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  • 1. Abdulhadi, Nadia
    et al.
    Al Shafaee, Mohammed
    Freudenthal, Solveig
    Östenson, Claes-Göran
    Wahlström, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Clinical Epidemiology.
    Patient-provider interaction from the perspectives of type 2 diabetes patients in Muscat, Oman: a qualitative study2007In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 7, p. 162-Article in journal (Refereed)
    Abstract [en]

    Background: Patients' expectations and perceptions of the medical encounter and interactions are important tools in diabetes management. Some problems regarding the interaction during encounters may be related to a lack of communication skills on the part of either the physician or the patient. This study aimed at exploring the perceptions of type 2 diabetes patients regarding the medical encounters and quality of interactions with their primary health-care providers. Methods: Four focus group discussions ( two women and two men groups) were conducted among 27 purposively selected patients ( 13 men and 14 women) from six primary health-care centres in Muscat, Oman. Qualitative content analysis was applied. Results: The patients identified some weaknesses regarding the patient-provider communication like: unfriendly welcoming; interrupted consultation privacy; poor attention and eye contact; lack of encouraging the patients to ask questions on the providers' side; and inability to participate in medical dialogue or express concerns on the patients' side. Other barriers and difficulties related to issues of patient-centeredness, organization of diabetes clinics, health education and professional competency regarding diabetes care were also identified. Conclusion: The diabetes patients' experiences with the primary health-care providers showed dissatisfaction with the services. We suggest appropriate training for health-care providers with regard to diabetes care and developing of communication skills with emphasis on a patient-centred approach. An efficient use of available resources in diabetes clinics and distributing responsibilities between team members in close collaboration with patients and their families seems necessary. Further exploration of the providers' work situation and barriers to good interaction is needed. Our findings can help the policy makers in Oman, and countries with similar health systems, to improve the quality and organizational efficiency of diabetes care services.

  • 2.
    Bjorkman, Annica
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. Caring Sci Univ Gavle, Fac Hlth & Occupat Studies, Gavle, Sweden.
    Engström, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Caring Sci Univ Gavle, Fac Hlth & Occupat Studies, Gavle, Sweden; Lishui Univ, Med & Hlth Coll, Nursing Dept, Lishui, Peoples R China.
    Olsson, Annakarin
    Caring Sci Univ Gavle, Fac Hlth & Occupat Studies, Gavle, Sweden.
    Wahlberg, Anna Carin
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Stockholm, Sweden.
    Identified obstacles and prerequisites in telenurses' work environment: a modified Delphi study2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, no 1, article id 357Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Telenursing is an expanding part of healthcare, staffed with registered nurses whose work environment is typical of a call centre. Work-related stress has been shown to be a major problem in nurses' work environments and of importance to the outcome of care, patient safety, nurse job satisfaction and burnout. Today, however, we have a limited understanding of and knowledge about the work environment for telenurses. The aim of the present study is to explore and reach consensus on perceived important obstacles and prerequisites in telenurses' work environment.

    METHODS: A modified Delphi design, using qualitative as well as quantitative data sequentially through three phases, was taken. Data were initially collected via semi-structured interviews (Phase I) and later using a web survey (Phase II-III) between March 2015 and March 2016.

    RESULTS: The findings present a consensus view of telenurses' experiences of important obstacles and prerequisites in their work environment. Central to the findings are the aspects of telenurses having a demanding work, cognitive fatigue and having no opportunity for recovery during the work shift was ranked as important obstacles. Highly ranked prerequisites for managing were being able to focus on one caller at a time, working in a calm and pleasant environment and having technical support 24/7.

    CONCLUSIONS: Managers need to enable telenurses to experience control in their work, provided with possibilities to control their work and to recover during work; shortening work time could improve their work environment. Limited possibilities to perform work might contribute to feelings of stress and inability to perform work.

  • 3.
    Bjurling-Sjöberg, Petronella
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD).
    Wadensten, Barbro
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Pöder, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Jansson, Inger
    Göteborgs universitet.
    Nordgren, Lena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: A grounded theory study2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 831Article in journal (Refereed)
    Abstract [en]

    Background: Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context.

    Methods: The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data.

    Results: A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational.

    Conclusions: The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.

  • 4.
    Burström, Lena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Letterstal, Anna
    Engström, Marie-Loise Walker
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Berglund, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Enlund, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    The patient safety culture as perceived by staff at two different emergency departments before and after introducing a flow-oriented working model with team triage and lean principles: a repeated cross-sectional study2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 296-Article in journal (Refereed)
    Abstract [en]

    Background: Patient safety is of the utmost importance in health care. The patient safety culture in an institution has great impact on patient safety. To enhance patient safety and to design strategies to reduce medical injuries, there is a current focus on measuring the patient safety culture. The aim of the present study was to describe the patient safety culture in an ED at two different hospitals before and after a Quality improvement (QI) project that was aimed to enhance patient safety. Methods: A repeated cross-sectional design, using the Hospital Survey On Patient Safety Culture questionnaire before and after a quality improvement project in two emergency departments at a county hospital and a university hospital. The questionnaire was developed to obtain a better understanding of the patient safety culture of an entire hospital or of specific departments. The Swedish version has 51 questions and 15 dimensions. Results: At the county hospital, a difference between baseline and follow-up was observed in three dimensions. For two of these dimensions, Team-work within hospital and Communication openness, a higher score was measured at the follow-up. At the university hospital, a higher score was measured at follow-up for the two dimensions Team-work across hospital units and Team-work within hospital. Conclusion: The result showed changes in the self-estimated patient safety culture, mainly regarding team-work and communication openness. Most of the improvements at follow-up were seen by physicians, and mainly at the county hospital.

  • 5.
    Burström, Lena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Starrin, Bengt
    Engström, Marie-Louise
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Thulesius, Hans
    Waiting management at the emergency department - a grounded theory study2013In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, p. 95-Article in journal (Refereed)
    Abstract [en]

    Background: An emergency department (ED) should offer timely care for acutely ill or injured persons that require the attention of specialized nurses and physicians. This study was aimed at exploring what is actually going on at an ED. Methods: Qualitative data was collected 2009 to 2011 at one Swedish ED (ED1) with 53.000 yearly visits serving a population of 251.000. Constant comparative analysis according to classic grounded theory was applied to both focus group interviews with ED1 staff, participant observation data, and literature data. Quantitative data from ED1 and two other Swedish EDs were later analyzed and compared with the qualitative data. Results: The main driver of the ED staff in this study was to reduce non-acceptable waiting. Signs of non-acceptable waiting are physical densification, contact seeking, and the emergence of critical situations. The staff reacts with frustration, shame, and eventually resignation when they cannot reduce non-acceptable waiting. Waiting management resolves the problems and is done either by reducing actual waiting time by increasing throughput of patient flow through structure pushing and shuffling around patients, or by changing the experience of waiting by calming patients and feinting maneuvers to cover up. Conclusion: To manage non-acceptable waiting is a driving force behind much of the staff behavior at an ED. Waiting management is done either by increasing throughput of patient flow or by changing the waiting experience.

  • 6.
    Di Paolo, Antonello
    et al.
    Univ Pisa, Sect Pharmacol, Dept Clin & Expt Med, Via Roma 55, I-56126 Pisa, Italy.
    Sarkozy, Francois
    FSNB Hlth & Care, Carenity, Paris, France.
    Ryll, Bettina
    Uppsala University, Disciplinary Domain of Science and Technology, Biology, Department of Organismal Biology, Evolution and Developmental Biology. Melanoma Patient Network Europe.
    Siebert, Uwe
    UMIT Univ Hlth Sci Med Informat & Technol, Dept Publ Hlth Hlth Serv Res & Hlth Technol Asses, Hall In Tirol, Austria.;ONCOTYROL Ctr Personalized Canc Med, Area Hlth Technol Assessment, Innsbruck, Austria..
    Personalized medicine in Europe: not yet personal enough?2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 289Article in journal (Refereed)
    Abstract [en]

    Background: Personalized medicine has the potential to allow patients to receive drugs specific to their individual disease, and to increase the efficiency of the healthcare system. There is currently no comprehensive overview of personalized medicine, and this research aims to provide an overview of the concept and definition of personalized medicine in nine European countries. Methods: A targeted literature review of selected health databases and grey literature was conducted to collate information regarding the definition, process, use, funding, impact and challenges associated with personalized medicine. In-depth qualitative interviews were carried out with experts with health technology assessment, clinical provisioning, payer, academic, economic and industry experience, and with patient organizations. Results: We identified a wide range of definitions of personalized medicine, with most studies referring to the use of diagnostics and individual biological information such as genetics and biomarkers. Few studies mentioned patients' needs, beliefs, behaviour, values, wishes, utilities, environment and circumstances, and there was little evidence in the literature for formal incorporation of patient preferences into the evaluation of new medicines. Most interviewees described approaches to stratification and segmentation of patients based on genetic markers or diagnostics, and few mentioned health-related quality of life. Conclusions: The published literature on personalized medicine is predominantly focused on patient stratification according to individual biological information. Although these approaches are important, incorporation of environmental factors and patients' preferences in decision making is also needed. In future, personalized medicine should move from treating diseases to managing patients, taking into account all individual factors.

