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  • 151.
    Nordin, Pär
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Zetterström, H
    Carlsson, P
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cost-effectiveness analysis of local, regional and general anaesthesia for inguinal hernia repair using data from a randomized clinical trial2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 4, p. 500-505Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Inguinal hernia repair is a common operation in general surgery and can be performed under local, regional or general anaesthesia. This multicentre randomized trial was undertaken to compare the costs of the three anaesthetic methods in general surgical practice.

    METHODS: Between January 1999 and December 2001, 616 patients at ten hospitals who underwent primary inguinal hernia repair were randomized to local, regional or general anaesthesia. The primary endpoints were direct costs. Secondary endpoints were indirect costs and recurrence rates.

    RESULTS: Total intraoperative, as well as total early postoperative, data showed local anaesthesia to have significant cost advantages over regional and general anaesthesia (P < 0.001). The advantage was also significant for total hospital and total healthcare costs (P < 0.001), whereas there was no significant difference between regional and general anaesthesia.

    CONCLUSION: The use of local anaesthesia for inguinal hernia repair was significantly less expensive than regional or general anaesthesia.

  • 152.
    Nordyke, Katrina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Rosén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Emmelin, Maria
    Lund University.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Internalizing the threat of risk: a qualitative study about adolescents' experience living with screening-detected celiac disease 5 years after diagnosis2014In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 12, article id 91Article in journal (Other academic)
    Abstract [en]

    BACKGROUND: Mass screening could identify those with unrecognized celiac disease (CD), but the experience of being detected through screening and living with screening-detected CD should be explored before considering this as acceptable intervention. For this study we invited screening-detected adolescents to describe their experience living with screening-detected CD five years after diagnosis with the aim to explore how their perceptions, practices, and beliefs evolved.

    METHODS: Adolescents who were diagnosed through a population-based CD screening were invited to write narratives after being diagnosed. Of 153 adolescents who were eventually diagnosed through the screening, 91 wrote narratives one year after diagnosis and 72 five years after diagnosis. A qualitative content analysis resulted in a theme and categories that describe the experience living with screening-detected CD five years after diagnosis.

    RESULTS: The overall theme - "Internalizing the threat of risk" - illustrates that being detected through screening and the internalized threat of future health complications have impacted how these adolescents felt about the diagnosis, coped with the gluten-free diet (GFD), and thought about CD screening. This theme is supported by four categories: maintaining an imposed disease identity describes how they continued to define their diagnosis in relation to the screening. They also expressed moving from forced food changes to adapted diet routines by describing habits, routines, coping strategies, and the financial burden of the GFD. They had enduring beliefs of being spared negative consequences, however, even after five years, some doubted they had CD and worried that being detected and eating a GFD might not be beneficial, i.e. "continuing to fear it is "all in vain".

    CONCLUSIONS: There was maintenance and evolution in the perceptions, practices, and beliefs of the adolescents after five years. Some have adjusted to the disease and adapted new habits and coping strategies to deal with the GFD, while others still doubt they have CD or that being detected was beneficial. The transition to adapting to the disease and GFD is ongoing, illustrating the importance of providing ongoing support for those with screening-detected CD as they adjust to this chronic disease and the GFD.

  • 153.
    Norlin, Jenny M.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology. The Swedish Institute for Health Economics (IHE), Lund, Sweden.
    Steen Carlsson, Katarina
    Department of Clinical Sciences, Skåne University Hospital, Clinical Research, Lund University, Malmö, Sweden.
    Persson, Ulf
    Institute for Economic Research, School of Economics, Lund University, Lund, Sweden.
    Schmitt-Egenolf, Marcus
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology.
    Register-Based Evaluation of Relative Effectiveness of New Therapies: Biologics Versus Conventional Agents in Treatment of Psoriasis in Sweden2015In: BioDrugs, ISSN 1173-8804, E-ISSN 1179-190X, Vol. 29, no 6, p. 389-398Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The Swedish National Register for Systemic Treatment of Psoriasis (PsoReg) was established in 2006. This article analyzes the implementation phase of biologics in the treatment of moderate to severe psoriasis in Sweden in the period 2006-2012. Clinical studies have shown efficacy of biologic agents in psoriasis, but their relative effectiveness in real-world clinical practice has rarely been studied.

    OBJECTIVE: To estimate the incremental changes in clinical health-related quality-of-life measures in patients receiving biologics versus conventional systemic agents.

    METHODS: Patients fulfilling the clinical criteria for moderate to severe psoriasis were included. Average treatment effects were estimated from longitudinal data as incremental changes in: (1) the Psoriasis Area and Severity Index (PASI) score, (2) the Dermatology Life Quality Index (DLQI) score, and (3) the EQ-5D score, by matching patients switching to biologics with patients remaining on conventional systemic agents.

    RESULTS: The study included 239 biologic-treated patients and 378 conventionally treated patients. The matched patient groups were essentially equivalent in terms of important patient characteristics. The average treatment effects of biologics versus conventional systemic agents were 2.2 for PASI, 3.5 for DLQI, and 0.11 for EQ-5D. The estimated incremental benefits of biologics for the subgroup of patients not responding to their conventional systemic agent were even greater.

    CONCLUSION: Register-based research complements knowledge from randomized controlled trials regarding relative effectiveness in clinical practice. This information can be used to support health care decision making. This research suggests that there is both under- and overtreatment with biologics in Swedish clinical practice. Reallocation of biologics to more severe cases of psoriasis could improve overall health in the total patient population.

  • 154. Nyamhanga, T
    et al.
    Frumence, Gasto
    Mwangu, M
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Achievements and challenges of resource allocation for health in a decentralized system in Tanzania: perspectives of national and district level officers2013In: East African Journal of Public Health, ISSN 0856-8960, Vol. 10, no 2, p. 417-428Article in journal (Refereed)
    Abstract [en]

    Objective: The goal of this study was to identify the achievements and challenges of a resource allocation process in a decentralized health system in Tanzania as they are perceived by national and district level officers.

    Methodology: This study was conducted between May 2011 and July 2012 in two districts of Dodoma region: Kongwa and Bahi. Data were collected from 25 key people involved in policy, planning and management aspects for the allocation of financial resources from the central government to local government districts. Thus, the recruitment of the study participants was purposive, as it took account of their positions and experience in health resource allocation and management. The data were collected through conversation in face-to-face in-depth interviews with the officers concerned. The data were analysed manually using qualitative content analysis.

    Results: The study has identified the achievements and challenges of resource allocation in a decentralized health system of Tanzania. The achievements include: the design and use of a needs-based resource allocation formula; reduced resource allocation inequalities between rural and urban districts; and a wide discretion by the district council to mobilize and utilize health insurance funds and user fees. On the other hand, the challenges are: the disbursed funds fall far short of centrally determined budget ceilings, and the funds are sent late; Council Health Management Teams (CHMT) develop budgets but are restricted on the percentage they can allocate to different areas – so there is severe under-funding of disease prevention and health promotion initiatives at the community level.

    Conclusion: This study has identified achievements that should be further nurtured and challenges that should be worked on for the improvement of the decentralized health system. Thus, as a way forward, it is recommended that the equitable allocation of resources should go beyond the recurrent costs for the delivery of health services.

  • 155.
    Nyström, Monica
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Characteristics of health care organizations associated with learning and development: lessons from a pilot study2009In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 18, no 4, p. 285-294Article in journal (Refereed)
    Abstract [en]

    Characteristics of health care organizations associated with an ability to learn from experiences and to develop and manage change were explored in this study. Understanding of these characteristics is necessary to identify factors influencing success in learning from the past and achieving future health care quality objectives. A literature review of the quality improvement, strategic organizational development and change management, organizational learning, and microsystems fields identified 20 organizational characteristics, grouped under (a) organizational systems, (b) key actors, and (c) change management processes. Qualitative methods, using interviews, focus group reports, and archival records, were applied to find associations between identified characteristics and 6 Swedish health care units externally evaluated as delivering high-quality care. Strong support for a characteristic was defined as units having more than 4 sources describing the characteristic as an important success factor. Eighteen characteristics had strong support from at least 2 units. The strongest evidence was found for the following: (i) key actors have long-term commitment, provide support, and make sense of ambiguous situations; (ii) organizational systems encourage employee commitment, participation, and involvement; and (iii) change management processes are employed systematically. Based on the results, a new model of "characteristics associated with learning and development in health care organizations" is proposed.

  • 156.
    Nyström, Monica E
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet.
    Höög, Elisabet
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
    Garvare, R.
    Andersson Bäck, M.
    Terris, D. D.
    Hansson, J.
    Exploring the potential of a multi-level approach to improve capability for continuous organizational improvement and learning in a Swedish healthcare region2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 376Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Eldercare and care of people with functional impairments is organized by the municipalities in Sweden. Improving care in these areas is complex, with multiple stakeholders and organizations. Appropriate strategies to develop capability for continuing organizational improvement and learning (COIL) are needed. The purpose of our study was to develop and pilot-test a flexible, multilevel approach for COIL capability building and to identify what it takes to achieve changes in key actors' approaches to COIL. The approach, named "Sustainable Improvement and Development through Strategic and Systematic Approaches" (SIDSSA), was applied through an action-research and action-learning intervention.

    METHODS: The SIDSSA approach was tested in a regional research and development (R&D) unit, and in two municipalities handling care of the elderly and people with functional impairments. Our approach included a multilevel strategy, development loops of five flexible phases, and an action-learning loop. The approach was designed to support systems understanding, strategic focus, methodological practices, and change process knowledge - all of which required double-loop learning. Multiple qualitative methods, i.e., repeated interviews, process diaries, and documents, provided data for conventional content analyses.

    RESULTS: The new approach was successfully tested on all cases and adopted and sustained by the R&D unit. Participants reported new insights and skills. The development loop facilitated a sense of coherence and control during uncertainty, improved planning and problem analysis, enhanced mapping of context and conditions, and supported problem-solving at both the individual and unit levels. The systems-level view and structured approach helped participants to explain, motivate, and implement change initiatives, especially after working more systematically with mapping, analyses, and goal setting.

    CONCLUSIONS: An easily understood and generalizable model internalized by key organizational actors is an important step before more complex development models can be implemented. SIDSSA facilitated individual and group learning through action-learning and supported systems-level views and structured approaches across multiple organizational levels. Active involvement of diverse organizational functions and levels in the learning process was facilitated. However, the time frame was too short to fully test all aspects of the approach, specifically in reaching beyond the involved managers to front-line staff and patients.

  • 157.
    Nyström, Monica E
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet.
    Karltun, J
    Keller, C
    Andersson Gäre, B
    Collaborative and partnership research for improvement of health and social services: researcher's experiences from 20 projects2018In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 16, article id 46Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Getting research into policy and practice in healthcare is a recognised, world-wide concern. As an attempt to bridge the gap between research and practice, research funders are requesting more interdisciplinary and collaborative research, while actual experiences of such processes have been less studied. Accordingly, the purpose of this study was to gain more knowledge on the interdisciplinary, collaborative and partnership research process by investigating researchers' experiences of and approaches to the process, based on their participation in an inventive national research programme. The programme aimed to boost collaborative and partnership research and build learning structures, while improving ways to lead, manage and develop practices in Swedish health and social services.

