| 1. |
- Brower Scribani, Melissa, 1979-
(författare)
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Insights on weight maintenance and impacts of obesity for two rural populations in the United States and Sweden
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Obesity is a serious public health concern worldwide, and nearly 40% of all adults in the United States and 21% in Sweden are now living with obesity. Efforts focusing mainly on weight loss have fallen short in reducing obesity prevalence. There is a great need for improved insight into what factors may promote a healthy weight, thereby avoiding the adverse health outcomes linked to obesity. Primary weight maintenance is a prevention strategy that emphasizes keeping a long-term stable weight in the non-obese range.Aim: The overall aims of this thesis were to improve understanding of the patterns of obesity and obesity-related mortality among rural adults in Central New York State (U.S.) and Västerbotten County (Sweden), and to explore factors that are related to primary weight maintenance.Material and methods: Data from U.S. health surveys and health examinations in Sweden were used to compare twenty-year (1989-2009) trends in body mass index (BMI) and obesity using multi-factor analysis of variance. The association between obesity and risk of 1) premature all-cause death, and 2) premature circulatory death, was compared between the U.S. and Sweden using proportional hazards regression. In 2009, a longitudinal questionnaire of attitudes, behaviors and perceptions regarding weight maintenance was administered to U.S. subjects. Associations between ten-year weight change and survey variables were tested using multiple linear regression, separately for sex and age strata. To gain a deeper understanding of influences, facilitators and barriers to healthy eating and physical activity, a qualitative interview study was conducted with U.S. women aged 26-35, with data analyzed by qualitative content analysis.Results: Over twenty years, BMI increased for both men and women in all age strata in both countries, and those with no university education consistently had higher BMI than their university-educated counterparts. BMI increased more for younger groups (ages 36-45) compared to those aged 46-55 and 56-62. U.S. females aged 36-45 showed the greatest increases in average BMI, particularly when comparing 1999 to 2009. Increases in the prevalence of obesity (BMI≥30) in Sweden were more modest than in the U.S. Severe obesity (BMI≥35) was associated with significantly increased risk of premature death from all causes and from circulatory causes for all subjects. Severe obesity was less common in Sweden (2% of men, 3% of women) than in the U.S. (8% of men, 9% of women). Nonetheless, severely obese Swedish men had 2.9 times the risk of premature death from all causes compared to those of normal weight, and 4.9 times the risk for circulatory causes. The gradient of risk among U.S. men was significantly lower than in Sweden; those with severe obesity had a 1.6 times increased risk for all-cause premature death and 3.2 times increased risk for premature circulatory death. The pattern of risk among women did not differ between countries. Longitudinal analysis of U.S. health survey participants showed that women aged 26-35 gained the most weight of any group (mean=10.3kg gained over ten years). The variables found to be associated with ten-year weight change were different across sex and age groups. Among women, all variables associated with weight change were exercise-related. Among men, three of the four predictors were focused on eating habits. Interviews with women aged 26-35 revealed the challenges of healthy eating and engaging in physical activity. Women often identified as caregivers for others, and those with more social support, who were financially stable and showed self-efficacy around healthy choices were able to more consistently engage in healthy habits.Conclusions: Obesity is an increasing problem for the rural adult population in both the U.S. and Sweden. When primary weight maintenance strategies are designed to support individuals towards healthy eating and increased physical activity, the complexity of the living environment must be considered. Individual conditions and personal relationships as well as the physical environment, home environment and work environment must be included in the assessment. Development of targeted programs for primary weight maintenance should be a focus of public health work for adults in rural areas in both Sweden and the U.S.
