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  • 51.
    Fjellfeldt, Maria
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Development of a Swedish community mental health service market2019In: Nordic Social Work Research, ISSN 2156-857X, E-ISSN 2156-8588, no 1, p. 72-84Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to examine changes in an organizational field over time when implementing a freedom of choice model. Main focus was on the range and characteristics of providers and services. Our findings suggest that the expected effects of the reform in terms of variety of providers and services within the organizational field did not materialise due to a lack of market competition. Providers complemented each other rather than competed with each other, and the logics of care, choice, and advocacy challenged each other within the quasi-market. All informants described financial conditions in the market as extremely strained. Strong personal commitment characterized providers entering and exiting the market. A gap was found between policy goals and experiences among stakeholders, and efficiency was found to be the policy goal achieved most often in practice. This raises the questions of how the Swedish community mental health service market will develop in the future and what the implications are for the participants.

  • 52. Fjelltun, Aud-Mari
    et al.
    Henriksen, Nils
    Norberg, Astrid
    Umeå University, Faculty of Medicine, Department of Nursing.
    Gilje, Fredicka
    Normann, Hans Ketil
    Functional levels and nurse workload of elderly awaiting nursing home placement and nursing home residents: a comparative study.2009In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 23, no 4, p. 736-747Article in journal (Refereed)
    Abstract [en]

    The aim of this study was twofold: to compare the functional levels of elderly awaiting nursing home placement and nursing home residents, and to compare their nurses' physical and psychological workloads. In Norway, the demand for nursing home placement has increased greatly. Elderly awaiting placement can receive care from home health care services and/or from their families. Documenting elderly's functional levels may illuminate the extent of the carers' workloads and the need for support during the waiting period. The study was conducted in 2005 on two groups in northern Norway. Using the Multi-Dimensional Dementia Assessment Scale to assess functional levels, one group of nurses assessed elderly awaiting nursing home placement (n = 36) and another group of nurses assessed nursing home residents (n = 47). The nurses also reported physical and psychological workloads in caring for these elderly. A comparison of the functional levels between elderly awaiting nursing home placement and nursing home residents showed few statistically significant differences. Nursing home residents had two lower motor functions, needed more assistance with activities of daily living, more regular administration of enemas, were more often unable to speak, and showed lower orientation levels. Clinically significant similarities were found in five motor functions, including rising from lying to sitting, rising out of bed and walking, and in behavioural and psychiatric symptoms. Both groups of elderly had a high prevalence of sadness and fearfulness. The results of this study indicate that elderly awaiting nursing home placement can be as frail as nursing home residents. These results highlight the elderly's need for assistance and reveal the need for more nursing home beds. Nurses in home health care and nursing homes rated physical and psychological workloads similarly. As many carers provide care 24 hours a day, these results also illuminate the need to support carers during the waiting period.

  • 53. Flores, Walter
    et al.
    Ruano, Ana Lorena
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Phé Funchal, Denise
    Social participation within a context of political violence: implications for the promotion and exercise of the right to health in guatemala2009In: Health and Human Rights: An International Journal, ISSN 1079-0969, E-ISSN 2150-4113, Vol. 11, no 1, p. 37-48Article in journal (Refereed)
    Abstract [en]

    Social participation has been understood in many different ways, and there are eventypologies classifying participation by the degree of a population’s control in decisionmaking. Participation can vary from a symbolic act, which does not involve decisionmaking, to processes in which it constitutes the principal tool for redistributing powerwithin a population. This article argues that analyzing social participation from a perspectiveof power relations requires knowledge of the historical, social, and economicprocesses that have characterized the social relations in a specific context. Applyingsuch an analysis to Guatemala reveals asymmetrical power relations characterized bya long history of repression and political violence. The armed conflict during the secondhalf of the 20th century had devastating consequences for a large portion of thepopulation as well as the country’s social leadership. The ongoing violence resulted innegative psychosocial effects among the population, including mistrust toward institutionsand low levels of social and political participation. Although Guatemala madeprogress in creating spaces for social participation in public policy after signing thePeace Accords in 1996, the country still faces after-effects of the conflict. One importanttask for the organizations that work in the field of health and the right to healthis to help regenerate the social fabric and to rebuild trust between the state and itscitizens. Such regeneration involves helping the population gain the skills, knowledge,and information needed in order to participate in and affect formal political processesthat are decided and promoted by various public entities, such as the legislative andexecutive branches, municipal governments, and political parties. This process alsoapplies to other groups that build citizenship through participation, such as neighborhoodorganizations and school and health committees.

  • 54.
    Forsell, N.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Holzmann, M.
    Taki, H.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Eriksson, A.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine.
    Ruge, Toralph
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Transport time from crash scene may influence survival2017In: Trauma, ISSN 1460-4086, E-ISSN 1477-0350, Vol. 19, no 1, p. 77-78Article in journal (Refereed)
  • 55.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, India.
    Muraleedharan, V. R.
    San Sebastian, Miguel
    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.
    Accountability in the health system of Tamil Nadu, India: exploring its multiple meanings2019In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, article id 44Article in journal (Refereed)
    Abstract [en]

    Background: Accountability is increasingly being demanded of public services and is a core aspect of most recent frameworks of health system strengthening. Community-based accountability is an increasingly used strategy, and wasa core aspect of India's flagship National Rural Health Mission (NRHM; 2005-2014). Research on policy implementation has called for policy analysts to go beyond the superficial articulation of a particular policy intervention to study the underlying meaning this has for policy-makers and other actors of the implementation process and to the way in which problems sought to be addressed by the policy have been identified and problematised'.

    Methods: This research, focused on state level officials and health NGO leaders, explores the meanings attached to the concept of accountability among a number of key actors during the implementation of the NRHM in the south Indian state of Tamil Nadu. The overall research was guided by an interpretive approach to policy analysis and the problematisation lens. Through in-depth interviews we draw on the interviewees' perspectives on accountability.

    Results: The research identifies three distinct perspectives on accountability among the key actors involved in the implementation of the NRHM. One perspective views accountability as the achievement of pre-set targets, the other as efficiency in achieving these targets, and the final one as a transformative process that equalises power differentials between communities and the public health system. We also present the ways in which these differences in perspectives are associated with different programme designs.

    Conclusions: This research underlines the importance of going beyond the statements of policy to exploring the underlying beliefs and perspectives in order to more comprehensively understand the dynamics of policy implementation; it further points to the impacts of these perspectives on the design of initiatives in response to the policy.

  • 56.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Indian Institute of Technology – Madras, Centre of Technology and Policy, Chennai, India.
    Oxman, Andrew D
    Okebukola, Peter O
    Rada, Gabriel
    Interventions to reduce corruption in the health sector2016In: Cochrane Database of Systematic Reviews, ISSN 1469-493X, E-ISSN 1469-493X, no 8, article id CD008856Article, review/survey (Refereed)
    Abstract [en]

    Background: Corruption is the abuse or complicity in abuse, of public or private position, power or authority to benefit oneself, a group, an organisation or others close to oneself; where the benefits may be financial, material or non-material. It is wide-spread in the health sector and represents a major problem.

    Objectives: Our primary objective was to systematically summarise empirical evidence of the effects of strategies to reduce corruption in the health sector. Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence.

    Search methods: We searched 14 electronic databases up to January 2014, including: CENTRAL; MEDLINE; EMBASE; sociological, economic, political and other health databases; Human Resources Abstracts up to November 2010; Euroethics up to August 2015; and PubMed alerts from January 2014 to June 2016. We searched another 23 websites and online databases for grey literature up to August 2015, including the World Bank, the International Monetary Fund, the U4 Anti-Corruption Resource Centre, Transparency International, healthcare anti-fraud association websites and trial registries. We conducted citation searches in Science Citation Index and Google Scholar, and searched PubMed for related articles up to August 2015. We contacted corruption researchers in December 2015, and screened reference lists of articles up to May 2016.

