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  • 201.
    Sundberg, Linda
    et al.
    Centrum för psykiatriforskning.
    Fredelius, Gunilla
    Lindqvist, Cecilia
    Sandell, Rolf
    Sandahl, Christer
    Schubert, Johan
    Prioritering av patienter för psykoterapi: formella och informella kriterier i praktisk tillämpning2009Report (Other (popular science, discussion, etc.))
  • 202. Sundström, Johan
    et al.
    Björkelund, Cecilia
    Giedraitis, Vilmantas
    Hansson, Per-Olof
    Högman, Marieann
    Janson, Christer
    Koupil, Ilona
    Kristenson, Margareta
    Lagerros, Ylva Trolle
    Leppert, Jerzy
    Lind, Lars
    Lissner, Lauren
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, School of Dentistry.
    Ludvigsso, Jonas F.
    Nilsson, Peter M.
    Olsson, Håkan
    Pedersen, Nancy L.
    Rosenblad, Andreas
    Rosengren, Annika
    Sandin, Sven
    Snackerstrom, Tomas
    Stenbeck, Magnus
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Heart Center, Umeå University, Umeå.
    Weiderpass, Elisabete
    Wanhainen, Ers
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Fortier, Isabel
    Heller, Susanne
    Storgards, Maria
    Svennblad, Bodil
    Rationale for a Swedish cohort consortium2019In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 124, no 1, p. 21-28Article in journal (Refereed)
    Abstract [en]

    We herein outline the rationale for a Swedish cohort consortium, aiming to facilitate greater use of Swedish cohorts for world-class research. Coordination of all Swedish prospective population-based cohorts in a common infrastructure would enable more precise research findings and facilitate research on rare exposures and outcomes, leading to better utilization of study participants' data, better return of funders' investments, and higher benefit to patients and populations. We motivate the proposed infrastructure partly by lessons learned from a pilot study encompassing data from 21 cohorts. We envisage a standing Swedish cohort consortium that would drive development of epidemiological research methods and strengthen the Swedish as well as international epidemiological competence, community, and competitiveness.

  • 203.
    Szilcz, Máté
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Income inequalities in leisure time physical inactivity in northern Sweden: a decomposition analysis2019In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed)
    Abstract [en]

    AIMS: Increasing income inequalities in leisure time physical inactivity have been reported in the relatively socially equal setting of northern Sweden. The present report seeks to contribute to the literature by exploring the contribution of different factors to the income inequalities in leisure time physical inactivity in northern Sweden.

    METHODS: This study was based on the 2014 Health on Equal Terms survey, distributed in the four northernmost counties of Sweden. The analytical sample consisted of 21,000 respondents aged 16-84. Six thematic groups of explanatory variables were used: demographic variables, socioeconomic factors, material resources, family-, psychosocial conditions and functional limitations. Income inequalities in leisure time physical inactivity were decomposed by Wagstaff-type decomposition analysis.

    RESULTS: Income inequalities in leisure time physical inactivity were found to be explained to a considerable degree by health-related limitations and unfavourable socioeconomic conditions. Material and psychosocial conditions seemed to be of moderate importance, whereas family and demographic characteristics were of minor importance.

    CONCLUSIONS: This study suggests that in order to achieve an economically equal leisure time physical inactivity, policy may need to target the two main barriers of functional limitations and socioeconomic disadvantages.

  • 204.
    Söderholm, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Validation of Hospital Performance Measures of Acute Stroke Care Quality. Riksstroke, the Swedish Stroke Register2016In: Neuroepidemiology, ISSN 0251-5350, E-ISSN 1423-0208, Vol. 46, no 4, p. 229-234Article in journal (Refereed)
    Abstract [en]

    Background: Registers are increasingly used to monitor stroke care performance. Fair benchmarking requires sufficient data quality. We have validated acute care data in Riksstroke, the Swedish Stroke Register.

    Methods: Completeness was assessed by comparisons with diagnoses at hospital discharge recorded in the compulsory National Patient Register and content validity by comparisons with (a) key variables identified by European stroke experts, and (b) items recorded in other European stroke care performance registers. Five test cases recorded by 67 hospitals were used to estimate inter-hospital reliability.

    Results: All 72 Swedish hospitals admitting acute stroke patients participated in Riksstroke. The register was estimated to cover at least 90% of acute stroke patients. It includes 18 of 22 quality indicators identified by international stroke experts and 14 of 15 indicators used by at least 2 stroke performance registers in other European countries. Inter-hospital reliability was high (85%) in 77 of 81 Riksstroke items.

    Conclusions: A nationwide stroke care register can be maintained with sufficient data quality to permit between-hospital performance benchmarking. Our experiences may serve as a model for other stroke registers while evaluating data quality.

  • 205.
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Participatory approaches to strengthening district health managers' capacity: Ugandan and global experiences2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Introduction:

    Residents of low in-come countries have persistently suffered poor health outcomes, modest progress made over time notwithstanding. Weak health systems are one of the key reasons for the less than optimum progress. These health systems are constrained by inadequately equipped managers who play a main role in curbing this progress. Strengthening the capacity of health managers capacity is one of the known ways to improve the performance of health systems. This study examined strategies for strengthening the capacity of health managers at the sub-national level, with a special focus on the Participatory Action Research (PAR) approach.

    Methods:

    I used an emergent qualitative design which included both primary data collection and a literature review. Primary data collection techniques included individual interviews, Focus Group Discussions (FGDs), participant observations, and a review of project documents and meeting minutes, while searching for peer-reviewed databases was used for the literature review. Several analytical tools were adopted to answer the objectives, including the grounded theory, content and thematic analysis approaches. The Critical Interpretive Synthesis (CIS) method was used to analyze the literature reviewed.

    Findings:

    Stakeholders’ perceived the approaches to strengthening health managers’ capacity as an overarching process comprised of three interconnected subprocesses namely: the professionalizing of health managers, the use of engaging approaches to learning, and the availability of a supportive work environment. PAR as an engaging approach to learning was experienced by stakeholders as a nuanced awakening approach. On the one hand, stakeholders felt engaged, valued, responsible, awakened and a sense of ownership. On the other hand, they felt conflicted, stressed and uncertain. The PAR approach enhanced health managers’ capacity to collaborate with others, be creative, attain goals, and review progress. Expanded spaces for interaction, the encouragement of flexibility, the empowerment of local managers and the promotion of reflection and accountability enabled this enhancement. Lastly, the literature reviewed revealed five interrelated elements for harnessing PAR to strengthen health managers capacity. These were: a shared purpose, skilled facilitation and social psychological safety, activity integration into organizational procedures, organizational support and supportive external monitoring.

    Conclusions:

    Health managers have a central role in strengthening health systems; hence the formalization of their role, especially within the public-sector, is needed. In addition, significant investments into developing and strengthening their capacity is required. Strengthening the capacity of health managers is an iterative process that draws synergies from different approaches. The process leans on formal trainings as well as more engaging means of learning, such as PAR. As an engaging approach to learning, PAR expands interaction spaces, provides inclusiveness and flexibility, promotes local ingenuity and shared responsibility, and allows for monitoring and learning. PAR had positive effects on the strengthening of the capacity of health managers while at the same time achieving other project outcomes. Participatory approaches are hence relevant for dealing with the complex challenges bedevilling health systems. The approach nonetheless should be applied with a more nuanced appreciation of the challenges when using it and the elements for harnessing it to strengthen health systems.

