folkhälsodoktorerna i stort sett var nöjda med sin forskarutbildning. De har minnen av suveräna föreläsningar, intressanta tvärfackliga diskussioner och en stimulerande stu-diemiljö. De upplevde dock att de haft få möjligheter att diskutera sina av-handlingsarbeten med andra doktorander och övriga forskare/lärare på NHV. De menade också att de inte tillräckligt utvecklade ett kritiskt förhållnings-sätt under sin forskarutbildning. Flertalet hade genomgått få ämnes- och metodkurser utöver de kurser som ingick i MPH-examen. Forskarutbild-ningen, som i genomsnitt tog 4 år, innebar i princip att ytterligare 3 – 4 em-piriska studier skulle planeras, genomföras och dokumenteras. Jämfört med dagens kursplan för forskarutbildning på NHV (1999), är det tydligt att kra-ven på ämnes- och metodkunskaper har ökat betydligt. Folkhälsodoktorerna hade både positiva och negativa synpunkter på den handledning de fått. När extern och intern handledning vägdes samman, ansåg sig dock flertalet nöjda med den handledning de fått. Några var dock otillfredsställda med handledningen och ansåg sig ha klarat av avhandlings-arbetet genom insatser från andra lärare vid och utanför NHV. Avhandlings-arbetet upplevdes som ett pionjärarbete, som till stora delar utfördes i en-samhet. Flera av de svagheter i forskarutbildningen som angavs i under-sökningen, har tillgodosetts genom den nya kursplanen för forskarutbild-ningen, som antogs av NHVs styrelse 1999.

Antalet individer med funktionsnedsättning ökar, dels beroende på att numera kan sjukdomar botas som tidigare inte kunde botas och dels beroende på att allt fler för tidigt födda barn kan räddas. Den orala hälsan är ofta negativt påverkad hos personer med funktionsnedsättning och det föreligger risk att dessa personer, trots ett större tandvårdsbehov än andra, erhåller mindre tandvård. Anledningen till detta är inte helt känd. Syftet med våra studier var därför att fördjupa kunskapen om hur personer med funktionsnedsättning och deras anhöriga prioriterar och tänker om oral hälsa. Syftet med studierna var också att fördjupa kunskapen om hur hälso- och sjukvårdspersonal samt tandvårdspersonal tänker om behov avseende bemötande och oral hälsa hos personer med funktionsnedsättning. Den kvalitativa forskningsmetoden grounded theory har valts då den är speciellt lämplig på områden där teorier är sparsamt förekommande eller saknas. Öppna kvalitativa intervjuer har genomförts med 65 informanter. Studierna visade att föräldrar till barn med funktionsnedsättning samt vuxna personer med kognitiva och/eller fysiska funktionsnedsättningar inte prioriterade den orala hälsan på grund av att andra mer akuta problem upplevdes som viktigare. Många personer med funktionsnedsättning vårdas kortare eller längre tid på vårdinrättningar, men kunskapen om oral hälsa var låg och inte prioriterad av personal inom hälso- och sjukvården. Personer med funktionsnedsättning återfinns inom såväl allmäntandvård som specialisttandvård och kunskapen om dessa patienters vårdbehov och bemötande av dem varierade mycket mellan olika kliniker, allmän- och specialisttandvård och mellan olika tandvårdspersonal. Sammantaget utgör dessa resultat en möjlig förklaring till varför personer med funktionsnedsättning löper ökad risk för oral ohälsa. Detta innebär också att en prioriterad, god oral hälsa och ett adekvat bemötande av personermed funktionsnedsättningar snarare kan handla om tur än om en jämlik rättighet.

Violence against women is a problem in all countries in the world, including the small autonomy of the Åland Islands. The violence ranges from psychological threats to femicide. In the Åland Islands the issue has been placed on the agenda of politicians and the authorities, while reports about severe violence against women have been brought to the public. In Åland no scientific research on violence against women has been performed. The overall aim of this dissertation is to gain a deeper insight into how battered women in Åland are cared for by nurses, and how the official organizations have responded to the government policy directives. In this thesis, the first study, a descriptive survey, describes how nurses identify and support battered women. In the second and third studies, the method of grounded theory was used to explore the experiences and perceptions of nurses and battered women of violence against women. In the fourth study a case study approach was used to explore government policies for intimate partner violence. The main findings in this thesis are that battered women used health services to receive help. We found that nurses identified and supported abused women, even though services for these women were inadequate. Nurses were willing to help the women, but they often lacked support. Battered women reported that they received ad hoc help. They were often left alone, dependent on a nearby person to escape, survive, and recover. Another finding was that the Government of the Åland Islands demanded that the official organizations should allocate services to battered women, but the organizations’ response to the directives had some limitations. From a public health perspective, the phenomenon presents an urgent challenge. Overall, the public health community can and should contribute greatly towards the understanding, prevention, and control of violence by applying and adapting already constructed principles, and by implementing strategies.

Aim: The overall aim of this thesis is to learn more about how to contribute to improving the daily lives of persons with dementia and those of their carers, and to increase these people’s participation in society.

Methods: The thesis comprises four studies carried out between2003and2011. Study Iwas based on qualitative interviews with 20 persons with early-onset dementia living in the Southern Norway. Study II was a qualitative study with interviews of 19 support contacts,from the Southern Norway. Study III was also based on interviews, in this study with 35 administrators in local authorities, from 32 Norwegian rural and urban local authorities.Study IV was an evaluation study of an intervention for carers of people with dementia and datawere obtained in three steps; (1) a self-derived questionnaires with space for comments, completed by 45 carers after the intervention and 12 months after the starting point of the intervention; (2) interviews with 13 carers 12 months after the starting point of the intervention and analysed together with the comments from the evaluation questionnaires; and (3) a new intervention for carers of younger persons with dementia was developed based onthe findings from the two first steps. The new intervention was evaluated with a self-report questionnaire completed by the carers with space for comments based on the findings from the two first steps. The questionnaire was completed by 48 carers after the new intervention and 12 months after the starting point of this intervention.

Main findings: StudyI describes how people with dementia experience living with dementia, their experiences of the process towards a dementia diagnosisand their descriptions of how they try to maintain their “quality of life”. Study II describes how support contacts perceive their work in dementia care. The study also shows the support contacts’motives for becoming a support contact and their encouraging and discouraging experiences while being a support contact. Furthermore, Study III describes the variation in the process that leads or does not lead to the use of support contacts as a service offered to families with dementia. The administrators’ skills, the accessibilityand management of the service are factorsthat influence this process of offering families with dementia a support contact.Study IV showsthat carers rated the original intervention as beingbeneficial for them,a benefit that remained. These findingscorrespondwith the findings from the interviews. Study IV also shows that the carers of younger persons with dementia benefited from the new intervention aimed at carers of younger people with dementia, a benefit that remained. The carershad valuable proposals for further interventions.

