| 1. |
- Brännström, Inger, 1945-
(författare)
-
Community participation and social patterning in cardiovascular disease intervention
- 1993
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This study addresses health policy and public health in the field of cardiovascular disease (CVD) on the local level in Sweden. The overall aim is to contribute to the assessment of structural and social conditions within public health by analysing participation processes and outcome patterns in a local health programme. The northern Swedish MONICA study served as a reference area. The research strategy has been to integrate quantitative and qualitative methodologies and, thereby, focus on different aspects of the health programme under study.The mortality rate was excessive in the study area of Norsjö relative to both provincial and national figures over a period of more than 10 years. This finding formed the basis for a tenyear comprehensive and community-based health programme towards the prevention of CVD and diabetes.Even in this seemingly homogeneous area it was found that socio-economic circumstances were associated with the public health. Almost half of the study population had hypercholesterolaemia (;>6.5 mmol/1), 19% of men and 25% of women were smokers and 30% and 29%, respectively, had high blood pressure. Age had a strong impact on all outcome measures. After adjustments for age and social factors it was found that the relative risk of having hypercholesterolaemia dropped significantly in both sexes during the six years of intervention. The probability of being a smoker was significantly reduced only in highly educated groups. No statistically significant change over time could be found for the risk of suffering high blood pressure. In the reference area of northern Sweden there were no changes over time for any of the selected risk factors. The likelihood of self-assessed good health decreased with increasing risk factor load, with the exception of hypercholesterolaemia , in all social strata.The authorities, including the health and medical staff, were the main actors on the mediastage. Men in manual occupations were least affected by the media coverage. The actors and the public as well as the media viewed the health programme as orientated towards individual lifestyles. Community participation was mainly defined by the actors based on the medical and health planning approach. Differences in interpretations, social interests, personal conflicts and ideological constraints among the actors at local level were observed. Some critical attitudes towards the organization and management of the health programme were also noted among the citizens. However, a majority of the public wanted the health programme to continue. The present study underlines the importance of considering age, gender and social differences in the planning and evaluation of CVD preventive programmes.
|
|
| 2. |
- Philipson, Anna, 1978-
(författare)
-
Health economic aspects of emotional problems and pain symptoms in childhood and adolescence : Long-term outcomes, efficacy and cost-effectiveness of interventions
- 2022
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Emotional problems and pain symptoms among children and adolescents are a global public health challenge that imposes a great burden on the individuals affected and on society. Because resources are limited, allocation and prioritization are needed. Health economic analysis can constitute a foundation for such decisions.The overall aim of this thesis is to estimate long-term outcomes associated with adolescent depression and to evaluate interventions for emotional problems and pain symptoms in childhood and adolescence from a health economic perspective. The thesis is based on four papers: paper I is a longitudinal cohort study of 539 participants, showing that adolescent depression is associated with reduced earnings in adulthood, papers II, III, and IV are based on two randomized controlled trials of interventions. In paper II, a dance intervention for 112 adolescent females with internalizing symptoms were evaluated. A cost–utility analysis was performed, indicating that the intervention was costeffective given a willingness-to-pay threshold of USD 50,000 with an incremental cost-effectiveness ratio of USD 3830/quality-adjusted life year. Papers III and IV evaluated a dance and yoga intervention for 121 girls, 9–13 years old, with functional abdominal pain disorders. Paper III showed that the intervention group decreased their abdominal pain more than did the control group. In paper IV, the cost–utility analysis of the trial indicated a negative incremental cost-effectiveness ratio, investigated from a societal perspective, over both one and ten years.In conclusion, this thesis identifies a need for preventive as well as treatment interventions for emotional problems in adolescence, to decrease the prevalence of emotional problems and mitigate negative outcomes. Dance or dance and yoga combined can be effective and cost-effective early treatment interventions for emotional problems and pain symptoms among females in childhood and adolescence. These findings may assist decision-makers in resource allocation within this area
|
|
| 3. |
- Ennab Vogel, Nicklas, 1981-
(författare)
-
Optimizing prehospital acute stroke care in the presence of economic constraints
- 2024