  • 206.
    Tetui, Moses
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Zulu, Joseph Mumba
    School of Public Health, University of Zambia, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ekirapa-Kiracho, Elizabeth
    Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Kiwanuka, Suzanne N.
    Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Coe, Anna-Britt
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Elements for harnessing participatory action research to strengthen health managers’ capacity: a critical interpretative synthesis2018In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 16, article id 33Article, review/survey (Refereed)
    Abstract [en]

    Background: Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers’ capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers’ capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter.

    Methods: A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers’ capacity. The critical interpretive synthesis method’s approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104–111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains.

    Results: Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers’ capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning.

    Conclusions: The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers’ capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.

  • 207. Thorlin, Thorleif
    et al.
    Wikkelsø, Carsten
    Landtblom, Anne-Marie
    Brundin, Lou
    Fredrikson, Sten
    Malm, Jan
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurology.
    Mattson, Peter
    Petersson, Jesper
    Lindgren, Arne
    [Neurological issues common during internship. A questionnaire study as a basis for continuous development of neurology teaching].2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 108, no 4, p. 152-155Article in journal (Refereed)
    Abstract [en]

    To obtain knowledge if basic medical education satisfies the demands the medical graduates face during internship is a basis for the design and evaluation of teaching.The aim of the study was to evaluate the physicians’ satisfaction with the teaching of neurology at universities in Sweden subsequent to having tested the obtained skills in the 21 months internship needed for Swedish physician licence.A questionnaire with 23 questions was sent in 2007 to 1628 newly licensed doctors who received their cards between 2005-01-01 and 2007-10-09, after completing Swedish internship.Onethousand-fiftyone physicians (65%) answered the questionnaire. Most felt that the quality of the theoretical and practical education in neurology obtained at the university was good or very good. Physicians with less coherent university neurology teaching time indicated to a greater degree that teaching time at the undergraduate level was too short. The physicians indicated that neurological issues are common during the internship. A majority indicated that that they had received too little training in neurology during their internship. The results give a good feedback for further development of neurology teaching. Similar studies could be carried out also for other areas of graduate medical education.

  • 208.
    Tinc, Pamela J.
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Northeast Center for Occupational Health and Safety: Agriculture, Forestry, and Fishing; Cooperstown, NY, USA.
    Jenkins, Paul
    Bassett Healthcare Network Research Institute, Cooperstown, NY, USA.
    Sorensen, Julie A.
    Bassett Healthcare Network Research Institute, Cooperstown, NY, USA.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gadomski, Anne
    Lindvall, Kristina
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Key factors for successful implementation of the National Rollover Protection Structure Rebate Program: A correlation analysis using the consolidated framework for implementation research2019In: Scandinavian Journal of Work, Environment and Health, ISSN 0355-3140, E-ISSN 1795-990XArticle in journal (Refereed)
    Abstract [en]

    Objectives: On US farms, tractor overturns are the leading cause of death; however, these fatalities are preventable with the use of a rollover protection structure (ROPS). A ROPS rebate program was established in New York in 2006 to address these fatalities. Due to its success, the program expanded to six additional states before being implemented as the National ROPS Rebate Program (NRRP) in 2017. The aim of this study was to evaluate the success of the NRRP implementation using short- and long-term ROPS outcome measures and identify which components of the consolidated framework for implementation research (CFIR) correlate with these outcomes.

    Methods: Stakeholders involved in the NRRP implementation were surveyed at four time points, beginning at the time of the NRRP launch and then every six months. These surveys measured 14 relevant CFIR constructs. Correlations between CFIR survey items (representing constructs) and three outcome measures (intakes, funding progress, and retrofits) were used to identify CFIR survey items that are predictive of the outcomes.

    Results: Eight CFIR survey items were highly correlated (rho ≥0.50) with at least one of the three outcome measures. These eight CFIR survey items included four constructs: access to knowledge and information, leadership engagement, engaging (in fundraising and funding requests), and reflecting and evaluating.

    Conclusions: The results of this study provide important guidance for continuing the implementation of the NRRP. Similarly, these findings can inform the evaluation of other similarly structured implementation efforts and the application of CFIR in a variety of settings.

  • 209.
    Tistad, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. School of Education, Health and Social Studies, Dalarna University, Falun, Sweden; Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
    Palmcrantz, Susanne
    Wallin, Lars
    Ehrenberg, Anna
    Olsson, Christina B.
    Tomson, Goeran
    Holmqvist, Lotta Widen
    Gifford, Wendy
    Eldh, Ann Catrine
    Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness2016In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 5, no 8, p. 477-486Article in journal (Refereed)
    Abstract [en]

    Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers' leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention's potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers' behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

  • 210. Tolf, Sara
    et al.
    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, Karolinska Institutet, Stockholm.
    Tishelman, Carol
    Brommels, Mats
    Hansson, Johan
    Agile, a guiding principle for health care improvement?2015In: International Journal of Health Care Quality Assurance, ISSN 0952-6862, E-ISSN 1758-6542, Vol. 28, no 5, p. 468-493Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The purpose of this paper is to contribute to increased understanding of the concept agile and its potential for hospital managers to optimize design of organizational structures and processes to combine internal efficiency and external effectiveness.

    DESIGN/METHODOLOGY/APPROACH: An integrative review was conducted using the reSEARCH database. Articles met the following criteria: first, a definition of agility; second, descriptions of enablers of becoming an agile organization; and finally, discussions of agile on multiple organizational levels. In total, 60 articles qualified for the final analysis.

    FINDINGS: Organizational agility rests on the assumption that the environment is uncertain, ranging from frequently changing to highly unpredictable. Proactive, reactive or embracive coping strategies were described as possible ways to handle such uncertain environments. Five organizational capacities were derived as necessary for hospitals to use the strategies optimally: transparent and transient inter-organizational links; market sensitivity and customer focus; management by support for self-organizing employees; organic structures that are elastic and responsive; flexible human and resource capacity for timely delivery. Agile is portrayed as either the "new paradigm" following lean, the needed development on top of a lean base, or as complementary to lean in distinct hybrid strategies.

    PRACTICAL IMPLICATIONS: Environmental uncertainty needs to be matched with coping strategies and organizational capacities to design processes responsive to real needs of health care. This implies that lean and agile can be combined to optimize the design of hospitals, to meet different variations in demand and create good patient management.

    ORIGINALITY/VALUE: While considerable value has been paid to strategies to improve the internal efficiency within hospitals, this review raise the attention to the value of strategies of external effectiveness.

