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Co-operation, participation and conflicts faced in public health: lessons learned from a long-term prevention programme in Sweden
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
Umeå University, Faculty of Social Sciences, Department of Sociology.
(Department of Education, University of Umeå S-901 87 Umeå, Sweden)
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1994 (English)In: Health Education Research, ISSN 0268-1153, E-ISSN 1465-3648, Vol. 9, no 3, 317-329 p.Article in journal (Refereed) Published
Abstract [en]

A comprehensive community-based programme for prevention of cardiovascular diseases (CVD) and diabetes was established in 1985 in a small municipality in northern Sweden. A cross-sectional survey to the general public was performed and semi-structured open-ended interviews were taken of actors at different levels. Notes from official records were also included in the study. The aim was to describe and discuss some factors that promote or constrain community participation in health programmes. The results generally confirmed that the right of definition concerning the health programme mainly remained with the health professionals. Community participation was mainly defined by the actors based on the medical and health planning approach and, thereby, as a means to transform health policy plans into reality by transmitting health knowledge and increasing consciousness among the citizens of the need for changing lifestyles. However, participation as a means of identifying problems and demonstrating power relationships and as elements in promoting local democracy was hardly represented among the actors at all. Overall, the CVD health programme was characterized by consensus between the actors. Despite this, debates and arguments about interpretations, social interests, personal conflicts and ideological constraints were observed. However, a majority of the public wanted the CVD preventive programme to continue.

Place, publisher, year, edition, pages
Oxford University Press, 1994. Vol. 9, no 3, 317-329 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:umu:diva-3848DOI: 10.1093/her/9.3.317PubMedID: 10150452OAI: oai:DiVA.org:umu-3848DiVA: diva2:142732
Available from: 2004-04-06 Created: 2004-04-06 Last updated: 2013-03-04Bibliographically approved
In thesis
1. Self-rated health in public health evaluation
Open this publication in new window or tab >>Self-rated health in public health evaluation
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

There is still a debate concerning the evidence base for community interventions. The randomised clinical trial design (RCT) is increasingly challenged as a gold standard for their evaluation. This thesis takes the Norsjö health programme in Västerbotten as the starting point for a discussion about the ethical platform of community interventions and for exploring the role of self-rated health. The specific objectives are: 1) to better understand barriers to community participation and to assess the role of ethical premises among decision-makers, 2) to explore how health related norms and attitudes interact with self-rated health and the risk factor outcome of an intervention and 3) to analyse the gender and socio-cultural interplay of self-rated health with biomedical risk factors for cardiovascular disease.

The participation and views of different actors in the planning and implementation phases of the intervention were studied by contrasting information between official documents, interviews with decision makers and professionals and questionnaires to community members. The role of basic values in setting priorities and choosing intervention strategies utilised a questionnaire design with hypothetical scenarios sent to a representative sample of Swedish health care politicians. Qualitative research interviews were used to explore health related norms and attitudes. Health examination measurements and questionnaire data formed the basis for analysis of the development of self-rated health and risk factor load during a 10-year follow-up of the intervention. Access to a stroke registry enabled a case-referent approach for studying the interaction between bio-medical risk factors, socio-demographic factors and self-rated health. Data from the Västerbotten Intervention Programme (VIP) could be utilised for a cross-country comparison with a “sister project” in Otsego, U.S.A.

The results point to both strengths and limitations of the efforts made to involve people in the intervention. The problem definition mainly remained with the professionals and participation as a goal in itself, strengthening local democracy was felt to be an exaggerated ambition. However, there was an overall agreement about the seriousness of the health problem, the need to intervene and about the implementation mode. Self-rated health and reported behavioural change were important indicators of participation and young men with bad health seemed to have been least involved. Among Swedish health care politicians there was an overall agreement to allocate resources for prevention directed towards communities when there are serious health problems. The majority preferred an intervention strategy that involved primary health care. The risk of harm by creating some degree of anxiety or stigma was for many considered an acceptable drawback of a successful intervention. The follow-up study revealed a positive risk factor reduction accompanied by a positive development of self-rated health, especially for men. Additional support for an intervention effect was given through a comparison with a reference area. The interaction pattern between risk reduction and self-rated health was more polarised for men than for women, with a corresponding pattern for the lower compared to the higher educated. These results could be linked to a transition in the health related norm system and to “ideal types” representing attitudinal sets towards the intervention. The case-referent analysis suggested an interaction effect between self-rated health and bio-medical risk factor load in predicting stroke that was greater for men than for women. The cross-country comparison revealed a stronger influence of education in the U.S.A. The lower educated, with a high risk load, had a greater risk of self-rated poor health than their Swedish counterparts.

The thesis suggests that self-rated health is an unexplored indicator, potentially important for understanding the complexity of community interventions. Self-rated health may predict disease development as well as modify the impact of established risk factors.

Publisher
100 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 884
Keyword
Public health, process evaluation, community intervention, self-rated health, public health, Folkhälsomedicin
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-226 (URN)91-7305-624-3 (ISBN)
Public defence
2004-04-23, 135, 9A, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2004-04-06 Created: 2004-04-06 Last updated: 2010-01-22Bibliographically approved
2. Community participation and social patterning in cardiovascular disease intervention
Open this publication in new window or tab >>Community participation and social patterning in cardiovascular disease intervention
1993 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 1993. 49 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 383
Keyword
cardiovascular disease, diabetes, prevention, social factors, evaluation, social epidemiology, folkhälsovetenskap
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology; Public health
Identifiers
urn:nbn:se:umu:diva-7544 (URN)91-7174-816-4 (ISBN)
Public defence
1993-11-19, Tandläkarhögskolan, Rosa salen, 9tr., Umeå universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Projects
digitalisering@umu
Available from: 2008-01-10 Created: 2008-01-10 Last updated: 2013-03-05Bibliographically approved

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Emmelin, MariaDahlgren, LarsWall, Stig

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