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- Edvardsson, Kristina, 1973-
(författare)
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Health promotion in pregnancy and early parenthood : the challenge of innovation, implementation and change within the Salut Programme
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In 2005, the Västerbotten County Council launched a child health promotion programme, “the Salut Programme”, in response to an alarming prevalence of overweight and obesity, and trends of increased dental caries, among young county citizens. The programme, initially developed in four pilot areas, is built on multidisciplinary and cross-sectoral collaboration and aims to support and strengthen health promotion activities in health care, social services and school settings. It targets children and adolescents (0-18 years of age) and their parents, and starts during pregnancy. This thesis focuses on interventions provided by antenatal care, child health care, dental services, and open pre-schools, directed to expectant parents and families with children aged 0-1 ½ years. Within the programme context, the aim was to explore socio-demographic patterns of overweight and obesity in expectant parents (Paper I), firsttime parents’ experiences of health promotion and lifestyle change during pregnancy and early parenthood (Paper II), professionals’ experiences of factors influencing programme implementation and sustainability (Paper III and IV), and early programme outcomes on professionals’ health promotion practices and collaboration following countywide dissemination and implementation (Paper IV). Methods and results: A population based cross-sectional study among expectant parents showed overweight and obesity in 29% of women (pre-pregnancy) and in 53% of men (n=4,352♀, 3,949♂). The likelihood for obesity was higher in expectant parents with lower levels of education, among those unemployed or on sick leave, and those living in rural areas. In 62% of couples, at least one of the partners was overweight or obese; a positive partner correlation was also found for BMI (I). An interview study with 24 first-time parents (n=12♀, 12♂) revealed that they primarily undertook lifestyle changes to secure the health of the fetus in pregnancy, and to provide a healthy environment in childhood. Parents described themselves as highly receptive to information about how their lifestyle could influence fetal health, and they frequently discussed pregnancy risks related to tobacco and alcohol, as well as toxins and infectious agents in foods. However, parents did not seem inclined to make lifestyle changes primarily to promote their own health. The antenatal and child health care services were perceived as being mainly directed towards women, and parents described a lack of a holistic view of the family which included experiences of fathers being treated as less important (II). An interview study undertaken with professionals (n=23) in the Salut Programme pilot areas indicated programme sustainability at most sites, two years after implementation, although less adherence was described within child health care. Factors influencing programme sustainability, as described by professionals, were identified at multiple organisational levels (III). A before-and-after survey among professionals (n=144) measured outcomes of the county-wide implementation of the Salut Programme in 13 out of 15 county municipalities. Results showed significant improvements in professionals’ health promotion practices and collaboration across sectors. A number of important implementation facilitators and barriers, acting at different organizational levels, were also identified via a survey comprised of open-ended questions (IV). Conclusion: The Salut Programme, developed with high involvement of professionals, and strongly integrated in existing organisational structures and practices, shows potential for improving health promotion practices and cross-sectoral collaboration. The findings can inform further development of the Salut Programme.as well as new health promotion initiatives, and inform policy practice and future research. These aspects include approaches in health promotion and prevention, father involvement during pregnancy and early parenthood, and factors influencing implementation and sustainability of cross-sectoral health promotion programmes.