  • 211. Tolley, C.
    et al.
    Mullins, A.
    Kilgariff, S.
    Arbuckle, R.
    Green, J.
    Burstedt, Marie
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Ophthalmology.
    Holopigian, K.
    Stasi, K.
    Sloesen, B.
    Qualitative interviews to inform development of a patient reported outcome (PRO) strategy in RLBP1 retinitis pigmentosa (RLBP1 RP)2017In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 20, no 9, p. A761-A761Article in journal (Other academic)
    Abstract [en]

    Objectives: RLBP1 RP is a rare autosomal recessive form of retinitis pigmentosa (RP), characterized by night blindness, prolonged dark adaptation, constricted visual fields and reduced macular function. This study aimed to better understand the patient experience of RLBP1 RP and to evaluate the content validity of existing patient reported outcome (PRO) instruments in this condition. Methods: This qualitative study involved 90 minute, semi-structured, concept elicitation and cognitive debriefing interviews with patients with RLBP1 RP in Canada (n=10) and Sweden (n=11). Qualitative analysis of anonymized, verbatim transcripts was performed using Atlas.Ti software and thematic analysis methods. Participants were cognitively debriefed on The National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25), Low Luminance Questionnaire (LLQ) and four items of the Visual Activities Questionnaire (VAQ). Results: Fourteen visual symptoms were reported. The symptoms most frequently reported were night blindness (n=21), difficulty adapting to changes in lighting (n=21) and difficulties seeing in bright lighting (n=18). Impacts on daily activities (n=21) and physical functioning (n=17) were important to participants. Other domains of quality of life affected included social functioning (n=21), emotional functioning (n=19), work and education (n=18), and psychological functioning (n=17). Participant understanding and interpretation of the NEI VFQ-25 and LLQ was mixed. Patients reported that examples in single items represented different levels of functional impairment. In addition, some items did not specify what lighting conditions should be considered when responding. LLQ items were more relevant to RLBP1 RP than NEI VFQ-25 items. The four VAQ items assessing light/dark adaptation were well understood and relevant to participants. There were both gaps and overlaps in conceptual coverage of the instruments. Conclusions: The symptoms of RLBP1 RP have a substantial impact on patients’ daily lives and physical functioning. Issues have been identified with conceptual coverage, rel- evance and patient understanding of the NEI VFQ-25, LLQ and VAQ in RLBP1 RP.

  • 212. Tozan, Yesim
    et al.
    Ratanawong, Pitcha
    Sewe, Maquines Odhiambo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wilder-Smith, Annelies
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Heidelberg Univ, Med Sch, Inst Publ Hlth, Heidelberg, Germany; Nanyang Technol Univ, Lee Kong Chian Sch Med, Singapore, Singapore.
    Kittayapong, Pattamaporn
    Household costs of hospitalized dengue illness in semi-rural Thailand2017In: PLoS Neglected Tropical Diseases, ISSN 1935-2727, E-ISSN 1935-2735, Vol. 11, no 9, article id e005961Article in journal (Refereed)
    Abstract [en]

    Background

    Dengue-related illness is a leading cause of hospitalization and death in Thailand and other Southeast Asian countries, imposing a major economic burden on households, health systems, and governments. This study aims to assess the economic impact of hospitalized dengue cases on households in Chachoengsao province in eastern Thailand.

    Methods

    We conducted a prospective cost-of-illness study of hospitalized pediatric and adult dengue patients at three public hospitals. We examined all hospitalized dengue cases regardless of disease severity. Patients or their legal guardians were interviewed using a standard questionnaire to determine household-level medical and non-medical expenditures and income losses during the illness episode.

    Results

    Between March and September 2015, we recruited a total of 224 hospitalized patients (< 5 years, 4%; 5-14 years, 20%, 15-24 years, 36%, 25-34 years, 15%; 35-44 years, 10%; 45+ years, 12%), who were clinically diagnosed with dengue. The total cost of a hospitalized dengue case was higher for adult patients than pediatric patients, and was US$153.6 and US$166.3 for pediatric DF and DHF patients, respectively, and US$171.2 and US$226.1 for adult DF and DHF patients, respectively. The financial burden on households increased with the severity of dengue illness.

    Conclusions

    Although 74% of the households reported that the patient received free medical care, hospitalized dengue illness cost approximately 19-23% of the monthly household income. These results indicated that dengue imposed a substantial financial burden on households in Thailand where a great majority of the population was covered by the Universal Coverage Scheme for health care.

  • 213.
    Umefjord, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Internet consultation in medicine: studies of a text-based Ask the doctor service2006Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The overall aim of this thesis was to cast light on the new phenomenon of Internet-based medical consultation. This was approached by studies of the use of an Ask the doctor service, by a web survey to the users who sent enquiries to the service, and by a questionnaire to the answering physicians of their respective expericence of the service.

    Written communication is becoming increasingly important, not only for communication between individuals outwith health care (e.g. by email, SMS and instant messaging), but also between doctors and patients. There is an ongoing shift in the way individuals look for medical information with an increasing number going first to the Internet berfore talking with their physicians. Also, there is an increasing interest from patients in accessing Internet-based services, including text-based consultations with doctors. These consultations can be part of the regular communication between a patient and his/her doctor or be carried out without any previous relationship. Our studies of the latter consultation type emanate from the free of charge Ask the doctor service at a Swedish public health web portal, Infomedica, financed by health authorities. At the Ask the doctor service, the communication has been merely text-based and the individual using the consultation service (here called the enquirer) might have been anonymous.

    We followed the development of the first four years use of the service (38 217 enquiries), finding that the typical enquirer was a woman aged 21-60 years. Three quarters of the enquirers were women, thus exceeding the gender difference seen in regular health care. The service was used all times of the day and night, seven days a week, and it was most used in densely populated areas as defined from postal codes.

    The enquiries submitted to the service included a broad variety of medical issues. Most enquirers asked on their own behalf. Almost half of the enquiries concerned a matter not previously evaluated by a medical professional. Only a few were frequent enquirers. The service was used e.g. for a primary evaluation of a medical problem, for getting more information on a medical issue under treatment, and for a second opinion. The most common reasons for turning to a doctor on the Internet were convenience, wish for anonymity and that doctors were experinced too busy. In free text a considerable number of participants expressed discontent and communication problems with a previous doctor as a reason to turn to the Ask the doctor service. Many participants expressed a view of the service as a complement to regular health care, and the majority were satisfied with the answer. Nearly half of the participants in the web survey stated that they received sufficient information in their answer and that they would not pursue their question further.

    The family physicians answering the enquiries at the Ask the doctor service were stimulated and challenged by the new task, in spite of the limitations caused by the lack of personal meetings and physical examinations. The opportunity to reflect on the answer before replying was appreciated, and the task was regarded as having a high educational value for themselves.

    The Internet not only allows easy access to medical information but also to medical consultation – to date mostly text-based. It is probable that in the near future an increasing number of doctors will adopt text-based communication via the Internet to be a natural part of their communication with patients. Therefore, training in text-based communication and carrying out Internet consultations should be integrated into the curricula of medical schools and of continuous professional development. Ethical guidelines should be established.

  • 214. Umefjord, Göran
    et al.
    Malker, H
    Olofsson, N
    Hensjö, LO
    Petersson, G
    Primary care phycians’ experiences of carrying out consultations on the Internet2004In: Informatics in Primary Care, ISSN 1476-0320, E-ISSN 1475-9985, Vol. 12, no 2, p. 85-90Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The internet is increasingly used for health matters, including consulting a doctor. Primary care physicians (general practitioners) will probably be involved in performing text-based consultations on the internet as a complement to physical meetings. In the present study, we explored the experiences of GPs already performing consultations on the internet: the challenges, worries and educational demands of the task. MATERIALS AND METHODS: A questionnaire was given to 21 GPs performing consultations on the internet for a public, non-commercial 'ask the doctor' service. The questionnaire was carried out at a meeting or sent by mail. The doctors answered a total of 28 questions, 12 of which included graded alternatives. RESULTS: The participating GPs were stimulated and challenged by performing consultations on the internet with previously unknown enquirers, in spite of limitations caused by the lack of personal meetings and physical examinations. The participants experienced a high educational value as a result of the problem-based learning situation induced by unfamiliar questions. The asynchronous feature was appreciated as it allowed time to reflect and perform relevant information searches before replying. Prior training and long-term experience as a family doctor were recommended before embarking on this method of consultation. CONCLUSIONS: We conclude that the GPs studied experienced their new role as internet doctors mainly in a positive way, with some limitations. With the increase in consultations on the internet, training in this technique should be integrated into the curricula of medical schools and of continuous professional development (CPD).