  • 7.
    Eldh, Ann Catrine
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden.;Linkoping Univ, Dept Med & Hlth Sci, SE-58183 Linkoping, Sweden..
    Almost, Joan
    Queens Univ, Kingston, ON, Canada..
    DeCorby-Watson, Kara
    Publ Hlth Ontario, Toronto, ON, Canada..
    Gifford, Wendy
    Univ Ottawa, Ottawa, ON, Canada..
    Harvey, Gill
    Univ Adelaide, Adelaide, SA, Australia.;Univ Manchester, Manchester, Lancs, England..
    Hasson, Henna
    Karolinska Inst, Med Management Ctr, Stockholm, Sweden.;Stockholm Cty Council, Ctr Epidemiol & Community Med, Stockholm, Sweden..
    Kenny, Deborah
    Univ Colorado, Colorado Springs, CO 80907 USA..
    Moodie, Sheila
    Western Univ, London, ON, Canada..
    Wallin, Lars
    Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden.;Karolinska Inst, Div Nursing, Dept Neurobiol Care Sci & Soc, Stockholm, Sweden.;Univ Gothenburg, Sahlgrenska Acad, Dept Hlth & Care Sci, Gothenburg, Sweden..
    Yost, Jennifer
    McMaster Univ, Sch Nursing, Hamilton, ON, Canada..
    Clinical interventions, implementation interventions, and the potential greyness in between -a discussion paper2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 16Article in journal (Refereed)
    Abstract [en]

    Background: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. Discussion: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. Conclusion: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

  • 8.
    Eldh, Ann Catrine
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. School of Education, Health, and Social Studies, Dalarna University, SE.
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Wallin, Lars
    School of Education, Health, and Social Studies, Dalarna University, SE.
    Dahlström, Tobias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Facilitators and barriers to applying a national quality registry for quality improvement in stroke care2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 354-Article in journal (Refereed)
    Abstract [en]

    Background: National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden. Methods: A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis. Results: An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data. Conclusion: While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.

  • 9.
    Eldh, Ann Catrine
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Wallin, Lars
    Karolinska Institutet.
    Dahlström, Tobias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Winblad, Ulrica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Depicting the interplay between organisational tiers in the use of a national quality registry to develop quality of care in Sweden2015In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, no 1, article id 519Article in journal (Refereed)
  • 10.
    Eriksson, Daniel
    et al.
    Quantify Res, Hantverkargatan 8, S-11221 Stockholm, Sweden..
    Karlsson, Linda
    Quantify Res, Hantverkargatan 8, S-11221 Stockholm, Sweden..
    Eklund, Oskar
    Quantify Res, Hantverkargatan 8, S-11221 Stockholm, Sweden..
    Dieperink, Hans
    Odense Univ Hosp, Dept Nephrol, Sdr Blvd 29, DK-5000 Odense C, Denmark..
    Honkanen, Eero
    Univ Helsinki, Cent Hosp, Dept Med, Div Nephrol, Haartmaninkatu 4,POB 372, FIN-00029 Hus Helsinki, Finland..
    Melin, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Renal Medicine.
    Selvig, Kristian
    Vestre Viken Hosp Trust, Dept Nephrol, Postboks 800 3004, Drammen, Norway..
    Lundberg, Johan
    Otsuka Pharma Scandinavia, Birger Jarlsgatan 27, S-11145 Stockholm, Sweden..
    Real-world costs of autosomal dominant polycystic kidney disease in the Nordics2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 560Article in journal (Refereed)
    Abstract [en]

    Background: There is limited real-world data on the economic burden of patients with autosomal dominant polycystic kidney disease (ADPKD). The objective of this study was to estimate the annual direct and indirect costs of patients with ADPKD by severity of the disease: chronic kidney disease (CKD) stages 1-3; CKD stages 4-5; transplant recipients; and maintenance dialysis patients. Methods: A retrospective study of ADPKD patients was undertaken April-December 2014 in Denmark, Finland, Norway and Sweden. Data on medical resource utilisation were extracted from medical charts and patients were asked to complete a self-administered questionnaire. Results: A total of 266 patients were contacted, 243 (91%) of whom provided consent to participate in the study. Results showed that the economic burden of ADPKD was substantial at all levels of the disease. Lost wages due to reduced productivity were large in absolute terms across all disease strata. Mean total annual costs were highest in dialysis patients, driven by maintenance dialysis care, while the use of immunosuppressants was the main cost component for transplant care. Costs were twice as high in patients with CKD stages 4-5 compared to CKD stages 1-3. Conclusions: Costs associated with ADPKD are significant and the progression of the disease is associated with an increased frequency and intensity of medical resource utilisation. Interventions that can slow the progression of the disease have the potential to lead to substantial reductions in costs for the treatment of ADPKD.

  • 11.
    Fredriksson, Mio
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Blomqvist, Paula
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Government.
    Winblad, Ulrika Spångberg
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Recentralizing healthcare through evidence-based guidelines – striving for national equity in Sweden2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 509-Article in journal (Refereed)
    Abstract [en]

    Background: The Swedish government has increasingly begun to rely on so called informative governance when regulating healthcare. The question this article sets out to answer is: considered to be “the backbone” of the Swedish state’s strategy for informative governance in healthcare, what kind of regulatory arrangement is the evidence-based National Guidelines? Together with national medical registries and an extensive system of quality and efficiency indicators, the National Guidelines constitutes Sweden’s quality management system. Methods: A framework for evaluating and comparing regulatory arrangements was used. It asks for instance: what is the purpose of the regulation and are regulation methods oriented towards deterrence or compliance? Results: The Swedish National Guidelines is a regulatory arrangement intended to govern the prioritizations of alldecision makers – politicians and administrators in the self-governing county councils as well as healthcare professionals – through a compliance model backed up by top-down benchmarking and built-in mechanisms for monitoring. It is thus an instrument for the central state to steer local political authorities. The purpose is to achieve equitable and cost-effective healthcare. Conclusions: This article suggests that the use of evidence-based guidelines in Swedish healthcare should be seen in the light of Sweden’s constitutional setting, with several autonomous levels of political authority negotiating the scope for their decision-making power. As decision-making capacity is relocated to the central government – from the democratically elected county councils responsible for financing and provision of healthcare – the Swedish National Guidelines is part of an ongoing process of healthcare recentralization in Sweden, reducing the scope for local decision-making. This represents a new aspect of evidence-based medicine (EBM) and clinical practice guidelines (CPGs).

  • 12. Frykman, Mandus
    et al.
    Hasson, Henna
    Athlin, Åsa Muntlin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Schwarz, Ulrica von Thiele
    Functions of behavior change interventions when implementing multi-professional teamwork at an emergency department: a comparative case study2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 218-Article in journal (Refereed)
    Abstract [en]

    Background: While there is strong support for the benefits of working in multi-professional teams in health care, the implementation of multi-professional teamwork is reported to be complex and challenging. Implementation strategies combining multiple behavior change interventions are recommended, but the understanding of how and why the behavior change interventions influence staff behavior is limited. There is a lack of studies focusing on the functions of different behavior change interventions and the mechanisms driving behavior change. In this study, applied behavior analysis is used to analyze the function and impact of different behavior change interventions when implementing multi-professional teamwork. Methods: A comparative case study design was applied. Two sections of an emergency department implemented multi-professional teamwork involving changes in work processes, aimed at increasing inter-professional collaboration. Behavior change interventions and staff behavior change were studied using observations, interviews and document analysis. Using a hybrid thematic analysis, the behavior change interventions were categorized according to the DCOM (R) model. The functions of the behavior change interventions were then analyzed using applied behavior analysis. Results: The two sections used different behavior change interventions, resulting in a large difference in the degree of staff behavior change. The successful section enabled staff performance of teamwork behaviors with a strategy based on ongoing problem-solving and frequent clarification of directions. Managerial feedback initially played an important role in motivating teamwork behaviors. Gradually, as staff started to experience positive outcomes of the intervention, motivation for teamwork behaviors was replaced by positive task-generated feedback. Conclusions: The functional perspective of applied behavior analysis offers insight into the behavioral mechanisms that describe how and why behavior change interventions influence staff behavior. The analysis demonstrates how enabling behavior change interventions, managerial feedback and task-related feedback interact in their influence on behavior and have complementary functions during different stages of implementation.