    METHODS: Interviews conducted with project leaders and/or lead researchers and documentation from 20 projects were analysed using directed and conventional content analysis.

    RESULTS: Collaborative approaches were achieved by design, e.g. action research, or by involving practitioners from several levels of the healthcare system in various parts of the research process. The use of dual roles as researcher/clinician or practitioner/PhD student or the use of education designed especially for practitioners or 'student researchers' were other approaches. The collaborative process constituted the area for the main lessons learned as well as the main problems. Difficulties concerned handling complexity and conflicts between different expectations and demands in the practitioner's and researcher's contexts, and dealing with human resource issues and group interactions when forming collaborative and interdisciplinary research teams. The handling of such challenges required time, resources, knowledge, interactive learning and skilled project management.

    CONCLUSIONS: Collaborative approaches are important in the study of complex phenomena. Results from this study show that allocated time, arenas for interactions and skills in project management and communication are needed during research collaboration to ensure support and build trust and understanding with involved practitioners at several levels in the healthcare system. For researchers, dealing with this complexity takes time and energy from the scientific process. For practitioners, this puts demands on understanding a research process and how it fits with on-going organisational agendas and activities and allocating time. Some of the identified factors may be overlooked by funders and involved stakeholders when designing, performing and evaluating interdisciplinary, collaborative and partnership research.

  • 158.
    Nyström, Monica E
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Terris, Darcey D
    Sparring, Vibeke
    Tolf, Sara
    Brown, Claire R
    Perceived organizational problems in health care: a pilot test of the structured problem and success inventory2012In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 21, no 2, p. 93-103Article in journal (Refereed)
    Abstract [en]

    Our objective was to test whether the Structured Problem and Success Inventory (SPI) instrument could capture mental representations of organizational and work-related problems as described by individuals working in health care organizations and to test whether these representations varied according to organizational position. A convenience sample (n = 56) of middle managers (n = 20), lower-level managers (n = 20), and staff (n = 16) from health care organizations in Stockholm (Sweden) attending organizational development courses during 2003-2004 was recruited. Participants used the SPI to describe the 3 most pressing organizational and work-related problems. Data were systematically reviewed to identify problem categories and themes. One hundred sixty-four problems were described, clustered into 13 problem categories. Generally, middle managers focused on organizational factors and managerial responsibilities, whereas lower-level managers and staff focused on operational issues and what others did or ought to do. Furthermore, we observed similarities and variation in perceptions and their association with respondents' position within an organization. Our results support the need for further evaluation of the SPI as a promising tool for health care organizations. Collecting structured inventories of organizational and work-related problems from multiple perspectives may assist in the development of shared understandings of organizational challenges and lead to more effective and efficient processes of solution planning and implementation.

  • 159.
    Nyström, Monica Elisabeth
    et al.
    Umeå University, Faculty of Social Sciences, Department of Psychology. Karolinska institutet.
    Höög, Elisabet
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Karolinska institutet.
    Garvare, Rickard
    Luleå tekniska universitet.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Change and learning strategies in large scale change programs: describing the variation of strategies used in a health promotion program2013In: Journal of Organizational Change Management, ISSN 0953-4814, E-ISSN 1758-7816, Vol. 26, no 6, p. 1020-1044Article in journal (Refereed)
    Abstract [en]

    Purpose The study identifies the variation of change strategies used in a complex large scale change program in health and social services in Sweden, aimed at changing professionals' health promoting practices. The purpose is to investigate the change strategies used over time and describe the potential variation in key change agent views, using a framework inspired by De Caluwe and Vermaak's multi paradigm change typology.

    Design/methodology/approach The first six years of the regional multi-sector program are examined. Results are based on content analyses of interviews with key change actors, and archival data describing program activities. Respondents belonged to either the strategic or the operational program management team, representing different sectors of health and social services in a region.

    Findings Multiple strategy paradigms showed varying influence over the program's different phases, partly due to program progress, change agent influence and/or varying contextual demands. Respondents' views on strategies and program focus varied depending on their program roles. Respondents expressed insights about the varying conditions for change and on the conflicting expectations within and between program management teams.

    Originality/value This study introduces the application of a new framework on a large scale, complex change program. The framework sheds light on a number of basic assumptions and change strategies that can be further compared with content and context factors, barriers, facilitators, outcomes, and in turn with other programs.

  • 160.
    Nyström, Monica Elisabeth
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77 Stockholm, Sweden.
    Strehlenert, Helena
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77 Stockholm, Sweden.
    Hansson, Johan
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77 Stockholm, Sweden.
    Hasson, Henna
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77 Stockholm, Sweden and Centre for Epidemiology and community medicine, Stockholm county council, SE 171 29 Stockholm, Sweden.
    Strategies to facilitate implementation and sustainability of large system transformations: a case study of a national program for improving quality of care for elderly people2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, article id 401Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Large-scale change initiatives stimulating change in several organizational systems in the health and social care sector are challenging both to lead and evaluate. There is a lack of systematic research that can enrich our understanding of strategies to facilitate large system transformations in this sector. The purpose of this study was to examine the characteristics of core activities and strategies to facilitate implementation and change of a national program aimed at improving life for the most ill elderly people in Sweden. The program outcomes were also addressed to assess the impact of these strategies.

    METHODS: A longitudinal case study design with multiple data collection methods was applied. Archival data (n = 795), interviews with key stakeholders (n = 11) and non-participant observations (n = 23) were analysed using content analysis. Outcome data was obtained from national quality registries.

    RESULTS: This study presents an approach for implementing a large national change program that is characterized by initial flexibility and dynamism regarding content and facilitation strategies and a growing complexity over time requiring more structure and coordination. The description of activities and strategies show that the program management team engaged a variety of stakeholders and actor groups and accordingly used a palate of different strategies. The main strategies used to influence change in the target organisations were to use regional improvement coaches, regional strategic management teams, national quality registries, financial incentives and annually revised agreements. Interactive learning sessions, intense communication, monitor and measurements, and active involvement of different experts and stakeholders, including elderly people, complemented these strategies. Program outcomes showed steady progress in most of the five target areas, less so for the target of achieving coordinated care.

    CONCLUSIONS: There is no blue-print on how to approach the challenging task of leading large scale change programs in complex contexts, but our conclusion is that more attention has to be given to the multidimensional strategies that program management need to consider. This multidimensionality comprises different strategies depending on types of actors, system levels, contextual factors, program progress over time, program content, types of learning and change processes, and the conditions for sustainability.

  • 161.
    Nyström, Monica
    et al.
    Karolinska Institutet, Medical Management Centre.
    Garvare, Rickard
    Westerlund, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Concurrent implementation of quality improvement programs. Coordination or conflict?2014In: International Journal of Health Care Quality Assurance, ISSN 0952-6862, E-ISSN 1758-6542, Vol. 27, no 3, p. 190-208Article in journal (Refereed)
    Abstract [en]

    Purpose

    – Competing activities and projects can interfere with implementing new knowledge and approaches. The purpose, therefore, was to investigate processes and impact related to implementing two concurrent quality initiatives in a Swedish hospital. These were a regionally initiated, system-wide organizational learning programme called the Dynamic and Viable Organization (DVO) and a national initiative on stopping healthcare-associated and hospital-acquired infections (SHAI). Both undertakings aspired to increase staff competence in systematic improvement approaches.

    Design/methodology/approach

    – Multiple methods were applied including surveys, observations, interviews, process diaries, documents and organizational measurements. Respondents were unit managers, change facilitators and improvement team members.

    Findings

    – Even though both initiatives shared the same improvement approach, there was no strong indication that they were strategically combined to benefit each other. The initiatives existed side by side with some coordination and some conflict. Despite absent management strategies to utilize the national SHAI initiative, positive developments in QI culture and communication were reported. The current study illustrates the inherent difficulties coordinating change initiatives, even in favourable circumstances.

    Orginality/value

    – This article addresses the lesser studied but common situation of coinciding and competing projects in organizations.

  • 162.
    Näsholm, Camilla
    Umeå University, Faculty of Science and Technology, Umeå Institute of Design.
    How to prevent occupational burnout?2016Independent thesis Basic level (degree of Bachelor), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    In the last decade, several epidemiological studies have found a high prevalence of occupational burnout in both western and developing countries. Burnout is a global concern and has the potential to negatively affect the individual’s psychological and physical health, as well as an organization’s and a country’s effectiveness and economy.

     

    The goal of this project was to create a stress management and prevention system that opens up for reflection and discussion on an individual, corporate and societal level. To achieve this the student investigated how stress could be quantified, visualized and communicated in a constructive way.

     

    The final concept assists the individual to recognize their stress and relaxation patterns and make constructive behavioral changes. In the workplace the system indicates stress levels and aims to enable real life communication regarding stress. Exposing stress data to the public empowers society to value and demand stress management.

  • 163.
    Näverlo, Simon
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Carson, D. B.
    Edin-Liljegren, A.
    Ekstedt, M.
    Patient perceptions of a Virtual Health Room installation in rural Sweden2016In: Rural and remote health, ISSN 1445-6354, Vol. 16, no 4, article id 3823Article in journal (Refereed)
    Abstract [en]

    Introduction: The Virtual Health Room (VHR) is an ehealth initiative in the village of Slussfors in northern Sweden. Construction of VHRs in other locations is taking place, and the Centre for Rural Medicine in the Vasterbotten County Council primary care department has implemented a VHR evaluation framework. This research focuses on evaluation of patient perceptions of the usability of the VHR and its contribution to their health care. Methods: Nineteen of the 25 unique users of the VHR during 2014/15 completed a survey asking about their attitudes to their own health (using the 13-question version of the Patient Activation Measure (PAM)), their demographic attributes, and their satisfaction with their visit to the VHR. Results: Respondents with lower PAM scores were less satisfied with the technical performance of the VHR, but equally likely to think the VHR made a good contribution to access to health care. In contrast, older patients were less likely to value the contribution of the VHR, but no less likely to be satisfied with its technical performance. There were no relationships between level of education and distance travelled and perceptions of the VHR. Conclusions: The research clearly demonstrated the distinction between technical performance of an ehealth initiative and its overall contribution to health care and access. Evaluation frameworks need to consider both aspects of performance. Transferability of these findings to other settings may depend at least in part on the nature of the catchment area for the VHR, with the Slussfors catchment being quite small and the impact of distance on access consequently limited.

  • 164. Otero-García, Laura
    et al.
    Briones-Vozmediano, Erica
    Vives-Cases, Carmen
    García-Quinto, Marta
    Sanz-Barbero, Belén
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Public Health Research Group, University of Alicante, Alicante, Spain.
    A qualitative study on primary health care responses to intimate partner violence during the economic crisis in Spain2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, no 6, p. 1000-1005Article in journal (Refereed)
    Abstract [en]

    Background: The objective of this study was to explore how health professionals perceived the effect of the economic crisis and associated austerity measures on the detection of and cares for intimate partner violence (IPV) in primary care in Spain.

    Methods: Qualitative study designed using semi-structured interviews carried out with 145 health professionals in 16 primary health care centres in different regions of Spain. An inductive thematic analysis was made of the transcriptions.