Conclusion: This thesis shows us that the opinions of these families, their supporters and those of other health personnel should not be overlooked when developing services in order to facilitate the provision of the chance to participate in society to families with dementia

SammanfattningBakgrund Otillräcklig fysisk aktivitetsnivå i befolkningen är en gemensam utmaning i de nordiska länderna. För att utbyta erfarenheter och samarbeta för att öka kunskapen och utveckla området livsstil på recept bildades ”Nordisk nettverk for fysisk aktivitet, mat og sunnhet”. I Danmark, Finland, Norge och Sverige har man under det senaste decenniet utvecklat olika modeller av ordination av fysisk aktivitet inom hälso- och sjukvården. Syftet med denna rapport är att beskriva de olika modellerna. Genom att sammanfatta erfarenheter och analysera de olika modellernas för och nackdelar är avsikten att ge rekommendationer för det framtida arbetet i Norden – att finna en nordisk ”best practice” av skriftlig ordination av fysisk aktivitet, med lokala anpassningsmöjligheter. Metod Material har sammanställts utifrån rapporter, vetenskapliga studier, hemsidor och kontakter med experter inom området i respektive land. Då förutsättningarna skiljer sig mellan länderna beskrivs kontexten för det hälsofrämjande arbetet med fysisk aktivitet och en kort historisk tillbakablick ges på det utvecklingsarbete som gjorts kring ordination av fysisk aktivitet. Skillnader respektive likheter identifieras mellan ländernas upplägg av förskrivning av fysisk aktivitet och gemensamma utvecklingsfrågor identifieras. En sammantagen analys leder till rekommendationer för det framtida arbetet i Norden. Resultat Den gemensamma nämnaren i de olika modellerna för fysisk aktivitet på recept är att läkare eller annan legitimerad hälso- och sjukvårdspersonal har ett samtal med patienten och gör en skriftlig ordination på fysisk aktivitet. Gemensamt tankesätt är även att i respektive land finns en eller ett par modeller som sedan anpassas utifrån lokala förutsättningar i varje region, landsting eller kommun. Olikheter mellan modellerna gäller framför allt vem som förskriver, vem som har det motiverande samtalet och följer upp den ordinerade aktiviteten samt vilka patienter som kan komma ifråga. Det är stor variation i hur intensiva interventionerna är, vilka delar som utförs inom hälso- och sjukvården respektive i samverkan med andra aktörer i samhället, om man fokuserar på att främja fysisk aktivitet på egen hand eller gruppaktivitet. Vissa modeller utnyttjar befintliga strukturer i samhället medan andra har utvecklat nya. Alla modeller har sina för- och nackdelar och olika modeller passar under olika förutsättningar. De modeller som har studerats vetenskapligt, har i samtliga fall lett till en ökad fysisk aktivitetsnivå. Slutsats Det är viktigt med en individuell anpassning av såväl ordinerad aktivitet som vilket stöd patienten är i behov av. Grovt indelat bör hälso- och sjukvårdspersonal använda två nivåer av insatser till patienter som behöver öka sin fysiska aktivitet i förebyggande eller behandlande syfte. I första hand erbjuds motiverande samtal med en individanpassad skriftlig ordination av fysisk aktivitet som patientens bedriver på egen hand (vardagsaktivitet och/eller organiserad aktivitet). För de patienter som behöver utökat stöd för att komma igång med fysisk aktivitet, erbjuds träningsgrupper inom vården som ett första steg. En individanpassad skriftlig ordination kan därefter underlätta övergången från strukturerad träning inom vården, till att individen blir varaktigt fysiskt aktiv på egen hand. Det är dock inte möjligt att föreslå en enda modell för fysisk aktivitet på recept i Norden som passar alla patienter, förskrivare och olika lokala villkor. Arbetet måste därför anpassas utifrån de aktuella förutsättningarna.

Aims: The main aim of this thesis was to study a perspective of women`s expressed wishes for mode of delivery and how they actually give birth. Additional aims were to examine the notion of risk applied to childbirth, to examine what characterizes women who want to give birth as naturally as possible without painkillers or intervention and the characteristics of women who would, if possible, choose to have a cesarean section.

Material and methods: The notion of risk was examined in an essay. Self-rating instruments were completed by 55,858 MoBa participants during week 30 of their pregnancy and available from The Norwegian Mother and Child Cohort Study (MoBa) by April, 2007. Individually reported information on socioeconomic factors, lifestyle factors, feelings related to childbirth, factors concerning psychosocial health, physical, psychological and sexual harassment and information on satisfaction with antenatal care health services were collected from a MoBa questionnaire. Data on the mother’s age, parity, physical health before and during the pregnancy, previous cesarean sections and actual mode of delivery were collected through a linkage to the The Medical Birth Registry of Norway.

Findings: General perspectives on risk differ depending on both the person and the profession. More and more childbearing women are in danger of being considered deficient and in the danger zone. Figures on risk are not objective values, and the association between risk and security is socially and culturally determined. Personal symbols can be basic assumptions about the life one leads, and the childbearing woman has preferences of her own. Interest in natural childbirth was expressed by 72 percent and a wish for caesarean section was expressed by ten percent of the women. Positive experience from previous childbirths, first birth or third or later birth, no dread of giving birth, and reporting positive intra-psychic phenomena are significantly associated with the wish for natural birth. Negative experiences from previous childbirths and fear of giving birth are two of the strongest factors associated with a wish for a caesarean section.Overall, 47 percent of the women who wanted ”as natural a birth as possible” had their preference fulfilled. The figures differed largely for primiparas and multiparas; the risk of acute caesarean sections was high among primiparas and the effects of the predictors of natural birth were stronger for primiparas than for multiparas.

Conclusions:The factors that influence the chance of having a natural birth are different for primiparas and multiparas. The high rate of non-natural births among first time mothers who actually want to have a vaginal birth without interventions should call attention to the increasing incidence of cesarean section in Norway. The chance of actually having a natural birth for women with a preference for a natural birth is much larger for multiparas. Negative experiences from previous childbirths and cesarean section are, however, important factors associated with non-natural birth and should be taken into consideration in public health

Background: Minority groups, including immigrants, generally tend to report lower self-rated health than the majority.

Aims: The overall object of the dissertation was to describe, analyze and compare the self-rated health of older Finland-Swedes, and deepen the understanding of their experience of health in a life-course perspective. The experience of health was qualitatively studied among older Finland-Swedes in Finland, Finland-Swedes in Sweden and after re-migration in Finland (parts I, IV). Self-rated health was quantitatively studied among older Finland-Swedes in Finland (part II), and among older Finland-Swedes in Sweden compared to older Finnish-speakers in Sweden (part III). Migration (parts III, IV) and ageing (parts I, II, IV) were reflected in the health of older persons.

Methods: The sample was obtained from the Population Register Centre of Finland and Statistics Sweden. The target groups consisted of 982 persons. The data was collected in structured oral and taped interviews, semi-structured taped interviews, structured interview forms, and postal enquiries. The data were analyzed through a hermeneutic approach with core narratives, thematic qualitative content analysis, cumulative multiple regression analysis, and chi-square test.

Results: The experiential health of older persons manifested itself in personality, physical health, social relations, and society. More than a half of the respondents rated their health as good. Better health was reported with less medicine, no pain/suffering, better functional capacity, more zest for life, and better financial position. Older Finland-Swedes in Sweden reported better health than the Finnish-speaking respondents in Sweden. Migration had caused difficulties in connection with the move to Sweden and with working life in Sweden. Ill-health and ageing could cause problems with remigration. Ageing involved an adjustment in setting own health and the present in perspective. The results showed that older persons could contribute knowledge about health factors.

Conclusions: From the perspective of public health science and health promotion, it is relevant to present minority groups from the vantage point of resources. It is essential to realize that there can be health differences between minorities, within minorities, and among ethnic minorities. Social and cultural variations can affect the way older persons evaluate their health. Older persons in minorities can be more vulnerable owing to ill-health, migration and gender.

Background and purpose Within health and medical care, demands on increased efficiency, availability and increased quality, as well as a reduced financial framework, have required changes in the health and medical care system. One aim of this thesis is to illustrate the practical significance of the concept of efficiency in health and medical care on the basis of the experience of professionals. Another aim, on the basis of different perspectives, is to illustrate leadership and employeeship in connection with structural changes within health and medical care.