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| 2. |
- Daerga, Laila, 1965-
(författare)
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Att leva i två världar : hälsoaspekter bland renskötande samer
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: There is a gap of knowledge of the health situation among the reindeer herding Sami in Sweden. The Swedish government has also got criticism for not taking responsibility for the Sami health. The aim of this thesis was to get more knowledge to understand the health situation of the reindeer herding Sami in Sweden. Furthermore, gender specific risk factors in the working environment among reindeer herders and their perception of healthcare and social services were investigated.Method: Cross–sectional questionnaires covering different aspects of health such as musculoskeletal disorders, trust for different healthcare providers and work related psychosocial factors was distributed to reindeer herding Sami and non-Sami populations. Interviews with nine reindeer herding Sami about trust in healthcare and social services were carried out and analyzed with thematic analysis. Sixteen discussion meetings with 80 reindeer herders focusing on psychosocial perspectives of working conditions in Sami communities were performed.Result: The prevalence of musculoskeletal symptoms from elbow, hand/wrist and lower back from male reindeer herders were higher compared to blue-collar worker. Psychosocial risk factors for health were identified such as high workload on a few herders, difficulties to get relief and support as well as to get appreciation in work and lack of participation in decisionmaking among women were common in the organization of reindeer husbandry. The trust in healthcare and social services was lower among reindeer herding Sami compared to non-Sami majority population. A hypothesis is that healthcare professionals do not know that the "Reindeer cloud" (metaphor to iCloud) affects all parts in the reindeer herders life. The distrust are influenced by historically traumas, reindeer herding Sami experiences from healthcare professionals and healthcare organization and culturally generated norms.Conclusio: The thesis hypothesized that health disorders, attitude towards healthcare and psychosocial environment are important aspects when trying to understand the health situation among the reindeer herding Sami. There is a need to introduce long-term public health work for all Sami people, to establish ethical guidelines for Sami health research and develop healthcare services that provides access to healthcare for the reindeer herding Sami, on equal terms.
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| 3. |
- Dewi, Fatwa Sari Tetra, 1969-
(författare)
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Working with community : exploring community empowerment to support non-communicable disease prevention in a middle-incom country
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Non communicable diseases (NCD) are recognized as a major burden of human health globally, especially in low and middle-income countries including Indonesia. This thesis addresses a community intervention program utilizing a community empowerment approach to study whether this is a reasonable strategy to control NCD.Objective: To explore possible opportunities, common pitfalls, and barriers in the process of developing a pilot community intervention program to prevent NCD in an urban area of a middle-income country.Methods: The study was conducted in Yogyakarta Municipality. The baseline risk factor survey in 2004 (n=3205) describes the pattern of NCD risk factors (smoking, physical inactivity and low fruit and vegetable intake) and demographic characteristics using STEPwise instrument. A qualitative study was conducted in order to illustrate peoples’ perceptions about NCD risk factors and how NCD might be prevented. A pilot intervention was developed based on the baseline survey and the qualitative data. The pilot intervention was conducted in four intervention communities while one community served as the referent area. The intervention was evaluated using quantitative and qualitative approaches. Finally, a second cross-sectional survey conducted in 2009 (n= 2467) to measure NCD risk factor changes during the five year period.Results: Baseline qualitative data showed that people in the high SES (Socio Economic Status) group preferred individual activities, whereas people in the low SES group preferred collective activities. Baseline survey data showed that the prevalence of all NCD risk factors were high. The community intervention was designed to promote passive smoking protection, promote healthy diet and physical activity, improve people’s knowledge of NCD, and provide a supporting environment. A mutual understanding between the Proriva team and community leadership was bargained. Several interactive group discussions were performed to increase NCD awareness. A working team was assigned to set goals and develop programs, and the programs were delivered to the community. There were more frequent activities and higher participation rates in the low SES group than in high SES group. The repeated cross-sectional surveys showed that the percentage of men predicted to be at high risk of getting an NCD event had significantly increased in 2009 compared to 2004.Conclusion: The community empowerment model was a feasible choice as a “moderate”strategy to accommodate with people’s need when implementing a community intervention that also interacts with the service provided by the existing health system. A community empowerment approach may improve program acceptance among the people.
