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  • 1.
    Carson, Dean B.
    et al.
    Umeå University, Arctic Research Centre at Umeå University. Northern Institute, Charles Darwin University, Darwin, Australia; Glesbygdsmedicinskt Centrum, Storuman, Sweden .
    Schoo, Adrian
    Berggren, Peter
    The 'rural pipeline' and retention of rural health professionals in Europe's northern peripheries2015In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 119, no 12, p. 1550-1556Article in journal (Refereed)
    Abstract [en]

    The major advance in informing rural workforce policy internationally over the past 25 years has been the recognition of the importance of the 'rural pipeline'. The rural pipeline suggests that people with 'rural origin' (who spent some childhood years in rural areas) and/or 'rural exposure' (who do part of their professional training in rural areas) are more likely to select rural work locations. What is not known is whether the rural pipeline also increases the length of time professionals spend in rural practice throughout their careers. This paper analyses data from a survey of rural health professionals in six countries in the northern periphery of Europe in 2013 to examine the relationship between rural origin and rural exposure and the intention to remain in the current rural job or to preference rural jobs in future. Results are compared between countries, between different types of rural areas (based on accessibility to urban centres), different occupations and workers at different stages of their careers. The research concludes that overall the pipeline does impact on retention, and that both rural origin and rural exposure make a contribution. However, the relationship is not strong in all contexts, and health workforce policy should recognise that retention may in some cases be improved by recruiting beyond the pipeline.

  • 2.
    Hartini, TNS
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Winkvist, A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lindholm, L
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Surjono, A
    Hakimi, M
    Energy intake during economic crisis depends on initial wealth and access to rice fields: the case of pregnant Indonesian women2002In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 61, no 1, p. 57-71Article in journal (Refereed)
    Abstract [en]

    Starting in August 1997, Indonesia experienced a radical and rapid deterioration in its economy. Between 1996 and 1998, dietary intake during the second trimester was measured in 450 pregnant women in Purworejo, Central Java, Indonesia. Using six 24 h recalls we describe the consequences of the economic crisis on the energy intake of pregnant Indonesian women. Depending on the date of data collection, women were grouped into 'before crisis', 'transition' and 'during crisis'. Mean energy intake among groups was compared using ANOVA and Student's t-test. All groups of pregnant women already had a mean energy intake before the emerging crisis that was lower than the Indonesian recommended dietary allowances (RDA). Nevertheless, energy intake differed significantly among women with different education levels (P = 0.00) and from different socio-economic groups (P = 0.00). 'During transition', a significant decrease in energy intake was experienced by urban poor women (P = 0.01). Poor women with access to rice fields had a higher rice consumption than other groups throughout the period. Our results most likely reflect the effect of higher rice price on income and welfare. 'During crisis', energy intake improved among vulnerable groups, perhaps reflecting government intervention.

  • 3. Johansson, Catrin
    et al.
    Åström, Sture
    Umeå University, Faculty of Medicine, Department of Nursing. Department of Nursing, Health and Culture, University West, Trollhättan, Sweden.
    Kauffeldt, Anders
    Helldin, Lars
    Carlström, Eric
    Culture as a predictor of resistance to change: a study of competing values in a psychiatric nursing context2014In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 114, no 2-3, p. 156-162Article in journal (Refereed)
    Abstract [en]

    It is well known that a conservative organizational culture can hinder the implementation of new organizational models. Prior to introducing something new it is important to identify the culture within the organization. This paper sets out to detect the feasibility of reform in a psychiatric clinic in a Swedish hospital prior to implementation of a new working method - a structured tool based on the International Classification of Functioning Disability and Health. A survey consisting of two instruments - an organizational values questionnaire (OVQ) and a resistance to change scale (RTC) - was distributed to registered and assistant nurses at the clinic. The association between the organizational subcultures and resistance to change was investigated with regression analysis. The results revealed that the dominating cultures in the outpatient centers and hospital wards were characterized by human relation properties such as flexibility, cohesion, belongingness, and trust. The mean resistance to change was low, but the subscale of cognitive rigidity was dominant, reflecting a tendency to avoid alternative ideas and perspectives. An instrument like the one employed in the study could be a useful tool for diagnosing the likelihood of extensive and costly interventions.