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| 2. |
- Prawirohartono, Endy, 1953-
(författare)
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Prenatal zinc and vitamin A supplementation : a study on the impact of prenatal micronutrient supplementation in rural Indonesia
- 2012
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: To study the effects of prenatal zinc and vitamin A supplementation on birthsize, neonatal morbidity, infant mortality, and growth in children up to two years of age. Subjects and Methods: From September 1995 to December 1999 pregnant women inPurworejo District, Central Java, Indonesia with gestational age <17 weeks (n=2173) wererecruited to and participated in a community-based, individually randomized, placebo controlled,double blinded study aiming to evaluate the impact of supplementation (vitamin A,zinc, vitamin A + zinc) during pregnancy on maternal morbidity and pregnancy outcomes. Weanalyzed secondary data from that study regarding birth size, neonatal morbidity and infantmortality of the 1956 infants born alive. A subsample of infants (n=343) was followed until 2years of age concerning growth, feeding practices and morbidity. Outcomes were tested usingthe chi-square test, ANOVA, ANCOVA, and Cox’s proportional hazard function. Results: Birth weights in the zinc [mean ±Standard deviation (SD): 3.16 ± 0.52 kg], vitaminA (3.08 ± 0.46 kg) or the combined vitamin A and zinc (3.10 ± 0.59) groups did not differ fromplacebo (3.09 ± 0.50 kg) after adjustment for maternal pre-pregnancy weight, weight gainduring pregnancy, and parity (P=0.70). Birth lengths of infants born to mothers supplementedwith zinc or vitamin A were in average 0.3 cm and 0.2 cm longer than those in the placebogroup after adjustment for maternal height, pre-pregnancy weight, weight gain during pregnancy,and parity (P=0.04). The impact of prenatal supplementation on infant mortality andneonatal morbidity was not significant. There was a small effect of prenatal vitamin A supplementationon postnatal growth in height-for-age z-score (HAZ). The absolute differencesbetween the vitamin A only and vitamin A + zinc groups at 3 and 9 months were 0.34 SD and0.37 SD, respectively, and the absolute difference between the vitamin A only and zinc onlygroups at 18 months was 0.31 SD. Defining growth faltering as downward crossing of ≥2 majorpercentile lines, 50-75% of the children were faltering within 9 months of age, whereas 17%and 8% were <-2 SD for growth in weight-for-age z-score (WAZ) and HAZ, respectively.Prenatal supplementation did not reduce the prevalence of growth faltering. Conclusions: Prenatal vitamin A and zinc demonstrates a small but significant impact onbirth length, but it does not have any protective effect on infant mortality and neonatal morbidity.Prenatal vitamin A supplementation had a small but significant effect on postnatallength growth until 18 months of age, but no effect on weight gain, growth rate and it did notreduce the prevalence of growth faltering.
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| 3. |
- Kahn, Kathleen, 1960-
(författare)
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Dying to make a fresh start : mortality and health transition in a new South Africa
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Rationale: Vital registration is lacking in developing settings where health and development problems are most pressing. Policy-makers confront an “information paradox”: the critical need for information on which to base priorities and monitor progress, and the profound shortage of such information. Aims: To better understand the dynamics of mortality transition in rural South Africa over a decade of profound socio-political change coupled with emerging HIV/AIDS. Thereby to inform health and development programming, policy formulation, and the research agenda; and contribute to debate on the nature of the ‘health transition’. Methods: The Agincourt health and demographic surveillance system is based on continuous monitoring of the Agincourt sub-district population in rural north-east South Africa. This involves annual recording of all vital events, specifically deaths, births and migrations in 11,700 households comprising some 70,000 persons. A “verbal autopsy” is conducted on every death, and special modules provide additional data. Key findings: A major health transition has occurred over the past decade, with marked changes in population structure and rapidly escalating mortality particularly among children and younger adults. A quadruple burden of disease is evident with persisting infectious disease and malnutrition in children, emerging non-communicable disease in the middle-aged and older, high levels of violence in an apparently peaceful community, and rapidly escalating HIV/AIDS and tuberculosis. There is evidence of sex differences and socio-economic differentials in mortality; vulnerable sub-groups include the children of Mozambican immigrants and recently returned labour migrants. Implications: With respect to health transition, empirical data demonstrate a marked “counter transition” with mortality increasing in children and young adults; “epidemiologic polarization” is evident with the most vulnerable experiencing a higher mortality burden; and a “protracted transition” is reflected in the co-existence of persisting infectious disease and malnutrition, emerging HIV/AIDS, and increasing chronic non-communicable disease. With respect to health policy and practice there is urgent need to: strengthen HIV/AIDS prevention, treatment and care; offer effective long-term care to control the rising burden of chronic illness and related risk; maintain and improve maternal and child health services; and address differential access to care. This poses a substantial challenge to a severely stretched health system.