  • 13. Goras, Camilla
    et al.
    Wallentin, Fan Yang
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Nilsson, Ulrica
    Ehrenberg, Anna
    Swedish translation and psychometric testing of the safety attitudes questionnaire (operating room version)2013In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, p. 104-Article in journal (Refereed)
    Abstract [en]

    Background: Tens of millions of patients worldwide suffer from avoidable disabling injuries and death every year. Measuring the safety climate in health care is an important step in improving patient safety. The most commonly used instrument to measure safety climate is the Safety Attitudes Questionnaire (SAQ). The aim of the present study was to establish the validity and reliability of the translated version of the SAQ. Methods: The SAQ was translated and adapted to the Swedish context. The survey was then carried out with 374 respondents in the operating room (OR) setting. Data was received from three hospitals, a total of 237 responses. Cronbach's alpha and confirmatory factor analysis (CFA) was used to evaluate the reliability and validity of the instrument. Results: The Cronbach's alpha values for each of the factors of the SAQ ranged between 0.59 and 0.83. The CFA and its goodness-of-fit indices (SRMR 0.055, RMSEA 0.043, CFI 0.98) showed good model fit. Intercorrelations between the factors safety climate, teamwork climate, job satisfaction, perceptions of management, and working conditions showed moderate to high correlation with each other. The factor stress recognition had no significant correlation with teamwork climate, perception of management, or job satisfaction. Conclusions: Therefore, the Swedish translation and psychometric testing of the SAQ (OR version) has good construct validity. However, the reliability analysis suggested that some of the items need further refinement to establish sound internal consistency. As suggested by previous research, the SAQ is potentially a useful tool for evaluating safety climate. However, further psychometric testing is required with larger samples to establish the psychometric properties of the instrument for use in Sweden.

  • 14.
    Grooten, Wilhelmus Johannes Andreas
    et al.
    Karolinska Inst, Div Physiotherapy, Dept Neurobiol Care Sci & Soc, Huddinge, Sweden;Karolinska Univ Hosp, Allied Hlth Profess Funct, Funct Area Occupat Therapy & Physiotherapy, Stockholm, Sweden.
    Hansson, Amanda
    Karolinska Inst, Div Physiotherapy, Dept Neurobiol Care Sci & Soc, Huddinge, Sweden;Karolinska Univ Hosp, Allied Hlth Profess Funct, Funct Area Occupat Therapy & Physiotherapy, Stockholm, Sweden.
    Forsman, Mikael
    Karolinska Inst, Inst Environm Med, Stockholm, Sweden;Stockholm Cty Council, Ctr Occupat & Environm Med, Stockholm, Sweden;KTH Royal Inst Technol, Div Ergon, Huddinge, Sweden.
    Kjellberg, Katarina
    Karolinska Inst, Inst Environm Med, Stockholm, Sweden;Stockholm Cty Council, Ctr Occupat & Environm Med, Stockholm, Sweden.
    Toomingas, Allan
    Karolinska Inst, Inst Environm Med, Stockholm, Sweden;Stockholm Cty Council, Ctr Occupat & Environm Med, Stockholm, Sweden.
    Mueller, Mira
    Karolinska Inst, Div Physiotherapy, Dept Neurobiol Care Sci & Soc, Huddinge, Sweden.
    Svartengren, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Occupational and Environmental Medicine.
    Äng, Björn Olov
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna. Karolinska Inst, Div Physiotherapy, Dept Neurobiol Care Sci & Soc, Huddinge, Sweden;Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden.
    Non-participation in initial and repeated health risk appraisals: a drop-out analysis based on a health project2019In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 19, article id 130Article in journal (Refereed)
    Abstract [en]

    Background

    Health risk assessment (HRAs) are commonly used by occupational health services (OHS) to aid workplaces in keeping their employees healthy, but for unknown reasons, many employees choose not to participate in the HRAs. The aim of the study was to explore whether demographic, lifestyle and health-related factors in employees are associated with non-participation in initial and repeated HRAs.

    Methods

    In an OHS-based health project, 2022 municipal employees were asked to participate in three repeated HRAs. Multiple logistic regression analyses were used so as to determine associations between non-participating and demographic, lifestyle and health-related factors (e.g. biomarkers).

    Results

    Among the employees who were asked to participate in the health project, more than half did not participate in any HRA and among those who did, more than one third did not participate in repeated HRAs. Young age, male sex and being employed in the Technical department or Health and Social Care department in comparison with being employed in the department for Childcare and Education were factors significantly associated with non-participation in the initial HRA. These factors, together with being on sick leave and having unhealthy dietary habits, were factors associated with non-participation in repeated HRAs.

    Conclusions

    Among the non-participators in initial HRAs and in repeated HRAs younger men and those already related to ill-health were overrepresented. This implicates that health care providers to a higher extent should focus on those most needed and that employers should be more engaged in results of repeated HRA's. Future studies should focus on modifiable variables that could make the HRAs more attractive and inclusive.

  • 15.
    Gustavsson, Catharina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna. Dalarna Univ, Sch Educ Hlth & Social Studies, SE-79188 Falun, Sweden;Malardalen Univ, Sch Hlth Care & Social Welf, Box 883, SE-72123 Vasteras, Sweden.
    Nordqvist, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna. Malardalen Univ, Sch Hlth Care & Social Welf, Box 883, SE-72123 Vasteras, Sweden.
    Bröms, Kristina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Research and Development, Gävleborg. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Jerdén, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna. Dalarna Univ, Sch Educ Hlth & Social Studies, SE-79188 Falun, Sweden.
    Kallings, Lena V
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Swedish Sch Sport & Hlth Sci GIH, Dept Sport & Hlth Sci, Box 5626, SE-11486 Stockholm, Sweden.
    Wallin, Lars
    Dalarna Univ, Sch Educ Hlth & Social Studies, SE-79188 Falun, Sweden;Karolinska Inst, Div Nursing, Dept Neurobiol Care Sci & Soc, SE-17770 Stockholm, Sweden;Univ Gothenburg, Sahlgrenska Acad, Inst Hlth Care Sci, Box 457, S-40530 Gothenburg, Sweden.
    What is required to facilitate implementation of Swedish physical activity on prescription?: - interview study with primary healthcare staff and management2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 196Article in journal (Refereed)
    Abstract [en]

    Background: The method, Swedish Physical Activity on Prescription (SPAP), has been launched in Swedish healthcare to promote physical activity for prevention and treatment of lifestyle related health disorders. Despite scientific support for the method, and education campaigns, it is used to a limited extent by health professionals. The aim of the study was to describe the views of health professionals on perceived facilitators, barriers and requirements for successful implementation of SPAP in primary healthcare. Methods: Eighteen semi-structured interviews with stakeholders in SPAP, i.e. ten people working in local or central management and eight primary healthcare professionals in two regional healthcare organisations, were analysed using qualitative content analysis. Results: We identified an overarching theme regarding requirements for successful implementation of SPAP: Need for knowledge and organisational support, comprising four main categories: Need for increased knowledge and affirmative attitude among health professionals; Need for clear and supportive management; Need for central supporting structures; Need for local supporting structures. Knowledge of the SPAP method content and core components was limited. Confidence in the method varied among health professionals. There was a discrepancy between the central organisation policy documents declaring that disease preventive methods were prioritised and a mandatory assignment, while the health professionals asked for increased interest, support and resources from management, primarily time and supporting structures. There were somewhat conflicting views between primary healthcare professionals and managers concerning perceived barriers and requirements. In contrast to some of the management's beliefs, all primary healthcare professionals undisputedly acknowledged the importance of promoting physical activity, but they lacked time, written routines and in some cases competence for SPAP counselling. Conclusion: The study provides knowledge regarding requirements to facilitate the implementation of SPAP in healthcare. There was limited knowledge among health professionals regarding core components of SPAP and how to practise the method, which speaks for in-depth training in the SPAP method. The findings highlight the importance of forming policies and guidelines and establishing organisational supporting structures, and ensuring that these are well known and approved in all parts of the healthcare organisation.

