| 1. |
- Nguyen, Quang Ngoc, 1976-
(författare)
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Understanding and managing cardiovascular disease risk factors in Vietnam : integrating clinical and public health perspectives
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Vietnam, like other low-income countries, is facing an epidemic burden of cardiovascular disease risk factors (CVDRFs). The magnitude and directions of CVDRF progression are matters of uncertainty. Objectives: To describe the epidemiological progression of CVDRFs and the preventive effects of community lifestyle interventions, with reference to the differences in progression of CVDRF patterns between men and women. Methods: The study was conducted during 2001-2009 in nationally representative samples and in a local setting of rural areas of Ba-Vi district, Ha-Tay province. Both epidemiological and interventional approaches were applied: (i) a population-based cross-sectional survey of 2,130 people aged ≥25 years in Thai-Binh and Hanoi; (ii) an individual participant-level meta analysis of 23,563 people aged 24-74 years from multiple similar surveys in 9 provinces around Vietnam; (iii) a 17-month cohort study of 497 patients in a hypertension management programme; (iv) a quasi-experimental trial on community lifestyle promotion integrated with a hypertension management programme, evaluated by surveys of 4,645 people in both intervention and reference communes before and after a 3-year intervention. Main findings: (i) in the general adult population ≥25 years, CVDRFs were common, often clustered within individuals, and increased with age; (ii) the Vietnamese population is facing a growing epidemic of CVDRFs, which are generally not well managed; (iii) it is possible to launch a community intervention in low-resource settings within the scope of a commune-based patient-targeted programme on hypertension management; (iv) community health intervention with comprehensive healthy lifestyle promotion improves blood pressure and some behavioural CVDRFs. Conclusion: Alarming increases in CVDRFs in the general population need comprehensive multi-level prevention strategies, which combine both individual high-risk and population health approaches. The commune-based hypertension-centred management programmes integrated with community health promotion are the initial but essential steps towards comprehensive and effective management of CVDRFs and should be part of an integrated and co-ordinated national program on the prevention and control of chronic diseases in low-resource settings like Vietnam.
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| 2. |
- Nilsson, Maria, 1957-
(författare)
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Promoting health in adolescents : preventing the use of tobacco
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- There is a robust evidence base for the negative health effects from smoking. Smoking is linked to severe morbidity and to mortality, and kills up to half of its regular users. Tobacco use and production also bring other negative consequences such as economic loss for countries, poverty for individuals, child labour, deforestation and other environmental problems in tobacco growing countries. A combination of comprehensive interventions at different levels is needed to curb the tobacco epidemic. Tobacco control strategies at national levels in the western world often include components of information/education, taxation, legislative measures and influencing public opinion. Two approaches have dominated at the meso and micro levels: cessation support for tobacco users and prevention activities to support young people refraining from tobacco use. Smoking uptake is a complex process that includes factors at the societal level as well as social and individual characteristics. At national level, taxation and legislation can contribute to a societal norm opposing tobacco and creating a context for primary prevention aimed at tobacco free youth. There is no magic bullet in primary prevention. At the meso and micro levels, a continued development of knowledge on the underlying mechanisms and primary prevention methods is essential to prevent young people from starting to use tobacco. The overall aim of this thesis was to gain knowledge about factors that influence young people’s use of tobacco and of preventive mechanisms. The specific aims included to study the relation between Tobacco Free Duo, an intervention program targeting youth in Västerbotten County, and tobacco use prevalence. A specific interest was to explore the role adults can play in supporting young people to refrain from tobacco use. The thesis is based on four studies with three separate sets of data, two were quantitative and one was qualitative. The studies were conducted among adolescents (aged 13-15 yr) in Västerbotten County and on national level in Sweden (aged 13, 15 and 17 yr). Tobacco Free Duo is a school-based community intervention that started in 1993. An essential component of the intervention was to involve adults in supporting adolescents to stay tobacco free. Results showed decreased smoking in adolescents among both boys and girls in the intervention area during the study period of seven years. There was no change in a national reference group during the same time period. A bonus effect was a decrease in adult tobacco use in the intervention area. One out of four adults who supported a young person taking part in the intervention stopped using tobacco. In a qualitative assessment of young smokers, starting to smoke was described as a means of gaining control of their feelings and their situation during early adolescence. They expected adults to intervene against their smoking and claimed that close relations with caring adults could be a reason for smoking less or trying to quit smoking. In a quantitative study that used three decades of national data, over time adolescents became more positive toward parental action on children’s smoking. The adolescents strongly supported the idea of parental action, regardless of whether or not they themselves smoked. Adolescents preferred that actions from parents were dissuading their children from smoking, not smoking themselves, and not allowing their children to smoke at home. These results suggest that the Tobacco Free Duo program contributed to a reduction in adolescent smoking among both boys and girls. Using a multi-faceted intervention that includes an adolescent-adult partnership can decrease adolescent smoking uptake. Engaging adults as partners in tobacco prevention interventions that target adolescents has an important tobacco reducing bonus effect in the adults. The intervention has proven sustainable within communities. A growing majority of adolescents support parental interventions to help them refrain from tobacco. The findings dismiss the notion that adolescents ignore or even disdain parental practices concerning tobacco. A common and consequent norm against tobacco from both schools and parents using a supportive attitude can prevent tobacco use in young people.