    Selection criteria: For the primary analysis, we included randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies that evaluated the effects of an intervention to reduce corruption in the health sector. For the secondary analysis, we included case studies that clearly described an intervention to reduce corruption in the health sector, addressed either our primary or secondary objective, and stated the methods that the study authors used to collect and analyse data.

    Data collection and analysis: One review author extracted data from the included studies and a second review author checked the extracted data against the reports of the included studies. We undertook a structured synthesis of the findings. We constructed a results table and 'Summaries of findings' tables. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence.

    Main results: No studies met the inclusion criteria of the primary analysis. We included nine studies that met the inclusion criteria for the secondary analysis. One study found that a package of interventions coordinated by the US Department of Health and Human Services and Department of Justice recovered a large amount of money and resulted in hundreds of new cases and convictions each year (high certainty of the evidence). Another study from the USA found that establishment of an independent agency to investigate and enforce efforts against overbilling might lead to a small reduction in overbilling, but the certainty of this evidence was very low. A third study from India suggested that the impacts of coordinated efforts to reduce corruption through increased detection and enforcement are dependent on continued political support and that they can be limited by a dysfunctional judicial system (very low certainty of the evidence). One study in South Korea and two in the USA evaluated increased efforts to investigate and punish corruption in clinics and hospitals without establishing an independent agency to coordinate these efforts. It is unclear whether these were effective because the evidence is of very low certainty. One study from Kyrgyzstan suggested that increased transparency and accountability for co-payments together with reduction of incentives for demanding informal payments may reduce informal payments (low certainty of the evidence). One study from Germany suggested that guidelines that prohibit hospital doctors from accepting any form of benefits from the pharmaceutical industry may improve doctors' attitudes about the influence of pharmaceutical companies on their choice of medicines (low certainty of the evidence). A study in the USA, evaluated the effects of introducing a law that required pharmaceutical companies to report the gifts they gave to healthcare workers. Another study in the USA evaluated the effects of a variety of internal control mechanisms used by community health centres to stop corruption. The effects of these strategies is unclear because the evidence was of very low certainty.

    Authors' conclusions: There is a paucity of evidence regarding how best to reduce corruption. Promising interventions include improvements in the detection and punishment of corruption, especially efforts that are coordinated by an independent agency. Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry, internal control practices in community health centres, and increased transparency and accountability for co-payments combined with reduced incentives for informal payments. The extent to which increased transparency alone reduces corruption is uncertain. There is a need to monitor and evaluate the impacts of all interventions to reduce corruption, including their potential adverse effects.

  • 57.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine. PAREXEL International, Stockholm, Sweden.
    Alvarez, Maria
    Polyzoi, Maria
    Malaga, Xavier
    Pineda, Cristina
    Hernandez, Cesar
    Budget impact analysis of demineralized bone matrix in combination with autograft in lumbar spinal fusion procedures for the treatment of lumbar degenerative disc disease in Spain2018In: Journal of Medical Economics, ISSN 1369-6998, E-ISSN 1941-837X, Vol. 21, no 10, p. 977-982Article in journal (Refereed)
    Abstract [en]

    Objective: To estimate the budget impact (BI) of introducing local autograft (LA) combined with demineralized bone matrix (LA + DBM) in lumbar spinal fusion (LSF) procedures to treat lumbar degenerative disc disease (LDDD) in Spain.

    Methods: A decision tree model was developed to evaluate the 4-year BI associated with introducing LA + DBM putty to replace currently available grafting methods, including iliac crest bone graft (ICBG), LA alone, and LA combined with beta-tricalcium phosphate (LA + ceramics), with 30%, 40%, and 30% market shares, respectively. The analysis was conducted for a hypothetical cohort of 100 patients with LDDD receiving LSF, assuming LA + DBM would replace 100% of the standard of care mix. The fusion rates extracted from the literature were validated by an expert panel. Costs ((sic)2017) were obtained from different Spanish sources. Budget impact and incremental cost per successful fusion were calculated from the perspective of the Spanish National Health System (NHS).

    Results: Over 4 years, replacing currently available options with LA + DBM for 100 patients resulted in an additional cost of (sic)12,330 ((sic)123/patient), and an additional 14 successful fusions, implying a cost of (sic)881 per additional successful fusion. When costs of productivity loss were included, the introduction of LA + DBM resulted in cost savings of (sic)70,294 ((sic)703/patient).

    Limitations: The lack of high-quality, homogeneous, head-to-head research studying the efficacy of grafting procedures available to patients undergoing LSF, in addition to a lack of long-term follow-up in existing studies. Therefore, the number of fusions occurring within the model's time horizon may be underestimated.

    Conclusions: Acquisition costs of DBM were partially offset by costs of failed fusions, adverse events and reoperation when switching 100 hypothetical LDDD patients undergoing LSF procedures from standard of care grafting methods to LA + DBM from the perspective of the Spanish NHS. DBM cost was entirely offset when costs of lost productivity were considered.

  • 58.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Corcoran, K.
    Virhage, M.
    Anell, B.
    Estimating the Value of A New Antibiotic: A Novel Approach Using Esbl As A Case Study2016Conference paper (Refereed)
  • 59.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Dibbern, T.
    Virhage, M.
    Medin, E.
    Swedish Perspective on Health Technology Assessments with Incrementally Lower Costs and Effects2016Conference paper (Refereed)
  • 60.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Henriksson, M.
    Schmitt-Egenolf, Marcus
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology.
    The Relationship Between Disease Severity and Quality of Life In Patients With Moderate to Severe Psoriasis2015In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 18, no 7, p. A675-A675Article in journal (Refereed)
  • 61.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology. PAREXEL Int, Stockholm, Sweden.
    Henriksson, Martin
    Linköping Univ, Dept Med & Hlth Sci, Linköping, Sweden.
    Schmitt-Egenolf, Marcus
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology.
    How is disease severity associated with quality of life in psoriasis patients?: Evidence from a longitudinal population-based study in Sweden2017In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 15, no 1, article id 151Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Assessing the impact of disease severity on generic quality of life (QOL) is a critical step in outcomes research and in the development of decision-analytic models structured around health states defined by clinical measures. While data from routine clinical practice found in healthcare registers are increasingly used for research, more attention should be paid to understanding the relationship between clinical measures of disease severity and QOL. The purpose of this work was therefore to investigate this relationship in psoriasis using a population-based dataset.

    METHODS: Severity was measured by the Psoriasis Area and Severity Index (PASI), which combines severity of erythema, induration, and desquamation into a single value ranging from 0 to 72. The generic EQ-5D-3L utility instrument, under the UK tariff, was used to measure QOL. The association between PASI and EQ-5D-3L was estimated using a population-based dataset of 2674 patients with moderate to severe psoriasis enrolled over ten years in the Swedish psoriasis register (PsoReg). Given the repeated measurement of patients in the register data, a longitudinal fixed-effects model was employed to control for unobserved patient-level heterogeneity.

    RESULTS: Marginal changes in PASI are associated with a non-linear response in EQ-5D-3L: Moving from PASI 10 to 9 (1 to 0) is associated with an increase of 0.0135 (0.0174) in EQ-5D-3L. Furthermore, unobserved patient-level heterogeneity appears to be an important source of confounding when estimating the relationship between QOL and PASI.

    CONCLUSIONS: Using register data to estimate the impact of disease severity on QOL while controlling for unobserved patient-level heterogeneity shows that PASI appears to have a larger impact on QOL than previously estimated. Routine collection of generic QOL data in registers should be encouraged to enable similar applications in other disease areas.