    Results: Three main themes were identified: 'Women endure more violence during times of economic crisis', 'Fewer resources, fewer professionals and less time to respond to IPV' and 'Professionals' motivation as a requirement to respond to IPV'. Professionals perceived that economic precariousness triggered violence against women and made women more hesitant to put an end to violent relationships. They also reported that the austerity measures applied to primary health care negatively affected their ability to detect and adequately care for cases of IPV due to a heavy workload, reduced human resources, difficulties in training and the loss of resources to which women could be referred. To counteract these obstacles, health professionals' motivation played a vital role in the response to IPV.

    Conclusions: Institutional efforts to organize awareness programmes and training in order to improve and promote early diagnosis, care and rehabilitation of these women cannot stop during times of crisis and primary health care centres should facilitate health professionals' access to these programmes.

  • 165. Paina, Ligia
    et al.
    Wilkinson, Annie
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Barman, Debjani
    Ahmed, Tanvir
    Mahmood, Shehrin Shaila
    Bloom, Gerry
    Knezovich, Jeff
    George, Asha
    Bennett, Sara
    Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda2017In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, article id 109Article in journal (Refereed)
    Abstract [en]

    Background: The Theory of Change (ToC) is a management and evaluation too ! supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.

    Methods: This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams' experiences along four potential uses of ToCs, namely planning, communication, learning and. accountability.

    Results: The three teams developed ToCs for planning and. evaluation purposes as required for their initial plans for FHS in 2011 and. revised, them half-way through the project, based on assumptions informed, by and adjusted, through the teams' experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and. revision fostered, channels for both internal and external communication, among research team members and. with key stakeholders, respectively. The process of revising the ToCs challenged the teams' initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes.

    Conclusions: The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement.

  • 166. Parmar, Divya
    et al.
    Reinhold, Steffen
    Souares, Aurélia
    Savadogo, Germain
    Sauerborn, Rainer
    Institute of Public Health, Heidelberg University, Heidelberg, Germany.
    Does community-based health insurance protect household assets? Evidence from rural Africa2012In: Health Services Research, ISSN 0017-9124, E-ISSN 1475-6773, Vol. 47, no 2, p. 819-839Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate whether community-based health insurance (CBHI) protects household assets in rural Burkina Faso, Africa.

    DATA SOURCES: Data were used from a household panel survey that collected primary data from randomly selected households, covering 41 villages and one town, during 2004-2007(n = 890).

    STUDY DESIGN: The study area was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004-2006. We applied different strategies to control for selection bias-ordinary least squares with covariates, two-stage least squares with instrumental variable, and fixed-effects models.

    DATA COLLECTION: Household members were interviewed in their local language every year, and information was collected on demographic and socio-economic indicators including ownership of assets, and on self-reported morbidity.

    PRINCIPAL FINDINGS: Fixed-effects and ordinary least squares models showed that CBHI protected household assets during 2004-2007. The two-stage least squares with instrumental variable model showed that CBHI increased household assets during 2004-2005.

    CONCLUSIONS: In this study, we found that CBHI has the potential to not only protect household assets but also increase household assets. However, similar studies from developing countries that evaluate the impact of health insurance on household economic indicators are needed to benchmark these results with other settings.

  • 167. Perez-Urdiales, Iratxe
    et al.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Irazusta, Amaia
    Linander, Ida
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Sub-Saharan African immigrant women's experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain2019In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, article id 59Article in journal (Refereed)
    Abstract [en]

    BackgroundImmigrant populations face diverse barriers to accessing appropriate healthcare services on several levels. In the Basque Country, Sub-Saharan African women were identified as facing the largest barriers to access them. The aim of the study is to analyse Sub-Saharan African immigrant women's perceptions and experiences of access to appropriate healthcare in the public health system in the Basque Country, Spain.MethodsFourteen women from eight Sub-Saharan African countries who have used the Basque public healthcare services were interviewed. A qualitative content analysis was applied: meaning that units were identified, coded and the resulting codes were then organized into three categories.ResultsThe first category, Fearing to enter a health system perceived as not friendly for immigrants, included factors, mainly those related to legal conditions for accessing healthcare services and lack of lawful documentation, that made women avoid or discontinue seeking out healthcare.The second category, Being attended on professionals' own communication terms, comprised how the lack of effective communication compromised not only the access of the immigrant women to healthcare services, but also their health.Lastly, the third category, Is mistreatment based on racism or merely on bad luck? described how being an immigrant and black influenced the way they were (mis)treated in the health system.ConclusionFor Sub-Saharan African immigrant women, accessing appropriate healthcare in the Basque Country was perceived to be subject to institutional barriers. At the legal level, barriers included lack of entitlement, difficulties in fulfilling legal access conditions and lack of documentation. The lack of communication with health centre staff and their attitudes, guided by a stereotyped social image of immigrants and black people, also hindered their possibilities of receiving appropriate healthcare. Facilitators for accessing healthcare included strategies from individual professionals, personal networks and social actors to help them to cope with the barriers. There is a need of reinforcing inclusion values and rights-based approach to attention among staff at the health centres to have more non-discriminatory and culturally appropriate health systems.

  • 168.
    Petersson, Kerstin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Persson, Margareta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindkvist, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Hammarström, Margareta
    Haglund, Ingrid
    Nilses, Carin
    Skogsdal, Yvonne
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    User perspectives on the Swedish Maternal Health Care Register2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, article id 613Article in journal (Refereed)
    Abstract [en]

    Background: Established in 1999, the Swedish Maternal Health Care Register (MHCR) collects data on pregnancy, birth, and the postpartum period for most pregnant women in Sweden. Antenatal care (ANC) midwives manually enter data into the Web-application that is designed for MHCR. The aim of this study was to investigate midwives? experiences, opinions and use of the MHCR. Method: A national, cross-sectional, questionnaire survey, addressing all Swedish midwives working in ANC, was conducted January to March 2012. The questionnaire included demographic data, preformed statements with six response options ranging from zero to five (0 = totally disagree and 5 = totally agree), and opportunities to add information or further clarification in the form of free text comments. Parametric and non-parametric methods and logistic regression analyses were applied, and content analysis was used for free text comments. Results: The estimated response rate was 53.1%. Most participants were positive towards the Web-application and the included variables in the MHCR. Midwives exclusively engaged in patient-related work tasks perceived the register as burdensome (70.3%) and 44.2% questioned the benefit of the register. The corresponding figures for midwives also engaged in administrative supervision were 37.8% and 18.5%, respectively. Direct electronic transfer of data from the medical records to the MHCR was emphasised as significant future improvement. In addition, the midwives suggested that new variables of interest should be included in the MHCR ? e.g., infertility, outcomes of previous pregnancy and birth, and complications of the index pregnancy. Conclusions: In general, the MHCR was valued positively, although perceived as burdensome. Direct electronic transfer of data from the medical records to the MHCR is a prioritized issue to facilitate the working situation for midwives. Finally, the data suggest that the MHCR is an underused source for operational planning and quality assessment in local ANC centres.

  • 169. Polyzoi, M.
    et al.
    Alvarez, M.
    Geale, Kirk
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Malaga, X.
    Pineda, C.
    Hernandez, C.
    The Budget Impact of Introducing Demineralised Bone Matrix Combined with Local Bone to Replace Currently Available Treatments for Lumbar Spinal Fusion Procedures in Spain2017In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 20, no 9, p. A530-A530Article in journal (Other academic)
    Abstract [en]

    Objectives: Estimate the budget impact (BI) of introducing demineralised bone matrix (DBM) combined with local bone (LB) in lumbar spinal fusion to treat lumbar degenerative disk disease in Spain. Methods: A decision tree model was developed to evaluate the 4-year BI associated with introducing LB combined with DBM putty (LB+DBM) to replace currently available treatment options including iliac crest bone graft (ICBG), LB alone, and LB combined with ceramic bone graft extenders (LB+ceramic). The market shares of the currently available treatments were 30% ICBG, 40% LB, and 30% LB+ceramic respectively. The analysis was conducted for 100 patients assuming LB+DBM would replace the currently administered treatment mix. Patients receiving DBM were administered 5cc and those receiving ceramics were administered 10cc beta-tricalcium phosphate. The model structure was based on previously published models identified through a structured literature search. The cost of DBM, ceramic, surgical procedures, adverse events, treatment failure, and reoperations were ncluded in the base-case analysis, and productivity loss was analysed in sensitivity analysis. Costs were sourced for Spain in €2017 and no discounting was applied. The model’s inputs and assumptions were validated by two Spanish clinical experts. Results: Over 4 years, replacing currently available treatments with LB+DBM spinal fusions resulted in an additional cost of €12,330 (€123/patient) and an additional 14 successful fusions, implying a cost of €881 per additional successful fusion. Initial procedure costs were higher for LB+DBM, but result in subsequent cost savings in terms of reoperations and adverse events. When including costs of productivity loss, the introduction of LB+DBM resulted in cost savings of €70,294 (€703/patient). Conclusions: For patients eligible for lumbar spinal fusion in Spain, replacing currently available treatments with LB+DBM results in increased costs for the payer but cost savings for society, while providing more successful fusions in both cases.

  • 170.
    Pérez-Urdiales, Iratxe
    et al.
    Department of Nursing I, University of the Basque Country (UPV/EHU), Biscay, Spain.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Nursing I, University of the Basque Country (UPV/EHU), Biscay, Spain.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Free clinic utilisation by immigrants after the introduction of a restrictive health policy in the Basque Country (Spain)2018In: Public Health, ISSN 0033-3506, E-ISSN 1476-5616, Vol. 163, p. 9-15Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Policies restricting healthcare access for immigrants were applied in times of reduced public funding for welfare in Spain. This study aimed to assess the impact of the implementation of a more restrictive health policy in the Basque Country region, Decree 114/2012, on the number of consultations attended at a free clinic, where the majority of patients are undocumented immigrants.

    STUDY DESIGN: Interrupted time series.

    METHODS: A negative binomial regression model was applied in two phases to the number of healthcare consultations during the period 2007-2017 (n = 9272) to estimate the level and trend changes associated with the implementation of the policy. Data were analysed separately by sex and adjusted for consultations' seasonality and unemployment rate and the sex-specific percentage of migrant population in Biscay province as confounding factors.

    RESULTS: Different trends of attendance between men and women were observed during the whole period, constituting 76.94% and 23.06% of all consultations, respectively. After the implementation of the decree, the number of consultations for women per trimester decreased and increased for men by 1%, although it was not statistically significant in either of the trends.

    CONCLUSIONS: No clear relationship between the implementation of the Basque Decree 114/2012 and an increase in the attendance of immigrants in a free clinic during the studied period was found.

  • 171.
    Qvarsell, Roger
    Umeå University, Faculty of Arts, Department of historical, philosophical and religious studies.
    Ordning och behandling: psykiatri och sinnessjukvård i Sverige under 1800-talets första hälft1982Doctoral thesis, monograph (Other academic)
    Abstract [en]

    During the first half of the 19th century institutions for the treatment of the insane were established throughout Europe and North America. These institutions were generally the result of government initiative and were founded on a belief that existed in the new psychiatric theories of treatment.