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| 3. |
- 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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| 4. |
- Pujilestari, Cahya Utamie, 1982-
(författare)
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Abdominal obesity among older population in Indonesia : socioeconomic and gender inequality, pattern and impacts on disability and death
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Population ageing has contributed to the rise of chronic non-communicable diseases (NCDs). Concurrently, obesity prevalence is increasing in all age groups and has become a serious public health problem. Obesity is the main risk factors of the major chronic NCDs such as type 2 diabetes and has been linked to disability and mortality. Studies of socioeconomic inequalities in obesity among older people in Indonesia are scarce. Understanding socioeconomic inequalities are essential to develop appropriate health programme to improve the population health. This thesis describes the pattern of socioeconomic and gender inequality in abdominal obesity and analyses its impact on disability and all-cause mortality among older people in Indonesia.Methods: This thesis is based on four studies conducted in Purworejo Health and Demographic Surveillance System (HDSS) site in Purworejo district, Central Java, Indonesia. This thesis uses both quantitative and qualitative methods. The qualitative study (sub-study 1) was based on 12 Focus Group Discussions (FGDs) with 68 participants from different age groups, sex, and living area. Content analysis was used to describe the community perceptions on diabetes and its risk factors. The quantitative studies (sub-study 2 to 4) utilized longitudinal panel data from the 1st (n = 11,753 individuals) and 2nd wave (n = 14,235 individuals) of the WHO-INDEPTH Study on global AGEing and adult health (SAGE) conducted among all individuals aged 50 years and older in 2007 and 2010. Sub-study 2 used concentration index and decomposition analysis to analyse the pattern of socioeconomic and gender inequality in abdominal obesity. Sub-study 3 used linear regression to examine the association between abdominal obesity and disability. Sub-study 4 used Cox regression analysis with restricted cubic splines to examine the impact of abdominal obesity on all-cause mortality.Results: The FGDs reveals that the community holds unrealistic optimism in perceiving diabetes its risk factors. The community stated that chronic NCD such as diabetes is caused by modern lifestyles and mostly attacks those who are considered as the wealthy (sub-study 1). Socioeconomic inequality in abdominal obesity exists in Purworejo HDSS. Abdominal obesity was more prevalent among the affluent men and women, with a lesser inequality gaps between rich and poor among women. The main contributing factors to inequalities in abdominal obesity were occupation, wealth index, and education (sub-study 2). In three-year period, the mean waist circumference decreased significantly among the poor. An increase in waist circumference was significantly associated with disability, and the poor people were more disabled compared to the rich (sub-study 3). A U-shaped association was observed between waist circumference and all-cause mortality, particularly among women. This indicated an increased risk of mortality in the lower and upper end of the waist circumference distribution. The poor with low waist circumference had a higher risk of mortality than the rich (sub-study 4).Conclusion: Abdominal obesity was disproportionately more prevalent among older Indonesian women. Though the wealthy people have higher burden of abdominal obesity, the poor people experiences more disability and higher risk of death. Misperception on chronic NCDs and its risk factors exist among the Indonesian population. Abdominal obesity prevention strategies are needed to prevent chronic NCDs, disabilities, and mortality among Indonesian older population. The prevention strategies should be culturally sensitive and address all socioeconomic levels. Special attention should be given to disadvantaged women as the most vulnerable group.