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Mechanical thrombectomy (MT) has become standard of care for acute anterior circulation ischaemic stroke due to large vessel occlusion since the launch of second-generation stent retrievers for clinical use nearly a decade ago. Up until recently, the treatment was exclusively performed at university hospitals in Sweden. Sundsvall Regional Hospital joined as the eighth treatment facility in late 2023. Scarce resources of healthcare systems across the world hamper the complete implementation of MT in acute stroke care. Hence, efforts to improve patients’ accessibility to and healthcare providers’ utilization of MT remain prioritized. Methods for determining the optimal number and locations of treatment facilities for MT in economically constrained healthcare systems remain unstudied. The optimal number and locations of ambulance helicopters for prehospital transportation of patients with presumed acute stroke too. The aim of the thesis is to solve constrained optimization problems within the framework of cost-effectiveness analysis for prehospital acute stroke care management of patients with AIS. To fill these knowledge gaps, this thesis takes on an interdisciplinary research approach, and combines health economics, operations research, and medicine to identify cost-effective solutions for location problems with respect to the implementation of MT in the Swedish healthcare system. A comprehensive set of consolidated data based on anonymized, patient-level, nation-wide registry data for a study period of six years underlies analyses. This thesis employs predictive modelling, geographic network analysis, optimization, and decision modelling for economic evaluation within the framework of cost-effectiveness analysis to identify the most cost-effective solutions to implement. The fitting of predictive generalized linear models to four treatment modalities in acute stroke care for patients with acute ischaemic stroke established the linear associations in absolute effect measures between the modified Rankin Scale score at 90 days post-stroke and the time from symptom onset to treatment start with intravenous thrombolysis only, MT only and intravenous thrombolysis plus MT, respectively. With imposed economic constraints, the analysis identified the optimal number and locations of thrombectomy centres for the Swedish healthcare system. Furthermore, it identified the optimal number and locations of ambulance helicopters too. Finally, it was possible to determine the combination of optimally located thrombectomy centres and ambulance helicopters that comprises the most cost-effective solution to implement into the Swedish stroke system of care. This thesis demonstrates that economically constrained optimization of thrombectomy centres and ambulance helicopters in acute stroke systems of care comprises highly cost-effective solutions that entail immense health gains in patients with acute ischaemic stroke. Health economics, operational research and medicine can be combined to create a powerful decision-modelling tool in the evaluation of implementation strategies for prehospital acute stroke systems of care.
|
|
| 4. |
- Eriksson, Leif
(författare)
-
Knowledge Translation in Vietnam : Evaluating facilitation as a tool for improved neonatal health and survival
- 2012
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Neonatal mortality remains a problem worldwide, despite the existence of low-cost and evidence-based interventions. Unfortunately, the translation of these interventions into practice is deficient.The aim of this thesis was to study aspects of knowledge translation (KT) before and during the Neonatal Knowledge Into Practice (NeoKIP) trial in Quang Ninh, Vietnam. Over a period of three years, this trial evaluated the use of facilitators from the Women’s Union who supported maternal and newborn health groups (MNHG) comprised of eight local stakeholders, as an intervention for improved neonatal survival.In the first two studies (before intervention) we assessed primary health care staff’s knowledge and material preparedness regarding evidence-based neonatal care and explored how primary health care staff translated knowledge into practice. The last two studies (during intervention) were process evaluations aimed at describing the implementation, process and mechanism of the NeoKIP intervention.Primary health care workers achieved 60% of the maximum score in the knowledge survey. Two separate geographical areas were identified with differences in staff levels of knowledge and concurrent disparities in neonatal survival, antenatal care and post-natal home visits. Staff perceived formal training to be the best way to acquire knowledge but asked for more interaction between colleagues within the healthcare system. Traditional medicine, lack of resources, low workload and poorly paid staff constituted barriers for the development of staff knowledge and skills.Eleven facilitators were trained to cover eight facilitator positions. Of the 44 MNHGs, 43 completed their activities to the end of the study. In total, 95% of the monthly meetings with a MNHG and a facilitator were conducted with attendance at 86%. MNHGs identified 32 unique problems, mainly families’ knowledge/behavior, and implemented 39 unique actions, mostly regarding communication. MNHGs experienced that the group was strategically composed to influence change in the communes and facilitators were identified as being important to sustaining activities over time. The facilitators’ lack of health knowledge was regarded as a deficit in assisting the MNHGs, but their performance and skills increased over time.This low-cost model, building on local stakeholder involvement, has the capacity to be scaled up within existing healthcare structures.