  • 16.
    Henriksson, Dorcus Kiwanuka
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Karolinska Inst, Stockholm, Sweden.
    Ayebare, Florence
    Makerere Univ, Sch Publ Hlth, Coll Hlth Sci, Kampala, Uganda..
    Waiswa, Peter
    Karolinska Inst, Stockholm, Sweden.;Makerere Univ, Sch Publ Hlth, Coll Hlth Sci, Kampala, Uganda..
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Sch Publ Hlth, Coll Hlth Sci, Kampala, Uganda..
    Tumushabe, Elly K.
    Mukono Dist Local Govt, Mukono, Uganda..
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 103Article in journal (Refereed)
    Abstract [en]

    Background: The District Health System was endorsed as the key strategy to achieve 'Health for all' during the WHO organized inter-regional meeting in Harare in 1987. Many expectations were put upon the district health system, including planning. Although planning should be evidence based to prioritize activities, in Uganda it has been described as occurring more by chance than by choice. The role of planning is entrusted to the district health managers with support from the Ministry of Health and other stakeholders, but there is limited knowledge on the district health manager's capacity to carry out evidence-based planning. The aim of this study was to determine the barriers and enablers to evidence-based planning at the district level.

    Methods: This qualitative study collected data through key informant interviews with district managers from two purposefully selected districts in Uganda that have been implementing evidence-based planning. A deductive process of thematic analysis was used to classify responses within themes.

    Results: There were considerable differences between the districts in regard to the barriers and enablers for evidence-based planning. Variations could be attributed to specific contextual and environmental differences such as human resource levels, date of establishment of the district, funding and the sociopolitical environment. The perceived lack of local decision space coupled with the perception that the politicians had all the power while having limited knowledge on evidence-based planning was considered an important barrier.

    Conclusion: There is a need to review the mandate of the district managers to make decisions in the planning process and the range of decision space available within the district health system. Given the important role elected officials play in a decentralized system a concerted effort should be made to increase their knowledge on evidence-based planning and the district health system as a whole.

  • 17.
    Höglund, Anna T
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics.
    Falkenström, Erica
    Stockholms universitet.
    The status of ethics in Swedish health care management:: a qualitative study2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, no 608, p. 1-8Article in journal (Refereed)
    Abstract [en]

    Background

    By tradition, the Swedish health care system is based on a representative and parliamentary form of government. Recently, new management forms, inspired by market principles, have developed. The steering system is both national and regional, in that self-governing county councils are responsible for the financing and provision of health care in different regions. National and local documents regulating Swedish health care mention several ethical values, such as equity in health for the whole population and respect for autonomy and human dignity. It is therefore of interest to investigate the status of such ethical statements in Swedish health care management.

    Method

    The aim of the present study was to investigate perceptions of the status of ethics in the daily work of politicians, chief civil servants and Chief Executive Officers (CEOs) from care-giver organizations in the county council of Stockholm. A qualitative method was used, based on inductive content analysis of individual interviews with 13 health care managers.

    Results

    The content analysis resulted in four categories: Low status of ethics; Cost-effectiveness over ethics; Separation of ethics from management; and Lack of opportunities for ethical competence building. The informants described how they prioritized economic concerns over ethics and separated ethics from their daily work. They also expressed that they experienced that this development had been enforced by the marketization of the health care system. Further, they described how they lacked opportunities for ethical discussions, which could have helped develop their ethical competence.

    Conclusions

    In order to improve the status of ethics in health care management, ethical considerations and analyses must be integrated in the regular work tasks of politicians, chief civil servants and CEOs; such as decision-making, budgeting and reform work. Further, opportunities for ethical dialogues on a regular basis should be organized, in order to improve ethical competence on the management level. New steering forms, less focused upon market principles, might also be needed, in order to improve the status of ethics in the health care management organization.

  • 18.
    Isaksson, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Blomqvist, Paula
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Government.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Free establishment of primary health care providers: effects on geographical equity2016In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, article id 28Article in journal (Refereed)
    Abstract [en]

    Background

    A reform in 2010 in Swedish primary care made it possible for private primary care providers to establish themselves freely in the country. In the former, publicly planned system, location was strictly regulated by local authorities. The goal of the new reform was to increase access and quality of health care. Critical arguments were raised that the reform could have detrimental effects on equity if the new primary health care providers chose to establish foremost in socioeconomically prosperous areas.

    The aim of this study is to examine how the primary care choice reform has affected geographical equity by analysing patterns of establishment on the part of new private providers.

    Methods

    The basis of the design was to analyse socio-economic data on individuals who reside in the same electoral areas in which the 1411 primary health care centres in Sweden are established. Since the primary health care centres are located within 21 different county councils with different reimbursement schemes, we controlled for possible cluster effects utilizing generalized estimating equations modelling. The empirical material used in the analysis is a cross-sectional data set containing socio-economic data of the geographical areas in which all primary health care centres are established.

    Results

    When controlling for the effects of the county council regulation, primary health care centres established after the primary care choice reform were found to be located in areas with significantly fewer older adults living alone as well as fewer single parents – groups which generally have lower socio-economic status and high health care needs. However, no significant effects were observed for other socio-economic variables such as mean income, percentage of immigrants, education, unemployment, and children <5 years.

    Conclusions

    The primary care choice reform seems to have had some negative effects on geographical equity, even though these seem relatively minor.

  • 19.
    Jammer, Ib
    et al.
    Haukeland University Bergen.
    Andersson, Christina Allansdotter
    Olinder, Anna Lindholm
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, 118 83 Stockholm, Sweden.
    Selander, Bo
    Wallinder, Anna Elmerfeldt
    Hansson, Stefan Rocco
    Medical services of a multicultural summer camp event: experiences from the 22nd World Scout Jamboree, Sweden 20112013In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, p. 187-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Prevention and treatment of medical issues are the main task of a health service at a youth camp. However, only few reports about organisation and implementation of camp health care are available. This makes it difficult for future camp directors to plan and estimate the health care needed for a certain camp size. We summarize the experience in planning and running health care for the 22nd World Scout Jamboree (WSJ) 2011 in Sweden.

    METHODS:

    During the WSJ, 40,061 participants from 146 nations were gathered in southern Sweden to a 12 day summer camp. Another 31,645 people were visitors. Members for the medical service were 153 volunteering medical professionals with different language and cultural backgrounds from 18 different countries.

    RESULTS:

    Of 40,061 participants 2,893 (7.3%) needed medical assistance. We found an equal distribution of cases to approximately one third surgical, one third medical and one third unspecified cases. Much energy was spent on health prevention, hygiene measures and organizing of psychological support.

    CONCLUSIONS:

    A youth camp with a multicultural population and a size of a small city demands flexible staff with high communication skills. Special attention should be paid in prevention of contagious diseases and taking care of psychological issues.

  • 20.
    Kalengayi, Faustine Kyungu Nkulu
    et al.
    Umea Univ, Div Epidemiol & Global Hlth, Dept Publ Hlth & Clin Med, SE-90187 Umea, Sweden..
    Hurtig, Anna-Karin
    Umea Univ, Div Epidemiol & Global Hlth, Dept Publ Hlth & Clin Med, SE-90187 Umea, Sweden..
    Nordstrand, Annika
    Norrbotten Cty Council, Publ Hlth Ctr, SE-97189 Lulea, Sweden..
    Ahlm, Clas
    Umea Univ, Dept Clin Microbiol, Div Infect Dis, SE-90187 Umea, Sweden..
    Ahlberg, Beth Maina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Skaraborg Inst Res & Dev, SE-54130 Skovde, Sweden..
    Perspectives and experiences of new migrants on health screening in Sweden2016In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, article id 14Article in journal (Refereed)
    Abstract [en]

    Background: In Sweden, migrants from countries considered to have a high burden of certain infectious diseases are offered health screening to prevent the spread of these diseases, but also identify their health needs. However, very little is known about their experiences and perceptions about the screening process. This study aimed at exploring these perceptions and experiences in order to inform policy and clinical practice. Method: Using an interpretive description framework, 26 new migrants were interviewed between April and June 2013 in four Swedish counties. Thematic analysis was used to analyze data. Results: The three themes developed include: new country, new practices; new requirements in the new country; and unmet needs and expectations. Participants described what it meant for them to come to a new country with a foreign language, new ways of communicating with caregivers/authorities and being offered health screening without clarification. Participants perceived health screening as a requirement from the authorities to be fulfilled by all newcomers but conceded that it benefits equally the host society and themselves. However, they also expressed concern over the involvement of the Migration Board staff and feared possible collaboration with health service to their detriment. They further stated that the screening program fell short of their expectations as it mainly focused on identifying infectious diseases and overlooked their actual health needs. Finally, they expressed frustration over delay in screening, poor living conditions in reception centers and the restrictive entitlement to care. Conclusions: Migrants are aware of their vulnerability and the need to undergo health screening though they view it as an official requirement. Thus, those who underwent the screening were more concerned about residency rather than the actual benefits of screening. The issues highlighted in this study may limit access to and uptake of the screening service, and compromise its effectiveness. To maximize the uptake: (1) linguistically and culturally adapted information is needed, (2) other screening approaches should be tried, (3) trained medical interpreters should be used, (4) a holistic and human right approach should be applied, (5) the involvement of migration staff should be reconsidered to avoid confusion and worries. Finally, to improve the effectiveness, (6) all migrants from targeted countries should be offered screening and efforts should be taken to improve the health literacy of migrants and the living conditions in reception centers.

