| 1. |
- 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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| 2. |
- Kleppang, Annette Løvheim
(författare)
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Mental health and physical activity in adolescence
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis is to examine the association between physical activity and mental health among Norwegian adolescents.The thesis includes four studies among adolescents in grade 10, aged 15-16 years. Studies I, II and III are based on the Norwegian Youth Health Surveys and study IV is based on data retrieved from Ungdata. In 2000-2003 (Youth Health Survey), the adolescents completed a paper and pencil self-administered questionnaire at school during lesson time. In both 2009 (Youth Health Survey) and 2017 (Ungdata), the adolescents completed an anonymous web-based questionnaire.The Rasch analysis from study I showed that overall, the HSCL-10 showed good reliability and the items worked well. One item “Sleeping difficulties”, in the HSCL-10 instrument clearly misfit and some items worked differently for boys and girls. Study II showed that the association between physical activity, screen-based sedentary behaviour and psychological distress was weak. In study III, a significant association between physical activity and incident use of hypnotics was shown at short-term follow up. No significant associations were found for later use of antidepressants. Study IV showed that participating in a sports club was significantly associated with lower odds of depressive symptoms.Mental health and physical activity are both complex phenomena. When investigating the association between adolescent`s physical activity and mental health, it is important to look at physical activities in different contexts, not only volume and frequency.
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| 3. |
- Biswas, Animesh, 1978-
(författare)
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Maternal and Neonatal Death Review System to Improve Maternal and Neonatal Health Care Services in Bangladesh
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Bangladesh has made encouraging progress in reducing maternal and neonatal mortality over the past two decades. However, deaths are much higher than in many other countries. The death reporting system to address maternal, neonatal deaths and stillbirths is still poor. Moreover, cause identification for each of the community and facility deaths is not functional. The overall objective of this thesis is to develop, implement and evaluate the Maternal and Neonatal Death Review (MNDR) system in Bangladesh. The study has been conducted in two districts of Bangladesh. A mixed method is used in studies I and II, whereas a qualitative method is used in studies III-V, and cost of MNDR is calculated in study VI. In-depth interviews, focus group discussions, group discussions, participant observations and document reviews are used as data collection techniques. Quantitative data are collected from the MNDR database. In study I, community death notification in the MNDR system was found to be achievable and acceptable at district level in the existing government health system. A simple death notification process is used to capture community-level maternal and neonatal deaths and stillbirths. It was useful for local-level planning by health managers. In study II, death-notification findings explored dense pocket areas in the district. The health system took local initiatives based on the findings. This resulted in visible and tangible changes in care-seeking and client satisfaction. Death numbers in 2012 were reduced in comparison with 2010 in the specific area. In study III, verbal autopsies at community level enabled the identification of medical and social causes of death, including community delays. Deceased family members cordially provided information on deaths to field-level government health workers. The health managers used the findings for a remedial action plan, which was implemented as per causal findings. In study IV, social autopsy highlights social errors in the community, and promotes discussion based on a maternal or neonatal death, or stillbirth. This was aneffective means to deliver some important messages and to sensitize the community. Importantly, the community itself plans and decides on what should be done in future to avert such deaths. In study V, facility death review of maternal and neonatal deaths was found to be possible and useful in upazila and district facilities. It not only identified medical causes of death, but also explored gaps and challenges in facilities that can be resolved. The findings of facility death reviews were helpful to local health mangers and planners in order to develop appropriate action plans and improve quality of care at facility level. Finally, in study VI, the initial piloting costs required for MNDR implementation were estimated, including large capacity development and other developmental costs. However, in the following year, costs were reduced. Unit cost per activity was 3070 BDT in 2010, but, in the following years, 1887 BDT and 2207 BDT, in 2011 and 2012 respectively.