|
|
| 5. |
- Eriksson, Thérèse, 1988-
(författare)
-
Promises and pitfalls of value-based reimbursement in healthcare : A mixed method health economic approach
- 2021
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Financial incentives can be an effective tool to influence behaviour in almost any context and healthcare is no exception. The healthcare market is, however complex, characterised by uncertainty, information asymmetry and multiple agency connections. The reach and limits of financial incentives in healthcare has been widely debated for decades. Some argue that financial incentives increase efficient use of scarce resources, while others voice that it provides a hotbed for unintended and unethical behaviour. A well-functioning value-based reimbursement programme (VBRP) should facilitate alignment between financial incentives and professional values to secure both efficient and equitable healthcare. This thesis explores the promises and pitfalls of value-based reimbursement in the context of a value-based reimbursement programme within elective spine surgery in Region Stockholm, Sweden. By using mixed methods, this thesis explores what incentives arise from introducing a value-based reimbursement programme and how these incentives affect the provision of healthcare services. This thesis consists of four papers. Paper I examines the performance of healthcare providers (spine surgery clinics) on patient-reported outcome measures after the introduction of a value-based reimbursement programme and whether it has any effect on case mix regarding clinical and socio-economic factors. Paper II examines how a value-based reimbursement programme affects the cost of elective spine surgery to a third party payer/regional authority. Paper III explores how the intended incentives of the reimbursement programme was perceived by healthcare providers. In Paper IV, institutional logics within healthcare-providing organisations are identified and how their centrality and compatibility affect the institutionalisation of a value-based reimbursement programme in Region Stockholm. The results show that the VBRP had no effect on patient-reported outcome measures but decreased the mean cost per surgery. Thus, elective spine surgery in Region Stockholm may be considered more effective after the introduction of the VBRP. The removal of a production ceiling allowed healthcare providers to surgically treat more patients than was previously possible. The volume increased by 22 per cent, and the total cost increased by 11 percent. No indications of discrimination against sicker patients were found. A higher value was generated in elective spine surgery after the introduction of the VBRP. The idea of a VBRP was aligned with professional values. However, not all incentives were perceived as intended. The focus on minimising costs of post-discharge care was perceived to have a negative impact on quality aspects of physiotherapy and nursing. Taken together, a well-designed VBRP has the potential to promote a holistic healthcare perspective through 1) the level to which healthcare providers are held accountable for healthcare provision that increase the willingness to collaborate across healthcare providers and medical disciplines, 2) a better overall picture of patients healthcare utilisation and 3) challenging the traditional structures and ideas within healthcare that quality foremost depends on the performance of physicians. However, there are also challenges that needs to be addressed, 1) functioning routines for communication and follow-up between healthcare providers and the regional health authority, 2) to get different professions within a traditional hierarchical organisation to cooperate on equal terms, and 3) to create IT systems that create transparency and an understanding of the reimbursement programme. Continuous communication between healthcare providers and the regional health authority is therefore crucial to make the incentives of the reimbursement programme meaningful.
|
|
| 6. |
- Lindström, Emma, 1978-
(författare)
-
Nutrition and Oxidative Parameters in Pregnancy, Size at Birth and Metabolic Status of the Offspring at 4.5 Years : The MINIMat Trial in Rural Bangladesh
- 2012
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Undernutrition and oxidative stress in fetal life and infancy may lead to adverse health outcomes in the offspring. We studied nutrition and oxidative parameters in pregnancy and their associations with birth anthropometry and metabolic status in the children.In Matlab in rural Bangladesh, women were randomized to either early (Early) invitation to food supplementation or to start at their own liking (Usual). Women were also allocated to either; 1) 60 mg iron and 400 µg folic acid (Fe60F), 2) multiple micronutrients including 30 mg iron and folic acid (MMS), or 3) 30 mg iron and folic acid (Fe30F). Micronutrients (hemoglobin, iron, zinc, folic acid, vitamin B-12) were assessed in pregnancy week 14, lipid peroxidation in week 14 and 30, and DNA oxidation in week 19. The offspring were assessed for anthropometric measurements at birth and metabolic status at 4.5 years.Micronutrient deficiencies were common with zinc and vitamin B-12 deficiency being most prevalent. Anemia was present in approximately one third of women, however, iron deficiency was uncommon seen in only 2%.Maternal Early food supplementation group resulted in an improved lipid status in the children at 4.5 years compared to Usual food group. Prenatal use of MMS lowered the children’s glucose, insulin, HOMA-IR, and growth factors compared to Fe60F. Lipid peroxidation in early pregnancy was associated with size at birth and insulin and HOMA-IR levels in the children. Lipid peroxidation in late pregnancy, however, was associated with the children’s lipid status. Both increasing lipid peroxidation and increasing DNA oxidation was associated with decreasing IGF-1 levels. The beneficial effects of an Early start of food supplementation show that an improved prenatal nutrition may have lasting effects in the offspring and highlights the importance of early timing food supplementation. Use of MMS, however, resulted in lower insulin levels, which, considering the already low level of insulin in these children, may be a cause of concern. MMS also resulted in growth factors indicative of slower growth and further research appears to be needed before scaling up the use of MMS. Oxidative parameters in pregnancy were associated with longer-term outcomes in the offspring, suggesting that oxidative stress may be involved in the development of later metabolic disease.