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| 4. |
- Edvardsson, Berit, 1953-
(författare)
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"Det är inte mig det är fel på, det är huset" : en studie av prognosfaktorer och bemötande med fokus på sjuka hus-syndromet
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Bakgrund: Sick Building Syndrome, SBS, är fortfarande 2015 ett tillstånd som vållar mycket diskussion. Symtomen kan grupperas i slemhinnesymtom, hudsymtom och allmänna symtom. I definitionen ingår att personen/ personerna som fått symtom har exponerats för dålig inomhusluft i en speciell byggnad. När personen inte är i byggnaden så förbättras eller försvinner symtomen. Många olika faktorer kan orsaka eller medverka till uppkomst eller försämringar av SBS-symtom, som t.ex. luftens innehåll av olika ämnen, luftflöden, temperatur, buller, fukt och mögel. Utbredd enighet finns om att fukt och mögel i byggnaderna påverkar eller ger upphov till symtom hos vissa personer som exponeras där. Psykosociala faktorer som arbetets organisation och krav och individuella faktorer som kön och personlighet påverkar också.Syfte: Hypotesen är att faktorer som tidigare hälsa, åtgärder på arbetet, tid, behandling, personlighet och copingresurser alla kan påverka prognosen för SBS-patienterna. Syftet med avhandlingen är att undersöka hur symtomen påverkar arbetsförmågan och om patienterna återhämtar sig från SBS-symtomen. Ett annat syfte är att undersöka bemötande och de erfarenheter som SBS-symtomen gett en grupp av informanter med SBS. För att förstå om personlighet mätt med självbild och coping hade någon betydelse för progressionen av SBS-symtom och arbetsförmåga gjordes jämförelser av personlighet mellan en patientgrupp med SBS, en patientgrupp med handeksem, en patientgrupp med elkänslighet och en normalpopulation.Metod: En uppföljningsenkät skickades till 239 patienter med SBS-symtom som under åren 1986–1998 blivit undersökta och bedömda på Universitets-sjukhuset i Umeå, Sverige. Frågorna innehöll social och medicinsk status, nuvarande symtom, behandlingar, åtgärder på arbetsplatsen, coping och självbild och svarsfrekvensen var 79,1%. Prognos och riskfaktorer för prognos beräknades för SBS-patienterna. Mätningar av personlighetsfaktorer gjordes med instrumentet Structural analysis of Social Behaviour, SASB, och coping mättes med Coping Resources Inventory, CRI. Likadana uppföljningsenkäter skickades till en grupp patienter med handeksem och patienter med upplevd elkänslighet. Svarsfrekvensen var 68% respektive 73% och enkätsvaren har sedan analyserats och jämförts genom beräknngar av prognos med fokus på självbild och coping för SBS-patienterna och handeksempatienterna. Jämförelser gjordes också mellan de tre olika grupperna och en kontrollgrupp vad gäller självbild och coping. För att undersöka erfarenheterna av SBS-symtomen och bemötandet genomfördes kvalitativa intervjuer med 10 informanter som hade eller hade haft SBS-symtom. Fem av dem hade diagnostiserats en längre tid tillbaka medan de andra fem hade haft SBS-symtomen en kortare period. Semi-strukturerade intervjuformulär användes vid intervjuerna och anlyserades med kvalitativ innehållsanalys.Resultat: Graden och svårigheten av SBS-symtomen minskade över tid trots att nästan hälften av SBS-patienterna beskrev att symtomen var mer eller mindre oförändrade efter 7 år eller mer. Risken att ha symtom vid uppföljningen var större för de patienter som remitterats sent efter symtomdebut men även för de som hade kort uppföljningstid. Risken att inte ha någon arbetsförmåga vid uppföljningen var signifikant ökad om det var mer än ett års skillnad mellan symtomdebut och första läkarbesöket p.g.a. SBS-symtomen eller om patienten vid första undersökningen hade fler än 5 SBS-symtom. Dagliga aktiviteter som t.ex. bussåkning förvärrade också symtomen för patienterna. Informanternas upplevelser av SBS-symtomen från början visar en influensaliknande bild med rinnande näsa och ögon, heshet, hosta och huvudvärk. Informanterna agerar för att klara av situationen när symtomen förvärras. Genom hela processen upplever de en brist på bekräftelse och stöd från arbetsgivare, primärvård, företagshälsovård och fastighetsförvaltare.Alla tre patientgrupperna hade högre värden i spontan och positiv självbild i jämförelse med en kontrollgrupp. De hade också alla lägre värden i kontroll medan patienterna med handeksem och de med elkänslighet hade högre värden i sin negativa självbild. När det gäller coping skilde sig inte patientgrupperna från kontrollgruppen utom i CRI kognitiv där SBS-patienterna hade hög poäng i motsats till handeksempatienterna som hade låg poäng i samma domän. De elkänsliga patienterna hade i stället höga poäng i domänen andlig/filosofisk. Självbild eller copingförmåga var inte associerade med SBS-symtom eller symtom av handeksem vid uppföljningen och deras personlighet påverkade inte arbetsförmågan. Tidigare atopisk dermatit var en signifikant risk för kvarvarande symtom men inte för arbetsförmågan hos handeksempatienterna.Slutsats: En grupp av patienter som tidigare diagnostiserats för symtom från inomhusmiljön har kroniska symtom och påverkan på sitt sociala liv. Över tid minskar symtomen. Resultaten pekar på att ett tidigt omhändertagande är av vikt. SBS-symtomen är från början svåra att upptäcka för