  • 62.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. PAREXEL International, Stockholm, Sweden.
    Saridogan, Ertan
    Lehmann, Matthieu
    Arriagada, Pablo
    Hultberg, Marcus
    Henriksson, Martin
    Repeated intermittent ulipristal acetate in the treatment of uterine fibroids: a cost-effectiveness analysis2017In: ClinicoEconomics and Outcomes Research, ISSN 1178-6981, E-ISSN 1178-6981, Vol. 9, p. 669-676Article in journal (Refereed)
    Abstract [en]

    There are limited treatment options available for women with moderate to severe symptoms of uterine fibroids (UFs) who wish to avoid surgery. For these women, treatment with standard pharmaceuticals such as contraceptives is often insufficient to relieve symptoms, and patients may require surgery despite their wish to avoid it. Clinical trials demonstrate that ulipristal acetate 5 mg (UPA) is an effective treatment for this patient group, but its cost-effectiveness has not been assessed in this population. A decision-analytic model was developed to simulate a cohort of patients in this population under treatment with UPA followed by surgery as needed compared to treatment with iron and non-steroidal anti-inflammatory drug (NSAID) followed by surgery as needed (best supportive care, BSC). The analysis took the perspective of the National Health Service (NHS) in England, UK, and was based on the published UPA clinical trials. Results were calculated for the long-term costs and quality-adjusted life years (QALYs) for each treatment arm and combined into an incremental cost-effectiveness ratio (ICER) as the primary outcome. The impact of parameter uncertainty on the results was assessed using scenario, deterministic, and probabilistic sensitivity analyses. The results show that treating patients with the UPA strategy, instead of the BSC strategy, results in an additional cost of 1,115 pound and a gain of 0.087 QALYs, resulting in an ICER of 12,850 pound. Given commonly accepted cost-effectiveness thresholds in England, the use of UPA as a repeated, intermittent treatment for women with moderate to severe symptoms of UF wishing to avoid surgery is likely to be a cost-effective intervention when compared to BSC.

  • 63. Gerdle, Björn
    et al.
    Stålnacke, Britt-Marie
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Söderlund, Anne
    Åsenlöf, Pernilla
    Multimodal rehabilitation in pain too low a priority2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, no 11, p. 580-581Article in journal (Other (popular science, discussion, etc.))
  • 64.
    Ghatnekar, Ola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The burden of stroke in Sweden: studies on costs and quality of life based on Riks-Stroke, the Swedish stroke register2013Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The costs for stroke management and reduced health related quality of life (QoL) can extend throughout life as mental and physical disabilities are common. The aim of this thesis was to quantify this stroke-related burden with data from Riks-Stroke (RS), the Swedish stroke register.

    Costs for hospital and primary care, secondary drug prevention, home and residential care services, and production losses were estimated for first-ever stroke patients registered in the RS. The present value lifetime costs were estimated from the expected survival and discounted by 3%. Quality of life was estimated with the EQ-5D instrument on a subset of patients at 3 months after the index event and mapped to patient-reported outcome measures in the RS. Standard descriptive and analytic (multivariate regressions) statistical methods were used.

    The life-time societal present value cost per patient in 2009 was approximately €69,000 whereof home and residential care due to stroke was 59% and indirect costs for productivity losses accounted for 21% (year 2009 prices). Women had higher costs than men in all age groups. Treatment at stroke units had a low incremental cost per life-year gained compared to patients who were not treated at such facilities. The estimated disutility from stroke was greatest for women and the oldest, and compared to 1997 the cost per patient increased after a revised assumption. Hospitalisation costs were stable while long-term costs for ADL support increased in part due to a changed age structure. Patients with atrial fibrillation (AF; 24%) had €367 higher inpatient costs compared to non-AF stroke patients €8,914 (P<0.01; year 2001 prices). As the index case fatality was higher among AF patients, the cost difference was higher for patients surviving the first 28 days. A multivariate regression showed that AF, diabetes, stroke severity, and death during the 3-year follow-up period were independent cost drivers. Three regression techniques (OLS, Tobit, CLAD) were chosen for mapping EQ-5D utilities to patient-reported outcome measures in the RS. The mean utility was overestimated with all models and had lower variance than the original data.

    In conclusion, total societal lifetime cost for 22,000 first-ever stroke patients in 2009 amounted to €1.5 billion (whereof production losses were €314 million). About 56,600 QALYs were lost due to premature death and disability. Including a preference-based QoL instrument in the RS would allow cost-utility analyses, but it is important to control for confounders in comparator arms to avoid bias.

  • 65.
    Ghatnekar, Ola
    et al.
    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.
    The effect of atrial fibrillation on stroke-related inpatient costs in Sweden: a 3-year analysis of registry incidence data from 20012008In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 11, no 5, p. 862-868Article in journal (Refereed)
    Abstract [en]

    Objective: Atrial fibrillation (AF) is an important risk factor for stroke. It is prevalent in approximately one-fourth of stroke patients, and predictive of worse outcomes. This study aimed to analyze the effect of AF on stroke-related inpatient costs among first-ever stroke patients in Sweden.

    Methods: Hospitalizations and death records were monitored for 3 years in 6611 first-ever stroke patients. For stroke as primary diagnosis, inpatient costs were calculated on the basis of length of stay at different wards. For stroke as secondary diagnosis, costs were based on diagnosis-related groups.

    Results: Patients with AF (24% of all patients) were older (80 years vs. 73 years), had a higher prevalence of hypertension (49% vs. 41%) and/or diabetes (22% vs. 19%), higher risk of experiencing a restroke, and higher case fatality rate (43% vs. 25%) than patients without AF. The average cost per patient over 3 years was euro9004, with no statistically significant difference between AF and non-AF patients. However, a multiple regression analysis showed that the presence of AF resulted in higher costs after considering a number of background factors. Among patients surviving the index event, AF patients had on average euro818 higher inpatient costs over 3 years than non-AF patients (euro10,192 vs. euro9374, P < 0.01). The difference in costs was highest for patients aged <65 years, with a difference of euro4412 (P < 0.01).

    Conclusion: AF-related strokes are associated with higher 3-year inpatient costs than non-AF strokes when controlling for factors such as case fatality rates, other risk factors for stroke, and age.

  • 66.
    Ghatnekar, Ola
    et al.
    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.
    Persson, U
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The societal cost of stroke in Sweden 2009 and developments since 19972013In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 35, no Suppl. 3, p. 475-475Article in journal (Other academic)
  • 67.
    Ghatnekar, Ola
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Persson, Ulf
    Asplund, Kjell
    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.
    Costs for stroke in Sweden 2009 and developments since 19972014In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 30, no 2, p. 203-209Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of this study was to estimate direct and indirect excess costs attributable to stroke in Sweden in 2009 and to compare these with similar estimates from 1997. Methods: Data on first-ever stoke admissions in the first half of 2009 from the Swedish national stroke register (RS) were used for cost calculations and compared with results from 1997 also using RS data. A societal perspective was taken including the acute and follow-up phase, rehabilitation, stroke re-admissions, drugs, home-and residential care services for activities of daily life (ADL) support, and indirect costs for premature death and productivity losses (2009 prices). Survival was extrapolated to estimate the lifetime present value cost of stroke. Results: The societal lifetime present value cost for stroke in 2009 was (sic)68,800 per patient (ADL support: 59 percent; productivity losses: 21 percent). Women had higher costs than men in all age groups as a result from greater need for ADL support. Patients treated at a stroke unit indicated low incremental cost per life-year gained compared with those who had not. The total lifetime cost increased between 1997 and 2009. Hospitalization costs per patient were stable, while long-term costs for home-and residential care services increased. Conclusions: Changes in patient characteristics, longer expected survival, and possibly in the Swedish stroke care, have led to higher annual and lifetime costs per patient in 2009 compared with 1997. A comprehensive national stroke care performance register like RS may be suitable for health economic assessments.

  • 68.
    Ghatnekar, Ola
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Persson, Ulf
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terént, Andreas
    Cost of stroke in Sweden: an incidence estimate2004In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 20, no 3, p. 375-380Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To estimate the excess cost of stroke in Sweden and the potential costs that could be avoided by preventing first-ever strokes.