    Psychiatry was, at this time, an embryonic science, in which great conflict existed between different theoretical schools of thought, but in which a remarkable concensus existed regarding methods of treatment. Treatment was based on a view of the nature of man inspired by the philosophy of the Enlightenment, in which up-bringing was considered to be able to affect a person's entire character.

    In 1823, the Swedish Riksdag voted in favour of the etablishment of treatment hospitals. The background to this decision was the belief that it should be possible to diminish the costs of caring for the poor if mental illness could be treated. However, fears of a general increase in social unrest and philanthropic motives seem also to have been important factors. Sweden's first hospital for the treatment of the insane was established in Vadstena in 1826. Georg Engström (1 795-1 855) became the country's first full-time asylum doctor.

    Georg Engström was well-read in German, French and English psychiatric literature, but never himself formulated any psychiatric theory, neither did he write any articles of a principiai nature. His psychiatric activities may, however, be followed in his comprehensive medical journals and regular official reports. Engström saw the roots of mental illness in the existence of a surplus, a shortage, or an inbalance in the energy of the psyche. The cause of illness lay in the patients manner of living and, Engström stressed, in the importance of intense feelings and passions. The essence of treatment lay in the patient's being kept occupied and in his manner of living. Most of the recommendations for methods of treatment contained in the literature were tried out, a number of which — for example, being spun in a revolving chair — were quickly abandoned.

    The development of psychiatry and of the care and treatment of the mentally ill during the first half of the 19th century can be seen as a sign of the fact that science itself was developing and becoming paradigmatic. However, it is also possible the view developments from the perspective of the ideology of treatment and to focus on the way in which the philosophy of treatment and its concomitent optimism spread and reformed the old asylum system. Finally, it is also possible to observe developments from a pedagogical perspective, stressing the state's desire for control and order in a situation in which there were fears of an increasing social unrest.

  • 172. Rahman, S.
    et al.
    Mittendorfer-Rutz, E.
    Alexanderson, K.
    Jokinen, Jussi
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry. Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Tinghog, P.
    Disability pension due to common mental disorders and healthcare use before and after policy changes: a nationwide stud2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no 1, p. 90-96Article in journal (Refereed)
    Abstract [en]

    Background: Despite common mental disorders (CMDs) being a main reason for preterm exit from the labour market, there is limited knowledge regarding healthcare use around the time of being granted disability pension (DP) due to CMD. The aim was to study specialized healthcare use before and after being granted DP due to CMD and whether these trajectories differed before and after changes in DP granting criteria in Sweden in 2008. Methods: Included individuals lived in Sweden, aged 19-64 years with incident DP due to CMD before (wave 1, 2005-06, n = 24 298) or after (wave 2, 2009-10, n = 4056) the changes in 2008. Healthcare trajectories during a 7-year window were assessed by generalized estimating equations. Between-and within-wave differences were examined by interaction models. Results: Psychiatric healthcare increased until the year preceding DP and declined thereafter, with one exception; such outpatient care kept increasing in wave 1 following DP. In the year preceding DP, 4.6 and 19.2% of the individuals in wave 1 had psychiatric in-and specialized outpatient care, respectively, compared with 7.9 and 46.6% in wave 2. No clear pattern was observed regarding somatic healthcare. The slopes of the different DP waves differed mainly during DP granting years (1 year prior to 1 year after), showing a sharper decline in wave 2. Conclusion: Transition to DP due to CMD seems to be associated with changes in psychiatric healthcare use, with higher rates in the year preceding DP. Outpatient healthcare patterns somewhat differed among those granted DP after stricter rules were introduced.

  • 173.
    Reveiz, Ludovic
    et al.
    National University of Colombia.
    Tellez, Diana R
    National University of Colombia.
    Castillo, Juan S
    National University of Colombia.
    Mosquera Mendez, Paola
    Torres, Marcela
    National University of Colombia.
    Cuervo, Luis G
    World Health Organization.
    Cardona, Andres F
    National University of Colombia.
    Pardo, Rodrigo
    National University of Colombia.
    Prioritization strategies in clinical practice guidelines development: a pilot study2010In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 8, article id 7Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Few methodological studies address the prioritization of clinical topics for the development of Clinical Practice Guidelines (CPGs). The aim of this study was to validate a methodology for Priority Determination of Topics (PDT) of CPGs.

    METHODS AND RESULTS: Firstly, we developed an instrument for PDT with 41 criteria that were grouped under 10 domains, based on a comprehensive systematic search. Secondly, we performed a survey of stakeholders involved in CPGs development, and end users of guidelines, using the instrument. Thirdly, a pilot testing of the PDT procedure was performed in order to choose 10 guideline topics among 34 proposed projects; using a multi-criteria analysis approach, we validated a mechanism that followed five stages: determination of the composition of groups, item/domain scoring, weights determination, quality of the information used to support judgments, and finally, topic selection. Participants first scored the importance of each domain, after which four different weighting procedures were calculated (including the survey results). The process of weighting was determined by correlating the data between them. We also reported the quality of evidence used for PDT. Finally, we provided a qualitative analysis of the process. The main domains used to support judgement, having higher quality scores and weightings, were feasibility, disease burden, implementation and information needs. Other important domains such as user preferences, adverse events, potential for health promotion, social effects, and economic impact had lower relevance for clinicians. Criteria for prioritization were mainly judged through professional experience, while good quality information was only used in 15% of cases.

    CONCLUSION: The main advantages of the proposed methodology are supported by the use of a systematic approach to identify, score and weight guideline topics selection, limiting or exposing the influence of personal biases. However, the methodology was complex and included a number of quantitative and qualitative approaches reflecting the difficulties of the prioritization process.

  • 174. Richter, Anne
    et al.
    von Thiele Schwarz, Ulrica
    Lornudd, Caroline
    Lundmark, Robert
    Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77 Stockholm, Sweden.
    Mosson, Rebecca
    Hasson, Henna
    iLead-a transformational leadership intervention to train healthcare managers' implementation leadership2016In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 11, article id 108Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Leadership is a key feature in implementation efforts, which is highlighted in most implementation frameworks. However, in studying leadership and implementation, only few studies rely on established leadership theory, which makes it difficult to draw conclusions regarding what kinds of leadership managers should perform and under what circumstances. In industrial and organizational psychology, transformational leadership and contingent reward have been identified as effective leadership styles for facilitating change processes, and these styles map well onto the behaviors identified in implementation research. However, it has been questioned whether these general leadership styles are sufficient to foster specific results; it has therefore been suggested that the leadership should be specific to the domain of interest, e.g., implementation. To this end, an intervention specifically involving leadership, which we call implementation leadership, is developed and tested in this project. The aim of the intervention is to increase healthcare managers' generic implementation leadership skills, which they can use for any implementation efforts in the future.

    METHODS/DESIGN: The intervention is conducted in healthcare in Stockholm County, Sweden, where first- and second-line managers were invited to participate. Two intervention groups are included, including 52 managers. Intervention group 1 consists of individual managers, and group 2 of managers from one division. A control group of 39 managers is additionally included. The intervention consists of five half-day workshops aiming at increasing the managers' implementation leadership, which is the primary outcome of this intervention. The intervention will be evaluated through a mixed-methods approach. A pre- and post-design applying questionnaires at three time points (pre-, directly after the intervention, and 6 months post-intervention) will be used, in addition to process evaluation questionnaires related to each workshop. In addition, interviews will be conducted over time to evaluate the intervention.

    DISCUSSION: The proposed intervention represents a novel contribution to the implementation literature, being the first to focus on strengthening healthcare managers' generic skills in implementation leadership.

  • 175.
    Richter Sundberg, Linda
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Child and Adolescent Psychiatry.
    Garvare, Rickard
    Department of Business Administration, Technology and Social Sciences, Luleå University of Technology.
    Nyström, Monica Elisabeth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet.
    Reaching beyond the review of research evidence: a qualitative study of decision making during the development of clinical practice guidelines for disease prevention in healthcare2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, no 1, article id 344Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease.

    METHODS: A qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data.

    RESULTS: The guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: 'clinical knowledge and experience', 'potential guideline consequences' and 'needs of vulnerable groups'. The frequency of the use of various criteria in discussions varied over time. Gender, professional status, and interpersonal skills were perceived to affect individuals' relative influence on group discussions.

    CONCLUSIONS: The study shows that guideline development groups make compromises between rigour and pragmatism. The formal guideline development model incorporated multiple aspects, but offered few details on how the different criteria should be handled. The guideline development model devoted little attention to the role of the decision-model and group-related factors. Guideline development models could benefit from clarifying the role of the group-related factors and non-research evidence, such as clinical experience and ethical considerations, in decision-processes during guideline development.

  • 176. Robyn, Paul Jacob
    et al.
    Hill, Allan
    Liu, Yuanli
    Souares, Aurélia
    Savadogo, Germain
    Sié, Ali
    Sauerborn, Rainer
    Econometric analysis to evaluate the effect of community-based health insurance on reducing informal self-care in Burkina Faso2012In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 27, no 2, p. 156-165Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE This study examines the role of community-based health insurance (CBHI) in influencing health-seeking behaviour in Burkina Faso, West Africa. Community-based health insurance was introduced in Nouna district, Burkina Faso, in 2004 with the goal to improve access to contracted providers based at primary- and secondary-level facilities. The paper specifically examines the effect of CBHI enrolment on reducing the prevalence of seeking modern and traditional methods of self-treatment as the first choice in care among the insured population. METHODS Three stages of analysis were adopted to measure this effect. First, propensity score matching was used to minimize the observed baseline differences between the insured and uninsured populations. Second, through matching the average treatment effect on the treated, the effect of insurance enrolment on health-seeking behaviour was estimated. Finally, multinomial logistic regression was applied to model demand for available health care options, including no treatment, traditional self-treatment, modern self-treatment, traditional healers and facility-based care. RESULTS For the first choice in care sought, there was no significant difference in the prevalence of self-treatment among the insured and uninsured populations, reaching over 55% for each group. When comparing the alternative option of no treatment, CBHI played no significant role in reducing the demand for self-care (either traditional or modern) or utilization of traditional healers, while it did significantly increase consumption of facility-based care. The average treatment effect on the treated was insignificant for traditional self-care, modern self-care and traditional healer, but was significant with a positive effect for use of facility care. Discussion While CBHI does have a positive impact on facility care utilization, its effect on reducing the prevalence of self-care is limited. The policy recommendations for improving the CBHI scheme's responsiveness to population health care demand should incorporate community-based initiatives that offer attractive and appropriate alternatives to self-care.