  • 21.
    Kaltenbrunner, Monica
    et al.
    Univ Gavle, Fac Hlth & Occupat Studies, S-80176 Gavle, Sweden..
    Bengtsson, Lars
    Univ Gavle, Fac Engn & Sustainable Dev, S-80176 Gavle, Sweden..
    Mathiassen, Svend Erik
    Univ Gavle, Fac Hlth & Occupat Studies, S-80176 Gavle, Sweden..
    Engström, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Univ Gavle, Fac Hlth & Occupat Studies, S-80176 Gavle, Sweden.; Lishui Univ, Dept Nursing, Med & Hlth Coll, Lishui Shi, Peoples R China..
    A questionnaire measuring staff perceptions of Lean adoption in healthcare: development and psychometric testing2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, no 1, article id 235Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: During the past decade, the concept of Lean has spread rapidly within the healthcare sector, but there is a lack of instruments that can measure staff's perceptions of Lean adoption. Thus, the aim of the present study was to develop a questionnaire measuring Lean in healthcare, based on Liker's description of Lean, by adapting an existing instrument developed for the service sector.

    METHODS: A mixed-method design was used. Initially, items from the service sector instrument were categorized according to Liker's 14 principles describing Lean within four domains: philosophy, processes, people and partners and problem-solving. Items were lacking for three of Liker's principles and were therefore developed de novo. Think-aloud interviews were conducted with 12 healthcare staff from different professions to contextualize and examine the face validity of the questionnaire prototype. Thereafter, the adjusted questionnaire's psychometric properties were assessed on the basis of a cross-sectional survey among 386 staff working in primary care.

    RESULTS: The think-aloud interviews led to adjustments in the questionnaire to better suit a healthcare context, and the number of items was reduced. Confirmatory factor analysis of the adjusted questionnaire showed a generally acceptable correspondence with Liker's description of Lean. Internal consistency, measured using Cronbach's alpha, for the factors in Liker's description of Lean was 0.60 for the factor people and partners, and over 0.70 for the three other factors. Test-retest reliability measured by the intra-class correlation coefficient ranged from 0.77 to 0.88 for the four factors.

    CONCLUSIONS: We designed a questionnaire capturing staff's perceptions of Lean adoption in healthcare on the basis of Liker's description. This Lean in Healthcare Questionnaire (LiHcQ) showed generally acceptable psychometric properties, which supports its usability for measuring Lean adoption in healthcare. We suggest that further research focus on verifying the usability of LiHcQ in other healthcare settings, and on adjusting the instrument if needed.

  • 22.
    Kaminsky, Elenor
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Carlsson, Marianne
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. University of Gävle, Department of Health and Caring Sciences.
    Holmström Knutsson, Inger
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. Mälardalens högskola, School of Health, Care and Social Welfare.
    Larsson, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Goals of telephone nursing work - the managers' perspectives: a qualitative study on Swedish healthcare direct2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 188-Article in journal (Refereed)
    Abstract [en]

    Background

    Swedish Healthcare Direct (SHD) receives 6 million calls yearly and aims at increased public sense of security and healthcare efficiency. Little is known about what SHD managers perceive as the primary goals of telephone nursing (TN) work and how the organisation matches goals of health promotion and equitable healthcare, so important in Swedish healthcare legislation. The aim of the study was to explore and describe what the SHD managers perceive as the goals of TN work and how the managers view health promotion and implementation of equitable healthcare with gender as example at SHD.

    Methods

    The study was qualitative using an exploratory and descriptive design. All 23 managers employed at SHD were interviewed and data analysis used deductive directed content analysis.

    Results

    The findings reveal four themes describing the goals of TN work as recommended by the SHD managers. These are: ‘create feelings of trust’, ‘achieve patient safety’, ‘assess, refer and give advice’, and ‘teach the caller’. Most of the managers stated that health promotion should not be included in the goals, whereas equitable healthcare was viewed as an important issue. Varying suggestions for implementing equitable healthcare were given.

    Conclusions

    The interviewed managers mainly echoed the organisational goals of TN work. The managers’ expressed goal of teaching lacked the caller learning components highlighted by telenurses in previous research. The fact that health promotion was not seen as important indicates a need for SHD to clarify its goals as the organisation is part of the Swedish healthcare system, where health promotion should always permeate work. Time used for health promotion and dialogues in a gender equitable manner at SHD is well invested as it will save time elsewhere in the health care system, thereby facing one of the challenges of European health systems.

  • 23. Krohne, Kariann
    et al.
    Torres, Sandra
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Sociology.
    Slettebo, Ashild
    Bergland, Astrid
    Everyday uses of standardized test information in a geriatric setting: a qualitative study exploring occupational therapist and physiotherapist test administrators' justifications2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 72-Article in journal (Refereed)
    Abstract [en]

    Background: Health professionals are required to collect data from standardized tests when assessing older patients' functional ability. Such data provide quantifiable documentation on health outcomes. Little is known, however, about how physiotherapists and occupational therapists who administer standardized tests use test information in their daily clinical work. This article aims to investigate how test administrators in a geriatric setting justify the everyday use of standardized test information. Methods: Qualitative study of physiotherapists and occupational therapists on two geriatric hospital wards in Norway that routinely tested their patients with standardized tests. Data draw on seven months of fieldwork, semi-structured interviews with eight physiotherapists and six occupational therapists (12 female, two male), as well as observations of 26 test situations. Data were analyzed using Systematic Text Condensation. Results: We identified two test information components in everyday use among physiotherapist and occupational therapist test administrators. While the primary component drew on the test administrators' subjective observations during testing, the secondary component encompassed the communication of objective test results and test performance. Conclusions: The results of this study illustrate the overlap between objective and subjective data in everyday practice. In clinical practice, by way of the clinicians' gaze on how the patient functions, the subjective and objective components of test information are merged, allowing individual characteristics to be noticed and made relevant as test performance justifications and as rationales in the overall communication of patient needs.

  • 24.
    Krohne, Kariann
    et al.
    Högskole i Oslo & Akershus.
    Torres, Sandra
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Sociology.
    Slettebo, Å.
    Bergland, Astrid
    Högskole i Oslo & Akershus.
    Everyday uses of standardizedtest information: a qualitative study exploring professional testadministrators’ justifications2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963Article in journal (Refereed)
  • 25.
    Kunkel, Stefan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Rosenqvist, Urban
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Westerling, Ragnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    The structure of quality systems is important to the process and outcome, an empirical study of 386 hospital departments in Sweden.2007In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 7, p. 104-Article in journal (Refereed)
    Abstract [en]

    Background

    Clinicians, nurses, and managers in hospitals are continuously confronted by new technologies and methods that require changes to working practice. Quality systems can help to manage change while maintaining a high quality of care. A new model of quality systems inspired by the works of Donabedian has three factors: structure (resources and administration), process (culture and professional co-operation), and outcome (competence development and goal achievement). The objectives of this study were to analyse whether structure, process, and outcome can be used to describe quality systems, to analyse whether these components are related, and to discuss implications.

    Methods

    A questionnaire was developed and sent to a random sample of 600 hospital departments in Sweden. The adjusted response rate was 75%. The data were analysed with confirmatory factor analysis and structural equation modeling in LISREL. This is to our knowledge the first large quantitative study that applies Donabedian's model to quality systems.

    Results

    The model with relationships between structure, process, and outcome was found to be a reasonable representation of quality systems at hospital departments (p = 0.095, indicating no significant differences between the model and the data set). Structure correlated strongly with process (0.72) and outcome (0.60). Given structure, process also correlated with outcome (0.20).

    Conclusion

    The model could be used to describe and evaluate single quality systems or to compare different quality systems. It could also be an aid to implement a systematic and evidence-based system for working with quality improvements in hospital departments.

  • 26. Ljungquist, Therese
    et al.
    Hinas, Elin
    Nilsson, Gunnar H
    Gustavsson, Catharina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna.
    Arrelöv, Britt
    Alexanderson, Kristina
    Problems with sickness certification tasks: experiences from physicians in different clinical settings. A cross-sectional nationwide study in Sweden.2015In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, article id 321Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Many physicians find sickness certification of patients problematic. The aims were to explore problems that physicians in different clinical settings experience with sickness certification tasks in general and with assessment of function, work capacity, and need for sick leave, as well as handling of sick-leave spells of different durations.