alla inblandade och kunskap om hur symtomen kan uppstå i dagligt liv kan bidra till bredare förståelse. Erfarenheterna från personer med SBS visar på avsaknad av bekräftelse och stöd från vården, företagshälsan, arbetsgivare och fastighetsförvaltare. Sambandet mellan symtom och inomhusmiljö får inte glömmas bort. Stöd och bekräftelse innebär också kunskap om skyldigheter för arbetsgivare och fastighetsförvaltare.Skillnad i självbild i jämförelse med en kontrollgrupp ses hos patientgrupperna med symtom som är delvis oförklarade men också hos handeksempatienter med ett väletablerat tillstånd. Det kan innebära att patienter med kroniska tillstånd överlag kan avvika från den allmänna populationen. Patienterna visar som grupp en hög positiv och hög spontan självbild som kan leda till svårigheter att sätta gränser. Detta kan leda till en mental stress och i förlängningen också ge en ökad känslighet/sårbarhet för miljöfaktorer.
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| 5. |
- Fhärm, Eva, 1955-
(författare)
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Treatment of cardiovascular risk factors in type 2 diabetes : time trends and clinical practice
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives Patients with type 2 diabetes are at much greater risk of developing cardiovascular diseases (CVD), including coronary heart disease (CHD), compared to non-diabetics. The lowering of glucose, blood pressure, and plasma lipid levels has been shown to reduce CHD risk, and treatment goals for these risk factors are now part of clinical practice guidelines. However, the incidence and outcome of CHD in diabetic patients does not show the same favourable trend as in the general population. Thus, the overall aim of the thesis was to investigate how the treatment goals for CVD risk factors contained in the national guidelines for diabetes care were reflected in clinical practice, and to explore factors that might influence the remaining high incidence of CHD in the type 2 diabetes population. Research designs and results I. The effectiveness of the introduction of treatment goals for dyslipidaemia was evaluated in a retrospective observational population-based cross-sectional study of 971 diabetic patients participating in the Västerbotten Intervention Programme (VIP) 1995–2004. There was a stronger trend of decrease in cholesterol levels among patients with diabetes compared to the non-diabetic population in 2000–2004. Increased use of lipid-lowering agents influenced the trend in diabetic patients, even though only 25.3% received lipid-lowering treatment after the introduction of the new guidelines. II. The experiences of general practitioners relating to treatment practice for type 2 diabetes with specific focus on the prevention of cardiovascular disease were explored in a focus group study. The overall theme was ‘dilemmas’ in GPs’ treatment practice for patients with type 2 diabetes. Five main dilemma categories were identified. First, GPs were hesitant about labelling a person who feels healthy as ill. Second, as regards communicating a diabetes diagnosis and its consequences, GPs were unsure as to whether patients should be frightened or comforted. Third, GPs experienced uncertainty in their role: should they take responsibility for the care or not? Fourth, GPs expressed concern over a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties when attempting to translate science into reality. III. Screening for microvascular and coronary heart disease according to national guidelines was evaluated in a cross-sectional study of 201 screening-detected patients with type 2 diabetes 1.5±0.7 years after diagnosis. A larger proportion of diabetic patients was screened for nephropathy and retinopathy than for CHD. Twenty-three percent of the patients had minor or major ECG abnormalities, but ECG findings seemed to have little or no impact on CHD prevention using lipid-lowering medication and ASA. A clinical history of CHD correlated with a larger proportion of patients receiving secondary prevention. IV. Time trends relating to the achievement of treatment goals and 10-year CHD risk at three years of diabetes duration were studied in 19,382 patients with type 2 diabetes without CHD, who were reported by primary health care sources in the National Diabetes Register in 2003–2008. National treatment goals for glycaemia, blood pressure, total cholesterol, and LDL cholesterol were achieved in 78.4%, 65.5%, 55.6%, and 61.0%, respectively, of the diabetic patients in 2008 following a trend of improved results in 2003–2008. Absolute 10-year risk of CHD increased between year of diagnosis and follow up in a studied subgroup while modifiable risk decreased. Conclusions The introduction of treatment goals for dyslipidemia in Swedish national guidelines in 1999 were reflected in lowered cholesterol levels in people with type 2 diabetes. Since the introduction of the guidelines, an increasing number of diabetic patients are treated in accordance with guidelines. A remaining microvascular focus on the patients together with the revealed dilemmas within the GP’s consultation with diabetic patients might negatively influence the remaining high incidence of CHD in the type 2 diabetes population. Lipid levels, blood pressure and smoking are targets for further improvements.