  • 215.
    Uzochukwu, Benjamin
    et al.
    Enugu, Nigeria.
    Mbachu, Chinyere
    Enugu, Nigeria.
    Onwujekwe, Obinna
    Enugu, Nigeria.
    Okwuosa, Chinenye
    Enugu, Nigeria.
    Etiaba, Enyi
    Enugu, Nigeria.
    Nyström, Monica E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Karolinska Institutet, Stockholm, Sweden.
    Gilson, Lucy
    Cape Town, South Africa; London, UK.
    Health policy and systems research and analysis in Nigeria: examining health policymakers' and researchers' capacity assets, needs and perspectives in south-east Nigeria.2016In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 14, article id 13Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Health policy and systems research and analysis (HPSR+A) has been noted as central to health systems strengthening, yet the capacity for HPSR+A is limited in low- and middle-income countries. Building the capacity of African institutions, rather than relying on training provided in northern countries, is a more sustainable way of building the field in the continent. Recognising that there is insufficient information on African capacity to produce and use HPSR+A to inform interventions in capacity development, the Consortium for Health Policy and Systems Analysis in Africa (2011-2015) conducted a study with the aim to assess the capacity needs of its African partner institutions, including Nigeria, for HPSR+A. This paper provides new knowledge on health policy and systems research assets and needs of different stakeholders, and their perspectives on HPSR+A in Nigeria.

    METHODS: This was a cross-sectional study conducted in the Enugu state, south-east Nigeria. It involved reviews and content analysis of relevant documents and interviews with organizations' academic staff, policymakers and HPSR+A practitioners. The College of Medicine, University of Nigeria, Enugu campus (COMUNEC), was used as the case study and the HPSR+A capacity needs were assessed at the individual, unit and organizational levels. The HPSR+A capacity needs of the policy and research networks were also assessed.

    RESULTS: For academicians, lack of awareness of the HPSR+A field and funding were identified as barriers to strengthening HPSR+A in Nigeria. Policymakers were not aware of the availability of research findings that could inform the policies they make nor where they could find them; they also appeared unwilling to go through the rigors of reading extensive research reports.

    CONCLUSION: There is a growing interest in HPSR+A as well as a demand for its teaching and, indeed, opportunities for building the field through research and teaching abound. However, there is a need to incorporate HPSR+A teaching and research at an early stage in student training. The need for capacity building for HPSR+A and teaching includes capacity building for human resources, provision and availability of academic materials and skills development on HPSR+A as well as for teaching. Suggested development concerns course accreditation, development of short courses, development and inclusion of HPSR+A teaching and research-specific training modules in school curricula for young researchers, training of young researchers and improving competence of existing researchers. Finally, we could leverage on existing administrative and financial governance mechanisms when establishing HPSR+A field building initiatives, including staff and organizational capacity developments and course development in HPSR+A.

  • 216. Uzochukwu, Benjamin
    et al.
    Onwujekwe, Obinna
    Mbachu, Chinyere
    Okwuosa, Chinenye
    Etiaba, Enyi
    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 (LIME), Karolinska Institutet, 171 77 Stockholm, Sweden.
    Gilson, Lucy
    The challenge of bridging the gap between researchers and policy makers: experiences of a Health Policy Research Group in engaging policy makers to support evidence informed policy making in Nigeria2016In: Globalization and Health, ISSN 1744-8603, E-ISSN 1744-8603, Vol. 12, article id 67Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Getting research into policy and practice (GRIPP) is a process of going from research evidence to decisions and action. To integrate research findings into the policy making process and to communicate research findings to policymakers is a key challenge world-wide. This paper reports the experiences of a research group in a Nigerian university when seeking to 'do' GRIPP, and the important features and challenges of this process within the African context.

    METHODS: In-depth interviews were conducted with nine purposively selected policy makers in various organizations and six researchers from the universities and research institute in a Nigerian who had been involved in 15 selected joint studies/projects with Health Policy Research Group (HPRG). The interviews explored their understanding and experience of the methods and processes used by the HPRG to generate research questions and research results; their involvement in the process and whether the methods were perceived as effective in relation to influencing policy and practice and factors that influenced the uptake of research results.

    RESULTS: The results are represented in a model with the four GRIPP strategies found: i) stakeholders' request for evidence to support the use of certain strategies or to scale up health interventions; ii) policymakers and stakeholders seeking evidence from researchers; iii) involving stakeholders in designing research objectives and throughout the research process; and iv) facilitating policy maker-researcher engagement in finding best ways of using research findings to influence policy and practice and to actively disseminate research findings to relevant stakeholders and policymakers. The challenges to research utilization in health policy found were to address the capacity of policy makers to demand and to uptake research, the communication gap between researchers, donors and policymakers, the management of the political process of GRIPP, the lack of willingness of some policy makers to use research, the limited research funding and the resistance to change.

    CONCLUSIONS: Country based Health Policy and Systems Research groups can influence domestic policy makers if appropriate strategies are employed. The model presented gives some direction to potential strategies for getting research into policy and practice in the health care sector in Nigeria and elsewhere.

  • 217. van Tongeren-Alers, Margret
    et al.
    van Esch, Maartje
    Verdonk, Petra
    Johansson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hamberg, Katarina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lagro-Janssen, Toine
    Are New Medical Students' Specialty Preferences Gendered?: Related Motivational Factors at a Dutch Medical School2011In: Teaching and learning in medicine, ISSN 1040-1334, E-ISSN 1532-8015, Vol. 23, no 3, p. 263-268Article in journal (Refereed)
    Abstract [en]

    Background: Female students currently outnumber male students in most medical schools. Some medical specialties are highly gender segregated. Therefore, it is interesting to know whether medical students have early specialization preferences based on their gender. Consequently, we like to know importance stipulated to motivational factors. Aim: Our study investigates new medical students' early specialization preferences and motivational factors. Methods: New students at a Dutch medical school (n = 657) filled in a questionnaire about specialty preferences (response rate = 94%; 69.5% female, 30.5% male). The students chose out of internal medicine, psychiatry, neurology, pediatrics, surgery, gynecology and family medicine, " other"or "I don't know." Finally, they valued ten motivational factors. Results: Forty percent of the medical students reported no specialty preference yet. Taken together, female medical students preferred pediatrics and wished to combine work and care, whereas male students opted for surgery and valued career opportunities. Conclusions: Gender-driven professional preferences in new medical students should be noticed in order to use competencies. Changes in specialty preferences and motivational factors in pre- and post graduates should further assess the role of medical education.

  • 218. Vedin, Tomas
    et al.
    Edelhamre, Marcus
    Karlsson, Mathias
    Bergenheim, Michael
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Larsson, Per-Anders
    Management of Traumatic Brain Injury in the Emergency Department: Guideline Adherence and Patient Safety2017In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 26, no 4, p. 190-195Article in journal (Refereed)
    Abstract [en]

    Background: Traumatic brain injury is a common reason not only for emergency visits worldwide but also for significant morbidity and mortality. Several clinical guidelines exist but adherence is generally low.

    Aim: To study attitudes toward computed tomography of the head among emergency department Change to physicians throughout the article who manage patients with trauma to the head and doctors' adherence to guidelines.

    Methods: Quantitative questionnaire study with questionnaires collected over 3 months before introduction of new guidelines. After introduction, intermission of 8 months passed when information and education were given. Thereafter, questionnaires were collected for another 3 months.