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| 5. |
- 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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| 6. |
- 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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| 7. |
- 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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| 8. |
- 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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| 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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| 10. |
- Ng, Nawi, 1974-
(författare)
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Chronic disease risk factors in a transitional country : the case of rural Indonesia
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The epidemic of chronic diseases is largely neglected. Although a threatening burden of chronic diseases is emerging, developing public health efforts for their prevention and control is not yet a priority for trans-national and national health policy makers. Understanding the population burden of risk factors which predict chronic diseases is an important step in reducing the impact of the diseases themselves. Objective: This thesis responds to the increasing burden of chronic diseases worldwide, and aims to illustrate the gap in chronic disease risk factor research in developing countries. The thesis describes and analyses the distribution of chronic disease risk factors in a rural setting in Indonesia. It also describes how smoking, one of the most common risk factors, is viewed by rural Javanese boys. Ultimately, therefore, this thesis aims to contribute to policy and programme recommendations for community interventions in a rural setting in Indonesia Methods: The studies were conducted in Purworejo District, where a Demographic Surveillance System (DSS) has been running since 1994. The Purworejo DSS is part of the INDEPTH network (International Network of field sites for continuous Demographic Evaluation of Populations and Their Health in developing countries). Two representative cross-sectional studies (in 2001 and 2005) were conducted to assess the chronic disease risk factors (including smoking, elevated blood pressure, and overweight and obesity). The first cross-sectional study was followed up in 2002 and 2004. In each study, a total of 3 250 participants (approximately 250 individuals in each sex and age group among 15–74 year olds stratified into 10-year intervals) were randomly selected from the surveillance database from each enumeration area in the surveillance area. Instruments were adopted from the WHO STEPS survey and adapted to local setting. Since many Indonesians start to smoke at an earlier age, a qualitative study using a focus group discussion approach was conducted among school boys aged 13-17 years old to describe and explore beliefs, norms, and values about smoking in a rural setting in Java. Result: Both the rural and urban populations in Purworejo face an unequal distribution of risk factors for chronic diseases. The burden among the most well-off group in the rural area has already reached a level similar to that found in the urban area. Most of the risk factors increased in all age, sex and socioeconomic groups during the period of 2001 to 2005. However, women and the poorest group experienced the greatest increase in risk factor prevalence. The qualitative study showed that cultural resistance against women smoking in Indonesia remains strong. Smoking is being viewed as a culturally internalised habit that signifies transition into maturity and adulthood for boys. Smoking is utilised as a means for socialisation and signifies better socioeconomic status. The use of tobacco in the construction of masculinity underlines the importance of gender specific interventions. National tobacco control policy should emphasise a smoking free society as the norm, especially among boys and men, and regulations regarding the banning of smoking should be enforced at all levels and areas of the community. Within the demographic surveillance setting, it is possible to assess the population and health dynamics. Utilisation of a standardised methodology across sites in INDEPTH will produce comparable population-based data in developing countries. Such comparisons are important in global health. A comparison of smoking transition patterns between a Vietnamese DSS and an Indonesian DSS shows that Indonesian men started smoking regularly earlier and ceased less than Vietnamese men. Compared with Vietnam, which has already signed and ratified the Framework Convention on Tobacco Control, tobacco control activities in Indonesia are still deficient. Conclusion: The thesis concludes that the rural population is not spared from the emerging burden of chronic disease risk factors. The patterning of risks across different socioeconomic groups provides a macro picture of the vicious cycle between poverty and chronic diseases. Understanding of risk factors in a local context through a qualitative study provides insight into cultural aspects relating to risk factor adoption, and will allow the fostering and tailoring of culturally appropriate interventions. Combining data from demographic surveillance sites with the WHO STEP approach to chronic disease risk factor Surveillance addresses basic epidemiological questions on chronic diseases. The use of such data is a powerful advocacy tool in public health decision-making for chronic disease prevention in developing countries. With substantial existing evidence on the effectiveness of chronic disease prevention and intervention programmes, it is vital that Indonesia to starts planning intervention programmes to control the impending chronic disease epidemic, and most importantly, to translate all this evidence into public health action. Keywords: chronic disease, risk factor, demographic surveillance system, smoking, elevated blood pressure, overweight and obesity, population-based intervention
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