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| 6. |
- Furberg, Maria, 1970-
(författare)
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Towards the Limits – Climate Change Aspects of Life and Health in Northern Sweden : studies of tularemia and regional experiences of changes in the environment
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundIndigenous peoples with traditional lifestyles worldwide are considered particularly vulnerable to climate change effects. Large climate change impacts on the spread of infectious vector-borne diseases are expected as a health outcome. The most rapid climate changes are occurring in the Arctic regions, and as a part of this region northernmost Sweden might experience early effects. In this thesis, climate change effects on the lives of Sami reindeer herders are described and 30 years of weather changes are quantified. Epidemiology of the climate sensitive human infection tularemia is assessed, baseline serologic prevalence of tularemia is investigated and the disease burden is quantified across inhabitants in the region.MethodsPerceptions and experiences of climate change effects among the indigenous Sami reindeer herders of northern Sweden were investigated through qualitative analyses of fourteen interviews. The results were then combined with instrumental weather data from ten meteorological stations in a mixed-methods design to further illustrate climate change effects in this region. In two following studies, tularemia ecology and epidemiology were investigated. A total of 4,792 reported cases of tularemia between 1984 and 2012 were analysed and correlated to ecological regions and presence of inland water using geographical mapping. The status of tularemia in the Swedish Arctic region was further investigated through risk factor analyses of a 2012 regional outbreak and a cross-sectional serological survey to estimate the burden of disease including unreported cases.ResultsThe reindeer herders described how the winters of northern Sweden have changed since the 1970s – warmer winters with shorter snow season and cold periods, and earlier spring. The adverse effects on the reindeer herders through the obstruction of their work, the stress induced and the threat to their lifestyle was demonstrated, forcing the reindeer herders towards the limit of resilience. Weather data supported the observations of winter changes; some stations displayed a more than two full months shorter snow cover season and winter temperatures increased significantly, most pronounced in the lowest temperatures. During the same time period a near tenfold increase in national incidence of tularemia was observed in Sweden (from 0.26 to 2.47/100,000 p<0.001) with a clear overrepresentation of cases in the north versus the south (4.52 vs. 0.56/100,000 p<0.001). The incidence was positively correlated with the presence of inland water (p<0.001) and higher than expected in the alpine and boreal ecologic regions (p<0.001). In the outbreak investigation a dose-response relationship to water was identified; distance from residence to water – less than 100 m, mOR 2.86 (95% CI 1.79–4.57) and 100 to 500 m, mOR 1.63 (95% CI 1.08–2.46). The prevalence of tularemia antibodies in the two northernmost counties was 2.9% corresponding to a 16 times higher number of cases than reported indicating that the reported numbers represent only a minute fraction of the true tularemia.ConclusionsThe extensive winter changes pose a threat to reindeer herding in this region. Tularemia is increasing in Sweden, it has a strong correlation to water and northern ecoregions, and unreported tularemia cases are quite common.