    METHODS: We adopted the incidence approach for estimating the present value of both direct and indirect costs. Data on mortality, stroke recurrence, and inpatient care were estimated from a national register of patient data with a four-year follow-up period. To estimate costs for social services, we used survey data on living conditions before stroke onset and at three and at twenty-four months. Costs for outpatient visits, rehabilitation, drugs, and production losses due to premature death and early retirement were estimated on the basis of both published and nonpublished sources. Lifetime costs were based on life tables adjusted for excess mortality of stroke, and costs in year 4 were extrapolated to subsequent years.

    RESULTS: The present value direct cost for an average stroke patient is SEK 513,800 (USdollars 56,024 or Euro 60,825). The corresponding indirect cost is SEK 125,110 (USdollars 13,640 or Euro 14,810). Almost 45 percent of the direct costs were attributable to social services. Women had higher costs than men, and costs for survivors increased with age due to social services.

    CONCLUSIONS: With an incidence of 213 first-ever strokes per 100,000 individuals, the total excess direct and indirect cost of stroke would be SEK 12.3 billion (approximately US$ 1.3 billion or Euro 1.5 billion). Hence, there are large potential cost offsets both in the health-care sector and in the social service sector if the incidence of first-ever stroke could be reduced.

  • 69.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Edlund, Hilda
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Sukhova, M
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, B
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    More equal stroke unit care over time. A 15-year follow up of socioeconomic disparities in stroke unit care in Sweden2013In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 35, no Suppl. 3, p. 702-702Article in journal (Other academic)
  • 70.
    Goicolea, Isabel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hultstrand Ahlin, Cecilia
    Umeå University, Faculty of Medicine, Department of Nursing.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Marchal, Bruno
    Christianson, Monica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Wiklund, Maria
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Accessibility and factors associated with utilization of mental health services in youth health centers: a qualitative comparative analysis in northern Sweden2018In: International Journal of Mental Health Systems, ISSN 1752-4458, E-ISSN 1752-4458, Vol. 12, article id 69Article in journal (Refereed)
    Abstract [en]

    Background: Youth-friendly health care services can facilitate young people's access to health care services and promote their health, including their mental health. In Sweden, a network of youth health centers exist since the 1970s, incorporated within the public health system. Even if such centers take a holistic approach to youth health, the focus has been in sexual and reproductive health care, and the extent of integrating mental health care services is less developed though it varies notably between different centers. This study aims to analyse the various conditions that are sufficient and/or necessary to make Swedish youth health centers accessible for mental and psychosocial health.

    Methods: Multiple case study design, using qualitative comparative analysis to assess the various conditions that makes a youth health center accessible for mental and psychosocial issues and mental health. The cases included 18 youth health centers (from a total of 22) in the four northern counties of Sweden.

    Results: In order to enhance accessibility for mental health services, youth health centers need to be trusted by young people. Trust was necessary but not sufficient, meaning that it had to be combined with other conditions: either having a team with a variety of professions represented in the youth health center, or being a youth health center that is both easy to contact and well-staffed with mental health professionals.

    Conclusions: Differentiated, first-line services for youth can play an important role in promoting youth mental health if certain conditions are fulfilled. Trust is necessary, but has to be combined with either multidisciplinary teams, or expertise on mental health and easy accessibility.

  • 71.
    Goicolea, Isabel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Public Health Research Group, Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Alicante University, Alicante, Spain.
    Marchal, Bruno
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Vives-Cases, Carmen
    Briones-Vozmediano, Erica
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Why do certain primary health care teams respond better to intimate partner violence than others?: A multiple case study2019In: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 33, no 2, p. 169-176Article in journal (Refereed)
    Abstract [en]

    Objective: To analyse how team level conditions influenced health care professionals’ responses to intimate partner violence.

    Methods: We used a multiple embedded case study. The cases were four primary health care teams located in a southern region of Spain; two of them considered "good" and two s "average". The two teams considered good had scored highest in practice issues for intimate partner violence, measured via a questionnaire (PREMIS - Physicians Readiness to Respond to Intimate Partner Violence Survey) applied to professionals working in the four primary health care teams. In each case quantitative and qualitative data were collected using a social network questionnaire, interviews and observations.

    Results: The two "good" cases showed dynamics and structures that promoted team working and team learning on intimate partner violence, had committed social workers and an enabling environment for their work, and had put into practice explicit strategies to implement a women-centred approach.

    Conclusions: Better individual responses to intimate partner violence were implemented in the teams which: 1) had social workers who were knowledgeable and motivated to engage with others; 2) sustained a structure of regular meetings during which issues of violence were discussed; 3) encouraged a friendly team climate; and 4) implemented concrete actions towards women-centred care.

  • 72. Granström, Emma
    et al.
    Hansson, Johan
    Sparring, Vibeke
    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, Stockholm, Sweden.
    Enhancing policy implementation to improve healthcare practices: The role and strategies of hybrid national-local support structures2018In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 33, no 4, p. E1262-E1278Article in journal (Refereed)
    Abstract [en]

    Background In this study, we followed a national initiative to enhance the use of quality indicators gathered in national quality registries (NQRs) for improvement of clinical practices in Swedish healthcare, more specifically by investigating the support strategies of regional support centers with national and local missions. The aim was to increase knowledge on the role, challenges, and strategies of support structures with mixed and complex missions in the healthcare system. Methods Documents and 25 semistructured interviews with staff at 6 regional support centers, ie, quality registry centers, formed this multiple case study. Data were analyzed using conventional content analysis. Results The centers' strategies varied from developing the NQRs to become more suitable for improvement to supporting healthcare's use of NQRs, from the use of task to process-oriented support strategies, and from taking on national responsibilities to responding to local initiatives. All quality registry centers engaged in initiatives inspired by the Breakthrough Series approach. Some used preexisting change concepts or collaborated with local development units. A main challenge was to overcome a lack of formal mandate to act in the healthcare organizations they served. Conclusions Support functions with mixed and complex missions have to use a variation of strategies to reach relevant actors and achieve changes. This study provides valuable input for policy and decision-makers on the support strategies used and challenges of support functions with complex missions situated in-between national and local levels of the healthcare system, here denoted hybrid national-local support structures.

  • 73.
    Grill, Kalle
    et al.
    Umeå University, Faculty of Arts, Department of historical, philosophical and religious studies.
    Voigt, Kristin
    University of Oxford.
    The case for banning cigarettes2016In: Journal of Medical Ethics, ISSN 0306-6800, E-ISSN 1473-4257, Vol. 42, no 5, p. 293-301Article in journal (Refereed)
    Abstract [en]

    Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being.

  • 74. Gyllencreutz, J. Dahlen
    et al.
    Paoli, J.
    Bjellerup, M.
    Bucharbajeva, Zinaida
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology.
    Gonzalez, H.
    Nielsen, K.
    Sandberg, C.
    Synnerstad, I.
    Terstappen, K.
    Wennberg Larko, A. -M
    Diagnostic agreement and interobserver concordance with teledermoscopy referrals2017In: Journal of the European Academy of Dermatology and Venereology, ISSN 0926-9959, E-ISSN 1468-3083, Vol. 31, no 5, p. 898-903Article in journal (Refereed)
    Abstract [en]

    BackgroundMalignant melanoma and non-melanoma skin cancers are among the fastest increasing malignancies in many countries. With the help of new tools, such as teledermoscopy referrals between primary health care and dermatology clinics, the management of these patients could be made more efficient. ObjectiveTo evaluate the diagnostic agreement and interobserver concordance achieved when assessing referrals sent through a mobile teledermoscopic referral system as compared to referrals sent via the current paper-based system without images. MethodsThe referral information from 80 teledermoscopy referrals and 77 paper referrals were evaluated by six Swedish dermatologists. They were asked to answer questions about the probable diagnosis, the priority, and a management decision. ResultsTeledermoscopy generally resulted in higher diagnostic agreement, better triaging and more malignant tumours being booked directly to surgery. The largest difference between the referral methods was seen for invasive melanomas. Referrals for benign lesions were significantly more often correctly resent to primary health care with teledermoscopy. However, referrals for cases of melanoma in situ were also incorrectly resent five times. The interobserver concordance was moderate with both methods. ConclusionBy adding clinical and dermoscopic images to referrals, the triage process for both benign and dangerous skin tumours can be improved. With teledermoscopy, patients with melanoma especially can receive treatment more swiftly.