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| 4. |
- 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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| 5. |
- Fröding, Karin, 1974-
(författare)
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Public health, neighbourhood development and participation : research and practice in four Swedish partnership cities
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Det finns betydande skillnader i hälsa beroende på utbildning, socioekonomisk status, etnicitet, ålder och kön och det har konsekvenser för människors livslängd, livskvalitet och hälsa. Ojämlikheter i hälsa blir särskilt tydliga när man jämför olika geografiska områden, där vissa områden har hög koncentration av fattiga och socialt utslagna människor med dålig hälsa, arbetslöshet och låg utbildning. Att vidta åtgärder mot de utbredda hälsoskillnader som finns mellan människor med vitt skilda förutsättningar är en viktig utmaning för hälsofrämjande arbete. En strategi för att minska skillnader i hälsa mellan människor är att arbeta med områdesutveckling i prioriterade bostadsområden. Ett svenskt samarbete, Partnerskap för Hållbar Välfärdsutveckling, bildades 2003 mellan Helsingborg, Norrköping, Västerås och Örebro, kommunala bostadsbolag i dessa städer, flera nationella parter samt forskare vid Örebro universitet. Det centrala i partnerskapet var att genom erfarenhetsutbyte, metodutveckling och kunskapsspridning arbeta för en hållbar välfärdsutveckling i prioriterade bostadsområden (ett område från varje stad valdes ut). Integrerat i detta arbete var forskningsprogrammet ”Den hälsosamma staden - social integration, nätverkspolitik och hållbar välfärdsutveckling”, som följt partnerskapet vetenskapligt mellan åren 2003 och 2010. Det är av stor betydelse att integrera politik, praxis och forskning för att få kunskap om förutsättningar för en hälsosam utveckling i utsatta bostadsområden. Detta är en unik del av det nästan sjuåriga partnerskapsarbetet. Avhandlingens övergripande syfte har varit att inom ramen för Partnerskap för Hållbar Välfärdsutveckling studera folkhälsostrategier och lokalt utvecklingsarbete i kommuner och bostadsområden med särskild betoning på boendes deltagande för en hälsosam utveckling. Avhandlingens första studie syftar till att beskriva och analysera strategiskt folkhälsoarbete och lokalt områdesutvecklingsarbetet i fyra svenska kommuner samt den tidiga implementeringsfasen av Partnerskap för Hållbar Välfärdsutveckling. Datamaterialet består av dokumenterade intervjuer med folkhälsosamordnare och områdesutvecklare, deltagande observationer och skriftliga dokument. Resultatet visar att det redan i början av partnerskapsperioden fanns formella strukturer för folkhälsoarbetet i kommunen, till exempel ett folkhälsopolitiskt program, en utsedd samordnare, ett kontor och administrativa resurser samt politiker med särskilt ansvar för folkhälsofrågor. I uppbyggandet av de formella strukturerna var också de svenska nationella folkhälsomålen ett viktigt underlag. Vad gäller det lokala bostadsområdes arbete kan det ta sig olika uttryck även om målet är det samma. I partnerskapet fanns också tidigt höga förväntningar KARIN FRÖDING Public Health, Neighbourhood Development, and Participation I 83 att det skulle fungera som en sammanhållande kraft för ömsesidigt lärande och en positiv utveckling av prioriterade bostadsområden. Avhandlingens andra studie syftar till att analysera vad som karaktäriserar människor som deltar i områdesutveckling. Boende från tre av partnerskapskommunerna svarade på en enkät och resultatet visade på att människor som försökt påverka politiken i kommunen på olika sätt i större utsträckning deltar i områdesutveckling. Denna påverkan kan ske genom att kontakta en politiker eller lämna in ett medborgarförslag. Högt engagemang och aktivt deltagande var oberoende av individens sociodemografiska faktorer såsom utbildning eller inkomstnivå. Det var endast personer födda utanför Norden som i mindre utsträckning deltog i områdesutveckling. Avhandlingens tredje studie syftar till att undersöka en områdesbaserad interaktion mellan professionella (anställda), boende och forskare i en av partnerskapets utvalda stadsdelar. Baserat på deltagande observation under två år visar studien ett entydigt resultat: för att processen skall fungera krävdes att deltagarna öppet diskuterade enskilda situationer, personliga åtaganden och ömsesidiga förväntningar. Vidare var det viktigt att demaskera makt och auktoritet bland dem som deltar i processen för att inte några skulle ha mer inflytande på arbetet än de andra. Tiden visade sig vara viktig, att processen fick ta den tid det tog med konsensus som ett ledord. Slutligen var det viktigt att acceptera olika nivåer av deltagande. Allt detta bidrar till att skapa en gemensam känsla av engagemang och demokratisk dialog som är så viktigt i ett interaktivt