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| 7. |
- Jerdén, Lars
(författare)
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Health-promoting health services : personal health documents and empowerment
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In 2003, the Swedish Parliament adopted a national public health policy that included the domain - “A more health-promoting health service”. Strategies and tools are needed in the work to reorient health services. Personal health documents are documents concerning a person’s health, and are owned by the individual. Several studies that have evaluated such documents indicate that they could be of interest in health-promotion work. However, there is insufficient knowledge concerning personal health documents that target adolescents, and little is known about the feasibility of such documents in a Swedish cultural context. The concept of empowerment is gaining increased interest for health services, but the associations between empowerment, self-rated health and health behaviour are sparsely studied. The overall aim of the thesis is to explore a strategy - empowerment - and a tool - personal health documents - that might facilitate the work of the public health goal of a health-promoting health service. Specific aims are to examine the feasibility of using personal health documents in health promotion; to examine professionals’ experiences of working with health promotion and personal health documents; to examine the association between personal health documents and self-reported health behaviour change; and to examine the perception of empowerment in relation to self-rated health and health behaviour among adolescents. Two personal health documents that targeted adults and adolescents were developed and evaluated. Distribution to adults in different settings was compared in a cross-sectional study (n = 1 306). Adolescents received the document in school, and surveys were performed at baseline and after one year (n = 339). Practical use and attitudes by document owners were studied by questionnaires. Teachers (n = 69) answered a questionnaire, and community health nurses were interviewed (n = 12). The interviews also explored nurses’ experiences of working with health promotion in general, and were analysed by qualitative methodology. Adolescents’ empowerment was examined by a questionnaire (n = 1 046). Most participants reported reading in the documents; writing in the documents varied between 16% (distribution in occupational health) and 87% (adolescents). The health document was perceived as useful by 35% of the adolescents. Factors significantly related to personal usefulness were being born outside Sweden, experiencing fair treatment by teachers, being a non-smoker and having a positive school experience. Community health nurses were striving for a balance of being a doer of practical, disease-oriented tasks and a health-promotion communicator. The structural organisation in health care centres was important for their work with health promotion and the health document. Teachers were generally in favour of continued work with the document. In different settings, between 10% and 26% of adults reported changes in their health situations as a result of reading the booklet. Self-reported changes in health situations were less likely using postal distribution, and there were no significant differences between the other types of distribution. Adolescents with low empowerment scores reported poorer self-rated health and more risk-taking behaviours such as smoking and binge drinking. To conclude, personal health documents are feasible to use in different settings. Health promotion in health services needs active support from leaders as well as adequate support systems. Findings suggest that personal health documents can be tools for promoting self-reported lifestyle changes among adults in different settings. There is a close relation among adolescents between low empowerment in the domain of health, low self-rated health and health behaviours such as binge drinking and smoking.
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| 8. |
- Johansson, Helene, 1962-
(författare)
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En mer hälsofrämjande hälso- och sjukvård : hinder och möjligheter utifrån professionernas perspektiv
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduktion: Under de senaste decennierna har det förts en diskussion om behovet av att omorientera hälso- och sjukvårdens verksamhet för att på ett effektivare sätt bidra till befolkningens hälsa. Detta togs också upp som ett av målen i 2003 års svenska nationella folkhälsopolitik som sedan uppdaterades 2008. Målet ”en mer hälso- främjande hälso- och sjukvård anger att ett hälsofrämjande och sjukdomsförebyggande perspektiv ska genomsyra hela hälso- och sjukvården och vara en självklar del i all vård och behandling. Vårdpersonalen förväntas spela en nyckelroll i genomförandet. Deras inställning till och kunskap om hälsofrämjande kommer sannolikt att ha en stor inverkan på hur målet kommer att tillämpas i framtiden. Det övergripande syftet med denna avhandling är, att utifrån professionernas perspektiv, analysera möjligheterna till att omorientera hälso- och sjukvården mot en mer hälsofrämjande inriktning. De specifika frågeställningar som avhandlingen avser att besvara är hur vårdpersonalen uppfattar begreppen hälsa och hälsofrämjande, hur de uppfattar den hälsofrämjande rollen samt hur de uppfattar hinder och möjligheter för att ha en hälsofrämjande roll i det dagliga kliniska arbetet. Metoder: Avhandlingen baseras på fyra delarbeten utgående från två dataset, ett kvalitativt och ett kvantitativt. Sju fokusgrupper genomfördes med totalt 34 informanter från primärvård och olika sjukhuskliniker. Informanterna