    Results: A total of 694 patients were registered at the emergency department. A total of 161 questionnaires were analyzed; 50.9% did not use guidelines, 39% before intermission, and 60.5% after. When Canadian CT Head Rule was applied, 30.4% of patients with no loss of consciousness were referred to computed tomography, violating guideline recommendation.

    Conclusion: Guidelines are designed to improve performance but are not always applied correctly or as frequently as intended. Information and education did not increase guideline adherence. To improve guideline adherence, more innovative measures than formal guidelines must be undertaken. To find out what these measures are, we suggest qualitative studies to elucidate interventions that will have bigger impact on performance.

  • 219. Virhage, M.
    et al.
    Polyzoi, M.
    Geale, Kirk
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Parexel International, Stockholm, Sweden.
    Corcoran, K.
    Anell, B.
    Review of health economic models for antibiotics2016In: ISPOR 19TH ANNUAL EUROPEAN CONGRESS RESEARCH ABSTRACTS, ELSEVIER SCIENCE INC , 2016, Vol. 19, no 7, p. A373-A373Conference paper (Refereed)
    Abstract [en]

    Objectives: Critically appraise published health economic models evaluating treatments of bacteria resistant to antibiotics, focusing on methicillin-resistant Staphylococcus aureus (MRSA) and extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae.

    Methods: A structured literature review was conducted in Embase, identifying relevant publications by combining search facets for MRSA or ESBL, economic models, and antibiotics, excluding publications including the terms “animal” or “farm”. All search facets were search in the abstract and title, resulting in 40 publications. Two reviewers, blinded to the other’s initial evaluation, evaluated each of the titles and abstracts and found that 25 were relevant for a full review.

    Results: The absolute majority of the identified studies presented cost-effectiveness models with a decision-analytic approach and a time horizon ranging from two to four weeks. The site of infection studied was dominated by nosocomial pneumonia as well as skin and soft tissue infections caused by MRSA. Only one model concerned gram-negative pathogens. No model was identified studying ESBL as the cause of infection. The most common antibiotic agents modelled were linezolid, vancomycin, daptomycin or their combination with a median of two treatment lines modelled. One model studies the cost-effectiveness of carbapenems. Sources used for informing antibiotic efficacy data were primarily published literature, clinical trials or clinical expert opinion. The most common outcome measures modelled were direct medical costs and resource utilization as well as efficacy measured by treatment success or antibacterial usage estimates. Four models (16%) included quality-adjusted life years (QALYs) as outcome measure.

    Conclusions: The cost-effectiveness of linezolid and vancomycin for treatment of MRSA has been well-studied in various types of infections. There is a need for further cost-effectiveness and cost-benefit studies on antibiotic failure in more than two treatment lines, especially in carbapenem treatment of infections caused by ESBL, as these pose a significant resistance threat today.

  • 220. von Knorring, Mia
    et al.
    Sundberg, Linda
    Section of Personal Injury Prevention, Karolinska Institutet.
    Löfgren, Anna
    Alexanderson, Kristina
    Problems in sickness certification of patients: a qualitative study on views of 26 physicians in Sweden2008In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 26, no 1, p. 22-28Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To identify what problems physicians experience in sickness certification of patients. DESIGN: Qualitative analyses of data from six focus-group discussions. SETTING: Four counties in different regions of Sweden. PARTICIPANTS: Twenty-six physicians strategically selected to achieve variation with regard to sex, geographical location, urban/rural area, and type of clinic. RESULTS: The problems involved four areas: society and the social insurance system, the organization of healthcare, the performance of other actors in the system, and the physicians' working situation. In all areas the problems also involved manager issues such as overall leadership, organization of healthcare, and existing incentives and support systems for physicians' handling of patients' sickness certification. Many physicians described feelings of fatigue and a lack of pride in their work with sickness certification tasks, as they believed they contributed to unnecessary sickness absence and to medicalization of patients' non-medical problems. CONCLUSIONS: The problems identified have negative consequences both for patients and for the well-being of physicians. Many of the problems seem related to inadequate leadership and management of sickness certification issues. Therefore, they cannot be handled merely by training of physicians, which has so far been the main intervention in this area. They also have to be addressed on manager levels within healthcare. Further research is needed on how physicians cope with the problems identified and on managers' strategies and responsibilities in relation to these problems. If the complexity of the problems is not recognized, there is a risk that inadequate actions will be taken to solve them.

  • 221.
    Wagner, Ryan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bertram, MY
    Tollman, Stephen
    Forsgren, Lars
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Hofman, Karen
    Newton, CR
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A community health workers to improve adherence to anti-epileptic drugs in rural sub-Saharan Africa: Is it cost-effective?Article in journal (Refereed)
  • 222.
    Waldau, Susanne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Västerbotten County Council, Sweden.
    Bottom-up priority setting revised: a second evaluation of an institutional intervention in a Swedish health care organisation2015In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 119, no 9, p. 1226-1236Article in journal (Refereed)
    Abstract [en]

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

  • 223.
    Wang, Guan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Meili, Kaspar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Comparing disability weights between a Swedish and a Chinese context: Using the methods in Global Burden of Disease 2013 - A pilot study2016Independent thesis Advanced level (degree of Master (Two Years)), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    Introduction: Disability Adjusted Life Years (DALY) in the Global Burden of Diseasestudies (GBD) are a measure to describe the worldwide distribution of disability. Disabilityweights are a major part in calculating DALY. It has been discussed whether the samedisability weights can be used in different contexts.

    Aim: we aim to operationalize the methods for disability weights calculation based on theGBD 2013 study, conduct a pilot survey with Chinese and Swedish target groups, and tocheck if the disability weights are affected by the cultural contexts of China and Sweden.

    Methods: We applied procedures from the GBD 2010 and 2013 studies and chose five healthstates according to a Years Lived with Disability (YLD) ranking based on data from the GBD2013 study. We conducted a web survey with university students aged 18 to 30 from bothChina and Sweden. The survey contained eight paired comparison questions and threepopulation health equivalence questions. Probit regression was used to assess the relativedifferences between each pair of health states from paired comparison questions. To locatethe disability weight on a zero to one scale, we used the results of censored regression of thedata from the population health equivalence questions.

    Results: Of the 119 students that participated in the web survey, 58 were from China and 61from Sweden. The estimates of the regressions and the disability weights showed highvariance and inconsistencies. Although some differences of health state selection probabilitiesbetween the two groups could be indicators for different perceptions of disabilities, we cannotdraw clear conclusion on any cultural influences to disability weights between the two groups.

    Discussion: Within the half semester time, we have figured out the statistical method andused it to calculate the disability weights based on paired question surveys. We learned howto conduct survey questionnaire among students from two countries with totally differentcultures. To reach a larger sample size requires a different approach to recruit participantsthan what we used in this study. The main issue in this pilot study proofed to be theinsufficient sample size and difficulties in anchoring the disability weights on the 0 to 1 scale.Any future studies of this kind need to reach an adequate sample size, which is determined bythe required minimum differences in disability weights to differential the two groups.

    Conclusion: In this pilot study, we operationalized methods to calculate disability weights,similar to the ones used in GBD 2013 study. We conducted pilot surveys between two studentgroups in China and Sweden. The results show that in order to assess differences betweengroups, we need larger sample size than 119 to reach required precision of the disabilityweights due to its anchoring process on a 0-1 scale. Further study is needed to confirm thepossible indicator for different perceptions of disabilities found in this study. Due to thecomplexity of the statistical method, it is important to validate this method to ensure theirapplicability and accuracy in any future study. This study has fulfilled its three specificobjectives, although not the final aim of confirming the disability weights used in GBD2013study.