Method The thesis builds on four studies (I – IV) carried out with the help of a qualitative research approach. Study I builds upon interviews on the concept of efficiency with strategically selected representatives for an organisation’s three decision levels. Studies II and III builds upon interviews with employees from different professions who have participated in two different hospital mergers. In study IV employees were interviewed about their experiences in connection with the privatisation of a health and medical care organisation.

Outcome When there is no definition of the concept of efficiency in an organisation, different players are allowed scope to make their own interpretation, which can negatively affect fulfilment of objectives. During structural changes it is important that employees are given the opportunity to participate and to be able to balance their commitments in the process. It is also important that employees, in a process of change, have trust in the management and organisation. At the same time, structural changes can involve exciting challenges and new possibilities for development.

Conclusions Structural changes within health and medical care, with the purpose of streamlining, are complex and multifaceted. At the same time the concept of efficiency is ambiguous and difficult to evaluate. It is influenced by structure and leadership as well as employeeship. A process of change affects both leadership and employeeship. Success factors are the employees’ prospects for participation and balance, and their trust in both structure and leadership.

Göteborg är en socialt, ekonomiskt och etniskt starkt segregerad stad. Jämfört med andra delar av staden lever en större del av befolkningen i de nordöstra stadsdelarna i fattigdom, arbetslösheten är större, andelen med utländsk bakgrund dominerar mera, ungdoms-brottsligheten är högre, ohälsotalen är större, utbildningsresultaten hos skoleleverna är sämre. Den socioekonomiska ojämlikheten påverkar också tillgängligheten till hälsofrämjande resurser och möjligheten att få vård, vilket i sin tur bidrar till sociala skillnader i sjukdoms-börda och överlevnad och senare till skillnader i förtida dödlighet. (Folkhälsorapporten 2009). Som en del av ett större arbete med att utveckla denna del av Göteborg pågår ett intensifierat politiskt arbete med bl.a. ett utbyggt centrum i Angered, en ny bad- och ishall samt ett stort antal nya bostäder. Dessutom har lokala och regionala myndigheter beslutat att starta ett närsjukhus i Angered, med målsättning att tillgodose större delen av vårdbehovet för befolkningen i Nordost, dvs. de fyra stadsdelarna Bergsjön, Gunnared, Kortedala och Lärjedalen. Planeringen av detta nya vårdprojekt inleddes med en behovsanalys, som tydligt visade på ett mönster av översjuklighet och undervård i befolkningen i Nordost, och då inte minst bland barnen. Att arbeta aktivt med barns och ungdomars hälsa under de närmaste åren blev därför ett prioriterat mål, och en rad projekt har startats för att göra Angereds Närsjukhus till ett centrum för att förbättra barnens hälsa och därigenom göra stora vinster för både nuvarande och framtida folkhälsa och samhällslönsamhet. Trogen maximen First measure then act blev en tidig åtgärd att först kartlägga hur barnens hälsa och välbefinnande verkligen ser ut i området i dag för att rätt kunna värdera effekten av de insatser som görs från samhällets sida. Mitt uppdrag blev således att utveckla ett barnhälsoindex, som ska ge en samlad bild över barnens hälsostatus, både ur ett medicinskt och psykosocialt perspektiv, men även ta hänsyn till de indikatorer på hälsa som är viktigt ur befolkningens perspektiv. Indexet ska bygga på en rad indikatorer som fyller kraven på relevans, kvalitet och tillgänglighet, och det ska ge möjlighet att jämföra barnens situation i Nordost, både över tid och med andra kommundelar, med kommunen som helhet och med Regionen. Uppdraget redovisas härmed, och jag ber att redan nu få tacka de personer som på olika sätt hjälpt till att få styrsel på projektet och medverkat till att data kunnat samlas in. Detta är ju inte en definitiv och slutgiltig uppsättning av indikatorer, utan skall ses som ett första försök att systematisera och strukturera de kunskaper som finns på fältet. Förhoppningsvis kan rapporten ligga till grund för ett fortsatt utvecklingsarbete, så att det till slut existerar en komplett och högkvalitativ uppsättning av indikatorer, som på tillförlitligt och relevant sätt speglar barns och ungdomars hälsa och välbefinnande på kommundelsnivå.

Det finns i Göteborg stora skillnader mellan de olika stadsdelarna i socialt, ekono-miskt och etniskt avseende, och det avspeglar sig också i befolkningens hälsa. I en tidigare rapport (Barnhälsoindex för stadsdelarna i nordöstra Göteborg från 2010) visades klart hur denna ojämlikhet fått ett starkt genomslag hos också de yngsta: barnen 0-17 år i de fyra stadsdelarna i Nordost, Bergsjön, Gunnared, Kortedala och Lärjedalen, uppvisade i de allra flesta avseenden sämre hälsa än sammantaget för barnen i hela Göteborg. Rapporten fick stor spridning bland politiker och andra be-slutsfattare i staden, och förstärkte ambitionerna att på olika sätt investera i en soci-al, ekonomisk och hälsofrämjande utveckling av dessa stadsdelar. Men man insåg samtidigt att de andra delarna av staden inte nödvändigtvis måste vara utan problem. Ojämlikheten är inte begränsad till Nordost och det finns indikat-ioner på att ohälsa, missbruksproblem, anpassningssvårigheter och brist på stöd förekom inom andra områden, möjligen av annan typ och möjligen med annan för-delning. Men detaljerna visste man inte, för det finns inga data tillgängliga. Därför beslöt kommunfullmätige att helt enkelt utvidga kartläggningen till hela staden Göte-borg, att beställa ett barnhälsoindex för alla stadsdelarna. Eller som det uttrycks i folkhälsodelen av kommunstyrelsens budgetförslag för 2012: ”Vårt mål är att alla göteborgare ska ha samma goda folkhälsa som de grupper som idag har den bästa folkhälsan. Ohälsan slår hårdast mot de mest utsatta och det drabbar också barnen och den är intimt kopplad till barnfattigdom. I Göteborg lever nästan vart sjätte barn i fat-tigdom men skillnaderna mellan barns välfärd i olika stadsdelar är stor. Staden ska motverka ökade skillnader mellan människor och istället sträva efter jämlikhet i hälsa – särskilt riktat mot barn, ungdomar och deras föräldrar. Ohälsans klasstrappa i Göte-borg ska bort. En grundlig analys av situationen i Göteborg för barn och ungdomar behövs. Därför ska varje stadsdel i samverkan med hälso- och sjukvården ta fram un-derlag till ett barnhälsoindex. Barnhälsoindexet ska sedan användas som verktyg i verksamheter som rör barn och unga för att bryta trenden av den ojämlika hälsan i Göteborg”.Man insåg snart från stadsdelarnas sida att låta varje stadsdel ta fram varsitt barn-hälsoindex kanske inte var det bästa sättet att arbeta på. Risken för svårigheter att jämföra resultaten och för att komma i otakt med dem är överhängande. Jag fick därför återigen uppdraget att utveckla ett Barnhälsoindex, som både kunde ge en heltäckande bild av barnens hälsosituation i hela Göteborg, men som också kunde belysa de skillnader som i olika avseenden finns mellan stadsdelarna. Målet blev, som tidigare, att konstruera ett barnhälsoindex, som ska ge en samlad bild över barnens hälsostatus, både ur ett medicinskt och psykosocialt perspektiv, men även ta hänsyn till de indikatorer på hälsa som är viktigt ur ett befolkningsper-pektiv. Indexet ska bygga på en rad indikatorer som fyller kraven på relevans, kvali-tet och tillgänglighet, och det ska ge möjlighet att jämföra barnens situation i stadsde-larna, både över tid och med staden som helhet samt med Regionen och Riket, om data finns tillgängliga. Sedan jag senast gjorde ett Barnhälsoindex i Göteborg har stadens administrativa indelning ändrats, 2011 reducerades antalet stadsdelar från 21 till 10. Efter många överläggningar med berörda personer beslöt jag att använda de gamla stadsdelarna, för att kunna jämföra bakåt, men allra mest för att man på det viset bryter ner resul-taten till mindre enheter, vilket gynnar förståelsen och underlättar interventioner. En särskild statistikgrupp inom stadens förvaltning arbetar med att skapa ytterligare mindre statistiska enheter, s.k. mellanområden, som skall kunna belysa befolkning-ens liv och verksamhet på en mer lokal nivå än stadsdel, eftersom resultaten enligt kommunfullmäktige annars kan ge en missvisande bild. Det betyder att sådana mel-lanområden i framtiden kan bli lämplig indelningsgrund också för ett Barnhälsoin-dex, förutsatt att data görs tillgängliga på den nivån. Precis som i tidigare rapporter, internationella, nationella och lokala har Barnkonventionens definition av barn följts, dvs. individer under 18 år. Uppdraget redovisas härmed, och jag ber att få tacka de många personer som på olika sätt hjälpt till att få styrsel på projektet och medverkat till att data kunnat samlas in (se närmare sid 13 och 17). Särskilt vill jag tacka Mats Klingberg på NHV, som nog-grant konfigurerat data och placerat dem i tabellerna. Detta är ju inte en definitiv och slutgiltig uppsättning av indikatorer, utan skall ses som ett försök att systematisera och strukturera de kunskaper som finns på fältet. Förhoppningsvis kan rapporten leda till ett fortsatt utvecklingsarbete, så att det till slut existerar en komplett och högkvalitativ uppsättning av indikatorer, som på ett tillförlitligt och relevant sätt speglar barns och ungdomars hälsa och välbefinnande på kommun- och kommundelsnivå. Det ska också understrykas att detta Barnhälsoindex i första hand skall användas för att ge vägledning för aktiva insatser på barnhälsans område, och som sådant skall det var tydligt, lättförståeligt och överskådligt. Det är inte tänkt som en vetenskaplig publikation. En sådan lär komma senare, då med mer utvecklade statistiska bearbet-ningar och sambandsanalyser. Men det hindrar inte att det också i denna version har tillämpats ett kritiskt och vetenskapligt förhållningssätt till upplägg, metoder, data och tolkningar.