    METHODS: Data from a questionnaire sent to 33,144 physicians aged <68 years, living and working in Sweden in 2012 were analysed. The response rate was 57.6%. The study group comprised the 12,933 responders who had sickness certification tasks. Frequencies and odds ratios with 95% confidence intervals were calculated for questions concerning how problematic the physicians experienced different assessments related to patients' function, work capacity, and need for sick leave, as well as handling sick-leave spells of different durations.

    RESULTS: There were large differences between clinical settings regarding how often and to what extent sickness certification consultations were perceived as problematic. Physicians working in primary health care (PHC) had the highest proportions experiencing sickness certification consultations as problematic at least once a week (49.5%) and as very or fairly problematic (56.6%), followed by physicians working in psychiatry, pain management, or orthopaedics. More than half of the responders found it very or fairly problematic to assess patients' work capacity (57.8%), to make a long-term prognosis about patients' future work capacity (55.7%), and to handle long-term or very long-term sickness certifications (51.9% and 51.8%). The proportions were highest among physicians working in PHC, rheumatology, neurology, or psychiatry.

    CONCLUSIONS: The rates of physicians finding sickness certification task problematic varied much with clinical setting, and were highest among physicians in PHC. More knowledge is needed about the work conditions and prerequisites for optimal handling of sickness certification in different clinical settings.

  • 27.
    Mayora, Chrispus
    et al.
    Univ Witwatersrand, Sch Publ Hlth, 27 St Andrews Rd, ZA-2193 Johannesburg, South Africa;Makerere Univ, Dept Hlth Policy Planning & Management, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Kitutu, Freddy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Makerere Univ, Dept Pharm, Coll Hlth Sci, POB 7062, Kampala, Uganda.
    Kandala, Ngianga-Bakwin
    Univ Witwatersrand, Sch Publ Hlth, 27 St Andrews Rd, ZA-2193 Johannesburg, South Africa;Northumbria Univ, Fac Engn & Environm, Dept Math Phys & Elect Engn, Newcastle Upon Tyne NE1 8ST, Tyne & Wear, England.
    Ekirapa-Kiracho, Elizabeth
    Makerere Univ, Dept Hlth Policy Planning & Management, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Swartling Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Karolinska Inst, Dept Publ Hlth Sci, Hlth Syst & Policy Res Grp, SE-17177 Stockholm, Sweden.
    Wamani, Henry
    Makerere Univ, Dept Community Hlth & Behav Sci, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 532Article in journal (Refereed)
    Abstract [en]

    Background: Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda. Methods: Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013. Results: Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin (R) syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients' finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification. Conclusion: Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.

  • 28.
    Molarius, Anu
    et al.
    Competence Centre for Health, Västmanland County Council, Västerås, Sweden .
    Simonsson, Bo
    Competence Centre for Health, Västmanland County Council, Västerås, Sweden .
    Lindén-Boström, Margareta
    Department of Community Medicine and Public Health, Örebro County Council, Sweden.
    Kalander-Blomqvist, Marina
    Department of Public Health and Community Medicine, Värmland County Council, Karlstad, Sweden.
    Feldman, Inna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Eriksson, Hans G
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD).
    Social inequalities in self-reported refraining from health care due to financial reasons in Sweden: health care on equal terms?2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, p. 605-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The main goal of the health care system in Sweden is good health and health care on equal terms for the entire population. This study investigated the existence of social inequalities in refraining from health care due to financial reasons in Sweden.

    METHODS: The study is based on 38,536 persons who responded to a survey questionnaire sent to a random sample of men and women aged 18-84 years in 2008 (response rate 59%). The proportion of persons who during the past three months due to financial reasons limited or refrained from seeking health care, purchasing medicine or seeking dental care is reported. The groups were defined by gender, age, country of origin, educational level and employment status. The prevalence of longstanding illness was used to describe morbidity in these groups. Differences between groups were tested with chi-squared statistics and multivariate logistic regression models.

    RESULTS: In total, 3% reported that they had limited or refrained from seeking health care, 4% from purchasing medicine and 10% from seeking dental care. To refrain from seeking health care was much more common among the unemployed (12%) and those on disability pension (10%) than among employees (2%). It was also more common among young adults and persons born outside the Nordic countries. Similar differences also apply to purchasing medicine and dental care. The odds for refraining from seeking health care, purchasing medicine or seeking dental care due to financial reasons were 2-3 times higher among persons with longstanding illness than among persons with no longstanding illness.

    CONCLUSIONS: There are social inequalities in self-reported refraining from health care due to financial reasons in Sweden even though the absolute levels vary between different types of care. Often those in most need refrain from seeking health care which contradicts the national goal of the health care system. The results suggest that the fare systems of health care and dental care should be revised because they contribute to inequalities in health care.

  • 29.
    Nilsson, Annika
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Engström, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    E-assessment and an e-training program among elderly care staff lacking formal competence: results of a mixed-methods intervention study2015In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, article id 189Article in journal (Refereed)
    Abstract [en]

    Background: Among staff working in elderly care, a considerable proportion lack formal competence for their work. Lack of formal competence, in turn, has been linked to higher staff ratings of stress symptoms, sleep disturbances and workload. Objectives: 1) To describe the strengths and weaknesses of an e-assessment and subsequent e-training program used among elderly care staff who lack formal competence and 2) to study the effects of an e-training program on staff members' working life (quality of care and psychological and structural empowerment) and well-being (job satisfaction and psychosomatic health). The hypothesis was that staff who had completed the e-assessment and the e-training program would rate greater improvements in working life and well-being than would staff who had only participated in the e-assessments. Methods: An intervention study with a mixed-methods approach using quantitative (2010-2011) and qualitative data (2011) was conducted in Swedish elderly care. Participants included a total of 41 staff members. To describe the strengths and weaknesses of the e-assessment and the e-training program, qualitative data were gathered using semi-structured interviews together with a study-specific questionnaire. To study the effects of the intervention, quantitative data were collected using questionnaires on: job satisfaction, psychosomatic health, psychological empowerment, structural empowerment and quality of care in an intervention and a comparison group. Results: Staff who completed the e-assessments and the e-training program primarily experienced strengths associated with this approach. The results were also in line with our hypotheses: Staff who completed the e-assessment and the e-training program rated improvements in their working life and well-being. Conclusion: Use of the e-assessments and e-training program employed in the present study could be one way to support elderly care staff who lack formal education by increasing their competence; increased competence, in turn, could improve their self-confidence, working life, and well-being.

  • 30.
    Nkulu Kalengayi, Faustine Kyungu
    et al.
    Dept of Public Health and Clinical Medicine, Division of Epidemiology and Global Health, Umeå University, Sweden.
    Hurtig, Anna-Karin
    Dept of Public Health and Clinical Medicine, Division of Epidemiology and Global Health, Umeå University, Sweden.
    Ahlm, Clas
    Dept of Clinical Microbiology, Division of Infectious Diseases, Umeå University, Sweden.
    Ahlberg, Beth Maina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    "It is a challenge to do it the right way": an interpretive description of caregivers' experiences in caring for migrant patients in Northern Sweden2012In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 12, no 1, p. 433-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Experiences from nations with population diversity show extensive evidence on the need for cultural and linguistic competence in health care. In Sweden, despite the increasing diversity, only few studies have focused on challenges in cross-cultural care. The aim of this study was to explore the perspectives and experiences of caregivers in caring for migrant patients in Northern Sweden in order to understand the challenges they face and generate knowledge that could inform clinical practice.

    METHODS:

    We used an interpretive description approach, combining semi-structured interviews with 10 caregivers purposively selected and participant observation of patient-provider interactions in caring encounters. The interviews were transcribed and analyzed using thematic analysis approach. Field notes were also used to orient data collection and confirm or challenge the analysis.

    RESULTS:

    We found complex and intertwined challenges as indicated in the three themes we present including: the sociocultural diversity, the language barrier and the challenges migrants face in navigating through the Swedish health care system. The caregivers described migrants as a heterogeneous group coming from different geographical areas but also having varied social, cultural and religious affiliations, migration history and status all which influenced the health care encounter, whether providing or receiving. Participants also described language as a major barrier to effective provision and use of health services. Meanwhile, they expressed concern over the use of interpreters in the triad communication and over the difficulties encountered by migrants in navigating through the Swedish health care system.