  • 177.
    Rosenmüller, Mats H.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lindberg, Fredrik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Åberg, Sten-Olof
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamaki, Markku M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Costs and quality of life of small-incision open cholecystectomy and laparoscopic cholecystectomy: an expertise-based randomised controlled trial2017In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 17, article id 48Article in journal (Refereed)
    Abstract [en]

    Background: Health care providers need solid evidence based data on cost differences between alternative surgical procedures for common surgical disorders. We aimed to compare small-incision open cholecystectomy (SIOC) and laparoscopic cholecystectomy (LC) concerning costs and health-related quality of life using data from an expertise-based randomised controlled trial. Methods: Patients scheduled for cholecystectomy were assigned to undergo LC or SIOC performed by surgeons in two different expert groups. Total costs were calculated in USD. Reusable instruments were assumed for the cost analysis. Quality of life was measured using the EuroQol 5-D 3-L (EQ 5-D-3L), at five postoperative time points and calculated to Area Under Curve (AUC) for 1 year postoperatively. Two hospitals participated in the trial, which included both emergency and elective surgery. Results: Of 477 patients that underwent a cholecystectomy during the study period, 355 (74.9%) were randomised and 323 analysed, 172 LC and 151 SIOC patients. Both direct and total costs were less for SIOC than for LC patients. The total costs were 5429 (4293-6932) USD for LC and 4636 (3905-5746) USD for SIOC, P = 0.001. The quality of life index did not differ between the LC and SIOC groups at any time. Median values (25th and 75th percentiles (p25-p75)) for AUC at 1 year were as follows: 349 (337-351) for LC and 349 (338-350) for SIOC. Conclusions: In this expertise-based randomised controlled trial LC was a more costly procedure and quality of life did not differ after SIOC and LC. (ClinicalTrials.gov Identifier: NCT00370344, August 30, 2006).

  • 178.
    Rosvall, Per-Åke
    et al.
    Umeå University, Faculty of Social Sciences, Department of applied educational science.
    Nilsson, Stefan
    Göteborgs universitet.
    Gender-based generalisations in school nurses' appraisals of and interventions addressing students' mental health2016In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, article id 451Article in journal (Refereed)
    Abstract [en]

    Background: There has been an increase of reports describing mental health problems in adolescents, especially girls. School nurses play an important role in supporting young people with health problems. Few studies have considered how the nurses' gender norms may influence their discussions.

    Methods: To investigate this issue, semi-structured interviews focusing on school nurses' work with students who have mental health problems were conducted. Transcripts of interviews with Swedish school nurses (n = 15) from the Help overcoming pain early project (HOPE) were analysed using theories on gender as a theoretical framework and then organised into themes related to the school nurses' provision of contact and intervention. The interviewees were all women, aged between 42–63 years, who had worked as nurses for 13–45 years, and as school nurses for 2–28 years. Five worked in upper secondary schools (for students aged 16–19) and 10 in secondary schools (for students aged 12–16).

    Results: The results show that school nurses more commonly associated mental health problems with girls. When the school nurses discussed students that were difficult to reach, boys in particular were mentioned. However, very few nurses mentioned specific intervention to address students' mental health problems, and all of the mentioned interventions were focused on girls. Some of the school nurses reported that it was more difficult to initiate a health dialogue with boys, yet none of the nurses had organized interventions for the boys.

    Conclusions: We conclude that generalisations can sometimes be analytically helpful, facilitating, for instance, the identification of problems in school nurses' work methods and interventions. However, the most important conclusion from our research, which applied a design that is not commonly used, is that more varied approaches, as well as a greater awareness of potential gender stereotype pitfalls, are necessary to meet the needs of diverse student groups.

  • 179.
    Rusanganwa, Vincent
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Section of Virology. University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda; Ministry of Health, Kigali, Rwanda.
    Gahutu, Jean Bosco
    University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
    Evander, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Section of Virology.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Clinical Referral Laboratory Personnel’s Perception of Challenges and Strategies for Sustaining the Laboratory Quality Management System: A Qualitative Study in Rwanda2019In: American Journal of Clinical Pathology, ISSN 0002-9173, E-ISSN 1943-7722Article in journal (Refereed)
    Abstract [en]

    Objectives: To explore challenges explaining the decrease in quality performance and suggest strategies to improve and sustain laboratory quality services.

    Methods: Twenty key informants’ interviews from laboratory personnel were conducted in five laboratories. Four had previously shown a decrease in quality performance. Interviews were transcribed verbatim and analyzed using inductive thematic analysis.

    Results: Two themes emerged: (1) insufficient coordination and follow-up system towards accreditation, where lack of coordination, follow-up, and audits explained the decrease in performance; (2) inadequate resource optimization, where insufficient knowledge in Laboratory Quality Management System (LQMS), ownership by laboratory workforce, and insufficient stakeholders’ communication contributed to low-quality performance.

    Conclusions: The coordination, follow-up, and assessments of LQMS, in conjunction with training of laboratory workforce, would establish an institutional culture of continuous quality improvement (CQI) towards accreditation and sustainment of quality health care. To achieve CQI culture, routine gap checking and planning for improvement using a system approach is required.

  • 180. Salminen, Vesa
    et al.
    Sanerma, Paivi
    Niittymaki, Seppo
    Eklund, Patrik
    Umeå University, Faculty of Science and Technology, Department of Computing Science.
    Ontology based service environment supports successful aging2018In: Advances in Human Factors, Business Management and Leadership: Proceedings of the AHFE 2017 International Conferences on Human Factors in Management and Leadership, and Business Management and Society, July 17−21, 2017, The Westin Bonaventure Hotel, Los Angeles, California, USA / [ed] Kantola, JI Barath, T Nazir, S, Springer, 2018, p. 40-51Conference paper (Refereed)
    Abstract [en]

    The aging individuals living independently at home need new kinds of services. Digitalization of services and the wellbeing data gathered from the individual creates an opportunity for optimized and punctual services. It is important to pilot the new technology solutions at actual home and well-being environments to get certainty of usability, flexibility and accessibility of the digitalized services for citizens and nurses. The implementation of digitalization has to happen according to ethical rules and take the values and individual capabilities into account. The data gathered through digital equipment can be used in optimizing service processes. However, there is missing generic data as common ontology of service process and semantic architecture to use the gathered data for service optimization. In the article is introduced what type of ontology based semantic architecture could be used in social and health care and how geriatric data should be integrated in caring elderly people.

  • 181.
    Sanz-Barbero, Belén
    et al.
    National School of Public Health, Health Institute Carlos III, Madrid, Spain ; CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain.
    Otero-García, Laura
    National School of Public Health, Health Institute Carlos III, Madrid, Spain ; CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain.
    Blasco-Hernández, Teresa
    National Centre of Tropical Medicine, Health Institute Carlos III, Madrid, Spain.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Factors associated with the utilization of primary care emergency centers in a Spanish region with high population dispersion: a mixed-methods study2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 368-Article in journal (Refereed)
    Abstract [en]

    Background: Adequate access to primary care emergency centers is particularly important in rural areas isolated from urban centers. However, variability in utilization of emergency services located in primary care centers among inhabitants of nearby geographical areas is understudied. The objectives of this study are twofold: 1) to analyze the association between the availability of municipal emergency care centers and utilization of primary care emergency centers (PCEC), in a Spanish region with high population dispersion; and 2) to determine healthcare providers' perceptions regarding PCEC utilization. Methods: A mixed-methods study was conducted. Quantitative phase: multilevel logistic regression modeling using merged data from the 2003 Regional Health Survey of Castile and Leon and the 2001 census data (Spain). Qualitative phase: 14 in-depth-interviews of rural-based PCEC providers. Results: Having PCEC as the only emergency center in the municipality was directly associated with its utilization (p < 0.001). Healthcare providers perceived that distance to hospital increased PCEC utilization, and distance to PCEC decrease its use. PCEC users were considered to be predominantly workers and students with scheduling conflicts with rural primary care opening hours. Conclusions: The location of emergency care centers is associated with PCEC utilization. Increasing access to primary care by extending hours may be an important step toward optimal PCEC utilization. Further research would determine whether lower PCEC use by certain groups is associated with disparities in access to care.

  • 182. Schunemann, Holger J.
    et al.
    Lerda, Donata
    Dimitrova, Nadya
    Alonso-Coello, Pablo
    Grawingholt, Axel
    Quinn, Cecily
    Follmann, Markus
    Mansel, Robert
    Sardanelli, Francesco
    Rossi, Paolo Giorgi
    Lebeau, Annette
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Broeders, Mireille
    Ioannidou-Mouzaka, Lydia
    Duffy, Stephen W.
    Borisch, Bettina
    Fitzpatrick, Patricia
    Hofvind, Solveig
    Castells, Xavier
    Giordano, Livia
    Warman, Sue
    Saz-Parkinson, Zuleika
    Autelitan, Mariangela
    Colzani, Edoardo
    Danes, Jan
    Knox, Susan
    Langendam, Miranda
    McGarrigle, Helen
    Perez Gomez, Elsa
    Torresin, Alberto
    van Engen, Ruben
    Young, Kenneth
    van Landsveld-Verhoeven, Cary
    Rigau, David
    Sola, Ivan
    Ballesteros, Monica
    Arevalo-Rodriguez, Ingrid
    Posso, Margarita
    Martinez Garcia, Laura
    Canelo-Aybar, Carlos
    Nino De Guzman, Ena
    Valli, Claudia
    Ricci-Cabello, Ignacio
    Superchi, Cecilia
    Piggott, Thomas
    Baldeh, Tejan
    Parmelli, Elena
    Methods for Development of the European Commission Initiative on Breast Cancer Guidelines Recommendations in the Era of Guideline Transparency2019In: Annals of Internal Medicine, ISSN 0003-4819, E-ISSN 1539-3704, Vol. 171, no 4, p. 273-280Article in journal (Refereed)
    Abstract [en]

    Neither breast cancer prevention and early-detection programs, nor their outcomes, are uniform across Europe. This article describes the rationale, methods, and process for development of the European Commission ( EC) Initiative on Breast Cancer Screening and Diagnosis Guidelines. To be consistent with standards set by the Institute of Medicine and others, the EC followed 6 general principles. First, the EC selected, via an open call, a panel with broad representation of areas of expertise. Second, it ensured that all recommendations were supported by systematic reviews. Third, the EC separately considered important subgroups of women, included patient advocates in the guidelines development group, and focused on good communication to inform women's decisions. Fourth, EC rules on conflicts of interest were followed and the GRADE ( Grading of Recommendations Assessment, Development and Evaluation) Evidence to Decision frameworks were used to structure the process and minimize the influence of competing interests. Fifth, it focused its recommendations on outcomes that matter to women, and certainty of the evidence is rated for each. Sixth, the EC elicited stakeholder feedback to ensure that the recommendations remain up to date and relevant to practice. This article describes the approach and highlights ways of disseminating and adapting the recommendations both within and outside Europe, using innovative information technology tools.