För 10 år sedan fi rade vi med stor pompa och ståt NHVs 40-års-jubileum. Också då med tillbakablickande och framåtseende, akademisk festivitas och glad samvaro. Det är förresten ett genomgående drag på NHV att tillvarata alla möjligheter att fira något, med akademisk högtid och glada fester. Så har skett vid invigning av nya lokaler, vid promoveringar och installationer, och firandet har alltid skett med fokus på de viktigaste målen för vår verksamhet: folkhälsa, utbildning och Norden. Min uppgift i den här skriften är att ge en skildring av NHVs historia. ”The longer you look back, the further you can look forward”, är Churchills berömda argument för historisk forskning. Med andra ord: Ju mer man vet om NHVs uppkomst och utveckling, desto lättare är det att förstå hur NHV blivit vad den är i dag och ju säkrare kan man predicera vad den kan bli i morgon. Det gäller också att vara bakåtklok för att inte bli framåtdum. Det finns flera sätt att beskriva det förflutenhetens landskap som historien utgör, enligt Peter Englund. Man kan skildra Den Stora Historien, dvs. kungar, krig, storpolitik, samhälleliga omstörtningar, eller Den Lilla Historien, dvs. vardagslivets tysta gång och lugna rytmer, som i facit kanske har betytt väl så mycket för människans villkor som aldrig så spektakulära krig och fredsfördrag. I en skildring av NHV skulle väl Den Stora Historien motsvaras av de omfattande utredningar och genomgripande förändringar av skolans statuter och resurser som skett via de nordiska samarbetsorganen. Och Den Lilla Historien skulle väl vara det inre, dagliga arbetet med undervisning och utbildningsplaner, med forskning och konferenser, med kollegiemöten och kvalitetsutveckling, med ledningsgrupper och fack och alla dessa möten med kreativa personer på alla nivåer. Jag har i denna exposé valt att koncentrera mig på några områden, som jag tror skall ge en inblick i båda dessa aspekter på historien. Det kommer således att handla om Utredningar och Ut-värderingar, Ideologier och Strategier, Byggnader och andra resurser samt om Människor. Dessa områden hänger naturligtvis ihop och är beroende av varandra, men vissa huvudlinjer kan dock skönjas. Eftersom historien alltid måste tolkas innehåller den ju ett visst mått av subjektivitet, dvs. händelser har valts ut och satts in i sitt sammanhang på ett bestämt sätt. Historien handlar ju, som en annan svensk historiker har sagt, ytterst om den som skriver den. Men det hindrar inte att jag skall försöka lämna plats åt andra också och vara så kritisk och sanningssökande som möjligt.

Background: Drug utilisation among the elderly is complex due to multiplemorbidities, extensive drug utilisation and an increased sensitivity to drugs. One of the most common drug groups utilised in this population is psychotropic drugs, which include antipsychotics, anxiolytics, hypnotics, and antidepressants. In appropriat eutilisation of drugs among the elderly is an issue of great public health importance.

Aims: The overall aim of this thesis is to assess and analyse potentially in appropriat eutilisation of psychotropic drugs among the elderly in Sweden. The specific aims are to assess to what extent the indicator “concurrent use of three or more psychotropic drugs”captures the utilisation of Potentially Inappropriate Psychotropics (PIP) among theelderly, and to analyse potentially inappropriate utilisation of psychotropic drugs inrelation to time, mental disorders, institutionalisation, and socioeconomic determinants among the elderly in Sweden.

Methods: Data from individual-based registers on dispensed drugs and socioeconomic determinants in 2006, the Gothenburg 95+ Study (1996-1998), and aggregated drug sales statistics from 2000-2008 were used. The agreement between the two indicators“concurrent use of three or more psychotropic drugs” and PIP was assessed. Utilisationof psychotropic drugs and PIP was assessed in relation to mental disorders and institutionalisation among the 95-year olds, and in relation to socioeconomic determinants among individuals aged 75 years and older. Further, trends over time inutilisation of PIP and recommended drugs were analysed.

Results: During 2006, about half of the elderly aged 75 years and older utilised psychotropic drugs and one fifth of all elderly utilised PIP. One fourth of individualsutilising PIP were captured by the indicator “concurrent use of three or morepsychotropic drugs”. In 1996-1998, less than one tenth of the 95-year olds with depression utilised antidepressants, while hypnotics and anxiolytics were more common. Individuals with low income and the non-married were more likely to utilise PIP compared to those with high income and the married, respectively. During 2000-2008, utilisation of PIP decreased and utilisation of recommended psychotropic drugs increased.