representerade sju av vårdens stora yrkesgrupper. Data analyserades med kvalitativ innehållsanalys. Uppfattningar och frågor som genererades av den kvalitativa datainsamlingen låg till grund för utformningen av en enkät, som pilottestades och användes i en undersökning. Av totalt 3.751 anställda som arbetade dagtid med kliniskt arbete i Västerbottens läns landsting inbjöds 1.810 att delta. Dessa representerade arbets- terapeuter, barnmorskor, dietister, kuratorer, läkare, sjukgymnaster, sjuksköterskor och psykologer. Huvudsakliga resultat och konklusion: Majoriteten av vårdpersonalen hade en holistisk syn på hälsa, samtidigt ansåg 40% att hälso- och sjukvården genomsyras av en biomedicinsk syn på hälsa. Begreppet hälsofrämjande framstod som diffust, svårgripbart och därmed svårt att tillämpa i praktiken. Detta var delvis kopplat till en brist på samsyn beträffande förhållandet mellan hälsofrämjande och sjukdoms- förebyggande. Avhandlingen visar att det finns ett starkt stöd för omorientering av hälso- och sjukvården mot en mer hälsofrämjande inriktning. Majoriteten av de tillfrågade ansåg att hälso- och sjukvården har stor betydelse när det gäller den långsiktiga hälso- utvecklingen i befolkningen och såg ett behov av att utveckla den hälsofrämjande och sjukdomsförebyggande rollen för att på sikt få en effektivare hälso- och sjukvård. Önskan att fokusera mer på hälsofrämjande och sjukdomsförebyggande rapporterades signifikant oftare av kvinnor än män och av primärvårdspersonal jämfört med sjukhus- personal. Speciellt viktigt att beakta är att män och läkare, dvs grupper som ofta har en hög maktposition, rapporterade mindre positiva attityder till en mer hälsofrämjande hälso- och sjukvård, samtidigt som psykologer, arbetsterapeuter och sjukgymnaster oftast rapporterade det motsatta. En medvetenhet om maktrelationerna spelar därför en strategisk roll i förändringsprocessen. De vanligaste hindren för att ha en hälso- främjande roll i det dagliga kliniska arbetet var en pressad arbetssituation, brist på riktlinjer och otydliga mål. Ledningens stöd är avgörande för tillgången till tid och andra resurser som krävs för vårdpersonal att bedriva hälsofrämjande och sjukdomsförebyggande arbete.
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| 9. |
- Kardakis, Therese, 1975-
(författare)
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Strengthening lifestyle interventions in primary health care : the challenge of change and implementation of guidelines in clinical practice
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Lifestyle habits like tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity are risk factors for developing non-communicable diseases, which are the leading, global causes of death. Furthermore, ill health and chronic diseases are costly and put an increased burden on societies and health systems. In order to address this situation, governmental bodies and organizations’ have encouraged healthcare providers to reorient the focus of healthcare and undertake effective interventions that support patients to engage in healthy lifestyle habits. In Sweden, national clinical practice guidelines (CPGs) on lifestyle interventions were released in 2011. However, the challenges of changing clinical practice and introducing guidelines are well documented, and health interventions face particular difficulties. The overall purpose of this thesis is to contribute towards a better understanding of the complexities of shifting primary health care to become more health oriented, and to explore the implementation environment and its effect on lifestyle intervention CPGs. The specific aims are to investigate how implementation challenges were addressed during the guideline development process (Study I), to investigate several dimensions of readiness for implementing lifestyle intervention guidelines, including aspects of the intervention and the intervention context (Study II), to explore the extent to which health care professionals are working with lifestyle interventions in primary health care, and to describe and develop a baseline measure of professional knowledge, attitudes and perceived organizational support for lifestyle interventions (Study III), and to assess the progress of implementing lifestyle interventions in primary care settings, as well as investigate the uptake and usage of the CPGs in clinical practice (Study IV). Methods and results: Interviews were conducted with national guideline-developers (n=7). They were aware of numerous implementation challenges, and applied strategies and ways to address them during the guideline development process. The strategies adhered to four themes: (a) broad agreements and consensus about scope and purpose, (b) systematic and active involvement of stakeholders, (c) formalized and structured development procedures, and (d) openness and transparent development procedures. At the same time, the CPGs for lifestyle interventions challenged the development-model at the National Board of Health and Welfare (NBHW) because of their preventive and non-disease specific focus (I).A multiple case study was also conducted, using a mixed methods approach to gather data from key organizational individuals that were accountable for planning the implementation of CPGs (n=10), as well as health professionals and managers (n=340). Analysis of this data revealed that conditions for change were favorable in the two organizations that served as case studies, especially concerning change focus (health orientation) and the specific intervention (national guidelines on lifestyle interventions). Somewhat limited support was found for change and learning, and change format (national guidelines in general). Furthermore, factors in the outer context were found to influence the priority and timing of the intervention, as