  • 224.
    Weinehall, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Monica
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Karolinska Institutet.
    Garvare, Rickard
    Luleå tekniska universitet.
    Johansson, Helene
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kardakis, Therese
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sundberg, Linda
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Höög, Elisabet
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Berit
    Staben för verksamhetsutveckling, Västerbottens läns landsting.
    Nationella Riktlinjer för vårdens hälsofrämjande arbete: utmaningen att gå från evidens till klinisk tillämpning. Slutrapport från Vinnvårdsprojekt A2008-0252014Report (Other academic)
  • 225.
    Westerberg, Kristina
    et al.
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Tafvelin, Susanne
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Changes in commitment to change among leaders in home help services2015In: Leadership in Health Services, ISSN 1751-1879, E-ISSN 1751-1887, Vol. 28, no 3, p. 216-227Article in journal (Refereed)
    Abstract [en]

    Purpose: The purpose of the this study was to explore the development of commitment to change among leaders in the home help services during organizational change and to study this development in relation to workload and stress. During organizational change initiatives, commitment to change among leaders is important to ensure the implementation of the change. However, little is known of development of commitment of change over time. Design/methodology/approach: The study used a qualitative design with semi-structured interviews with ten leaders by the time an organizational change initiative was launched and follow-up one year later. Thematic content analysis was used to analyze the interviews. Findings: Commitment to change is not static, but seems to develop over time and during organizational change. At the first interview, leaders had a varied pattern reflecting different dimensions of commitment to change. One year later, the differences between leaders’ commitment to change was less obvious. Differences in commitment to change had no apparent relationship with workload or stress. Research limitations/implications: The data were collected from one organization, and the number of participants were small which could affect the results on workload and stress in relation to commitment to change. Practical implications: It is important to support leaders during organizational change initiatives to maintain their commitment. One way to accomplish this is to use management team meetings to monitor how leaders perceive their situation. Originality/value: Qualitative, longitudinal and leader studies on commitment to change are all unusual, and taken together, this study shows new aspects of commitment.

  • 226.
    Westerlund, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Garvare, Rickard
    Department of Business Administration, Luleå University of Technology, Luleå, Sweden.
    Höög, Elisabet
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Information, Management and Ethics, Karolinska Institutet, Stockholm.
    Nyström, Monica
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Information, Management and Ethics, Karolinska Institutet, Stockholm.
    Facilitating system-wide organizational change in health care2015In: International Journal of Quality and Service Sciences, ISSN 1756-669X, E-ISSN 1756-6703, Vol. 7, no 1, p. 72-89Article in journal (Refereed)
    Abstract [en]

    Purpose: The purpose of this paper was to investigate the role of an intra-organizational change facilitating function (CFF) in relation to a multi-level development initiative in a health care organization. Involved actors’ views on factors in need of attention and how the CFF related to these factors were studied.

    Design/methodology/approach: A longitudinal case study design was used, combining data from questionnaires, process diaries and interviews with employees at the CFF, managers and clinic staff.

    Findings: Factors on micro, meso and macro levels, crucial to attend to, were highlighted by respondents at staff and managerial levels. The CFF related to some of these factors by acting upon them, or by developing plans to handle them, while other factors were unattended to. The CFF activities also had indirect influence on other factors. The CFF role and responsibilities were not clearly defined beforehand, and a need to clarify a division of roles and responsibilities is highlighted.

    Research limitations/implications: Our study contributes to current knowledge on facilitation of change by relating it to an organizational dimension of implementation.

    Practical implications: The description of important factors to handle during a large organizational change process and issues a CFF can encounter may aid others involved in designing and managing large organizational development initiatives.

    Originality/value:The study elaborates on less studied functions and roles of an intra-organizational CFF in relation to factors of vital importance for organizational change and development in health-care organizations.

  • 227.
    Westerlund, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Garvare, Rickard
    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, Stockholm, Sweden.
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindkvist, Marie
    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.
    Managing the initiation and early implementation of health promotion interventions: a study of a parental support programme in primary care2017In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 31, no 1, p. 128-138Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Mental health problems are increasing among children and adolescents worldwide, and parental support programmes have been suggested as one preventive intervention. However, the actual impact and low rates of adoption and sustainability of prevention programmes have proven to be a concern, and thus, further studies on their implementation are needed.

    AIM: This study focused on the initial implementation of the International Child Development Programme (ICDP) in primary care. The aim was to investigate the involved actors' views on factors likely to affect implementation and the strategies used to manage them.

    DESIGN: A case study design with a mixed-methods approach combining quantitative and qualitative data from questionnaires and interviews was used.

    METHODS: Eighty-two professionals at different positions in the involved organisations participated. Directed content analysis was used for analyses, focusing on perceived levels of importance and the manifestation of implementation factors.

    FINDINGS: Interviews and questionnaires provided descriptions of factors influencing the initial ICDP implementation. Uncertainty on how to manage important factors and vague change strategies was reported. Discrepancies in the perceived levels of importance versus manifestation were found regarding several factors, including hands-on support, time and resources, communication and information, a comprehensive plan of action, follow-ups, and external and internal collaborations. Manifested factors were a need for change, motivation and the ICDP's compatibility with existing norms, values and practices.

    CONCLUSIONS: Implementing a parental support programme in a complex setting will benefit from being preceded by a thorough examination of the intervention and the target context and the development of clear implementation strategies based on the results of that examination. This study provides insights into how and by whom knowledge on implementation is applied during the launch of a health promotion programme, and these insights might help increase the rate of adoption and the use of such programmes and thereby increase their effectiveness.

  • 228.
    Westman, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Planning primary health care provision: assessment of development work at a health centre1986Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    At the Primary Health Care Centre in Vännäs (VPHCC), northern Sweden, a development work was implemented in 1976-1980. The overall purpose was to enhance primary health care planning. In trying to improve health care delivery cooperation with community members was initiated and some organizational changes like a new appointment system, a new medical record and local care programs for some common diseases were introduced. Official statistics were also used for comparative purposes.

    The aims of the work were postulated (increased accessibility, higher continuity, more equitable distribution and enhanced cooperation) and suitable methods were designed. From postal surveys, chartreviews and administrative data (from hospitals, out-patient clinics and health centres) figures and information were collected.

    Accessibility was studied by waiting room time which was reduced and continuity, analyzed with a new concept - visit based provider continuity - was improved. The question of equitable distribution was studied by the consultation rates at different out-patient clinics. It seemed as if the local development work changed the patterns of utilization but some important issues were not decisively answered.

    Repeated postal surveys reflected the question of equitable distribution and the cooperation between the VPHCC and the community members. Positive responses were recorded in aspects like telephone accessibility and health care information. In a tracer study of diabetes the quality of care was studied. The local care program was actually implemented in the daily practice but the question of care quality needs further penetration.

    Within the frames of the development work new methods in the health care planning were introduced. Our work started from the prerequisits of the VPHCC and other health centres might find other ways of planning for care provision. On a general level, however, the structure of our work - defining aims, means and evaluation methods - can be used by others.

  • 229. Wiitavaara, Birgitta
    et al.
    Fahlström, Martin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Professionell Development.
    Djupsjöbacka, Mats
    Prevalence, diagnostics and management of musculoskeletal disorders in primary health care in Sweden: an investigation of 2000 randomly selected patient records2017In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 23, no 2, p. 325-332Article in journal (Refereed)
    Abstract [en]

    RATIONALE, AIMS AND OBJECTIVES: The aims of this study is to investigate the prevalence of patients seeking care due to different musculoskeletal disorders (MSDs) at primary health care centres (PHCs), to chart different factors such as symptoms, diagnosis and actions prescribed for patients that visited the PHCs due to MSD and to make comparisons regarding differences due to gender, age and rural or urban PHC.