Conclusions: There are substantial problems in the utilisation of psychotropic drugsamong the elderly. This thesis found that the agreement between two indicators of inappropriate psychotropic drug utilisation was poor, which emphasises the importance of choosing relevant indicators. The findings also show socioeconomic inequities inpsychotropic drug utilisation among the elderly, a low utilisation of antidepressants among 95-year olds diagnosed with depression, and a trend towards the utilisation of recommended rather than inappropriate psychotropic drugs among the elderly

Den här forskningsrapporten, som finansierats av Nordiska Ministerrådet, är en komparativ studie av hur reformer inom psykiatri och socialtjänsten översatts till konkreta vård- och stödinsatser i fyra nordiska länder: Danmark, Finland, Norge och Sverige. Att Island utelämnats beror på att vi inte funnit någon intresserad forskarkollega som haft möjlighet att anta utmaningen. Arbetet med projektet ingår i den s.k. Handlingsplanen för Psykisk hälsa där ytterligare ett antalprojekt har genomförts. Samtliga dessa projekt har organiserats av Nordiska Akademin för forskning om psykisk hälsa vid NHV och med docent Lars Fredén som huvudansvarig.Rapporten innehåller dels en inledande komparativ analys och därefter följer en beskrivning av reformutvecklingen i varje enskilt land. Rapporten ger en bild av hur policyintentioner, servicesystem, arbetsformer och samverkansformer gestaltar sig i de fyra nordiska länderna och i vilka avseenden likheter och skillnader finns. Trots att det finns stora kulturella likheter mellan länderna finns också olikheter som bl.a. innebär skillnader i hur begrepp och terminologi används. I ett par av länderna, Danmark och Finland, är det tveksamt om man överhuvudtaget kan tala om specifika psykiatrireformer eftersom det handlar om en utveckling med ett tämligen långt utdraget förlopp där olika politikområden berörs. I Norge och Sverige kan vi däremot iaktta relativt specifika och avgränsade reformer. En annan aspekt som rör begrepp och terminologi är att man i Finland och Norge använder begreppet psykiatri när man mer entydigt refererar till den aktuella medicinska disciplinen, medan man använder sig av begreppen mentalvårdsarbete respektive psykisk helsearbeid när vill inkludera socialtjänstens och andra organisationers insatser för personer med psykisk ohälsa. I Danmark och till viss del även i Sverige använder man sig av begreppet socialpsykiatri för motsvarande verksamhet. Vi har valt att inkludera länderrapporterna skrivna med den i landet gängse terminologin eftersom den återspeglar de diskussioner och ställningstaganden man gjort vad gäller policyinriktning och servicestruktur. I den komparativa analysen har videlvis frångått detta språkbruk till förmån för en mer enhetlig begreppsapparat. Vi kan bara hoppas att läsaren gör sina egna reflektioner om hur utvecklingen av policy och servicestruktur återspeglas i vår analys.

Background. Falls among older persons are a public health problem in Denmark, the Nordic countries and the rest of the Western world. In a population perspective fall-prevention has been characterised by an individual behavioural modificationand a regulating mode. This kind of fall-prevention discourseis nowbreaking up.

Aim. To describe how community-dwelling older adults experience and handle falls, falling and loss ofbalance. The focus is also on examination offalls as contextual phenomena with the older adults’ experiences. This study will contribute to develop health promotion and fall-prevention to individuals and to the fall-prevention as so.

Methodology. This thesis consists offour studies/articles (I-IV). Interpretative phenomenology as philosophical and analytical method was used. In one study (III) case study methodwas used as a framework,complemented bycritical discourse-analytic interpretation of documents. Within thefour studies nine women and four men (75-94 years old) were interviewed in narrative in-depth interviews about falling. In article III,five health and social workers and a nurse were interviewed.

Results. In coping withfalling accidents, vulnerability, frailty and death imminence the participants developed various methods ofmanagingeveryday lifeat home. They describedadaptive resourcesused to achieve an adequate quality oflife andexperiencea feeling of well-being (I). Fear of fallingwas always present and was met in differentways. On one handwas worry aboutungraceful situationsnot able to manage on your own; on the other hand was the willto live with the fear.(II). The two protagonists, dependent onhome-care developed their own strategies for preventingfalls. The health professionals created a supportive network; a platform of continuity where the efforts of the older persons and the staff complemented each other. The staff had no clear approachto addressing issues raised by accidental falls or the prevention of falls (III).Eating and appetite on foodwerenot trivial everyday routines. The participants showed no particular interest in eating but ateto stay alive. Even if they had little appetite forfood, the participants showed great appetite forestablishing social relationships withfamily, neighbours and health care staff,as well as appetite forestablishing an influence in these relations and in local communities and society.

Conclusion. In the future,fall-prevention must takea health promotion approach and contextualise falling accidents withexperiences and meanings as point of reference. Fall-prevention will be not only multifactorial,but also multidimenssional and existential

INTRODUCTION. This dissertation concerns childbirth and its position within the Greenlandic society. It takes a world relational view to health promotion during, focusing on the perinatal family and the importance of the mothers, the child, their families and the local community as equal pieces of a whole.

AIM. The aim of the dissertation is to present new concepts and knowledge concerning the health of the perinatal family in Greenland. It looks holistically at the place of birth with focus on the issue of support of the perinatal family. It seeks to present the perinatal family and its position within the Greenlandic society. It links the changes in health policy with the concepts of family, attitude and community structure. It draws on statistical, historical, anthropological and cultural data within the context of the Greenlandic perinatal family.

METHOD AND MATERIAL. The dissertation is comprised of four studies and uses multidisciplinary methods. Over an eight-year period from 2003 to 2011, narrative interviews and focus groups were collected at four sites in Greenland: Nuuk, Ilulissat, Sisimiut and Tasiilaq. Data included seven focus groups with 35 participants, supplemented with 18 individual interviews of mothers, fathers and Culture Bearers, as well as two literature studies. The mode of conducting focus groups and interviews was based on the principles in the Helsinki Declaration.

RESULTS. The perinatal family’s concepts of safety are often connected directly to access to family and community. Family is perceived as security, and lack of family support and network as insecurity. The concept of family and community is culturally specific and connected to the immediate family, extended family and kin. There is a cultural room for birth in Greenland, where the health of the perinatal family lies in their ability to strengthen the bonds within family, kinship and community networks. The mothers of the study perceived themselves as the bearers of their children; the fathers considered themselves to be the artisans and caregivers for their family; the community, including the extended family, deemed an important support network for the families.

CONCLUSION. It is important to understand the link that exists between traditional and cultural properties and the health of the child within the family. These are elements of the eco cultural pathways that are already integrated within the family interactions and could be a way to strengthen family interaction and health. Families and community support these traditions and in healthy eco cultural exchanges it enhances the child’s role as a health–promoting agent within the family. Greenlandic public health, health promotion programs and the national perinatal guidelines have a physical health focus, but do not address the mental, social and spiritual dimensions of perinatal health. This fragmented way of perceiving and implementing health does not support the relational worldview that is an integral part of the culture of Greenland, and thus many families struggle to exercise choice within the system

Dette er slutrapporten udarbejdet i den fælles Nordisk forskningsgruppe. Gruppen har fokuseret på at undersøge psykisk sygdom, ved hjælp af de Nordiske populations registre. Projektet er finansieret af Nordisk Ministerråd under handlingsplanen för psykisk hälsa, med en bevilling som er tildelt ”Nordiska akademin för forskning om psykisk hälsa, Nordiska högskolan för folkhälsovetenskap”.Vi har fra de nationale patientregistre udtrukket oplysninger om indlæggelser med psykisk sygdom, samt fundet dødsdag og dødsårsag i dødsårsagsregistrene. Ud fra disse oplysninger har vi lavet en række undersøgelser omkring dødelighed og forventet livslængde blandt personer med registreret psykisk sygdom. Vores overordnede mål har været at undersøge overdødeligheden blandt psykisk syge personer i forhold til den generelle befolkning. Herunder at se på udviklingen over tid, forventede levetider, forskelle på undergrupper af psykisk sygdom, samt undersøge eventuelle forskelle imellem de tre lande. Resultaterne er beskrevet i fem artikler som i øjeblikket er indsendt til peer-review hos internationale tidsskrifter, eller under udarbejdelse og klargøring til indsendelse. En kort beskrivelse af disse artikler er at finde til sidst i rapporten. Det er på grund af ophavsrettigheder desværre ikke muligt at vedhæfte artiklerne i denne rapport. Resultaterne vil desuden blive fremlagt på en konference den 22.11.2010 i København. Her vil repræsentanter for alle de nordiske lande være til stede. Projektgruppen har udover produktion af artikler afholdt nordiske forsknings seminarer om psykiatrisk registerforskning.