    CONCLUSIONS:

    The study illuminates complex challenges facing health care providers caring for migrant populations and highlights the need for multifaceted approaches to improve the delivery and receipt of care. The policy implications of these challenges are discussed in relation to the need to (a) adapt care to the individual needs, (b) translate key documents and messages in formats and languages accessible and acceptable to migrants, (c) train interpreters and enhance caregivers' contextual understanding of migrant groups and their needs, (d) and improve migrants' health literacy through strategies such as community based educational outreach.

  • 31. Nyström, Monica E.
    et al.
    Westerlund, Anna
    Hoog, Elisabet
    Millde-Luthander, Charlotte
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Grunewald, Charlotta
    Healthcare system intervention for prevention of birth injuries: process evaluation of self-assessment, peer review, feedback and agreement for change2012In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 12, p. 274-Article, review/survey (Refereed)
    Abstract [en]

    Background: Patient safety is fundamental in high quality healthcare systems but despite an excellent record of perinatal care in Sweden some children still suffer from substandard care and unnecessary birth injuries. Sustainable patient safety improvements assume changes in key actors' mental models, norms and culture as well as in the tools, design and organisation of work. Interventions positively affecting team mental models on safety issues are a first step to enhancing change. Our purpose was to study a national intervention programme for the prevention of birth injuries with the aim to elucidate how the main interventions of self-assessment, peer review, feedback and written agreement for change affected the teams and their mental model of patient safety, and thereby their readiness for change. Knowledge of relevant considerations before implementing this type of patient safety intervention series could thereby be increased. Methods: Eighty participants in twenty-seven maternity units were interviewed after the first intervention sequence of the programme. A content analysis using a priori coding was performed in order to relate results to the anticipated outcomes of three basic interventions: self-assessment, peer review and written feedback, and agreement for change. Results: The self-assessment procedure was valuable and served as a useful tool for elucidating strengths and weaknesses and identifying areas for improvement for a safer delivery in maternity units. The peer-review intervention was appreciated, despite it being of less value when considering the contribution to explicit outcome effects (i.e. new input to team mental models and new suggestions for actions). The feedback report and the mutual agreement on measures for improvements reached when signing the contract seemed exert positive pressures for change. Conclusions: Our findings are in line with several studies stressing the importance of self-evaluation by encouraging a thorough review of objectives, practices and outcomes for the continuous improvement of an organisation. Even though effects of the peer review were limited, feedback from peers, or other change agents involved, and the support that a clear and well-structured action plan can provide are considered to be two important complements to future self-assessment procedures related to patient safety improvement.

  • 32.
    Paul, Mandira
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Gemzell-Danielsson, Kristina
    Department of Women’s and Children’s Health, Karolinska Institutet, University Hospital, Stockholm, Sweden.
    Kiggundu, Charles
    Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda.
    Namugenyi, Rebecka
    Department of Public Health Sciences, Makerere University, Kampala, Uganda.
    Klingberg-Allvin, Marie
    Department of Women’s and Children’s Health, Karolinska Institutet, University Hospital, Stockholm, Sweden.
    Barriers and facilitators in the provision of post-abortion care at district level in central Uganda: a qualitative study focusing on task sharing between physicians and midwives2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, no 1, p. 28-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Abortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians' and midwives' perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care.

    METHODS:

    In-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach.

    RESULTS:

    Post-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified.

    CONCLUSIONS:

    Task sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda.

  • 33.
    Plate, Susann
    et al.
    Arvika Sjukhus, Kirurgiska Klin, Dept Surg, S-67080 Arvika, Sweden..
    Emilsson, Louise
    Landstinget Varmland, Primary Care Res Unit, Karlstad, Norway.;Univ Oslo, Inst Hlth & Soc, Oslo, Norway..
    Söderberg, Martin
    Vaxjo Hosp, Dept Oncol, Vaxjo, Sweden..
    Brandberg, Yvonne
    Karolinska Inst, Dept Oncol, Pathol, Stockholm, Sweden..
    Wärnberg, Fredrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    High experienced continuity in breast cancer care is associated with high health related quality of life2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 127Article in journal (Refereed)
    Abstract [en]

    Background: High experienced continuity is known to be associated with lower needs for supportive care and most likely higher quality of life. On this background, the aim of this study was to investigate if patient-experienced continuity of care was associated with health-related quality of life (HRQoL) in breast cancer patients treated at two different-sized breast cancer units.

    Methods: In 2016, two questionnaires, "Statements on experienced continuity of care" and "The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30)", were sent out to patients diagnosed between 2011 and 2014 at two different-sized breast cancer units in Sweden. Lead times and other data reflecting medical quality were collected from the patients' medical records and from the National Swedish Breast Cancer Quality Register.

    Results: Of 356 eligible patients, 231 (65%) answered the questionnaires, of whom 218 patients were included in the analyses. A statistically significant association was found between high experienced continuity and high global HRQoL (p = 0.03). Continuity was higher at the smaller unit, while no major differences between the units were found regarding medical quality or lead times.

    Conclusion: The study found that high experienced continuity and HRQoL was strongly associated. A statistically significant higher continuity of care was found at the smaller unit, in line with what was expected. The absence of clinically relevant differences in lead times and medical quality may indicate that continuity could be achieved without loss of quality.

  • 34.
    Swartling, Malin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Clinical Epidemiology.
    Wahlström, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Clinical Epidemiology.
    Isolated specialist or system integrated physician - different views on sickness certification among orthopaedic surgeons: an interview study2008In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 8, p. 273-Article in journal (Refereed)
    Abstract [en]

    Background: Sickness certification is a frequent and sometimes problematic task for orthopaedic surgeons. Our aim was to explore how orthopaedic surgeons view their sick-listing commission and sick-listing practice. Methods: Semi-structured interviews with seventeen orthopaedic surgeons from five orthopaedic clinics in four Swedish counties. The focus was on the experiences of these physicians in relation to handling of sickness certification. Phenomenographic analysis was performed to reveal differences in existing views. Results: The orthopaedic surgeons' views on sick-listing seemed mainly to be a consequence of how they perceived their role in the healthcare system. Three categories were found: The "isolated specialists", whose work and responsibilities were confined to the orthopaedic clinic, and did not really include sickness certification; the "orthopaedic   advisers", who saw themselves mainly as advice-givers in the general health care system and perceived sickness certification as part of their job; the "system-integrated physicians", who perceived the orthopaedic clinic as one part of the healthcare system and whose   ultimate goal was to get the patient well functioning in her life again with regained work ability, seeing sick-listing as one of the instruments to achieve this. Some informants described difficulties in handling conflicting opinions with patients in relation to the need for   sick-leave. Conclusion: Orthopaedic surgeons certify a large proportion of total sickness benefits. Some orthopaedic surgeons may certify sickness benefits sub-optimally for patients and society due to a narrow view of their role in the health care system or due to poor skills in handling discordant opinions with the patient. This problem can be addressed at the level of the individual physician and at the system level.

  • 35. Syhakhang, Lamphone
    et al.
    Soukaloun, Douangdao
    Tomson, Göran
    Petzold, Max
    Rehnberg, Clas
    Wahlström, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Provider performance in treating poor patients - factors influencing prescribing practices in lao PDR: a cross-sectional study2011In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, p. 3-Article in journal (Refereed)
    Abstract [en]

    Background: Out-of-pocket payments make up about 80% of medical care spending at hospitals in Laos, thereby putting poor households at risk of catastrophic health expenditure. Social security schemes in the form of community-based health insurance and health equity funds have been introduced in some parts of the country. Drug and Therapeutics Committees (DTCs) have been established to ensure rational use of drugs and improve quality of care. The objective was to assess the appropriateness and expenditure for treatment for poor patients by health care providers at hospitals in three selected provinces of Laos and to explore associated factors. Methods: Cross-sectional study using four tracer conditions. Structured interviews with 828 in-patients at twelve provincial and district hospitals on the subject of insurance protection, income and expenditures for treatment, including informal payment. Evaluation of each patient's medical record for appropriateness of drug use using a checklist of treatment guidelines (maximum score = 10). Results: No significant difference in appropriateness of care for patients at different income levels, but higher expenditures for patients with the highest income level. The score for appropriate drug use in insured patients was significantly higher than uninsured patients (5.9 vs. 4.9), and the length of stay in days significantly shorter (2.7 vs. 3.7). Insured patients paid significantly less than uninsured patients, both for medicines (USD 14.8 vs. 43.9) and diagnostic tests (USD 5.9 vs. 9.2). On the contrary the score for appropriateness of drug use in patients making informal payments was significantly lower than patients not making informal payments (3.5 vs. 5.1), and the length of stay significantly longer (6.8 vs. 3.2), while expenditures were significantly higher both for medicines (USD 124.5 vs. 28.8) and diagnostic tests (USD 14.1 vs. 7.7). Conclusions: The lower expenditure for insured patients can help reduce the number of households experiencing catastrophic health expenditure. The positive effects of insurance schemes on expenditure and appropriate use of medicines may be associated with the long-term effects of promoting rational use of drugs, including support to active DTC work.