  • 4. Johns, Benjamin
    et al.
    Probandari, Ari
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mahendradhata, Yodi
    Centre for Health Service Management, Faculty of Medicine, Gadjah Mada University, Sekip Utara, Yogyakarta 55281, Indonesia.
    Ahmad, Riris Andono
    Department of Public Health, Faculty of Medicine, Gadjah Mada University, Sekip Utara, Yogyakarta 55281, Indonesia.
    An analysis of the costs and treatment success of collaborative arrangements among public and private providers for tuberculosis control in Indonesia2009In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 93, no 2-3, p. 214-224Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To identify the cost-effectiveness of collaborative arrangements among public and private providers to employ the Directly Observed Treatment short-course (DOTS) strategy for tuberculosis (TB) control in Indonesia.

    METHODS: Three strategies were assessed: hospital out-patient diagnosis with referral to public health centres (PHCs) for treatment, hospital out-patient diagnosis and treatment, and private practitioner referral of suspects to PHCs. The outcome was the number of sputum smear positive TB cases successfully treated. Costs include direct costs to providers and patients. Uncertainty analysis was done for both costs and effectiveness data.

    RESULTS: The average cost per case successfully treated ranged from US$169 to $567 for different strategies. The cost per additional case successfully treated incremental to existing TB programmes ranged from US$152 to $982. In three of four provinces assessed, there was a clearly preferred strategy or strategies, although the preferred strategy differed by province; in one province a preferred strategy could not be identified.

    CONCLUSIONS: All strategies increased TB case finding, although attribution is tentative because of the study design. Neither collaboration among private practitioners nor among hospitals is clearly preferred based on cost-effectiveness. For hospitals, this study suggests that having hospitals refer patients to health centres is preferable over hospitals administering treatment.

  • 5.
    Lundälv, Jörgen
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Social Work, University of Gothenburg, Gothenburg, Sweden.
    Larsson, Per-Olof
    Törnbom, Marie
    Sunnerhagen, Katharina Stibrant
    The ICF: International Classification of Functioning, Disability and Health (ICF) - A Swiss army knife? Accessibility and disability in a Scandinavian disability magazine (SDM) - A quantitative content analysis2012In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 108, no 1, p. 67-75Article in journal (Refereed)
    Abstract [en]

    Background: The study describes the extent to which the concept of accessibility and accessibility issues has been reported in a national Scandinavian disability magazine. In this study particular attention is paid to how the compatibility between the various domains of the international classification - International Classification of Functioning, Disability and Health (ICF) - has been covered in the magazine over a decade. Furthermore, other types of descriptions that the magazine has made of accessibility for people with physical disabilities are considered. Methods: The study is based on a quantitative content analysis of a total of 326 articles from the Swedish disability magazine (SDM); 450 text pages published during the years 2000-2009. The magazine's coverage has been comprehensive. Results and conclusions: More than half of the studied texts were news items about various accessibility issues. Every third article can be characterised as a news article or feature article. The most frequently reported of the ICF domains consist of two perspectives: environmental accessibility and civil rights. Public opinion articles in the form of letters to editors and editorials focused on accessibility have a low frequency. Likewise, research reports are few. The study has included a review of illustrations and photographs. The illustrations are generally of high quality, reinforcing the disability message of the article.