Abstract Background and aim: Stroke is most frequently the cause of adult disability. In Denmark more than 50.000 people suffer from the sequels of stroke. One of them may be aphasia, i.e. reduced ability to communicate. Primary and secondary prevention may reduce the incidence and the severity of stroke. The interest in quality of life with a chronic disease is increasing. Rehabilitation efforts are targeted for physical, mental and social function but the impact on health related quality of life after stroke has not been studied with stroke specific instruments. Aphasic patients are normally excluded from studies where communicative skills are required. The aim of this thesis is to develop an instrument suitable for measuring health related quality of life after stroke. Methods and material: The design of the thesis is quantitative. In study I Stroke Specific Quality of Life Scale, version 2.0, SSQOL © (copyright Linda S. Williams), an American instrument recently developed, was translated and culturally adapted to Danish according to established guidelines. With 49 items SSQOL covers 12 domains comprising physical and mental issues. Thirteen items covers an appraisal of each domain compared to pre stroke status and overall quality of life. Psychometric properties was examined by studying three samples of stroke survivors. Study II and III examined reliability, validity and responsiveness. Established generic scales were used as external criteria. Study IV tested a proxy-version meant for stroke patients with language impairment or patients who are unable to fill in a questionnaire. The patients chose the proxies. Study V provided health related quality of life in a group of mildly affected patients after stroke or transient ischemic attack, TIA. Significant covariates with deteriorated health related quality of life were studied. Data were analyzed with mean and standard deviations, median and range, proportions correlations and logistic regression. Results: The Danish version of SSQOL, SSQOL-DK, showed good face- and content validity. It can be completed in less than 25 minutes. Test-retest showed correlations rs 0.65-0.99. Internal consistency showed Cronbach’s alpha from 0.81-0.94 in study II, 0.75-0.96 in study III and 0.64-0.87 in study V. Ceiling effect was 24-52%, floor-effect was modest. Construct validity showed shared variance with external criteria, r2 0.03-0.62. Convergent validity showed (r) >0.40 for 48 out of 49 items. SSQOL-DK classified direction of change in over all quality of life concordantly from 43-58% with external criteria. The agreement between patient- and proxy data was good. Fifty seven (57) percent of mildly affected patients after stroke or TIA rated their overall quality of life unchanged one year after stroke compared to pre stroke status. In the regression model male sex OR 3.77), working outside home (OR 2.84), and less than 5.00 (maximum score) on the domains Mood and Work/productivity at three months were significant predictors for rating over all quality of life deteriorated at 12 months. Conclusion: The SSQOL-DK has demonstrated satisfactory reliability and validity and can be used on group level measuring health related quality of life among Danish survivors after mild to moderate stroke and TIA. Stroke survivors with severe communication problems are still limited as validity of the proxy data should be further tested

De 13 essäer som presenteras i denna rapport representerar ungefär lika många olika sätt att närma sig temat. Samtliga studenter hade erfarenhet av olika slags arbete med personer med funktionshinder och de använde sina egna erfarenheter tillsammans med litteraturstudier i sina skrivningar. En kategorisering av de ämnen som behandlas visar ett brett spektrum. Här finns essäer som tar sin utgångspunkt i diagnoser eller tillstånd: utvecklingsstörning, Usher syndrom, cystisk fibros, muskelsjukdom, demens i ung ålder och tekniska hjälpmedel till personer med demens. En essä diskuterar barn- och föräldrainflytande vid samverkan med habiliteringen och en hälsofrämjande sjukhus som ett sätt att föra in ett folkhälsoperspektiv på specialiserad sjukvård. Etnicitet och funktionshinder är temat för ett arbete. Rehabilitering är utgångspunkt för tre essäer. En av dessa beskriver den s.k. Sassam-metodiken, dvs. Strukturerad Arbetsmetodik för Sjukfallsutrdening och Samordnad rehabilitering. I den andra diskuteras anpassad fysisk aktivitet för personer med funktionshinder. I den tredje tas rehabilitering efter ryggmärgsskada upp ur Danskt perspektiv. Den sista av de 13 essäerna belyser frågan om äldres mobilitet versus trafiksäkerhet. Antalet tänkbara infallsvinklar på temat funktionshinder ur folkhälsoperspektiv är i det närmaste oändligt. Föreliggande 13 perspektiv ska naturligtvis ses som exempel.

Lena Widerlund tar i sin essä, Delaktighet som hälsofrämjande faktor, med fokus på personer med utvecklingsstörning, utgångspunkt i de politiska ambitioner som formulerats i Sverige och övriga nordiska länder. I essän lyfts också ICF (International Classification of Functioning, Disability and Health) upp som en viktig del i modern habilitering och rehabilitering. ICF är centralt i flera av de presenterade essäerna. Moa Wahlqvist går i sin essä, Funktionshinder och folkhälsa. Diskussion kring relationen mellan funktionshinder och folkhälsa med exemplet dövblindhet och Usher syndrom typ II, i närkamp med just det som titeln på essän lovar. Ellen Julie Hunstad lyfter fram hur det är att leva med cystisk fibros och de komplikationer sjukdomen kan ha. Speciellt fokuserar hon den nödvändiga och besvärliga infektionskontrollen då människor med cystisk fibros är extremt infektionskänsliga också för s.k. kryssmitta. Irene Lund närmar sig relationen mellan folkhälsa och funktionshinder med hjälp av personer med muskelsjukdom. Hon formulerar också några idéer om vad som bör göras för att förbättra livet också för personer med funktionsnedsättning. I Margit Gausdals arbete om yngre personer med demens lyfts personer med förvärvade kognitiva svårigheter fram. Gausdal diskuterar de svårigheter som möter personer som drabbas av demens i relativt unga år (under 65 år) och hon visar hur vårt samhälle är byggt för personer med god kognitiv förmåga. Hon poängterar också vikten av att identifiera och ta hänsyn till personer med demens egna upplevelser och perceptioner. Linda Gjöra diskuterar användning av tekniska hjälpmedel vid demens. Traditionellt har möjligheter till hjälpmedel inte förknippats med demens. Gjöra visar att det finns en utveckling av tekniska hjälpmedel som kan vara mycket användbara för att underlätta situationen för personer med demens. Framförallt gäller det att försöka kompensera för brister i orienteringsförmåga och minne. Ändamålet med hjälpmedlen är att hjälpa personen behålla så många funktioner som möjligt så länge som möjligt. Anita Nyqvist tar sig an den svåra uppgiften att diskutera barns och föräldrars inflytande vid s.k. gränsöverskridande samverkan med utgångspunkt från habiliteringsinsatser. I analysen använder hon bl.a. FN’s konvention om barns rättigeher. Hon tar också upp centrala begrepp som barn, funktionedsättning, habilitering och samverkan till diskussion. I Elisabeth Brodins arbete finns en ny vinkling, nämligen ”hälsofrämjande sjukhus”. Hon berättar vad det begreppet står för och beskriver hemofiliteamets arbete på ett sådant sjukhus för att illustrera ett hälsobrämjande perspektiv i inom den specialiserade sjukvården. Marijeh Mehdiyar analyserar situaionen för personer med funktionsnedsättning som kommer från annan etnisk bakgrund än nordisk. I analysen använder hon begreppet intersektionalitet för att beskriva att det kan vara mångdubbelt problematiskt att befinna sig i skärningspunkten av två eller fler utsatta positioner. Samuel Luneno beskriver i sin essä den s.k. Sassam-modellen. Metoden går ut på dels att få högsta möjliga grad av medverkan från rehabiliteringspatienter och dels att samordna hela rehabiliteringsteamets insatser. Carina Häggman diskuterar behovet av s.k. ”tilpasset fysisk aktivitet” för personer med funktionsnedsättning. Det har ju visats att personer med funktionsnedsättning är mindre fysiskt aktiva men att de kanske har ännu större behov av fysisk aktivitet än andra. I essän beskrivs viktiga komponenter för att få den anpassade fysiska aktiviteten att fungera. Hanne Vest Hansen fokuserar rehabilitering av personer med ryggmärgsskada. Den forskningsgenomgång som hon gör visar på behovet av patientmedverkan men också på vikten av en sant humanistisk inriktning hos de personer som arbetar med rehabilitering. Hilde Fleitscher tar i sin essä upp ett problem som också har stor folkhälsovetenskaplig relevans, nämligen äldre som bilförare i relation till trafiksäkerhet. I essän belyses äldres med åldern, tilltagande funktionsförluster och konsekvenser av för förmågan att köra bil. Den forskning som presenteras visar att sambanden mellan ålder och trafiksäkerhet dock inte är kristallklara. Genom den frihet varje författare har haft är det naturligt att det förekommer en del upprepningar i essäerna. Exempelvis är det flera författare som använder tankarna i ICF som utgångspunkt i texten. Även Antonovskys idéer har påverkat många.