samarbete. I avhandlingens fjärde studie är syftet att studera utvecklingsprocesser för att nå hållbara strukturer för lokalt områdesutvecklingsarbete i de fyra partnerskapsstäderna. Arbetet i Partnerskap för Hållbar Välfärdsutveckling har liksom kommunerna och det lokal områdesarbetet följts mellan åren 2003-2009. Genom en serie studier inom forskningsprogrammet med intervjuer, enkäter, deltagande observation och dokumentanalys har det utformats en databas för fallstudier. Resultatet visar att det under partnerskapsperioden fanns byggstenar i form av politiskt stöd, lokala partnerskap och boendes deltagande i områdesarbetet. När Partnerskap för Hållbar Välfärdsutveckling upphörde fanns dock få hållbara strukturer för områdesutveckling kvar. Det politiska stödet för områdesutveckling var under partnerskapstiden konstant högt men cykliskt, vilket innebar att prioriteringar ändrades. I samtliga fyra studerade stadsdelar hade områdesarbetet delvis avstannat och politiskt stöd och resurser lagts på andra områden i respektive kommun. I ett lokalt partnerskapssamarbete mellan kommun och kommunalt bostadsbolag finns dock möjlighet att bilda hållbara strukturer när såväl det strategiska som det lokala involveras i den praktiska delen av områdesutveckling. Medborgarnas deltagande verkar också utgöra en viss hållbar struktur för områdesutveckling, trots minskat politiskt stöd och resurser. Sammanfattningsvis visar denna avhandling att ett partnerskap för lokalt folkhälsoarbete kan fungera som en sammanhållande länk för lärande och utveckling bland alla inblandade aktörer. För ett fungerande områdesutvecklingsarbete är den lokala kontexten av största vikt liksom formella strukturer och ett nationellt stöd. Det är dessutom nödvändigt att beakta alla boende som potentiella deltagare i områdesutveckling oberoende av utbildning, kön eller inkomstnivå. När ett projektbaserat partnerskap avslutas måste det dessutom finnas strukturer som kan ta vid efter projekttidens slut. Avslutningsvis visar avhandlingen att ett områdesbaserat samspel med deltagande av professionella, boende och forskare ställer krav på en öppen, jämbördig dialog med ett accepterande förhållningssätt till olika nivåer av deltagande samt stort tidsutrymme.
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| 6. |
- Quennerstedt, Mikael, 1966-
(författare)
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Att lära sig hälsa
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this dissertation is to contribute to an understanding of the subject content in Physical Education (PE) foremost from a health perspective. By using an approach deriving from John Dewey’s transactional perspective on meaningmaking (Bentley & Dewey 1949), and a discourse theoretical position, the discourses identified in the dissertation’s studies are consequently regarded as participants in pupils’ meaning-making. This makes it possible to discuss the results of the studies in terms of the institutional content and conditions of meaning-making in PE. The thesis consists of three different discourse analyses, where the institutionalised aspect of meaning-making in PE is examined by analysing local curriculum documents from 72 Swedish compulsory schools. The results of the dissertation show that in the study of subject content in PE a dominance of an activity discourse can be identified, although a social development discourse is also identified as being important in the documents. The results, thus, suggest that the subject content of PE can be characterised by a wide variety of activities, where pupils are expected to be active participants in the sense of being physically active. The content is also characterised by actions promoting good relationships, co-operation and consideration for others. Actions privileged within the discourses in PE are movement, physical activity, trying many different activities together, active participation, good relations and enjoyment. The results also show that health is explicitly constituted as fitness training, life-long physical activity and knowledge about physical training based on scientific facts from physiology and anatomy. Learning health in PE thus mainly consists of a pathogenic health discourse. But from a salutogenic perspective, health is also constituted as the possibility to participate in movement, physical leisure activities and social relations, and enjoy a life-long engagement in different movement and sport activities. The analysis also shows, however, that within the frame of the subject content of PE, it is also possible to regard health in terms of a commitment to health- and environmental issues, a sense of well-being in ongoing activities and an active involvement in subject content matters within PE. Health can therefore be constituted in different ways within PE, although this is not always made explicit in the local curriculum documents.