  • 6.
    Löfroth, Emil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Centre for Epidemiology, National Board of Health and Welfare, SE-106 30, Stockholm, Sweden.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wilhelmsen, Lars
    Rosén, Måns
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Centre for Epidemiology, National Board of Health and Welfare, SE-106 30, Stockholm, Sweden.
    Optimising health care within given budgets: primary prevention of cardiovascular disease in different regions of Sweden2006In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 75, no 2, p. 214-229Article in journal (Refereed)
    Abstract [en]

    This study investigated the consequences of applying strict health maximisation to the choice between three different interventions with a defined budget. We analysed three interventions or preventing cardiovascular diseases, through doctor's advice on smoking cessation, through blood-pressure-lowering drugs. and through lipid-lowering drugs. A state transition model has been used to estimate the cost-utility ratios for entire population in three different county Councils in Sweden, where the populations were stratified into mutually excluding risk groups. The incremental cost-utility ratios are being presented in a league table and combined with the local resources and the local epidemiological data as a proxy for need for treatment, All interventions with an incremental cost-utility ratio exceeding the threshold ratios are excluded from being funded, The threshold varied between 1687 EURO and 6192 EURO. The general reallocation of resources between the three interventions Was a 60% reduction of blood-pressure-lowering drugs with redistribution of resources to advice on smoking cessation and to lipid-lowering drugs. One advantage of this method is that the results are very concrete. Recommendations can thereby he more precise which hopefully will create a public debate between decision-makers, practising phsicians and patient groups.

  • 7. Madi, Banyana Cecilia
    et al.
    Hussein, Julia
    Hounton, Sennen
    D'Ambruoso, Lucia
    Immpact, University of Aberdeen, Department of Public Health, United Kingdom.
    Achadi, Endang
    Arhinful, Daniel Kojo
    Setting priorities for safe motherhood programme evaluation: a participatory process in three developing countries.2007In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 83, no 1, p. 94-104Article in journal (Refereed)
    Abstract [en]

    A participatory approach to priority setting in programme evaluation may help improve the allocation and more efficient use of scarce resources especially in low-income countries. Research agendas that are the result of collaboration between researchers, programme managers, policy makers and other stakeholders have the potential to ensure rigorous studies are conducted on matters of local priority, based on local, expert knowledge. This paper describes a process involving key stakeholders to elicit and prioritise evaluation needs for safe motherhood in three developing countries. A series of reiterative consultations with safe motherhood stakeholders from each country was conducted over a period of 36 months. In each country, the consultation process consisted of a series of participatory workshops; firstly, stakeholder's views on evaluation were elicited with parallel descriptive work on the contexts. Secondly, priorities for evaluation were identified from stakeholders; thirdly, the evaluation-priorities were refined; and finally, the evaluation research questions, reflecting the identified priorities, were agreed and finalised. Three evaluation-questions were identified in each country, and one selected, on which a full scale evaluation was undertaken. While there is a great deal written about the importance of transparent and participatory priority setting in evaluation; few examples of how such processes could be implemented exist, particularly for maternal health programmes. Our experience demonstrates that the investment in a participatory priority-setting effort is high but the process undertaken resulted in both globally and contextually-relevant priorities for evaluation. This experience provides useful lessons for public health practitioners committed to bridging the research-policy interface.

  • 8.
    Månsdotter, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Winkvist, Anna
    Paternity leave in Sweden: costs, savings and health gains.2007In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 82, no 1, p. 102-115Article in journal (Refereed)
  • 9.
    Månsdotter, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Öhman, Ann
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Women, men and public health - how the choice of normative theory affects resource allocation.2004In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 69, no 3, p. 351-364Article in journal (Refereed)
  • 10. Thanh, Nguyen Xuan
    et al.
    Hang, Hoang Minh
    Chuc, Nguyen Thi Kim
    Rudholm, Niklas
    Emmelin, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Does "the injury poverty trap" exist? A longitudinal study in Bavi, Vietnam.2006In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 78, no 2-3, p. 249-257Article in journal (Refereed)
    Abstract [en]