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| 4. |
- Westerlund, Anna, 1978-
(författare)
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The role of implementation science in healthcare improvement efforts : investigating three complex interventions
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- For decades, scholars have found significant gaps between the knowledge available and the knowledge applied in healthcare. Many potential benefits of adequate knowledge based interventions are therefore never achieved. A considerable body of knowledge has evolved on how to promote a better uptake of evidence-based knowledge into routine use. Even so, the actual impact and usefulness of implementation research findings among healthcare practitioners have not been extensively studied.Accordingly, the overall aim of this thesis is to contribute to the understanding of how the implementation of complex interventions into healthcare can be improved. This is done by investigating whether some of these efforts do correspond with available scientific knowledge on implementation.The thesis is based on three cases contributing to four studies. The cases studied are: the National Perinatal Patient Safety program (NPPS), the Dynamic and Viable Organisation initiative (DVO), and the International Child Development Program (ICDP). All studies focuses on the early stages of implementation.A mixed methods approach was adopted, involving both qualitative and quantitative methods. Data collection consisted of interviews, questionnaires, observations, and process diaries. Qualitative content analysis (conventional and directed), descriptive and non-parametric statistics were used. The focus was on implementation strategies used by healthcare actors in relation to factors influencing implementation processes and outcomes. More specifically, healthcare actors perspectives on such factors and whether they were addressed by the strategies used, was investigated. A process evaluation of implementation outcomes was also part of the thesis.The healthcare actors in focus were the adopters, i.e. practitioners expected to change their work practices, and implementation facilitators. The latter refer to actors with a more or less explicit responsibility to implement new practices or interventions aimed at improving the quality and effectiveness of the provided health services.Variation was found regarding how the implementation strategies used in the three cases corresponded with available scientific knowledge on implementation. In Case NPPS, the implementation facilitators planned, designed, and ensured that the core interventions of the implementation strategy were executed in a rational manner. Several important implementation factors were addressed by the strategy. The process evaluation of effects on readiness for change by the development of a team mental model among adopters showed positive results.In Case DVO a strategy was used that evolved over time, partly based on raised questions and feedback from staff and managers involved. The strategy can be described as an intuitive ‘socially accomplished activity’. This strategy involved addressing ‘Implementation Process-related factors’ in order to affect motivation and increase the tension for change among adopters.In Case ICDP, the results reflected a shortage of strategies during the early stage of implementation. The main intervention was the stepwise ICDP-education. A more comprehensive implementation strategy covering implementation factors highlighted as important among adopters was not developed. The process evaluation revealed vague directives on what was expected regarding the use and adaptation of ICDP to current practice versus preservation of fidelity to the original ICDP. This situation resulted in a rather large variation in how the changes in work practices were perceived among the health centres involved. No health centre practiced ICDP in its original form.A new knowledge-practice gap is discussed based on the findings in this thesis: a gap between the scientific knowledge on implementation and the actual implementation strategies used in practice during improvement efforts initiated by healthcare actors. The findings show that correspondence between scientific knowledge on implementation and what is actually done in order to accomplish change in practice might be more random (or implicit) than systematic. The question of how to transfer scientific knowledge on implementation into user-friendly resources for practitioners is discussed. A tentative model is suggested, which contributes to existing determinant frameworks by focusing on relations among factors. The model may be used in healthcare practice, to guide the design of an implementation strategy (or as a pathway for tailored implementation interventions) and aid the assignment of responsibilities in relation to factors that are known to affect implementation processes and outcomes.The question of how to transfer models and frameworks into user-friendly resources needs further attention. It is suggested that action oriented research aiming at further developing and establishing the concept of ‘practical implementation science’ should be conducted. This could be a way of bridging the knowledge-practice gap in healthcare.
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