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| 7. |
- Al-Alawi, Kamila, 1974-
(författare)
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Team-based approach in the management of diabetes at primary health care level in Muscat, Oman : challenges and opportunities
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: The growth of type 2 diabetes is considered an alarming epidemic in Oman. The efficient team-based approach to diabetes management in primary health care is an essential component for providing ideal diabetic care. This thesis aimed to explore the current situation related to team-based management of type 2 diabetes in public Primary Health Care Centres (PHCCs) under the Ministry of Health (MOH) in Oman, including the various challenges associated with diabetes management and the most preferable Human Resources for Health (HRH) management mechanism, and to examine how this could be optimized from provider and patient perspectives.Materials and methods: The entire project was conducted in Muscat Governorate and was based on one quantitative and three qualitative studies. In the quantitative study, 26 public PHCCs were approached through cross-sectional study. The core diabetes management team recommended by the MOH for PHCCs in Oman was explored in terms of their competencies, values, skills, and resources related to the team-based approach to diabetes management. For the qualitative studies, five public purposely-selected PHCCs were approached. The diabetes consultations conducted by the core members and other supportive members involved in diabetes management were observed and later the Primary Health Care Providers (PHCPs) were interviewed. The different approaches explored challenges related to diabetes management and the most preferable HRH mechanism by PHCPs. Seven type 2 diabetes patients with different gender, employment status, and education were consequently interviewed to explore their perceptions towards the current diabetes management service and their opinions towards nurse-led clinics.Results: The survey provided significant and diverse perceptions of PHCPs towards their competencies, values, skills, and resources related to diabetes management. Physicians considered themselves to have better competencies than nurses and dieticians. Physicians also scored higher on team-related skills and values compared with health educators. In terms of team-related skills, the difference between physicians and nurses was statistically significant and showed that physicians perceived themselves to have better skills than nurses. Confusion about the leadership concept among PHCPs with a lack of pharmacological, technical, and human resources was also reported. The observations and interviews with PHCPs disclosed three different models of service delivery at diabetes management clinics. The challenges explored involved PHCCs’ infrastructure, nurses’ knowledge, skills, and non-availability of technical and pharmaceutical support. Other challenges that evolved into the community were cultural beliefs, traditions, health awareness, and public transportation. Complete implementation of task-sharing mechanisms within the team-based approach was selected by all PHCPs as the most preferable HRH mechanism. The selection was discussed in the context of positive outcomes, worries, and future requirements. The physicians stated that nurses’ weak contribution to the team within the selected mechanism could be the most significant aspect. Other members supported the task-sharing mechanism between physicians and nurses. However, type 2 diabetes patients’ non-acceptance of a service provided by the nurses created worries for the nurses. The interviews with type 2 diabetes patients disclosed positive perceptions towards the current diabetes management visits; however, opinions towards nurse-led clinics varied among the patients.Conclusions and recommendations: The team-based approach at diabetes management clinics in public PHCCs in Oman requires thoughtful attention. Diverse presence of the team members can form challenges during service delivery. Clear roles for team members must be outlined through a solid HRH management mechanism in the context of a sharp leadership concept. Nurse-led clinics are an important concept within the team; however, their implementation requires further investigation. The concept must involve clear understandings of independence and interdependence by the team members, who must be educated to provide a strong gain for team-based service delivery.
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| 8. |
- Islam, Farzana, 1969-
(författare)
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Quality Improvement System for Maternal and Newborn Health Care Services at District and Sub-district Hospitals in Bangladesh
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In Bangladesh, research focusing on the quality of maternal and newborn health (MNH) services in hospitals remains neglected. There have only been a few studies conducted on quality issues and found the quality of MNH care provided at district and sub-district hospitals to be poor. The overall objective of this thesis was to develop, implement and evaluate a framework for quality improvement (QI) system for MNH care at the district and sub-district level government hospitals in Bangladesh. The thesis is comprised of four papers. Mixed methods were used in paper I and paper IV. In paper II quantitative methods were utilized, and to develop the “Model QI System”, exploratory methodological approaches were used and illustrated in paper III. Group discussions, focus group discussions, in-depth interviews, documents review and photography were utilised as qualitative data collection techniques. Through structured observation and exit interviews quantitative data were obtained. Findings of baseline survey identified several keyfactors that affected the quality of patient care: shortage of staff and logistics; lack of laboratory support; under useof patient-management protocols; lack of training; and insufficient supervision. The clinical performance of health care providers was found unsatisfactory. Utilizing the baseline survey findings and existing information on QI models, theories and QI intervention programmes implemented in defferent settings an adapted “Model QI System” and its implementation framework, guidelines and tools were developed. The key areas of this “Model QI System” included health system support, clinical service delivery, inter-departmental coordination; and utilization of services and client satisfaction. The adopted “Model QI System” was incorporated within the existing hospital management system and it was found that the quality of care improved. The evaluation of the study showed that the “Model QI System” was acceptable to the top health managers, health care providers and hospital support staff and feasible to implement in district and sub-district hospitals in Bangladesh.
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| 9. |
- 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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| 10. |
- 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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