    In this study we concentrate on injuries and affected households' capacities to earn incomes. A longitudinal study was performed in Bavi district, Vietnam, with the specific objectives to investigate: (1) the affects of injuries on incomes by comparing income changes in injured and non-injured individuals; (2) the affect of injuries on social mobility by estimating households' relative risk of dropping into poverty for households with and without injuries and estimating the relative risk of escaping from poverty for households without and with injuries. The propensity score matching method using a logit model was used for data analysis. The results show that on average, the loss per household is estimated at VND 1,084,000 (USD 72) for poor and VND 2,598,000 (USD 173) for non-poor, equivalent to 11 (9) and 15 (13) working months of an average person in the poor and non-poor group, respectively, during 1999 (2001). The relative risk of dropping into poverty for non-poor households with and without injuries equal to 1.21 (p=0.08) and the relative risk of escaping from poverty between poor households without and with injuries equal to 0.96 (p=0.39). In conclusion, it has been argued that the introduction of user fees created a poverty trap and thus their removal may be a solution. However, user fees are only a part of the burden on households. Loss of income during the illness period is likely to be a problem of the same magnitude. A successful solution must thus follow two tracks: prepayment of health care and some insurance based compensation of income losses during the illness period. Both reforms, if they are persistent, must be done within the resource limits of the local society. If the risk of catastrophic illness is more evenly spread across the society, it would increase the general welfare even if no more resources are provided.

  • 11. Thanh, Nguyen Xuan
    et al.
    Löfgren, Curt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Phuc, Ho Dang
    Chuc, Nguyen Thi Kim
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    An assessment of the implementation of the Health Care Funds for the Poor policy in rural Vietnam.2010In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 98, no 1, p. 58-64Article in journal (Refereed)
    Abstract [en]

    User fees at public health care facilities and out-of-pocket payments for health care services are major health financing problems in Vietnam. In 2002, the Government launched the Health Care Funds for the Poor (HCFP) policy which offered free public health care services to help the poor access public health services and reduce their health care expenditure (HCE). This paper is an assessment of the implementation of the HCFP in a rural district of Vietnam. The impacts of HCFP on household HCE as a percentage of total expenditure and health care utilization were assessed by a double-difference propensity score matching method using panel data of 10,711 households in 2001, 2003, 2005 and 2007. The results showed that the HCFP significantly reduced the HCE as a percentage of total expenditure and increased the use of the local public health care among the poor. However, the impacts of HCFP on the use of the higher levels of public health care and the use of go-to-pharmacies were not significant. In conclusion, this assessment indicates that the HCFP has met its objectives by reducing HCE for the poor and increasing their use of the local public health care services. However, further efforts are needed to help them access higher levels of public health care. Pharmacists should be better regulated and incorporated with primary health care to improve efficiency of the system.

  • 12.
    Uttjek, Margaretha
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dufåker, Mona
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Stenberg, Berndt
    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, Dermatology and Venerology.
    Nygren, Lennart
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Priority dilemmas in psoriasis care and visions of a future care in a group of administrators, politicians and professionals in northern Sweden.2008In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 87, no 2, p. 203-216Article in journal (Refereed)
    Abstract [en]

    During the 1990s priority discussions were actualized in Sweden due to increased demands on health care and limited resources. In the county of Västerbotten in northern Sweden, with large rural areas, the decision makers faced special challenges due to distances and cost. Despite discussions striving for fairness in priorities, decision makers are still dealing with limited resources and difficult priority decisions regarding different diseases and treatments.

    In this study we aimed at describing views on priorities in public psoriasis care and visions of a future care among politicians, administrators and professionals in the county of Västerbottten in northern Sweden. Qualitative research interviews were performed with 23 key-persons. The findings revealed priority dilemmas about issues on organization, accessibility and ethics. Visions of a future care appeared as ambitions of a more effective care with good accessibility, continued research, information and a holistic approach in priorities.

    We conclude that dilemmas revealed in this study were a reflection of a gap between intentions and practice. In efforts to reduce these dilemmas we suggest methods with fairness in economic planning and priority setting, with concrete, official statements about the dominating views on which the priorities are based, and public information about these statements.