  • 75.
    Hanberger, Anders
    et al.
    Umeå University, Faculty of Social Sciences, Department of applied educational science, Umeå Centre for Evaluation Research (UCER).
    Lindgren, Lena
    Förvaltningshögskolan, Göteborgs universitet.
    Evaluation systems in local eldercare governance2019In: Journal of Social Work, ISSN 1468-0173, E-ISSN 1741-296X, Vol. 19, no 2, p. 233-252Article in journal (Refereed)
    Abstract [en]

    This article explores how three evaluation systems in eldercare governance, two national and one local, operate and interact at the municipal, administrative, and service levels in a Swedish municipality. The case study focuses on the three systems’ contributions to accountability and to improving eldercare quality. It is based on multiple sources, including 28 interviews with local key actors involved in local eldercare governance, and the results derive from a directed content analysis guided by four research questions.

    The study demonstrates that the three evaluation systems support accountability and quality improvement in different ways and have different consequences for local actors. The systems create multiple accountability problems and have multiple constitutive effects, for example, creating different notions of what quality in eldercare means. The systems’ contributions to improving eldercare quality differed: the net effect of the two national systems was negative, whereas the local system has helped improve eldercare quality without any identified negative effects so far.

    The article broadens our theoretical understanding and knowledge of regulatory mechanisms in eldercare governance. It has significance for eldercare policy by finding that policymakers and service providers must be aware of and manage multiple evaluation systems and accountability problems. Its implication for eldercare practice is that local actors must build evaluation capacity to manage existing evaluation systems in order to improve their own practices.

  • 76. Hansson, Johan
    et al.
    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 (LIME) and Medical Management Centre (MMC), Karolinska Institutet, Stockholm, Sweden.
    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 (LIME) and Medical Management Centre (MMC), Karolinska Institutet, Stockholm, Sweden.
    Action research for multi-level facilitation of improvement in health and social care: development of a change facilitation approach for a local R&D unit2017In: Action Research, ISSN 1476-7503, E-ISSN 1741-2617, Vol. 15, no 4, p. 339-356Article in journal (Refereed)
    Abstract [en]

    This paper reports an action research program designed to develop new approaches for a locally based Swedish R&D unit’s task to facilitate improvement in partner organizations, and to provide guidance on how to manage challenges in action research programs focusing on development in health and social care. Data were gathered from interviews with R&D members’, managers representing the two embedded pilot cases, as well as from the lead action researchers. Key findings were the need to continually monitor and revise the action research plan and that each step should be given specific weights based on the conditions at hand. As the action program evolved the participants were given autonomy to take action in the partner organizations and the role of the action researchers became advisory and consultative. These findings accentuate the emergent nature of action research and the need for flexible and dynamic intervention planning, especially when multiple level actors and several organizations are involved. Based on these findings we discuss some implications for the action researcher’s role and how similar programs can be designed to manage change in complex health and social care systems reaching various stakeholders at many levels.

  • 77.
    Hirve, Siddhivinayak
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. KEM Hosp Res Ctr, Pune 411011, Maharashtra, India.
    Verdes, Emese
    WHO, CH-1211 Geneva, Switzerland.
    Lele, Pallavi
    KEM Hosp Res Ctr, Pune 411011, Maharashtra, India.
    Juvekar, Sanjay
    KEM Hosp Res Ctr, Pune 411011, Maharashtra, India.
    Blomstedt, Yulia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Steve
    University of the Witwatersrand, Johannesburg, South Africa.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Chatterji, Somnath
    WHO, CH-1211 Geneva, Switzerland.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Evaluating Reporting Heterogeneity in Self-Rated Health Among Adults Aged 50 Years and Above in India: An Anchoring Vignettes Analytic Approach2014In: Journal of Aging and Health, ISSN 0898-2643, E-ISSN 1552-6887, Vol. 26, no 6, p. 1015-1031Article in journal (Refereed)
    Abstract [en]

    Objective: To use anchoring vignettes to evaluate reporting heterogeneity (RH) in self-rated mobility and cognition in older adults. Method: We analyzed vignettes and self-rated mobility and cognition in 2,558 individuals aged 50 years and above. We tested for assumptions of vignette equivalence (VE) and response consistency (RC). We used a joint hierarchical ordered probit (HOPIT) model to evaluate self-rating responses for RH. Results: The assumption of VE was met except for "learning" vignettes. Higher socioeconomic status (SES) and education significantly lowered thresholds for cognition ratings. After correction for RH, women, lower SES, and older respondents were significantly more likely to report greater difficulty in mobility. The influence of age, SES, and education on thresholds was less apparent for cognition. Discussion: Our study provides strong evidence of RH in self-rated mobility and cognition. We highlight the need to formally test basic assumptions before using vignettes to adjust self-rating responses for RH.

  • 78.
    Hitimana, Regis
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health economic evaluation for evidence-informed decisions in low-resource settings: the case of Antenatal care policy in Rwanda2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Introduction: The general aim of this thesis is to contribute to the use of health economic evidence for informed health care decisions in low-resource settings, using antenatal care (ANC) policy in Rwanda as a case study. Despite impressive and sustained progress over the last 15 years, Rwanda’s maternal mortality ratio is still among the highest in the world. Persistent gaps in health care during pregnancy make ANC a good candidate among interventions that can, if improved, contribute to better health and well-being of mothers and newborns in Rwanda.

    Methods: Data used in this thesis were gathered from primary and secondary data collections. The primary data sources included a cross-sectional household survey (N=922) and a health facility survey (N=6) conducted in Kigali city and the Northern Province, as well as expert elicitation with Rwandan specialists (N=8). Health-related quality of life (HRQoL) for women during the first-year post-partum was measured using the EQ-5D-3L instrument. The association between HRQoL and adequacy of ANC utilization and socioeconomic and demographic predictors was tested through bivariate and linear regression analyses (Paper I). The costs of current ANC practices in Rwanda for both the health sector and households were estimated through analysis of primary data (Paper II). Incremental cost associated with the implementation of the 2016 World Health Organization (WHO) ANC recommendations compared to current practice in Rwanda was estimated through simulation of attendance and adaptation of the unit cost estimates (Paper III). Incremental health outcomes of the 2016 WHO ANC recommendations were estimated as life-years saved from perinatal and maternal mortality reduction obtained from the expert elicitation (Paper III). Lastly, a systematic review of the evidence base for the cost and cost-effectiveness of routine ultrasound during pregnancy was conducted (Paper IV). The review included 606 studies published between January 1999 and April 2018 and retrieved from PubMed, Scopus, and the Cochrane database.

    Results: Sixty one percent of women had not adequately attended ANC according to the Rwandan guidelines during their last pregnancy; either attending late or fewer than four times. Adequate utilization of ANC was significantly associated with better HRQoL after delivery measured using EQ-VAS, as were good social support and household wealth. The most prevalent health problems were anxiety or depression and pain or discomfort. The first ANC visit accounted for about half the societal cost of ANC, which was $44 per woman (2015 USD) in public/faith-based facilities and $160 in the surveyed private facility. Implementing the 2016 WHO recommendations in Rwanda would have an incremental national annual cost between $5.8 million and $11 million across different attendance scenarios. The estimated reduction in perinatal mortality would be between 22.5% and 55%, while maternal mortality reduction would range from 7% to 52.5%. Out of six combinations of attendance and health outcome scenarios, four were below the GDP-based cost-effectiveness threshold. Out of the 606 studies on cost and cost-effectiveness of ultrasound during pregnancy retrieved from the databases, only nine reached the data extraction stage. Routine ultrasound screening was reported to be a cost-effective intervention for screening pregnant women for cervical length, for vasa previa, and congenital heart disease, and cost-saving when used for screening for fetal malformations.