  • 36.
    Trimmer, Charlotte
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Clinical communication and caregivers' satisfaction with child healthcare in Nepal: results from Nepal Health Facility Survey 20152019In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 19, article id 17Article in journal (Refereed)
    Abstract [en]

    Background: Patient satisfaction is an important measure of quality of care and a determinant of health service utilisation and the choice of health facility. Measuring patients' experiences is important for understanding and improving the quality of care at health facilities. The aim of this study was to assess levels and identify associated factors of caregivers' satisfaction and provider-caregiver communication within child healthcare in Nepal.

    Methods: Secondary analysis of Sick Child Exit Interviews (n=2092) sourced from 2015 Nepal Health Facility Survey data. Satisfaction was measured through caregivers' satisfaction with services received and their willingness to recommend the health facility visited. Communication indicators were chosen based on the 2014 WHO IMCI guidelines and aggregate communication scores were calculated based on the number of indicators acknowledged during assessments. Logistic regression was used for analysis.

    Results: Although most respondents (82.1%) reportedly were satisfied with the care provided, only 35.9% experienced good communication with their providers. Caregivers who had ever attended school were more likely to be satisfied with services (1.44, CI 95% 1.04-1.99). Type of provider, sex of child or who the caregiver was had no association with caregivers' satisfaction. Having been given a diagnosis doubled the chances of satisfaction (AOR 2.04, 95% CI 1.38-3.00), as did discussion of the child's growth (OR 1.71, 95% CI 1.06-2.76) and having discussed any of the included topics (AOR 1.98, CI 95% 1.14-3.45).

    Conclusions: Interventions to improve healthcare staff's communication skills are needed in Nepal to further enhance satisfaction with services and increase quality of care. However, this is an area that need further investigation given the high levels of satisfaction displayed despite poor communication. Other factors in the health care exchange between provider and clients are influencing the level of satisfaction and need to be identified and promoted further. High-quality care is no longer a goal for the future or only for high income settings; it is essential for reaching global health goals.

  • 37.
    Wallin, Lars
    et al.
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Nga, Nguyen Thu
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Hoa, Dinh P.
    Hanoi School of Public Health, Ba ĐÌnh District, Hà Nội, Việt Nam.
    Huy, Tran Q.
    Ministry of Health, Ba ĐÌnh District, Hà Nội, Việt Nam.
    Duc, Duong M.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Implementing knowledge into practice for improved neonatal survival: a cluster-randomised, community-based trial in Quang Ninh province, Vietnam2011In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, no 239Article in journal (Refereed)
    Abstract [en]

    Background: Globally, almost 4 million newborns die during the first 4 weeks of life every year. By increased use of evidence-based knowledge in the healthcare system a large proportion of these neonatal deaths could be prevented. But there is a severe lack of knowledge on effective methods for successful implementation of evidence into practice, particularly in low- and middle-income countries. Recent studies have demonstrated promising results with increased survival among both mothers and newborns using community-based approaches. In Vietnam evidence-based guidelines on reproductive health were launched in 2003 and revised in 2009. The overall objective of the current project is to evaluate if a facilitation intervention on the community level, with a problem-solving approach involving local representatives if the healthcare system and the community, results in improvements of neonatal health and survival.

    Methods/Design: The study, which has been given the acronym NeoKIP (Neonatal Health - Knowledge Into Practice), took place in 8 districts composed by 90 communes in a province in northern Vietnam, where neonatal mortality rate was 24/1000 in 2005. A cluster randomised design was used, allocating clusters, as defined as a commune and its correponding Commune Health Center (CHC) to either intervention or control arm. The facilitation intervention targeted staff at healthcare centres and key persons in the communes. The facilitator role was performed by lay women (Women's Union representatives) using quality improvement techniques to initiate and sustain improvement processes targeting identified problem areas. The intervention has been running over 3 years and data were collected on the facilitation process, healthcare staff knowledge in neonatal care and their behaviour in clinical practice, and reproductive and perinatal health indicators. Primary outcome is neonatal mortality.

    Discussion: The intervention is participatory and dynamic, focused on developing a learning process and a problem-solving cycle. The study recognises the vital role of the local community as actors in improving their own and their newborns' health, and applies a bottom-up approach where change will be accomplished by an increasing awareness at and demand from grass root level. By utilising the existing healthcare structure this intervention may, if proven successful, be well suited for scaling up.

  • 38.
    Winblad, Ulrika
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Blomqvist, Paula
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Government.
    Karlsson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Do public nursing home care providers deliver higher quality than private providers?: Evidence from Sweden2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 487Article in journal (Refereed)
    Abstract [en]

    Background: Swedish nursing home care has undergone a transformation, where the previous virtual public monopoly on providing such services has been replaced by a system of mixed provision. This has led to a rapidly growing share of private actors, the majority of which are large, for-profit firms. In the wake of this development, concerns have been voiced regarding the implications for care quality. In this article, we investigate the relationship between ownership and care quality in nursing homes for the elderly by comparing quality levels between public, for-profit, and non-profit nursing home care providers. We also look at a special category of for-profit providers; private equity companies.

    Methods: The source of data is a national survey conducted by the Swedish National Board of Health and Welfare in 2011 at 2710 nursing homes. Data from 14 quality indicators are analyzed, including structure and process measures such as staff levels, staff competence, resident participation, and screening for pressure ulcers, nutrition status, and risk of falling. The main statistical method employed is multiple OLS regression analysis. We differentiate in the analysis between structural and processual quality measures.

    Results: The results indicate that public nursing homes have higher quality than privately operated homes with regard to two structural quality measures: staffing levels and individual accommodation. Privately operated nursing homes, on the other hand, tend to score higher on process-based quality indicators such as medication review and screening for falls and malnutrition. No significant differences were found between different ownership categories of privately operated nursing homes.

    Conclusions: Ownership does appear to be related to quality outcomes in Swedish nursing home care, but the results are mixed and inconclusive. That staffing levels, which has been regarded as a key quality indicator in previous research, are higher in publicly operated homes than private is consistent with earlier findings. The fact that privately operated homes, including those operated by for-profit companies, had higher processual quality is more unexpected, given previous research. Finally, no significant quality differences were found between private ownership types, i.e. for-profit, non-profit, and private equity companies, which indicates that profit motives are less important for determining quality in Swedish nursing home care than in other countries where similar studies have been carried out.

  • 39.
    Wisell, Kristin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmacy.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Sporrong, Sofia Kälvemark
    Univ Copenhagen, Dept Pharm, Univ Pk 2, DK-2100 Copenhagen O, Denmark.
    Stakeholders’ expectations and perceived effects of the pharmacy ownership liberalization reform in Sweden: a qualitative interview study2016In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, article id 379Article in journal (Refereed)
    Abstract [en]

    Background: Reforms in the health-care sector, including the pharmacy sector, can have different rationales. The Swedish pharmacies were prior to 2009 organized in a state-owned monopoly. In 2009, a liberalization of the ownership took place, in which a majority of the pharmacies were sold to private owners. The rationales for this liberalization changed profoundly during the preparatory work, making it probable that other rationales than the ones first expressed existed. The aim of this study was to explore the underlying rationales (not stated in official documents) for the liberalization in the Swedish pharmacy sector, and also to compare the expectations with the perceived outcomes.

    Methods: Semi-structured interviews were conducted with representatives from key stakeholder organizations; i.e., political, patient, and professional organizations. The analysis was performed in steps, and themes were developed in an inductive manner.

    Results: One expectation among the political organization participants was that the ownership liberalization would create opportunities for ideas. The competition introduced in the market was supposed to lead to a more diversified pharmacy sector. After the liberalization, the participants in favor of the liberalization were surprised that the pharmacies were so similar.

    Among the professional organization participants, one important rationale for the liberalization was to get better use of the pharmacists’ knowledge. However, all the professional, and some of the patient organization participants, thought that the counseling in the pharmacies had deteriorated after the liberalization.

    As expected in the interviews, the post-liberalization pharmacy sector consists of more pharmacies. However, an unexpected perceived effect of the liberalization was, among participants from all the stakeholder groups, less access to prescription medicines in the pharmacies.

    Conclusions: This study showed that the political organization participants had an ideological basis for their opinion. The political stakeholders did not have a clear view about what the liberalization should lead to, apart from abolishing the monopoly. The perceived effects are quite similar in the different stakeholder groups, and not as positive as were expected.

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