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.

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.

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

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?

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.

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

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.

Bakgrund och syfte: Könsrelaterat våld ses som ett globalt folkhälsoproblem och som den mest genomgripande, men minst uppmärksammade kränkningen mot mänskliga rättigheter. Prevalensen i Sverige har skattats till 10 % med ett troligt stort mörkertal. Sexuella övergrepp kan påverka både fysisk och psykisk hälsa negativt och utsatta kvinnor söker för många olika symtom utan att nämna övergreppen. Det övergripande syftet med denna avhandling var att öka kunskapen om kvinnor som varit utsatta för sexuella övergrepp under uppväxten och nu sökt sig till självhjälpsgrupper, rörande hälsa, personliga resurser, relationer och omständigheter kring övergreppen, samt hur de upplevt att delta i självhjälpsgrupp (SHG). Metod: Avhandlingen bygger på fyra delstudier (I – IV) och har både kvantitativ och kvalitativ forskningsansats. Delstudie I (n=81) syftade till dels att mäta Känsla av Sammanhang, KASAM, hos kvinnorna, dels att analysera sambandet mellan KASAM-värde och frågor i ett formulär som konstruerats för delstudie I och II. Delstudie II (n=87) syftade till att mäta psykiska och psykosomatiska symtom (SCL-90-R) hos kvinnorna samt förekomsten av posttraumatiska stressymtom (IES-R). Delstudie III (n=10) hade både kvantitativ och kvalitativ ansats och syftade till att undersöka om och hur kvinnorna verbalt uttryckte outtalad skam via kodord i intervjuer. I den kvalitativa delstudie IV (n=17) intervjuades kvinnorna om upplevelsen av att ha deltagit i en självhjälpsgrupp och om det medfört några förändringar i hälsa, livssituationer och relationer. Resultat: Kvinnorna uppgav attdet vanligaste skälet för att delta i en självhjälpsgrupp var att vilja tala med andra kvinnor med liknande erfarenheter, följt av att få hjälpa varandra. Medelvärdet på KASAM var 104,1 med de lägsta värdena för dem som inte mindes hur många år de varit utsatta (I). De hade en dålig psykisk hälsa och signifikant sämre än en jämförelsegrupp bestående av kvinnliga psykiatriska patienter med olika diagnoser. Resultaten från IES-R visade att 57,5 % av kvinnorna hade värden som indikerade risk för post traumatisk stress (PTSD). I delstudie III framkom att kvinnorna använde kodord som indikerade skambenägenhet. Affekten skam påverkade deras hälsa, syn på sig själva och relationer negativt. Kvinnorna beskrev i delstudie (IV) att självhjälpsgrupperna fungerat som en väg ut ur ensamhet, att deras självbilder förändrats positivt, att symtom som t.ex. depression och ångest minskat samt minskade PTSD-symtom. Dessa förändringar kan indikera att kvinnorna har uppnått empowerment. Konklusion: Problematiken kring sexuella övergrepp som sker under uppväxten är komplext. Att tänka hälsopromotivt – t.ex. genom ett helhetsperspektiv kring hälsa samt delaktighet – kring denna problematik är av vikt för dem som utsatts för övergrepp ocsom behöver adekvat hjälp att bearbeta detta. Detta är också viktigt för professionella behandlare för att kunna ge rätt hjälp. En av hälsopromotionens grundstenar, empowerment, tycks ha uppnåtts i de deltagarstyrda självhjälpsgrupperna. Men självhjälpsgrupper ska endast ses som ett komplement till professionell vård. Därför behöver kunskaper spridas och utvecklas i de sektorer där man möter problematiken. En ökad kunskap bör kunna leda till ökad benägenhet att undersöka om sexuella övergrepp ligger bakom de symtom kvinnor uppvisar. Det är den grund som krävs för att kunna erbjuda en adekvat och rättvis vård

This reprot presents a review of Nordic research literature on the relationship between unemployment and mental health among adults aged 15-29 years. It includes published studies conducted between1995 and2011. Overall unemploymentis associated with poorer mental health than being employed.This association is evident even in two studies which respectively take into account mental health prior to unemployment and time invariant characteristics of the individual.Further, the review suggests that young women are more affected by unemploymentthan young men, and that young adults are more affected than older adults. Economic problems and the level of social integration are important factors in explaining why some unemployed experience poorer mental healthyetothers do not.Transition into labour market programs, education or employment is associated with improved mental health. The mental healthof young adults in employment and education is poorer during periods of economic recession than during periods of economic growth. We found no studies examiningthe link between unemployment and mental healthamong especially vulnerable groups such as young adults with immigrant background or those with mental or physical health problems. The studies included in this reviewof Nordic literaturehave several shortcomings. First, a majority of the studies are Swedish and based on small and local samples.Secondly, most studies are more than ten years old. Thirdly, only a minority of the studies have made use of more statistically advanced techniques to address inverse causality and selection. Thus, we recommend more research into large scale studies that can employmore statistically advanced methods. Further, knowledge of vulnerable groups and more extensive knowledge of the effect of various labour market policies are needed. Despite the shortcomings presented, we are still able to make some recommendations to those in charge of labour market and health policies. First, a continued effort into education and labour market policies, in order to qualify young adults for the labour market, is also important in a mental health perspective. Secondly, labour market policiesshould be implementedin a way that ensures that their effects can be evaluated and to include mental health measures as one element of the evaluation.