    Conclusions: The use of health economic evidence in decision making for low-income countries should be promoted. It is currently among the least used types of evidence, yet there is a huge potential of gaining many QALYs given persistent and avoidable morbidity and mortality. In this thesis, ANC policy in Rwanda was used as a case to contribute to evidence informed decision-making using health economic evaluation methods. Low-income countries, particularly those that that still have a high burden of maternal and perinatal mortality should consider implementing the 2016 WHO ANC recommendations.

  • 79.
    Hitimana, Regis
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krantz, G.
    Nzayirambaho, M.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Systematic Review of Cost and Cost-effectiveness of Routine Ultrasound during pregnancyManuscript (preprint) (Other academic)
  • 80.
    Hitimana, Regis
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Cost of antenatal care for the health sector and for households in Rwanda2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 262Article in journal (Refereed)
    Abstract [en]

    Background: Rwanda has made tremendous progress in reduction of maternal mortality in the last twenty years. Antenatal care is believed to have played a role in that progress. In late 2016, the World Health Organization published new antenatal care guidelines recommending an increase from four visits during pregnancy to eight contacts with skilled personnel, among other changes. There is ongoing debate regarding the cost implications and potential outcomes countries can expect, if they make that shift. For Rwanda, a necessary starting point is to understand the cost of current antenatal care practice, which, according to our knowledge, has not been documented so far.

    Methods: Cost information was collected from Kigali City and Northern province of Rwanda through two cross-sectional surveys: a household-based survey among women who had delivered a year before the interview (N = 922) and a health facility survey in three public, two faith-based, and one private health facility. A micro costing approach was used to collect health facility data. Household costs included time and transport. Results are reported in 2015 USD.

    Results: The societal cost (household + health facility) of antenatal care for the four visits according to current Rwandan guidelines was estimated at $160 in the private health facility and $44 in public and faith-based health facilities. The first visit had the highest cost ($75 in private and $21 in public and faith-based health facilities) compared to the three other visits. Drugs and consumables were the main input category accounting for 54% of the total cost in the private health facility and for 73% in the public and faith-based health facilities.

    Conclusions: The unit cost of providing antenatal care services is considerably lower in public than in private health facilities. The household cost represents a small proportion of the total, ranging between 3% and 7%; however, it is meaningful for low-income families. There is a need to do profound equity analysis regarding the accessibility and use of antenatal care services, and to consider ways to reduce households’ time cost as a possible barrier to the use of antenatal care.

  • 81.
    Hitimana, Regis
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation2019In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, article id 36Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.

    METHODS: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).

    RESULTS: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.

    DISCUSSION: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

  • 82.
    Holgersson, Annelie
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Review of on-scene management of mass-casualty attacksManuscript (preprint) (Other academic)
    Abstract [en]

    Background: The scene of a mass-casualty attack (MCA) entails a crime scene, a hazardous space, and a great number of people needing medical assistance. Public transportation has been the target of such attacks and involves a high probability of generating mass casualties. The review aimed to investigate challenges for on-scene responses to MCAs and suggestions made to counter these challenges, with special attention given to attacks on public transportation and associated terminals. Methods: Articles were found through PubMed and Scopus, “relevant articles” as defined by the databases, and a manual search of references. Inclusion criteria were that the article referred to attack(s) and/or a public transportation-related incident and issues concerning formal on-scene response. An appraisal of the articles’ scientific quality was conducted based on an evidence hierarchy model developed for the study. Results: One hundred and five articles were reviewed. Challenges for command and coordination on scene included establishing leadership, inter-agency collaboration, multiple incident sites, and logistics. Safety issues entailed knowledge and use of personal protective equipment, risk awareness and expectations, cordons, dynamic risk assessment, defensive versus offensive approaches, and joining forces. Communication concerns were equipment shortfalls, dialoguing, and providing information. Assessment problems were scene layout and interpreting environmental indicators as well as understanding setting-driven needs for specialist skills and resources. Triage and treatment difficulties included differing triagesystems, directing casualties, uncommon injuries, field hospitals, level of care, providing psychological and pediatric care. Transportation hardships included scene access, distance to hospitals, and distribution of casualties. Conclusion: Commonly encountered challenges during unintentional incidents were added to during MCAs, implying specific issues for safety, assessment, triage, and treatment, which require collaborative planning and specific training.

  • 83.
    Holgersson, Annelie
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sahovic, Dzenan
    Umeå University, Faculty of Social Sciences, Department of Political Science.
    Saveman, Britt-Inger
    Umeå University, Faculty of Medicine, Department of Nursing.
    Björnstig, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Factors influencing responders' perceptions of preparedness for terrorism2016In: Disaster Prevention and Management, ISSN 0965-3562, E-ISSN 1758-6100, Vol. 25, no 4, p. 520-533Article in journal (Refereed)
    Abstract [en]

    Purpose: The purpose of this paper is to analyse factors influencing perceptions of preparedness in the response to terrorist attacks of operational personnel in Swedish emergency organizations. Design/methodology/approach: Data were collected using a questionnaire distributed to operational personnel from the police, rescue and ambulance services in eight Swedish counties; 864 responses were received and analysed. Findings: Three aspects of the perception of preparedness for terrorist attacks among Swedish emergency responders were studied: willingness to respond; level of confidence with tasks; and estimated management capability. Factors which positively influenced these perceptions were male sex, training in first aid and dealing with mass casualty incidents, terrorism-related management training (MT), table-top simulations, participation in functional exercises, and access to personal protective equipment (PPE); work experience was inversely related. Occupation in police or rescue services was positively associated with willingness to respond whereas occupation within the emergency medical services was positively associated with estimated management capability. Practical implications: These findings show that terrorism-related MT and access to PPE increase the perceptions of preparedness for terrorism among the emergency services, aiding judgements about investments in preparedness by crisis management planners. Originality/value: Limited research in disaster management and hazard preparedness has been conducted in a European context, especially regarding terrorism. Little is known about aspects of preparedness for terrorism in Sweden, particularly from the perspective of the emergency responders.

  • 84.
    Holgersson, Annelie
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Saveman, Britt-Inger
    Umeå University, Faculty of Medicine, Department of Nursing.
    Kunskapsöversikt - passagerarsäkerhet i tåg2011Report (Refereed)
  • 85.
    Holgersson, Annelie
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Strandh, Veronica
    Umeå University, Faculty of Social Sciences, Department of Political Science.
    Emergency organizations’ diverging perceptions of terrorist attacksManuscript (preprint) (Other academic)
    Abstract [en]

    Purpose: To analyse how the police, the rescue services and the emergency medical services (EMS) perceive the threat of terrorism and preparedness for a terrorist-induced crisis. It also aims to unravel differences among the emergency organizations and to discuss their potential implications for emergency preparedness. Methodology: Data were collected using a questionnaire distributed to operational personnel from the emergency services in eight Swedish counties; 864 responses were received and analysed. Findings: There were significant differences between the police, rescue and ambulance services regarding perceptions of event likelihood, willingness to respond, estimated management capability and level of confidence with tasks to be performed on scene. Perceived likelihood of events appeared affected by institutional logic; events within their respective domain of responsibility were perceived as more likely. The police stood out in many aspects, with more personnel with experience of violence on duty and a high grading of the probability of terrorist attacks compared to the other organizations. Fewer police had high estimates of their organizations’ management capability and knowledge of tasks on-scene. Practical implications: Differences in perspectives of terrorism preparedness and response among the emergency services were shown, highlighting the importance of enabling inter-organizational insights on safety culture, with risk awareness and management strategies, as well as knowledge of the other organizations’ institutional logics and main tasks, so as to achieve an effective, collaborative response to terrorism-induced crises. Originality: Little research has been conducted comparatively with regard to the emergency services and their perceptions of terrorism-specific threats and preparedness, particularly in the Swedish context. 