  • 183. Seiger Cronfalk, Berit
    et al.
    Ternestedt, Britt-Marie
    Franklin Larsson, Lise-Lotte
    Henriksen, Eva
    Norberg, Astrid
    Umeå University, Faculty of Medicine, Department of Nursing. Ersta Sköndal University College, Palliative Research Centre, Stockholm, Sweden .
    Österlind, Jane
    Utilization of palliative care principles in nursing home care: educational interventions2015In: Palliative & Supportive Care, ISSN 1478-9515, E-ISSN 1478-9523, Vol. 13, no 6, p. 1745-1753Article in journal (Refereed)
    Abstract [en]

    Objective: This study is part of the overarching PVIS (Palliative Care in Nursing Homes) project aimed at building competence in palliative care for nursing home staff. Our objective was to describe nursing home staff's attitudes to competence-building programs in palliative care. Method: Three different programs were developed by specialist staff from three local palliative care teams. In all, 852 staff at 37 nursing homes in the greater Stockholm area participated. Staff from 7 nursing homes participated in 11 focus-group discussions. Variation in size between the seven nursing homes initiated purposeful selection of staff to take part in the discussions, and descriptive content analysis was used. Results: The results suggest that staff reported positive experiences as they gained new knowledge and insight into palliative care. The experiences seemed to be similar independent of the educational program design. Our results also show that staff experienced difficulties in talking about death. Enrolled nurses and care assistants felt that they carried out advanced care without the necessary theoretical and practical knowledge. Further, the results also suggest that lack of support from ward managers and insufficient collaboration and of a common language between different professions caused tension in situations involved in caring for dying people. Significance of results: Nursing home staff experienced competence-building programs in palliative care as useful. Even so, further competence is needed, as is long-term implementation strategies and development of broader communication skills among all professions working in nursing homes.

  • 184.
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda.
    Pregnancy and delivery-related complications in Rwanda: prevalence, associated risk factors, health economic impact, and maternal experiences2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Every year more than 1.5 million women suffer from pregnancy and delivery-related complications (PDCs) during pregnancy and childbirth worldwide, and these women are a vulnerable population for lifelong consequences, somatically, psychologically and financially. Following the establishment of Millennium Development Goal no 5, which targeted a reduction of 75% of the maternal mortality ratio from 1990 to 2015, many efforts were made to reduce maternal mortality worldwide. In low-income countries saving a pregnant woman’s life requires a focused medical intervention so that near-miss cases of death are considered as obstetric success and thus postpartum follow-up may be neglected. In Rwanda, maternal mortality is estimated to 210 per 100,000 live births and main obstetric complications are hypertensive disorders during pregnancy, obstructive/prolonged labour, post-partum haemorrhage (PPH) and sepsis/infections. However, the specific prevalence of PDCs as well as their consequences to the woman and her family is currently relatively unknown.

    Aims: The overall aim of this thesis was to determine the prevalence of PDCs and their associated risk factors and to investigate delivered women’s experiences of PDCs, the consequences of these complications on postpartum health and family situation, and to estimate the societal economic costs of pregnancy, delivery and postpartum-related problems.

    Subjects and methods: A population-based cross-sectional study including 921 women who gave birth within the past 13 months prior to time of data collection (Paper I) and a health facility-based study including 817 women that were at discharge time (Paper II) were conducted in the Northern Province of Rwanda and Kigali City. Fifteen women who experienced PDCs were interviewed through individual in-depth qualitative interviews (Paper III). A micro costing approach to collect health facility data and household costs including opportunity cost, transport and food cost was conducted to estimate the societal economic cost of PDCs (Paper I-V). Descriptive statistics, Chi-Square, bi- and multivariable logistic regression, Cox regression, and health economic analysis were applied for quantitative data analyses (Papers I, II and IV). Qualitative manifest and latent content analysis was used for qualitative data analyses (Paper III).

    Results: Prevalence of anaemia, hypertension, diabetes mellitus during pregnancy, and severe bleeding during pregnancy and labour were estimated to 15.0%, 4.9%, 2.4%, and 3.7%, respectively (Paper I). In total, 56.4% of the participants were transferred and the majority were transferred from health centres to district hospitals, with caesarean section (CS) as the main reason for transfer. Almost three-quarters of the women started labour spontaneously; 5% had induced labour and 28.4% of all pregnant women were delivered by CS (Paper II). Pre-eclampsia/eclampsia, PPH, and caesarean section (CS) due to prolonged labour/dystocia represented 1%, 2.7% and 5.4% of all participants, respectively (Paper II). Risk factors for CS due to prolonged labour or dystocia were poverty, nulliparity, and residence far from health facility (Paper II). The prevalence of poor-self rated health (poor-SRH) for participants who gave birth within the past 14 months prior to time of data collection was 32.2% at one day postpartum, 7.8% at one month, and 11.7% at time of the interview (Paper I). Most participants who had experienced PDCs reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications (Paper III). Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems (Paper III). PDCs negatively affected participants’ economic situation due to increased health care expenses and lowered income because of impaired working capacity (Paper III). The estimated total societal cost of a normal uncomplicated vaginal delivery was 107 United States dollars (USD). The incremental cost of a vaginal delivery followed by PPH was 55 USD. The incremental cost of prolonged, dystocic or obstructed labour resulting in a CS was 146 USD. The incremental cost of pre-eclampsia with vaginal delivery and pre-eclampsia with CS were 289 and 339 USD, respectively. The major cost categories of the estimated costs for each mode of delivery were staff, the hospitalisation rooms, and household expenditures (Paper IV).

    Conclusions: A high prevalence of poor self-rated health status was reported in the early postpartum period. Identified factors associated with poor-SRH were severe bleeding, hypertension, infection, and anaemia during pregnancy and postpartum haemorrhage. The estimated prevalences of specific pregnancy and delivery-related complications were relatively low, probably in part due to underestimation. Rwandan women experiencing PDCs are facing many challenges and problems during pregnancy, delivery and postpartum period. The costs of PDCs were calculated to be very high in comparison to the net median monthly wage in Rwanda. In addition, the Rwandan health system presents weaknesses in relation to the prevention of PDCs. Above all, there is an insufficient postpartum health care provision and community support to women experiencing PDCs. The results from this thesis call for interventions, to improve the postpartum health care services and call for the community sensitisation for the increased support to women who face difficult living circumstances because they have experienced severe pregnancy and delivery-related complications.

  • 185.
    Semasaka Sengoma, Jean Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. La Trobe University.
    Krantz, Gunilla
    University of Gothenburg.
    Nzayirambaho, Manasse
    University of Rwanda.
    Munyanshongore, Cyprien
    University of Rwanda.
    Hitimana, Regis
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of Rwanda.
    Edvardsson, Kristina
    La Trobe University.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Estimation of the economic costs of pregnancy and delivery-related complications in RwandaManuscript (preprint) (Other academic)
  • 186.
    Sirili, Nathanael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health workforce development post-1990s health sector reforms: the case of medical doctors in Tanzania2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Health systems in many low- and middle-income countries suffer from critical shortages and inequitable geographical distribution of the health workforce. Since the 1940s, many low- and middle-income countries have passed through different regimes of health sector reforms; the most recent one was in the 1990s. Tanzania is a good example of these countries. From the 1990s, Tanzania has been implementing the third generation of health sector reforms. This thesis analysed the health workforce development following the 1990s health sector reforms in Tanzania.

    Methods: An exploratory case study employing both quantitative and qualitative research approaches was used to analyse the training, deployment, and retention of medical doctors about two decades following the 1990s healthsector reforms. The quantitative approach involved analysis of graduation books and records from the Medical Council of Tanganyika to document the number of doctors who graduated locally and abroad, a countrywide survey of available doctors as of July 2011, and analysis of staffing levels to document the number of doctors recommended for the health sector as of 2012. The gap between the number of available and required doctors was computed by subtracting available from required in that period. The qualitative approach involved key informant interviews, focus group discussions, and a documents review. Key informants were recruited from districts, regions, government ministries, national hospitals, medical training institutions in both the public and private sectors, Christian Social Services Commission and the Association of Private Health Facilities in Tanzania. Focused group discussion participants were members of Council Health Management Teams in three selected districts. Documents reviewed included country human resources for health profiles, health sector strategic plans, human resources for health strategic plans and published and grey literature on health sector reforms, health workforce training, and deployment and retention documentation. For the training, analysis of data was done thematically with the guide of policy analysis framework. For deployment and retention, qualitative content analysis was adopted.

    Results: Re-introduction of the private sector in the form of public-private partnerships has boosted the number of doctors graduating annually sevenfold in 2010 compared to that in 1992. Despite the increase in the number of doctors graduating annually, their training faces some challenges, including the erosion of university autonomies prescribed by the law; coercive admission of many medical students greater than the capacity of the medical schools, thus threatening the quality of the graduates; and lack of coordination between trainers and employers. Tanzania requires a minimum of 3,326 doctors to attain the minimum threshold of 0.1 doctor per 1,000 population, as recommended by the World Health Organization. However, a countrywide survey has revealed the existence of around 1,300 doctors working in the health sector—almost the same as the number before the reforms. Failure to offer employment to all graduating doctors, uncertainties around the first appointment, failure to respect doctors’ preferences for first appointment workplaces, and the feelings of insecurity in going to districts are among the major challenges haunting the deployment of doctors in Tanzania. For those who went to the districts, the issues of unfavourable working conditions, unsupportive environment in the community, and resource scarcity have all challenged their retention.

    Conclusions: The development of human resources for health after the 1990s health sector reforms have to some extent been contradictory. On the one hand, Tanzania has succeeded in training more doctors than the minimum it requires, despite some challenges facing the training institutions. On the other hand, failure to deploy and retain an adequate number of doctors in its health system has left the country to continue suffering from a shortage and inequitable distribution of doctors in favour of urban areas. For health sector reforms to bring successes with minimal challenges in health workforce development, a holistic approach that targets doctors’ training, deployment, and retention is recommended.

  • 187.
    Sirili, Nathanael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Frumence, Gasto
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kiwara, A
    Mwangu, M
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    "Doctors ready to be posted are jobless on the street..." the deploymnet process and shortage of doctors in TanzaniaManuscript (preprint) (Other academic)
  • 188.
    Sirili, Nathanael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Kiwara, Angwara
    Mwangu, Mughwira
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    "Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania.2019In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, no 1, article id 11Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The World Health Organization advocates that health workforce development is a continuum of three stages of entry, available workforce and exit. However, many studies have focused on addressing the shortage of numbers and the retention of doctors in rural and remote areas. The latter has left the contribution of the entry stage in particularly the deployment process on the shortage of health workforce less understood. This study therefore explored the experiences of medical doctors (MDs) on the deployment process after the internship period in Tanzania's health sector.

    METHODS: A qualitative case study that adopted chain referral sampling was used to conduct 20 key informant interviews with MDs who graduated between 2003 and 2009 from two Medical Universities in Tanzania between February and April 2016. These MDs were working in hospitals at different levels and Medical Universities in eight regions and five geo-political zones in the country. Information gathered was analysed using a qualitative content analysis approach.

    RESULTS: Experiences on the deployment process fall into three categories. First, "uncertainties around the first appointment" attributed to lack of effective strategies for identification of the pool of available MDs, indecision and limited vacancies for employment in the public sector and private sector and non-transparent and lengthy bureaucratic procedures in offering government employment. Second, "failure to respect individuals' preferences of work location" which were based on the influence of family ties, fear of the unknown rural environment among urbanized MDs and concern for career prospects. Third, "feelings of insecurity about being placed at a regional and district level" partly due to local government authorities being unprepared to receive and accommodate MDs and territorial protectionism among assistant medical officers.

    CONCLUSIONS: Experiences of MDs on the deployment process in Tanzania reveal many challenges that need to be addressed for the deployment to contribute better in availability of equitably distributed health workforce in the country. Short-term, mid-term and long-term strategies are needed to address these challenges. These strategies should focus on linking of the internship with the first appointment, work place preferences, defining and supporting career paths to health workers working under the local government authorities, improving the working relationships and team building at the work places and fostering rural attachment to medical students during medical training.