Aim: The aim of the thesis is to develop a general model for interactive music therapy adjustable to different target groups. Introduction and method: The thesis is a monograph with a hermeneutic view of knowledge and a predominantly qualitative and explorational investigative focus. The goal of music therapy is to contribute to better health and quality of life. As background to the aim of the thesis music is defined and discussed. Music therapy is also defined and linked to theories of music in therapy, in intrapsychological and interpersonal processes, and to systems theory. Music therapeutic approaches are presented with their respective theoretical foundations. Music therapy is also described from a clinical perspective linked to theories of bounding, play therapy and concepts such as arousal, vitality and emotions. A basic scientific approach is presented with reflections about suitable directions in music therapeutic research. International research on music therapy, with varying methodological approaches for diverse target groups and dysfunctions as well as research in music therapy in the Nordic countries, are presented with reflections of the more outstanding patterns in this research overview. Research on music therapy for the specific target groups in the study is presented. Three studies have been carried out in three areas with different target groups. Study 1: Music therapy with dialysis, cancer and psychiatric patients at a county hospital. Study 2: Music therapy with small children with cancer at a children’s hospital. Study 3:Music therapy at a treatment centre for adolescents with severe psychosocial problems. The studies have joint aims and research questions as well as methods of knowledge gathering, that is chiefly process descriptions and dialogue interviews with clients and personnel, which have been processed by content analysis. Target groups, implementation and results are presented for the respective studies. A comparative analysis of the three studies, that for which music therapy is shared and that for which is target group-specific, is presented. Results and conclusions: Implementation efforts to integrate music therapy in ordinary activities worked satisfactorily in cooperation with dedicated personnel. The planned music therapeutic form of interaction between therapist and patients/clients functioned consistently with the approach of adjusting music therapy to the patient’s/client’s needs and wishes. All clients/patients reported positive experiences of interaction with the music therapist, and the music could be used as a means of communication, both for establishing contact, as a stimulus to verbal communication, and as a means of non-verbal communication, for example with small children and withdrawn teenagers. All target groups reported emotional experiences with internal images and symbols linked to the music, which, in many cases could also be expressed in painted images and personal texts. Small children were stimulated by music therapy to play and activity, and increased interaction with their parents. Music selection and genre of previously recorded or improvised music, of an identity supportive or processing approach, as well as the possibilities to combine music with paintings and text, was influenced by both the needs and desires of those involved and by the target group’s age, maturity, life situation and dysfunctions, while also showing concern for other ongoing treatments. Aim: The aim of the thesis is to develop a general model for interactive music therapy adjustable to different target groups. Introduction and method: The thesis is a monograph with a hermeneutic view of knowledge and a predominantly qualitative and explorational investigative focus. The goal of music therapy is to contribute to better health and quality of life. As background to the aim of the thesis music is defined and discussed. Music therapy is also defined and linked to theories of music in therapy, in intrapsychological and interpersonal processes, and to systems theory. Music therapeutic approaches are presented with their respective theoretical foundations. Music therapy is also described from a clinical perspective linked to theories of bounding, play therapy and concepts such as arousal, vitality and emotions. A basic scientific approach is presented with reflections about suitable directions in music therapeutic research. International research on music therapy, with varying methodological approaches for diverse target groups and dysfunctions as well as research in music therapy in the Nordic countries, are presented with reflections of the more outstanding patterns in this research overview. Research on music therapy for the specific target groups in the study is presented. Three studies have been carried out in three areas with different target groups. Study 1: Music therapy with dialysis, cancer and psychiatric patients at a county hospital. Study 2: Music therapy with small children with cancer at a children’s hospital. Study 3:Music therapy at a treatment centre for adolescents with severe psychosocial problems. The studies have joint aims and research questions as well as methods of knowledge gathering, that is chiefly process descriptions and dialogue interviews with clients and personnel, which have been processed by content analysis. Target groups, implementation and results are presented for the respective studies. A comparative analysis of the three studies, that for which music therapy is shared and that for which is target group-specific, is presented. Results and conclusions: Implementation efforts to integrate music therapy in ordinary activities worked satisfactorily in cooperation with dedicated personnel. The planned music therapeutic form of interaction between therapist and patients/clients functioned consistently with the approach of adjusting music therapy to the patient’s/client’s needs and wishes. All clients/patients reported positive experiences of interaction with the music therapist, and the music could be used as a means of communication, both for establishing contact, as a stimulus to verbal communication, and as a means of non-verbal communication, for example with small children and withdrawn teenagers. All target groups reported emotional experiences with internal images and symbols linked to the music, which, in many cases could also be expressed in painted images and personal texts. Small children were stimulated by music therapy to play and activity, and increased interaction with their parents. Music selection and genre of previously recorded or improvised music, of an identity supportive or processing approach, as well as the possibilities to combine music with paintings and text, was influenced by both the needs and desires of those involved and by the target group’s age, maturity, life situation and dysfunctions, while also showing concern for other ongoing treatments.

Public health aspects of pharmaceutical prescription patterns: Exemplified by treatments for prevention of cardiovascular disease. Louise Silwer. ISBN: 978-91-85721-18-4 ISSN: 0283-1961Main aim:To study patterns and trends of dispensed prescriptions, to explore what proportion of the population is exposed to some of the more prevalently prescribed pharmaceuticals, and to find possible ways of measuring drug-induced adverse symptoms in the population. Further, to illuminate conditions surrounding prescribing in primary prevention of cardiovascular disease. Methods: In three descriptive studies of prescription patterns, prescription data at aggregate level from a Swedish county were analysed retrospectively, and proportions were calculated. Data from the first ten years of the studies were obtained from a local prescription study, and data from another five years were local data from a national prescription survey. Data from a Danish database (OPED), with data at the individual level, were used for a prescription sequence symmetry analysis, and when Swedish national prescription data at the individual level became accessible, they were used for calculations of drug prevalence in the entire Swedish population. In a qualitative analysis of interview data, a phenomenographic approach was used. Main results: The purchase of pharmaceuticals on prescription almost doubled in the studied county in the period 1988-2002. Some common pharmaceuticals that increased to a great extent among the older part of the population were cardiovascular preventive drugs, such as antihypertensive and lipid modifying agents, and also hormone replacement therapy for women. In 2005, over half of all Swedish citizens, aged 60 or over, purchased antihypertensive or lipid modifying preparations during a six-month period. The different views that were found among GPs, regarding beliefs and practical management of primary prevention of CVD, could be interpreted as a reflection of the complexity of patient counselling in primary prevention in practice. Conclusion: The increase in dispensed prescriptions over the 15 years and the magnitude of the prevalence of the studied pharmaceuticals, such as antihypertensive, lipid modifying and hormonal treatments, which to a great extent are used by ‘healthy’ people, point to the need of following-up both beneficial and harmful consequences on public health. The prevalence of preventive treatments together with the variation in views of administration of primary prevention of cardiovascular disease, also point to the need of clarification of guidelines regarding pharmaceutical primary prevention and encouragement of therapy discussions among GPs.

Nordic School of Public Health NHV (NHV) was a pioneer within Nordic public health science and education during 1953-2014. The activities at NHV rested on the three pillars of public health, Nordic ontext and international outlook. The Nordic Council of Ministers (NMR) was the responsible body for NHV, which was earlier also known by its Swedish names ‘Nordiska högskolan förfolkhälsovetenskap’ and ‘Nordiska hälsovårdshögskolan’. NHV was financed by the Nordic countries Denmark, Finland, Iceland, Norway and Sweden.

In June 2013, NMR decided to close NHV on the basis that education in public health could now befound at other Nordic universities. As a result, academic activities at NHV ended on December 31, 2014.

NHV had a clear objective to generate Nordic synergy and added value by having Nordic perspectives and Nordic participants as well as Nordic examples in both education and research. NHV focussed much effort on Nordic collaborations and networking. NHV’s mission statement was to create and disseminate knowledge that promotes good and equal health. Several evaluations demonstrated NHV’s strong role within the field of public health in Europe. This joint Nordic mission within education and research generated a unique competence at NHV, since no other institute of higher education could demonstrate a similar profile. Having had the entire Nordic region as the base of its activities, NHV had the possibility to take advantage of the access to stimulating similarities and differences between the Nordic countries.