  • 86. Hoogendoorn, Martine
    et al.
    Feenstra, Talitha L
    Asukai, Yumi
    Briggs, Andrew H
    Borg, Sixten
    Dal Negro, Roberto W
    Hansen, Ryan N
    Jansson, Sven-Arne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Leidl, Reiner
    Risebrough, Nancy
    Samyshkin, Yevgeniy
    Wacker, Margarethe E
    Rutten-van Mölken, Maureen P M H
    Patient Heterogeneity in Health Economic Decision Models for Chronic Obstructive Pulmonary Disease: Are Current Models Suitable to Evaluate Personalized Medicine?2016In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 19, no 6, p. 800-810Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To assess how suitable current chronic obstructive pulmonary disease (COPD) cost-effectiveness models are to evaluate personalized treatment options for COPD by exploring the type of heterogeneity included in current models and by validating outcomes for subgroups of patients.

    METHODS: A consortium of COPD modeling groups completed three tasks. First, they reported all patient characteristics included in the model and provided the level of detail in which the input parameters were specified. Second, groups simulated disease progression, mortality, quality-adjusted life-years (QALYs), and costs for hypothetical subgroups of patients that differed in terms of sex, age, smoking status, and lung function (forced expiratory volume in 1 second [FEV1] % predicted). Finally, model outcomes for exacerbations and mortality for subgroups of patients were validated against published subgroup results of two large COPD trials.

    RESULTS: Nine COPD modeling groups participated. Most models included sex (seven), age (nine), smoking status (six), and FEV1% predicted (nine), mainly to specify disease progression and mortality. Trial results showed higher exacerbation rates for women (found in one model), higher mortality rates for men (two models), lower mortality for younger patients (four models), and higher exacerbation and mortality rates in patients with severe COPD (four models).

    CONCLUSIONS: Most currently available COPD cost-effectiveness models are able to evaluate the cost-effectiveness of personalized treatment on the basis of sex, age, smoking, and FEV1% predicted. Treatment in COPD is, however, more likely to be personalized on the basis of clinical parameters. Two models include several clinical patient characteristics and are therefore most suitable to evaluate personalized treatment, although some important clinical parameters are still missing.

  • 87.
    Jacobsson, Lars
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    [Also physicians must interpret laws: not only the lawyers]2010In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 107, no 22, p. 1448-1449Article in journal (Refereed)
  • 88. Jana, Saim Nor
    et al.
    Ghazinour, Mehdi
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Richter, Jorg
    Mental health predicted by coping, social support, and resilience among young unwed pregnant Malaysian women and mothers living in shelter homes2016In: International journal of human rights in health care, ISSN 2056-4902, Vol. 9, no 3, p. 185-197Article in journal (Refereed)
    Abstract [en]

    Purpose - There is a dearth of research on unwed young pregnant Malaysian women and mothers' coping strategy and resilience in the context of limited social support they receive. Hence, the purpose of this paper is to investigate the prediction of mental health by coping, social support, and resilience among unwed young Malaysian pregnant women and mothers. Design/methodology/approach - Quantitative data of two assessments from respondents aged 11 to 32 years during their stay in shelter homes have been analyzed. Findings - The result from the longitudinal study found that the variability in mental health scores could be explained between 14 percent for depressive-behavioral symptoms and 36 percent for general health. The mental health scores from the first assessment were part of the regression equation with the highest standardized beta scores. Cross-sectional, the variance in the three independent variable sets explained between 6 percent (general health) and 23 percent (cognitive depressive symptoms) of the variance in the various mental health scores with different variables of significant standardized beta scores in the regression equation. The study also found there were no significant changes in social support, resilience and coping between the first and second assessments even if the respondents had been in the shelter homes for a period of time. Originality/value - The study highlighted the issue of mental health among Malaysian unwed mothers during residential periods in shelter homes. As the subject of unwed mothers is considered taboo, their rights are often deprived or overlooked.

  • 89.
    Jansson, Sven-Arne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Backman, Helena
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Andersson, M.
    Telg, G.
    Lundbäck, B.
    Rönmark, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Health care consumption and HRQOL in severe asthma in Sweden2017In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 20, no 9, p. A513-A513Article in journal (Other academic)
    Abstract [en]

    Objectives: Severe asthma is a disabling and costly disease, often poorly controlled despite high-dosage controller medications. The objectives of this analysis were to estimate health care consumption and to investigate health-related quality of life (HRQOL) in a severe asthma cohort, derived from a large-scale population survey in northern Sweden. Methods: Severe asthma was defined by US SARP criteria; high-dosage inhaled corticosteroids (ICS) by GINA 2014 criteria. In total, 32 patients with severe asthma were invited to a clinical examination and structured interview. Retrospective data of all asthma-related direct and indirect resource consumption during the last year were collected following a defined protocol. HRQOL was assessed by four patient-reported outcome measures: two general measures (SF-36; EQ-5D) and two disease-specific measures (SGRQ; ACT). The cohort was divided into two groups —patients with (OCS) or without maintenance oral corticosteroid (non-OCS) treatment. Results: Health care resource utilization was greater in the OCS-group compared with the non-OCS group. Mean annual number of visits to specialist care was 2.0 in the OCS group vs. 0.5 visits in the non-OCS group. Four patients in the OCS group had early retirement vs. none in the non-OCS group. HRQOL was worse in the OCS group, both when measured with general and disease-specific instruments. The Mental and Physical Component Summary scores of the SF-36 in the OCS vs. non-OCS group were 50.1 vs. 40.7 and 55.8 vs. 44.4, respectively. Similarly, the total SGRQ scores indicated worse HRQOL for the OCS-group compared with the non-OCS group (37.0 vs. 27.0). Conclusions: In this severe asthma population, patients treated with maintenance OCS consumed more health care resources, were more frequently early retired, and had worse HRQOL compared with those not receiving maintenance OCS. The results indicate a need for improved treatment for patients with severe asthma on maintenance OCS. Sponsor: AstraZeneca.

  • 90.
    Jansson, Sven-Arne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Backman, Helena
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Stenling, Anna
    AstraZeneca Nordic-Baltic, Department of Health Economics, SE-151 85 Södertälje, Sweden.
    Lindberg, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Rönmark, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lundbäck, Bo
    Health economic costs of COPD in Sweden by disease severity: has it changed during a ten years period?2013In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 107, no 12, p. 1931-1938Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The objectives of the presented study were to estimate societal costs of COPD in Sweden, the relationship between costs and disease severity, and possible changes in the costs during the last decade.

    METHODS: Subjects with COPD derived from the general population in Northern Sweden were interviewed by telephone regarding their resource utilisation and productivity losses four times quarterly during 2009-10. Mean annual costs were estimated for each severity stage of COPD.

    RESULTS: A strong relationship was found between disease severity and costs. Estimated mean annual costs per subject of mild, moderate, severe and very severe COPD amounted to 596 (SEK 5686), 3245 (SEK 30,957), 5686 (SEK 54,242), and 17,355 euros (SEK 165,569), respectively. The main cost drivers for direct costs were hospitalisations (for very severe COPD) and drugs (all other severity stages). The main cost driver for indirect costs was productivity loss due to sick-leave (for mild COPD) and early retirement (all other severity stages). Costs appeared to be lower in 2010 than in 1999 for subjects with severe and very severe COPD, but higher for those with mild and moderate COPD.

    CONCLUSION: Our results show that costs of COPD are strongly related to disease severity, and scaling the data to the whole Swedish population indicates that the total costs in Sweden amounted to 1.5 billion euros (SEK 13.9 bn) in 2010. In addition, costs have decreased since 1999 for subjects with severe and very severe COPD, but increased for those with mild and moderate COPD.