  • 189.
    Sirili, Nathanael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O.BOX 65454, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kiwara, Angwara
    Mwangu, Mughwira
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Public private partnership in training of doctors after the 1990s' health sector reforms: the case of Tanzania2019In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, article id 33Article in journal (Refereed)
    Abstract [en]

    Similar to many other low- and middle-income countries, public private partnership (PPP) in the training of the health workforce has been emphasized since the launch of the 1990s’ health sector reforms in Tanzania. PPP in training aims to contribute to addressing the critical shortage of health workforce in these countries. This study aimed to analyse the policy process and experienced outcomes of PPP for the training of doctors in Tanzania two decades after the 1990s’ health sector reforms. We reviewed documents and interviewed key informants to collect data from training institutions and umbrella organizations that train and employ doctors in both the public and private sectors. We adopted a hybrid thematic approach to analyse the data while guided by the policy analysis framework by Gagnon and Labonté. PPP in training has contributed significantly to the increasing number of graduating doctors in Tanzania. In tandem, undermining of universities’ autonomy and the massive enrolment of medical students unfavourably affect the quality of graduating doctors. Although PPP has proven successful in increasing the number of doctors graduating, unemployment of the graduates and lack of database to inform the training needs and capacity to absorb the graduates have left the country with a health workforce shortage and maldistribution at service delivery points, just as before the introduction of the PPP. This study recommends that Tanzania revisit its PPP approach to ensure the health workforce crisis is addressed in its totality. A comprehensive plan is needed to address issues of training within the framework of PPP by engaging all stakeholders in training and deployment starting from the planning of the number of medical students, and when and how they will be trained while taking into account the quality of the training.

  • 190. Sirili, Nathanael
    et al.
    Kiwara, Angawara
    Nyongole, Obadia
    Frumence, Gasto
    Semakafu, Avemaria
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Addressing the human resource for health crisis in Tanzania: The lost in transition syndrome2014In: Tanzania Journal of Health Research, ISSN 1821-6404, Vol. 16, no 2Article in journal (Refereed)
    Abstract [en]

    Tanzania is experiencing a serious Human Resource for Health (HRH) crisis. Shortages are 87.5% and 67% in private and public hospitals, respectively. Mal-distribution and brain drain compound the shortage. The objective of this study was to improve knowledge on the HRH status in Tanzania by analyzing what happens to the number of medical doctors (MD) and doctor of dental surgery (DDS) degree graduates during the transition period from graduation, internship to appointment. We analyzed secondary data to get the number of MDs and DDS; who graduated from 2001 to 2010, the number registered for internship from 2005 to 2010 and the number allowed for recruitment by government permits from 2006 to 2010. Self administered questionnaires were provided to 91 MDs and DDS who were pursuing postgraduate studies at Muhimbili University of Health and Allied Sciences during this study who went through the graduation-internship-appointment (GIA) period to get the insight of the challenges surrounding the MDs and DDS during the GIA period. From 2001 to 2010 a total of 2,248 medical doctors and 198 dental surgeons graduated from five local training institutions and abroad. From 2005 to 2010 a total of 1691 (97.13%) and 186 (126.53%) of all graduates in MD and DDS, respectively, registered for internship. The 2007/2008 recruitment permit allowed only 37.7% (80/218) and 25.0% (7/27) of the MDs and DDS graduated in 2006, respectively. The 2009/2010 recruitment permit allowed 265 MDs (85.48%) out of 310 graduates of 2008. In 2010/2011 permission for MDs was 57.58% (190/ 330) of graduates of 2009 and in 2011/2012 permission for MDs was for 61.03% ((249/408) graduates of 2010. From this analysis the recruitment permits in 2007/2008, 2009/2010, 2010/2011 1nd 2011/2012 could not offer permission for employment of 482 (38.10%) of all MDs graduated in the subsequent years. Major challenges associated with the GIA period included place of accommodation, allowance (for internship) or salary delay (for first appointment), difficulty working environment, limited carrier opportunities and concern for job security. The failure to enforce mandatory registration for internship and failure to absorb all produced MDs and DDS results to loss of a substantial number of these graduates during the graduation-internshipappointment period. To solve this problem, it is recommended to establish better human resource for health management system.

  • 191.
    Sjöström, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Mobile App for Treatment of Stress Urinary Incontinence: A Cost-Effectiveness Analysis2017In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 19, no 5, article id e154Article in journal (Refereed)
    Abstract [en]

    Background: Mobile apps can increase access to care, facilitate self-management, and improve adherence to treatment. Stress urinary incontinence (SUI) affects 10-35% of women and, currently, an app with instructions for pelvic floor muscle training (PFMT) is available as first-line treatment. A previous randomized controlled study demonstrated that the app benefitted symptom severity and quality of life (QoL); in this study we investigate the cost-effectiveness of the app. Objective: The objective of this study was to evaluate the health economy of the app for treating SUI. Methods: This deterministic cost-utility analysis, with a 1-year societal perspective, compared the app treatment with no treatment. Health economic data were collected alongside a randomized controlled trial performed in Sweden from March 2013 to October 2014. This study included 123 community-dwelling women participants of 18 years and above, with stress urinary incontinence >= 1 time per week. Participants were self-assessed with validated questionnaires and 2-day leakage diaries, and then randomized to 3 months of treatment (app group, n=62) or no treatment (controls, n=61). The app focused on pelvic floor muscle training, prescribed 3 times daily. We continuously registered treatment delivery costs. Data were collected on each participant's training time, incontinence aids, and laundry at baseline and at a 3-month follow-up. We measured quality of life with the International Consultation on Incontinence Modular Questionnaire on Lower Urinary Tract Symptoms and Quality of Life, and calculated the quality-adjusted life years (QALYs) gained. Data from the 3-month follow-up were extrapolated to 1 year for the calculations. Our main outcome was the incremental cost-effectiveness ratios compared between app and control groups. One-way and multiway sensitivity analyses were performed. Results: The mean age of participants was 44.7 years (SD 9.4). Annual costs were (sic)547.0 for the app group and (sic)482.4 for the control group. Annual gains in quality-adjusted life years for app and control groups were 0.0101 and 0.0016, respectively. Compared with controls, the extra cost per quality-adjusted life year for the app group ranged from -(sic) 2425.7 to (sic) 14,870.6, which indicated greater gains in quality-adjusted life years at similar or slightly higher cost. Conclusions: The app for treating stress urinary incontinence is a new, cost-effective, first-line treatment with potential for increasing access to care in a sustainable way for this patient group.

  • 192. Smits, Anja
    et al.
    Andersen, Peter M
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurology.
    Andersson, Magnus
    Andsberg, Gunnar
    Fredrikson, Sten
    Gunnarsson, Martin
    Hultgren, Margareta
    Landtblom, Anne-Marie
    Lycke, Jan
    Jensen, Svend Marup
    Naver, Hans
    Remahl, Ingela Nilsson
    Walentin, Fredrik
    [Representantives of the Swedish Neurological Association: Swedish neurology needs strong resource reinforcement]2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 36, p. 2428-9Article in journal (Other academic)
  • 193. Smits, Anja
    et al.
    Andsberg, Gunnar
    Andersen, Peter M
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurology.
    Andersson, Magnus
    Fredrikson, Sten
    Gunnarsson, Martin
    Kumlien, Eva
    Lycke, Jan
    Jensen, Svend Marup
    Remahl, Ingela Nilsson
    Nyholm, Dag
    [Changing neurology: from diagnostic to therapeutic discipline]2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 36, p. 2413-2416Article in journal (Other academic)
  • 194.
    Song, Yafeng
    et al.
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Stål, Per
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Yu, Jiguo
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine.
    Forsgren, Sture
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Bilateral increase in expression and concentration of tachykinin in a unilateral rabbit muscle overuse model that leads to myositis2013In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 14, article id 134Article in journal (Refereed)
    Abstract [en]

    Background: Tachykinins can have pro-inflammatory as well as healing effects during tissue reorganization and inflammation. Recent studies report an up-regulation in the expression of the substance P (SP)-preferred receptor, the neurokinin-1 receptor, in marked muscle inflammation (myositis). There is, however, only very little information on the expression patterns and levels of tachykinins in this situation.

    Methods: The tachykinin system was analyzed using a rabbit experimental model of muscle overuse, whereby unilateral muscle exercise in combination with electrical stimulation led to muscle derangement and myositis in the triceps surae muscle (experimental length 1--6 weeks). Evaluations were made for both parts of the muscle (soleus and gastrocnemius muscles) in experimental and non-experimental (contralateral) sides. Morphologic evaluation, immunohistochemistry, in situ hybridization and enzyme immunoassay (EIA) analyses were applied.

    Results: Myositis and muscle derangement occurred focally not only in the experimental side but also in the non-experimental side. In the inflammatory areas (focal myositis areas), there were frequent nerve fibers showing tachykinin-like immunoreactivity and which were parts of nerve fascicles and which were freely dispersed in the tissue. Cells in the inflammatory infiltrates showed tachykinin-like immunoreactivity and tachykinin mRNA expression. Specific immunoreactivity and mRNA expression were noted in blood vessel walls of both sides, especially in focally affected areas. With increasing experimental length, we observed an increase in the degree of immunoreactivity in the vessel walls. The EIA analyses showed that the concentration of tachykinin in the tissue on both sides increased in a time-dependent manner. There was a statistical correlation in the concentration of tachykinin and the level of tachykinin immunoreactivity in the blood vessel walls between experimental and non-experimental sides.

    Conclusions: The observations show an up-regulation of the tachykinin system bilaterally during muscle derangement/myositis in response to pronounced unilateral muscle overuse. This up-regulation occurred in inflammatory areas and was related not only to increased tachykinin innervation but also to tachykinin expression in blood vessel walls and inflammatory cells. Importantly, the tachykinin system appears to be an important factor not only ipsilaterally but also contralaterally in these processes.

  • 195. Sorensen, Julie
    et al.
    Johansson, Helene
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Jerdén, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Dalton, James
    Sheikh, Henna
    Jenkins, Paul
    May, John
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Health-Care Administrator Perspectives on Prevention Guidelines and Healthy Lifestyle Counseling in a Primary Care Setting in New York State2019In: HEALTH SERVICES RESEARCH AND MANAGERIAL EPIDEMIOLOGY, ISSN 2333-3928, Vol. 6, article id UNSP 2333392819862122Article in journal (Refereed)
    Abstract [en]

    Introduction: The incidence of chronic disease and treatment costs have been steadily increasing in the United States over the past few decades. Primary prevention and healthy lifestyle counseling have been identified as important strategies for reducing health-care costs and chronic disease prevalence. This article seeks to examine decision-makers' experiences and self-perceived roles in guideline and lifestyle counseling implementation in a primary care setting in the United States. Methods: Qualitative interviews were conducted with administrators at a health-care network in Upstate New York and with state-level administrators, such as insurers. Decision-makers were asked to discuss prevention guidelines and healthy lifestyle counseling, as well as how they support implementation of these initiatives. Interviews were analyzed using a thematic analysis framework and relevant sections of text were sorted using a priori codes. Results: Interviews identified numerous barriers to guideline implementation. These included the complexity and profusion of guidelines, the highly politicized nature of health-care provision, and resistance from providers who sometimes prefer to make decisions autonomously. Barriers to supporting prevention counseling included relatively time-limited patient encounters, the lack of reimbursement mechanisms for counseling, lack of patient resources, and regulatory complexities. Conclusions: Our research indicates that administrators and administrative structures face barriers to supporting prevention activities such as guideline implementation and healthy lifestyle counseling in primary care settings. They also identified several solutions for addressing existing primary prevention barriers, such as relying on nurses to provide healthy lifestyle support to patients. This article provides an important assessment of institutional readiness to support primary prevention efforts.