    METHODS: Patient records (2000) for patients in working age were randomly selected equally distributed on one rural and one urban PHC. A 3-year period was reviewed retrospectively. For all patient records' background data, cause to the visit and diagnosis were registered. For visits due to MSD, type and location of symptoms and actions to resolve the patients problems were registered. Data was analysed using cross tabulation, multidimensional chi-squared.

    RESULTS: The prevalence of MSD was high; almost 60% of all patients were seeking care due to MSD. Upper and lower limb problems were most common. Symptoms were most prevalent in the young and middle age groups. The patients got a variety of different diagnoses, and between 13 and 35% of the patients did not receive a MSD diagnose despite having MSD symptoms. There was a great variation in how the cases were handled.

    CONCLUSIONS: The present study points out some weaknesses regarding diagnostics and management of MSD in primary care.

  • 230. Wimo, Anders
    et al.
    Jönsson, Linus
    Fratiglioni, Laura
    Sandman, Per Olof
    Umeå University, Faculty of Medicine, Department of Nursing. Division of Caring Sciences, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden; Department of Health Sciences, Luleå University of Technology, Luleå, Sweden.
    Gustavsson, Anders
    Sköldunger, Anders
    Johansson, Lennarth
    The societal costs of dementia in Sweden 2012: relevance and methodological challenges in valuing informal care2016In: Alzheimer's Research & Therapy, E-ISSN 1758-9193, Vol. 8, article id 59Article in journal (Refereed)
    Abstract [en]

    Background: In this study, we sought to estimate the societal cost of illness in dementia in Sweden in 2012 using different costing approaches to highlight methodological issues.

    Methods: We conducted a prevalence-based cost-of-illness study with a societal perspective.

    Results: The societal costs of dementia in Sweden in 2012 were SEK 62.9 billion (approximately €7.2 billion, approximately US$ 9.0 billion) or SEK 398,000 per person with dementia (approximately €45,000, approximately US$ 57,000). By far the most important cost item is the cost of institutional care: about 60% of the costs. In the sensitivity analysis, different quantification and costing approaches for informal care resulted in a great variation in the total societal cost, ranging from SEK 60 billion (€6.8 billion, US$ 8.6 billion) to SEK 124 billion (€14.1 billion, US$ 17.8 billion).

    Conclusions: The societal costs of dementia are very high. The cost per person with dementia has decreased somewhat, mainly because of de-institutionalisation. The majority of the costs occur in the social care sector, but the costing of informal care is crucial for the cost estimates.

  • 231. Winge, Monica
    et al.
    Johansson, Lars-Åke
    Nyström, Monica
    Lindh-Waterworth, Eva
    Umeå University, Faculty of Social Sciences, Department of Informatics.
    Wangler, Benkt
    Need for a new care model: getting to grips with collaborative home care2010In: Studies in Health Technology and Informatics, ISSN 0926-9630, E-ISSN 1879-8365, Vol. 160, no Pt 1, p. 8-12Article in journal (Refereed)
    Abstract [en]

    In this paper we discuss the fact that more and more patients are treated in their homes by a set of organizations, sometimes with different ownership, and how this fact places new and severe demands on health care and home service staff to communicate and collaborate. We point to the need for managers in different organizations to agree on ways of communicating and collaborating on the operational level and how this aspect needs to be considered during procurement of home care services. Most importantly, by reasoning around a set of problematic areas, we derive a set of related problems and suggest solutions for dealing with them. The solutions are a mix of organizational/administrative measures and IT support for communication and coordination.

  • 232. Zhuo, Lang
    et al.
    Xu, Ling
    Ye, Jingtao
    Sun, Sun
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Health Outcomes and Economic Evaluation Research Group, Stockholm, Sweden; Centre for Healthcare Ethics, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Zhang, Yaoguang
    Burstrom, Kristina
    Chen, Jiaying
    Time Trade-Off Value Set for EQ-5D-3L Based on a Nationally Representative Chinese Population Survey2018In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 21, no 11, p. 1330-1337Article in journal (Refereed)
    Abstract [en]

    Objectives: To obtain a nationally representative Chinese three-level EuroQol five-dimensional questionnaire value set based on the time trade-off (TTO) method.

    Methods: A multistage, stratified, clustered random nationally representative Chinese sample was used. The study design followed an adapted UK Measurement and Valuation of Health protocol. Each respondent valued 11 random states plus state 33333 and "unconscious" using the TTO method in face-to-face interviews. Three types of models were explored: ordinary least squares, general least squares, and weighted least squares models.

    Results: In total, 5939 inhabitants aged 15 years and older were interviewed. Of these, 5503 satisfactorily interviewed participants were included in constructing models. An ordinary least squares model including 10 dummies without constant and N3 had a mean absolute error of 0.083 and a correlation coefficient of 0.899 between the predicted and mean values. Goodness-of-fit indices of two models based on split subsample were similar.

    Conclusions: TTO values were higher in our study compared with those in a study carried out in urban areas, which is mirrored by the higher values in rural areas. Several other aspects, in addition to the valuation procedure, might have influenced the results, such as factors beyond demographic factors such as view on life and death and believing in an afterlife, which need further investigation. Future studies using the three-level EuroQol five-dimensional questionnaire should consider using this value set based on a nationally representative sample of the Chinese population.

  • 233. Ziebland, Sue
    et al.
    Rasmussen, Birgit
    MacArtney, John
    Hajdarevic, Senada
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sand Andersen, Rikke
    How wide is the Goldilocks Zone in your health system?2019In: Journal of Health Services Research and Policy, ISSN 1355-8196, E-ISSN 1758-1060, Vol. 24, no 1, p. 52-56Article in journal (Refereed)
    Abstract [en]

    In astrophysics, the 'Goldilocks Zone' describes the circumstellar habitable zone, in which planets, sufficiently similar to Earth, could support human life. The children's story of Goldilocks and the Three Bears, one of the most popular fairy tales in the English language, uses this metaphor to describe conditions for life that are neither too hot nor too cold and neither too close to the sun nor too far from its warmth. We propose that the 'Goldilocks Zone' also offers an apt metaphor for the struggle that people face when deciding if and when to consult a health care provider with a possible health problem. Drawing on decades of research in Denmark, England and Sweden on people's accounts of their experiences of accessing health care, this essay considers the ambivalence of health care seeking that individuals face in identifying when it is 'just right' to consult a general practitioner and the steps that health systems and individual clinicians might take to widen the zone.