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

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

  • 92.
    Johansson, Eva E
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Röjlar, Hanna
    Eriksson, Bodil
    Frisk, Kristina
    Gender differences in media portrayals of doctors: a challenge in the socialisation of next-generation doctors2008In: Medical Education, ISSN 0308-0110, E-ISSN 1365-2923, Vol. 42, no 2, p. 226-226Article in journal (Refereed)
  • 93.
    Johansson, Helene
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lundström, Lena
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Reorientation to more health promotion in health services: a study of barriers and possibilities from the perspective of health professionals2010In: Journal of Multidisciplinary Healthcare, ISSN 1178-2390, E-ISSN 1178-2390, Vol. 3, p. 213-224Article in journal (Refereed)
    Abstract [en]

    This study found strong support for reorientation of health services in the incorporation of a greater health promotion. A number of professions that are not usually associated with health promotion practices are knowledgeable and wish to focus more on health promotion and disease prevention. Management has a major role in creating opportunities for these professionals to participate in health promotion practices. Men and physicians reported less positive attitudes to a more health-promoting health service and often possess high positions of power. Therefore, they may play an important role in the process of change toward more health promotion in health services.

  • 94.
    Järvholm, Bengt
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Albin, Maria
    Mannelqvist, Ruth
    Umeå University, Faculty of Social Sciences, Department of Law.
    Påtagliga brister i utredningsförslag om arbetsskadeförsäkringen.2017In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 114, article id ERYCArticle in journal (Other (popular science, discussion, etc.))
  • 95.
    Kardakis, Therese
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jerdén, Lars
    Nyström, Monica
    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.
    Johansson, Helene
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Implementation of clinical guidelines on lifestyle in primary health care - a two-year follow upIn: Article in journal (Refereed)
  • 96.
    Kardakis, Therese
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Johansson, Helene
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Richter-Sundberg, Linda
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Garvare, Rickard
    Weinehall, Lars
    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.
    Assessing context and intervention specific organisational readiness for change: Preparing primary healthcare for clinical practice guidelines on lifestyle interventionsManuscript (preprint) (Other academic)
  • 97.
    Kasenga, Fyson
    et al.
    Malawi Union of the Seventh Day Adventist Church, P. O. Box 951, Blantyre, Malawi.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Staff motivation and welfare in Adventist health facilities in Malawi: a qualitative study2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, no 1, article id 486Article in journal (Refereed)
    Abstract [en]

    Background To explore factors that motivate members of staff at Adventist health facilities in Malawi to maximize their potential for work and improve their welfare. This was a qualitative study that utilized group discussions and in-depth interviews with health care staff members.

    Methods Four group discussions with health care workers and support staff were conducted. Results: Both motivating and demotivating factors were found. The motivating factors were spiritual nourishment of the institutions and working conditions with long term benefits for individuals and their families. The demotivating factors were unfair treatment without respect to staff by management. Specific areas like working condition, housing, allowances, training, communication, and personal support were highlighted as some of the factors that poorly motivated staff to stay at the health facility Further, issues related to the loose of purpose, where Christian values were seen to be deteriorating were observed to be undermining mission of the institutions.

    Conclusions Staff motivation is vital in any working condition in as far as good performance at the work environment is concerned. Poor working conditions have not been exceptions among the Adventist health institutions. Based on these findings, the study recommended that conditions of services for the Adventist health facilities need to be revised and implemented accordingly; training of staff for further facility development to be intensified, communication between management and health care staff through scheduled routine meetings need to be strengthened. Spiritual nourishment through staff interaction with church officials and pastors should always be considered. A further study is needed to look at the community perceptions towards the services offered in the Adventist health facilities.

  • 98.
    Keisu, Britt-Inger
    et al.
    Umeå University, Faculty of Social Sciences, Department of Sociology. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Öhman, Ann
    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.
    Enberg, Birgit
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Employee effort: reward balance and first-level manager transformational leadership within elderly care2018In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 32, no 1, p. 407-416Article in journal (Refereed)
    Abstract [en]

    Background: Negative aspects, staff dissatisfaction and problems related to internal organisational factors of working in elderly care are well-known and documented. Much less is known about positive aspects of working in elderly care, and therefore, this study focuses on such positive factors in Swedish elderly care. We combined two theoretical models, the effort–reward imbalance model and the Transformational Leadership Style model. The aim was to estimate the potential associations between employee-perceived transformational leadership style of their managers, and employees' ratings of effort and reward within elderly care work.

    Methods: The article is based on questionnaires distributed at on-site visits to registered nurses, occupational therapists, physiotherapists (high-level education) and assistant nurses (low-level education) in nine Swedish elderly care facilities. In order to grasp the positive factors of work in elderly care, we focused on balance at work, rather than imbalance.

    Results: We found a significant association between employees' effort–reward balance at work and a transformational leadership style among managers. An association was also found between employees' level of education and their assessments of the first-level managers.

    Conclusions: We conclude that the first-level manager is an important actor for achieving a good workplace within elderly care, since she/he influences employees' psychosocial working environment. We also conclude that there are differences and inequalities, in terms of well-being, effort and reward at the work place, between those with academic training and those without, in that the former group to a higher degree evaluated their first-level manager to perform a transformational leadership style, which in turn is beneficial for their psychosocial work environment. Consequently, this (re)-produce inequalities in terms of well-being, effort and reward among the employees at the work place.

  • 99.
    Kien, Vu Duy
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Center for Population Health Sciences, Hanoi School of Public Health, Hanoi, Vietnam.
    Minh, HV
    Giang, KB
    Dao, A
    Tuan, LT
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Socioeconomic inequalities in catastrophic health expenditure and impoverishment associated with non-communicable diseases in urban Hanoi, Vietnam2016In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 15, article id 169Article in journal (Refereed)
    Abstract [en]

    Background: The catastrophic health expenditure and impoverishment indices offer guidance for developing appropriate health policies and intervention programs to decrease financial inequity. This study assesses socioeconomic inequalities in catastrophic health expenditure and impoverishment in relation to self-reported non-communicable diseases (NCD) in urban Hanoi, Vietnam. Methods: A cross-sectional survey was conducted from February to March 2013 in Hanoi, the capital city of Vietnam. We estimated catastrophic health expenditure and impoverishment using information from 492 slum household and 528 non-slum households. We calculated concentration indexes to assess socioeconomic inequalities in catastrophic health expenditure and impoverishment. Factors associated with catastrophic health expenditure and impoverishment were modelled using logistic regression analysis. Results: The poor households in both slum and non-slum areas were at higher risk of experiencing catastrophic health expenditure, while only the poor households in slum areas were at higher risk of impoverishment because of healthcare spending. Households with at least one member reporting an NCD were significantly more likely to face catastrophic health expenditure (odds ratio [OR] = 2.4; 95 % confidence interval [CI], 1.8-4.0) and impoverishment (OR = 2.3; 95 % CI, 1.1-6.3) compared to households without NCDs. In addition, households in slum areas, with people age 60 years and above, and belonging to the poorest socioeconomic group were significantly associated with increased catastrophic health expenditure, while only households that lived in slum areas, and belonging to the poor or poorest socioeconomic groups were significantly associated with increased impoverishment because of healthcare spending. Conclusion: Financial interventions to prevent catastrophic health expenditure and impoverishment should target poor households, especially those with family members suffering from NCDs, with older members and those located in slum areas in Hanoi Vietnam. Potential interventions derived from this study include targeting and monitoring of health insurance enrolment, and developing a specialized NCD service package for Vietnam's social health insurance program.

  • 100.
    Kien, Vu Duy
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Minh, HV
    Giang, KB
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Viet, N
    Eriksson, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Responsiveness of commune health stations to non-communicable disease in urban VietnamArticle in journal (Refereed)
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