|
|
| 7. |
- Lisi, Matteo, 1982-
(författare)
-
Insights into left atrial response to pressure and volume overload
- 2016
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The general purpose of this thesis is to establish the ability of Speckle Tracking Echocardiography (STE) in assessing left atrial (LA) response to pressure and volume overload respectively in aortic stenosis (AS) and mitral regurgitation (MR), and to evaluate its accuracy in predicting LA and right ventricular (RV) fibrosis in patients with end-stage heart failure (HF) undergoing heart transplantation (HTx).I demonstrated that assessment of left ventricular (LV) long axis systolic velocity and amplitude of excursion is more sensitive than simple determination of ejection fraction (EF) for revealing the beneficial impact of MR surgery on overall LV systolic performance.Severe symptomatic AS is associated with LA enlargement and compromised mechanical function with a high incidence of peri-operative atrial fibrillation (AF). Valve replacement reverses these abnormalities and regains normal atrial function, a behaviour which is directly related to the severity of pre-operative LV outflow tract obstruction. Early identification of LA size and function disturbances, as shown by myocardial strain measurements might contribute to better patient’s recruitment for a safe valve replacement.In late stage HF patients, the right ventricle is enlarged, with reduced systolic function due to significant myocardial fibrosis. RV free wall myocardial deformation is the most accurate function measure that correlates with the extent of RV myocardial fibrosis and functional capacity.In patients with preserved EF, severe MR masks LV and LA myocardial dysfunction and correlates with symptoms and post-operative cavity function instability. Three months after MVR, the underlying myocardial disturbances are unmasked suggesting that most pre-operative measurements are subject to loading conditions. Finally LA volume and PALS remain the main predictors of post-operative AF, thus should be used for stratifying surgical risk.STE has been shown to accurately determine the severity of impairment of LA myocardial function shown by suppressed PALS which was the strongest predictor of the presence and extent of fibrosis, over and above other structure and function parameters. These findings may assist in better stratifying patients with end stage HF and identifying particularly those requiring HTx.
|
|
| 8. |
- Målqvist, Mats, 1971-
(författare)
-
Who can save the unseen? : Studies on neonatal mortality in Quang Ninh province, Vietnam
- 2010
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Globally, neonatal mortality has remained basically unchanged for the last three to four decades and every year almost four million newborns die before reaching one month of age. This persistent mortality is related to an invisibility of the newborn child in policies and statistics and a neglect of health care decision-makers, planners and practitioners to deliver a perinatal continuum of care. In recent years attention has however been brought to the unchanged neonatal mortality in an effort to improve survival. The present thesis seeks to increase understanding of obstacles for better neonatal survival. The studies performed are undertaken as sub-studies to the NeoKIP project in Quang Ninh province in northern Vietnam, a randomized controlled trial of knowledge implementation for improved neonatal survival (Neonatal Health – Knowledge Into Practice, ISRCTN 44599712). In the first paper we investigated and discussed the scope of invisibility of neonatal mortality through measuring the accuracy of official statistics on neonatal deaths. The second paper reports an inquiry of determinants of neonatal mortality by use of a population-based case-referent design. Paper III and IV analyse delivery care utilization and care seeking patterns prior to and at delivery using narratives and GIS technique. There was a substantial under-reporting of neonatal mortality in the official statistics, with study results showing a four times higher neonatal mortality rate in Quang Ninh province than reported to the Ministry of Health. This neonatal mortality rate of 16/1000 live births (as compared to 4.2/1000 in official reports) was unevenly distributed in the province, showing large geographical discrepancies. In the rural and remote areas of Vietnam education level is lower and the concentrations of ethnic minorities and poor households are higher. Ethnic minority belonging was associated with a more than doubled risk of neonatal death compared to the hegemonic group of Kinh (OR 2.08 CI 95 % 1.39 – 3.10). This increased risk was independent of household economic status or maternal education level. Neonatal mortality was also associated with home deliveries, non-attendance to antenatal care and distance to the health care facilities. However, ethnic minority mothers still had an increased risk of experiencing a neonatal death even if they attended antenatal care, delivered at or lived close to a health facility. The invisibility of the neonatal period in health information systems hides the true width of the neonatal mortality challenge. By not acknowledging the problem, the marginalization of already disadvantaged groups continues, leaving ethnic minority babies with an elevated risk of dying during the first month in life. This example of ethnic inequity highlights the importance to target those most in need. The studies of the present thesis should therefore be looked upon as a contribution to the struggle to illuminate the global burden of neonatal mortality.