  • 196. Sparring, Vibeke
    et al.
    Granström, Emma
    Sachs, Magna Andreen
    Brommels, Mats
    Nyström, Monica E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE-17177 Stockholm, Sweden.
    One size fits none: a qualitative study investigating nine national quality registries' conditions for use in quality improvement, research and interaction with patients2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 802Article in journal (Refereed)
    Abstract [en]

    Background: Swedish National Quality Registries (NQRs) are observational clinical registries that have long been seen as an underused resource for research and quality improvement (QI) in health care. In recent years, NQRs have also been recognised as an area where patients can be involved, contributing with self-reported experiences and estimations of health effects. This study aimed to investigate what the registry management perceived as barriers and facilitators for the use of NQRs in QI, research, and interaction with patients, and main activities undertaken to enhance their use for these purposes. The aim was further to identify potential differences between various types of NQRs for their use in these areas.

    Methods: In this multiple case study, nine NQRs were purposively selected. Interviews (n = 18) were conducted and analysed iteratively using conventional and directed content analysis.

    Results: A recent national investment initiative enabled more intensive work with development areas previously identified by the NQR management teams. The recent focus on value-based health care and other contemporary national healthcare investments aiming at QI and public benchmarking were perceived as facilitating factors. Having to perform double registrations due to shortcomings in digital systems was perceived as a barrier, as was the lack of authority on behalf of the registry management to request participation in NQRs and QI activities based on registry outcomes. The registry management teams used three strategies to enhance the use of NQRs: ensuring registering of correct and complete data, ensuring updated and understandable information available for patients, clinicians, researchers and others stakeholders, and intensifying cooperation with them. Varied characteristics of the NQRs influenced their use, and the possibility to reach various end-users was connected to the focus area and context of the NQRs.

    Conclusions: The recent national investment initiative contributed to already ongoing work to strengthen the use of NQRs. To further increase the use, the demands of stakeholders and end-users must be in focus, but also an understanding of the NQRs' various characteristics and challenges. The end-users may have in common a need for training in the methodology of registry based research and benchmarking, and how to be more patient-centred.

  • 197. Spelman, T.
    et al.
    Geale, Kirk
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Anell, B.
    Hillert, J.
    Wong, S. L.
    The association between disease activity and health-related quality of life in RRMS patients2017In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 20, no 9, p. A728-A728Article in journal (Other academic)
    Abstract [en]

    Objectives: Relapse-remitting multiple sclerosis (RRMS) is the most common disease course of multiple sclerosis (MS) patients. Disease activity (DA) has been shown to impact intermediate clinical outcomes including relapse rates and disease progression. However, it is unclear to what extent DA is related to ultimate health outcomes such as health-related quality of life (HRQoL). This study investigates the association between HRQoL and DA. Methods: Generic HRQoL was measured using the EQ-5D-3L utility instrument index value under the United Kingdom tariff. A cohort of 3496 adult RRMS patients enrolled in the Swedish population-based MS register during 1996-2015 (inclusive) was included from the date of first recorded EQ-5D-3L assessment (baseline). Patients were grouped according to DA within +/- 12 months of baseline. Active disease was the reference group, defined as 1+ relapse or T2 lesion. Two high disease activity groups were considered: HDA-R defined as 2+ relapses recorded within 1 year of each other, or Highly Active RRMS (HA-RRMS) defined as 9+ T2 lesions or 1+ gadolinium-enhanced T1 lesion. Patients not fulfilling any DA criteria were labelled unclassified. A general estimating equation was used to analyse the association between longitudinal EQ-5D-3L and disease activity group; adjusting for age, sex, proportion of time treated with disease modifying treatment (%DMT), and time since registry enrolment. Results: HA-RRMS was associated with a statistically significant decrease in EQ-5D-3L (coefficient -0.01, p=0.04). HDA-R and unclassified patients were not statistically significantly associated with EQ-5D-3L. Female sex and increasing age were significantly associated with decreasing EQ-5D-3L, while %DMT and time since registry enrolment were significantly associated with increasing EQ-5D-3L. Conclusions: HA-RRMS is associated with lower HRQoL over time, although it is unclear whether it is clinically significant. Additional data and modelling may be required to uncover the subtleties of the relationship between DA and HRQoL.

  • 198.
    Stewart Williams, Jennifer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Research Centre for Gender, Health and Ageing, University of Newcastle, Australia.
    Ling, Rod
    Searles, Andrew M
    Doran, Christopher M
    Byles, Julie
    Identification of higher hospital costs and more frequent admissions among mid-aged Australian women who self-report diabetes mellitus2016In: Maturitas, ISSN 0378-5122, E-ISSN 1873-4111, Vol. 90, p. 58-63Article in journal (Refereed)
    Abstract [en]

    Objective: To ascertain whether the hospital costs for mid-aged Australian women who self-reported diabetes mellitus (DM) and who had one or more hospital admission during an eight and a half year period were higher than the hospital costs for other similarly aged non-DM women. Methods: The sample comprised 2,392 mid-aged women, resident in New South Wales (NSW) Australia and participating in the Australian Longitudinal Study on Women’s Health (ALSWH), who had any NSW hospital admissions during the eight and a half year period 1 July 2000 to 31 December 2008. Analyses were conducted on linked data from ALSWH surveys and the NSW Admitted Patient Data Collection (APDC). Hospital costs were compared for the DM and non-DM cohorts of women. A generalized linear model measured the association between hospital costs and self-reported DM. Results: Eight and a half year hospital costs were 41% higher for women who self-reported DM in the ALSWH surveys (p < 0.0001). On average, women who self-reported DM had significantly (p < 0.0001) more hospital admissions (5.3) than women with no reported DM (3.4). The average hospital stay per admission was not significantly different between the two groups of women. Conclusions: Self-reported DM status in mid-aged Australian women is a predictor of higher hospital costs. This simple measure can be a useful indicator for public policy makers planning early-stage interventions that target people in the population at risk of DM.

  • 199.
    Strehlenert, H
    et al.
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm.
    Richter-Sundberg, Linda
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm.
    Nyström, Monica
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm.
    Hasson, H
    Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm; Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm; Center for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden.
    Evidence-informed policy formulation and implementation: a comparative case study of two national policies for improving health and social care in Sweden2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, no 1, p. 169-179Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Evidence has come to play a central role in health policymaking. However, policymakers tend to use other types of information besides research evidence. Most prior studies on evidence-informed policy have focused on the policy formulation phase without a systematic analysis of its implementation. It has been suggested that in order to fully understand the policy process, the analysis should include both policy formulation and implementation. The purpose of the study was to explore and compare two policies aiming to improve health and social care in Sweden and to empirically test a new conceptual model for evidence-informed policy formulation and implementation.

    METHODS: Two concurrent national policies were studied during the entire policy process using a longitudinal, comparative case study approach. Data was collected through interviews, observations, and documents. A Conceptual Model for Evidence-Informed Policy Formulation and Implementation was developed based on prior frameworks for evidence-informed policymaking and policy dissemination and implementation. The conceptual model was used to organize and analyze the data.

    RESULTS: The policies differed regarding the use of evidence in the policy formulation and the extent to which the policy formulation and implementation phases overlapped. Similarities between the cases were an emphasis on capacity assessment, modified activities based on the assessment, and a highly active implementation approach relying on networks of stakeholders. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was empirically useful to organize the data.

    CONCLUSIONS: The policy actors' roles and functions were found to have a great influence on the choices of strategies and collaborators in all policy phases. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was found to be useful. However, it provided insufficient guidance for analyzing actors involved in the policy process, capacity-building strategies, and overlapping policy phases. A revised version of the model that includes these aspects is suggested.

  • 200.
    Sturesson, Marine
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy.
    Primärvårdens arbete med sjukskrivna – patientmötet, bedömningar och samverkan2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The ability to work can be reduced if a person has health problems which may lead to periods of sick leave. In Sweden sickness certification is issued by physicians. Many general practitioners (GPs) find sickness certification to be problematic. Some studies indicate that collaboration with other health care professions could be beneficial. The aim of the thesis was to provide knowledge on how the work with the sick leave process in primary health care can be improved and how occupational therapists’ (OT) assessment could be used prior to the decision on sick leave and rehabilitation. Initially seven focus groups were held, four with OTs and three with physicians. The discussions in the focus gropes were analysed by qualitative content analysis. An intervention project was initiated, where four health care centres in northern Sweden tested a working approach where sick listed patients were offered a supplementary assessment of activity and work-related problems by an OT. Data on sick leave, sickness certificates and patient questionnaires were collected from intervention health care centres (IHCC) and other health care centres (OHCC). Interviews were conducted with patients, GPs and OTs. The quality of the information in the collected sickness certificates was evaluated. Average values of sick leave were compared between the IHCCs and the OHCCs in the county. The interviews with sick listed patients were analysed by qualitative content analysis. In order to analyse the implementation of the intervention the Consolidated Framework for Implementation Research, CFIR, was used. An overall theme and four categories emerged from the focus groups. The theme expressed work ability as an obscure, complex and unique concept. The four categories illustrate the affecting factors and confirmed the complex structure of work ability: the person, the context of life, the work, and the society. No significant differences between IHCCs and OHCCs in data on sick leave or the mandatory information in the certificates were found. Thirty-four percent of the collected sickness certificates did not contain all requested information. More certificates issued for women than certificates issued for men lacked the required information. Full-time sick leave was significantly more often prescribed for male patients than for female. Two themes revealed that highlight important areas for persons on sick leave in their healthcare encounters. The theme ‘Trust in the relationship’ contains categories describing the patients’ feelings of participation, being believed, confirmed, and listened to. The second theme ‘Structure and balance’ contains the participants’ views on important factors that could facilitate the return-to-work process such as a structured plan and support to balance activity. The analysis with CFIR clarified that coaching and education for all the users are crucial to get fidelity when new interventions are tested as well as involvement by the clinical department manager. The work with sick leave issues in primary health care can be improved by developing cooperation with several different professionals. To achieve an increased cooperation new working approaches are required. These working approaches must be anchored in management and requires an applied implementation strategy. More focus on the quality of encounters with healthcare professionals can also improve the sick leave process in primary health care centres. The healthcare encounters must build on a mutual trust and sick-listed persons’ return to work can be facilitated by providing a clear structure in the process and support in occupational balance. For issuing sickness certification further education about the descriptions of functioning and the tasks included in the patient’s work is needed. A better gender awareness in the health care encounters is also necessary.

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