  • 234.
    Zingmark, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR). Community Care Administration, Municipality of Östersund, 83182 Östersund, Sweden.
    Nilsson, Ingeborg
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sahlén, Klas-Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Nursing.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Cost effectiveness of an intervention focused on reducing bathing disability2017In: European Journal of Ageing, ISSN 1613-9372, E-ISSN 1613-9380, Vol. 14, no 3, p. 233-241Article in journal (Refereed)
    Abstract [en]

    The onset of bathing disability among older people is critical for a decline in functioning and has implications for both the individuals’ quality of life and societal costs. The aim of this study was to evaluate longterm cost effectiveness of an intervention targeting bathing disability among older people. For hypothetical cohorts of community-dwelling older people with bathing disability, transitions between states of dependency and death were modelled over 8 years including societal costs. A five-state Markov model based on states of dependency was used to evaluate Quality-adjusted life years (QALYs) and costs from a societal perspective. An intervention group was compared with a no intervention control group. The intervention focused on promoting safe and independent performance of bathing-related tasks. The intervention effect, based on previously published trials, was applied in the model as a 1.4 increased probability of recovery during the first year. Over the full follow-up period, the intervention resulted in QALY gains and reduced societal cost. After 8 years, the intervention resulted in 0.052 QALYs gained and reduced societal costs by €2410 per person. In comparison to the intervention cost, the intervention effect was a more important factor for the magnitude of QALY gains and long-term societal costs. The intervention cost had only minor impact on societal costs. The conclusion was that an intervention targeting bathing disability among older people presents a cost-effective use of resources and leads to both QALY gains and reduced societal costs over 8 years.

  • 235.
    Zulu, Joseph Mumba
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Public Health, School of Medicine, University of Zambia, P.O. Box 50110, Lusaka, Zambia.
    Kinsman, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Michelo, Charles
    Univ Zambia, Sch Med, Dept Publ Hlth, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries2014In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, no 1, article id 987Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite the development of national community-based health worker (CBHW) programmes in several low- and middle-income countries, their integration into health systems has not been optimal. Studies have been conducted to investigate the factors influencing the integration processes, but systematic reviews to provide a more comprehensive understanding are lacking.

    METHODS: We conducted a systematic review of published research to understand factors that may influence the integration of national CBHW programmes into health systems in low- and middle-income countries. To be included in the study, CBHW programmes should have been developed by the government and have standardised training, supervision and incentive structures. A conceptual framework on the integration of health innovations into health systems guided the review. We identified 3410 records, of which 36 were finally selected, and on which an analysis was conducted concerning the themes and pathways associated with different factors that may influence the integration process.

    RESULTS: Four programmes from Brazil, Ethiopia, India and Pakistan met the inclusion criteria. Different aspects of each of these programmes were integrated in different ways into their respective health systems. Factors that facilitated the integration process included the magnitude of countries' human resources for health problems and the associated discourses about how to address these problems; the perceived relative advantage of national CBHWs with regard to delivering health services over training and retaining highly skilled health workers; and the participation of some politicians and community members in programme processes, with the result that they viewed the programmes as legitimate, credible and relevant. Finally, integration of programmes within the existing health systems enhanced programme compatibility with the health systems' governance, financing and training functions. Factors that inhibited the integration process included a rapid scale-up process; resistance from other health workers; discrimination of CBHWs based on social, gender and economic status; ineffective incentive structures; inadequate infrastructure and supplies; and hierarchical and parallel communication structures.

    CONCLUSIONS: CBHW programmes should design their scale-up strategy differently based on current contextual factors. Further, adoption of a stepwise approach to the scale-up and integration process may positively shape the integration process of CBHW programmes into health systems.

  • 236.
    Åberg, Torkel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Defence, counterattack, retreat?2004In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 26, no Suppl 1, p. S32-S35Article in journal (Refereed)
    Abstract [en]

    Cardio-thoracic surgery is facing changes which are imposed upon us from two sources, medical development within cardiology and the general demographic and economic development of the western world. These two developments have to be faced. This treaty describes one way of thinking in our response to the changes. Using old strategic principles our options are attack, defence and retreat. The three options are described in some detail. In order to be well prepared, knowledge and preparation for all three options is necessary in meeting the challenges of the future.

  • 237.
    Åberg, Torkel
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Hentschel, Jan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Improved total quality by monitoring of a cardiothoracic unit. Medical, administrative and economic data followed for 9 years.2004In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 3, no 1, p. 33-40Article in journal (Refereed)
    Abstract [en]

    To describe monitoring of a cardio-thoracic department from a total quality aspect point of view and to follow the development over 9 years. During the time period 1994-2002 a total of 10,828 cardio-thoracic operations were performed. Capacity, demographic, risk, quality, outcome and economic data were prospectively collected in various registries and analysed. Mean (and median) age increased from 64.2 to 65.3 (66-67). Patients above 70 years increased from 33.6 to 38.7% and above 80 from 2.9 to 5.5%. Operative mortality was unchanged over the time periods at slightly over 2%, with 1-year mortality 6-7%. Mortality for primary, elective coronary artery bypass grafting was 0.26% during the last 3 years. The rate of postoperative complications remained unchanged or decreased with few exceptions: Patients with postoperative confusion increased from 5.0 to 8.1% and patients with a need for face mask ventilation increased from 2.4 to 4.0%. Mean postoperative ventilation time was unchanged at around 22 h, whereas the median decreased from 9.5 to 5.3 h. The workload created by elderly patients was especially noticeable in the intensive care unit (ICU) as both number of postoperative deviations and ICU hours increased as a function of age. Cost per operation decreased by 11%. Total medical rationalisation was higher as salaries increased over time. Mean length of stay decreased by 3 days. Hospital staff hours per operation decreased whereas hospital staff hours per patient hour increased. Physician cost per operation was unchanged. Patient, staff and referring physician satisfaction was high. Several areas for improvement have been found. Monitoring and general feedback of total quality factors has shown itself a powerful tool to detect and follow large and subtle changes in the practice of cardio-thoracic surgery. Most followed factors show improvement in spite of an increase in mean and median age. Several areas may be defined where further development might decrease the trauma to the patient. Aiming at a total quality and patient safety system, monitoring is an essential prerequisite.

  • 238.
    Öhman, Ann
    et al.
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS). Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Keisu, Britt-Inger
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Enberg, Birgit
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Team social cohesion, professionalism, and patient-centeredness: gendered care work, with special reference to elderly care – a mixed methods study2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 381Article in journal (Refereed)
    Abstract [en]

    Background: Healthcare organisations are facing large demands in recruiting employees with adequate competency to care for the increasing numbers of elderly. High degrees of turnover and dissatisfaction with working conditions are common. The gendered notion of care work as 'women's work', in combination with low salaries and status, may contribute to negative work experiences. There is abundant information about the negative aspects of elderly care health services, but little is known about positive aspects of this work. The study aim was to investigate work satisfaction from a gender perspective among Swedish registered nurses, physiotherapists, and occupational therapists, focusing specifically on healthcare services for the elderly.

    Methods: A mixed methods approach was adopted in which we combined statistics and open-ended responses from a national survey with qualitative research interviews with healthcare professionals in elderly care organisations. The survey was administered to a random sample of 1578 registered nurses, physiotherapists, and occupational therapists. Qualitative interviews with 17 professionals were conducted in six elderly care facilities. Qualitative and quantitative content analyses, chi2 and constructivist grounded theory were used to analyse the data.

    Results: There was a statistically significant difference in overall work satisfaction between those who worked in elderly care and those who did not (64 and 74,4% respectively, p < 0.001). Nine themes were derived from open-ended responses in the questionnaire. The qualitative interviews revealed four prominent storylines: 'Team social cohesion', 'Career development and autonomy', 'Client-centeredness', and 'Invisible and ignored power structures'.

    Conclusions: The results show the complexity of elderly care work and describe several aspects that are important for work satisfaction among health professionals. The results reveal that work satisfaction is dependent on social interrelations and cohesion in the work team, in possibilities to use humour and to have fun together, and in the ability to work as professionals to provide client-centered elderly care. Power relations such as gendered hierarchies were less visible or even ignored aspects of work satisfaction. The storylines are clearly linked to the two central discourses of professionalism and gender equality.

2345 201 - 238 of 238
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