  • 13.
    Waldau, Susanne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Västerbotten County Council, Sweden.
    Bottom-up priority setting revised: a second evaluation of an institutional intervention in a Swedish health care organisation2015In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 119, no 9, p. 1226-1236Article in journal (Refereed)
    Abstract [en]

    Background: Transparent priority setting in health care based on specific ethical principles is requested by the Swedish Parliament since 1997. Implementation has been limited. In this case, transparent priority setting was performed for a second time round and engaged an entire health care organisation. Aims: Objectives were to refine a bottom-up priority setting process, reach a political decision on service limits to make reallocation towards higher prioritised services possible, and raise systems knowledge. Methods: An action research approach was chosen. The national model for priority setting was used with addition of dimensions costs, volumes, gender distribution and feasibility. The intervention included a three step process and specific procedures for each step which were created, revised and evaluated regarding factual and functional aspects. Evaluations methods included analyses of documents, recordings and surveys. Results: Vertical and horizontal priority setting occurred and resources were reallocated. Participants' attitudes remained positive, however less so than in the first priority setting round. Identifying low-priority services was perceived difficult, causing resentment and strategic behaviour. The horizontal stage served to raise quality of the knowledge base, level out differences in ranking of services and raise systems knowledge. Conclusions: Existing health care management systems do not meet institutional requirements for transparent priority setting. Introducing transparent priority setting constitutes a complex institutional reform, which needs to be driven by management/administration. Strong managerial commitment is required.

  • 14.
    Waldau, Susanne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Local prioritisation work in health care: assessment of an implementation process2007In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 81, no 2-3, p. 133-145Article in journal (Refereed)
    Abstract [en]

    Political, horizontal prioritisation requires knowledge on local health care resource use on unit or patient group level. This in turn requires unit level structures (meeting forums) and processes for creation of knowledge and continuous, open decision-making on prioritisation. Ideally, for decisions to be legitimate, such procedures should meet the "Accountability for reasonableness"-criteria of Daniels and Sabin [Daniels N. Accountability for reasonableness. Establishing a fair process for priority setting is easier than agreeing on principles. British Medical Journal 2000;321:1300-1]. A strategy, aiming at shaping such an organisational culture, was developed and set to work within a regional health care organisation, responsible for around 250000 inhabitants. This pilot study regarding topic and methodology assesses the changes of knowledge in open prioritisation as well as structures, processes for and results of such work on unit level in that organisation 1998 through early 2005. Initial interviews and two consecutive surveys were analysed. Results indicate that only early adopters respond to the surveys and among them a growing knowledge in priority setting, acceptance of personal leadership for local priority setting work and recognition of a need for adequate structures and processes. Among respondents, one could note a development: A tentative model expressing different positions towards prioritisation was developed.

  • 15.
    Waldau, Susanne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wiechel, Anna Helena
    Priority setting in practice: participants opinions on vertical and horizontal priority setting for reallocation2010In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 96, no 3, p. 245-254Article in journal (Refereed)
    Abstract [en]

    In the Västerbotten County Council in Sweden a priority setting process was undertaken to reallocate existing resources for funding of new methods and activities. Resources were created by limiting low priority services. A procedure for priority setting was constructed and fully tested by engaging the entire organisation. The procedure included priority setting within and between departments and political decision making. Participants' views and experiences were collected as a basis for future improvement of the process. Results indicate that participants appreciated the overall approach and methodology and wished to engage in their improvement. Among the improvement proposals is prolongation of the process in order to improve the knowledge base quality. The procedure for identification of new items for funding also needs to be revised. The priority setting process was considered an overall success because it fulfilled its political goals. Factors considered crucial for success are a wish among managers for an economic strategy that addresses existing internal resource allocation; process management characterized by goal orientation and clear leadership; an elaborate communications strategy integrated early in the process and its management; political unity in support of the procedure, and a strong political commitment throughout the process. Generalizability has already been demonstrated by several health care organisations that performed processes founded on this working model.

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