|
|
| 9. |
- Omer-Salim, Amal, 1964-
(författare)
-
Mothers’ Agency in Managing Breastfeeding and Other Work in Dar es Salaam, Tanzania and New Delhi, India
- 2015
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Combining breastfeeding and other forms of work is desirable from both public health and labour productivity perspectives. This is often challenging, especially in low- or middle-income fast-growing urban settings. The aim of this thesis was to gain a deeper understanding of mothers’ perspectives on combining breastfeeding and other work in the urban contexts of Dar es Salaam, Tanzania, and New Delhi, India. Individual semi-structured interviews were conducted with community mothers (n=8) and health worker mothers (n=12) in Dar es Salaam, and mothers working in the health (n=10) and education sectors (n=10) in New Delhi. The methods of analysis were: qualitative content analysis, grounded theory approach, and directed and general inductive content analyses. Mothers’ agency manifested in several ways. Striving to integrate or segment the competing domains of home and work was a goal of these mothers to reduce conflicts in managing breastfeeding and other work. Spatial and time constraints led mothers to engage in an array of carefully planned actions and troubleshooting tactics that included ways of ensuring proximity between them and their baby and efficient time managing. The timing of these strategic actions spanned from pregnancy, over maternity leave, to the return to employment. Managing breastfeeding and work triggered emotions such as stress, frustration and guilt, but also satisfaction and joy. Mothers negotiated with family, employers, colleagues and informal networks to gain support for their strategies, displaying both individual, collective and proxy agency. Changing family structures and roles highlight the potentially greater supportive role of the partner/husband. Work/Family Border Theory and Bandura’s agency constructs provided frameworks for a deeper understanding of mothers’ perspectives, but using existing family relationship constructs would better diffentiate between various modes of agency. Workplaces and maternity protection conditions were generally inadequate. Interventions are required: to strengthen the breastfeeding mother’s own agential capacity using an individual approach; to provide information to families and communities; to improve regulatory, structural and attitudinal conditions at workplaces, and to strengthen health and social services to adequately support mothers in managing breastfeeding and other work.
|
|
| 10. |
- Shaheen, Rubina, 1964-
(författare)
-
Prenatal food and micronutrient supplementation to malnourished women in Bangladesh : Effects, Equity, and Cost-effectiveness
- 2015
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Maternal nutrition is closely linked to child health and survival. In Bangladesh there is a high prevalence of undernutrition in the form of chronic energy deficiency [CED, Body Mass Index <18.5 (kg/m2)] in women and low birth weight. The aims of this thesis are to explore women’s perceptions of maternal undernutrition, to analyse the association between prenatal food supplementation and birth weight (BW), to analyse whether food- and multiple micronutrient interventions generate pro-disadvantaged equity in child survival, and to examine whether an early prenatal invitation to food supplementation and multiple micronutrient supplements (MMS) represents value for money in infant survival compared to invitation to food supplementation at usual time combined with 60 mg iron and 400 µg folic acid (standard practice).The study on women’s perceptions (n=236) was nested into the MINIMat randomized trial where women (n=4436) were allocated to early (E), or usual (U) time of invitation to prenatal food supplementation and 30 mg iron with 400 µg folic acid, or 60 mg iron with 400 µg folic acid, or MMS. Live births (n=3625) were followed-up. The analyses of equity and cost-effectiveness were based on this trial. A cohort design (n=619) was employed for the analysis of food supplements and BW.Women perceived maternal undernutrition as a serious health problem and attached very low scores to CED in pregnancy. An average of four months of prenatal food supplementation increased BW by 118 g. An early invitation to prenatal food supplementation and MMS lowered mortality in children before the age of five years and reduced social disparity in child survival chances. An increment from standard practice to E-MMS averted one extra infant death at a cost of US$797 to US$907, and saved one extra life year at a cost of US$27 to US$30.High priority should be given to the nutritional status of pregnant women in societies where undernutrition and food insecurity occurs. Prenatal food supplementation has the potential to significantly increase BW, and an early initiation of prenatal food supplementation combined with MMS was considered cost-effective in lowering infant mortality and increase social equity in child survival chances.
|
|