well as considerable inconsistencies across the professional groups (II). A cross-sectional study among physicians and nurses (n=315) in Swedish primary healthcare showed that healthcare professionals have a largely positive attitude and thorough overall knowledge of lifestyle intervention methods. However, both the level of knowledge and the involvement in patients’ lifestyle change, differed between professional groups. Organizational support like CPGs and the development of primary health care (PHC) collaborations with other stakeholders were identified as potential strategies for enhancing the implementation of lifestyle interventions in PHC (III).In addition to interviews and case studies, a longitudinal survey among health professionals (n=150; n=73) demonstrated that their use of methods to encourage patients to reduce or eliminate tobacco or alcohol use, had increased. The survey also indicated that nurses had increased the extent to which they addressed all four lifestyle habits. The progress of the implementation of CPGs on lifestyle interventions in PHC was somewhat limited, and important differences in physicians and nurses’ attitudes, as well as their use of the guidelines, were found (IV).Conclusions: Health orientation differs in many ways from more traditional fields in medicine. To strengthen the implementation of this very important (but not “urgent”) field in health care, it needs, first of all, to be prioritized at all levels! The results of the studies demonstrate relatively slow adoption of lifestyle intervention CPGs in clinical practice, and indicate room for improvement. The findings of this thesis can inform healthcare policy and research on further development of the health orientation perspective, as well as on the challenges of implementing CPGs on lifestyle interventions in primary care. In summary, this thesis presents important lessons learned regarding health orientation - from the development of CPGs in the field, via assessing healthcare organizations’ readiness to change and health professionals’ attitudes to methods to support patients with lifestyle changes.
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- Kien, Vu Duy, 1977-
(författare)
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Inequalities in non-communicable diseases in urban Hanoi, Vietnam : health care utilization, expenditure and responsiveness of commune health stations
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Non-communicable diseases (NCDs) are the leading causes of morbidity and mortality among adults in Vietnam. Little is known about the magnitude of socioeconomic inequalities in NCDs and other NCD-related factors in urban areas, in particular among the poor living in slum areas. Understanding these disparities are essential in contributing to the knowledge, needed to reduce inequalities and close the related health gaps burdening the disadvantaged populations in urban areas. Objective: To examine the burden and health system responsiveness to NCDs in Hanoi, Vietnam and investigate the role of socioeconomic inequalities in their prevalence, subsequent healthcare utilization and related impoverishment due to health expenditures. Methods: A cross-sectional study was conducted among 3,736 individuals aged 15 years and over who lived in 1211 randomly selected households in 2013 in urban Hanoi, Vietnam. The study collected information on household’s characteristics, household expenditures, and household member information. A qualitative approach was implemented to explore the responsiveness of commune health stations to the increasing burden of NCDs in urban Hanoi. In-depth interview approach was conducted among health staff involved in NCD tasks at four commune health stations in urban Hanoi. Furthermore, NCD managers at relevance district, provincial and national levels were interviewed. Results: The prevalence of self-reported NCDs was significantly higher among individuals in non-slum areas (11.6%) than those in slum areas (7.9%). However, the prevalence of self-reported NCDs concentrated among the poor in both slum and non-slum areas. In slum areas, the poor needed more health care services, but the rich consumed more health care services. Among households with at least one household member reporting diagnosis of NCDs, the proportion of household facing catastrophic health expenditure and impoverishment were the greater in slum areas than in non-slum areas. Poor households in slum areas were more likely to face catastrophic health expenditure and impoverishment. The poor in non-slum areas were also more likely to face impoverishment if their household members experienced NCDs. Health system responses to NCDs at commune health stations in urban Hanoi were weak, characterized by the lack of health information, inadequate human resources, poor financing, inadequate quality and quantity of services, lack of essential medicines. The commune health stations were not prepared to respond to the rising prevalence of NCDs in urban Hanoi. Conclusion: This thesis shows the existence of socioeconomic inequalities in the prevalence of self-reported NCDs in both non-slum and slum areas in urban Hanoi. NCDs associated with the inequalities in health care utilization, catastrophic health expenditure and impoverishment, particular in slum areas. Appropriate interventions should focus more on specific population groups to reduce the socioeconomic inequalities in the NCD prevalence and health care utilization related to NCDs to prevent catastrophic health expenditure and impoverishment among the households of NCD patients. The functions of commune health stations in the urban setting should be strengthened through the development of NCDs service packages covered by the health insurance.
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