Are universal measures sufficient in reducing child poverty in the Nordic countries? An analysis of policies and political commitments.

BACKGROUND: The five Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) have long traditions of social welfare policies that have eradicated poverty as part of their goals. The purpose of this study was to increase our understanding of why child poverty is still significant in the Nordic countries despite existing strategies. METHODS: A qualitative analysis of Nordic government documents and reports between 2007 and 2019 was carried out to track changes in public health priorities and political measures and to determine the similarities and differences between the five countries. RESULTS: In all countries, most of the measures were universal, such as benefits during pregnancy, paid parental leave before and after the child was born, paid parental leave related to children's sickness, child allowances, day care, free health care for children and support for disabled children. National policies aimed to reduce social inequalities and child poverty exist in all five countries, but unaffordable housing, unequal disposable family income distribution and unequal income distribution at local municipality levels seem to be obstacles to reaching national policy goals. CONCLUSIONS: Despite comprehensive universal measures to eradicate child poverty, inequalities are significant and increasing in some of the Nordic countries. This might be due to a lack of proportional universalism, where universal measures are in place in all Nordic countries, but with a lack of scale and intensity proportional to the children and families at risk. The significance of eliminating social inequalities needs to be emphasised at the local level.

Osteoporosis risk assessment in primary dental care-The attitudes of Swedish dentists, patients and medical specialists.

OBJECTIVE: To explore and identify the attitudes of dentists, patients and medical specialists regarding implementation of osteoporosis risk assessment into Swedish primary dental care. BACKGROUND: Osteoporosis is a major health problem leading to fragility fractures. As shown in academic-based research, dental radiological examination can be used for osteoporosis risk assessment. A substantial number of patients undergo radiographic examinations in primary dental care each year, but little is known about implementation of osteoporosis risk assessment in this setting. MATERIALS AND METHODS: A qualitative research approach using focus group discussions and manifest content analysis was applied. Five focus groups with dentists and representatives from patient support groups and a single individual interview with one medical specialist were included in the sample. RESULTS: From the manifest content analysis, three categories emerged: (a) barriers to change in practice, (b) benefits to change in practice, and (c) needs and requirements prior to change in practice. Most participants felt that there was insufficient knowledge of osteoporosis as well as a heavy existing workload. A concern was expressed about medical practitioners' willingness to take on responsibility for patients referred by dentists. Representatives from patient support groups highlighted a lack of knowledge about osteoporosis among both the general public and the medical professionals. Clear guidelines and improved communication channels between stakeholders would have to be established to ensure a smooth treatment path for patients. CONCLUSION: Despite interest in osteoporosis risk assessment in primary dental care, there are political, workflow and educational barriers that must be overcome for successful implementation.

Economic poverty among children and adolescents in the Nordic countries.

AIMS: This study aimed to identify applied definitions and measurements of economic poverty and to explore the proportions and characteristics of children and adolescents living in economic poverty in Denmark, Finland, Iceland, Norway and Sweden during the last decade and to compare various statistics between the Nordic countries. METHODS: Official data from central national authorities on statistics, national reports and European Union Statistics of income and living conditions data were collected and analysed during 2015-2016. RESULTS: The proportion of Nordic children living in economic poverty in 2014 ranged from 9.4% in Norway to 18.5% in Sweden. Compared with the European Union average, from 2004 to 2014 Nordic families with dependent children experienced fewer difficulties in making their money last, even though Icelandic families reported considerable difficulties. The characteristics of children living in economic poverty proved to be similar in the five countries and were related to their parents' level of education and employment, single-parent households and - in Denmark, Norway and Sweden - to immigrant background. In Finland, poverty among children was linked in particular to low income in employed households. CONCLUSIONS: This study showed that economic poverty among Nordic families with dependent children has increased during the latest decade, but it also showed that poverty rates are not necessarily connected to families' ability to make their money last. Therefore additional studies are needed to explore existing policies and political commitments in the Nordic countries to compensate families with dependent children living in poverty.

Health lifestyles of pre-school children in Nordic countries: parents' perspectives.

Summary: Holistic understanding of health is one of the key principles of health promotion indicating that the health status of individuals and populations is determined by a variety of environmental, economic, social and personal factors. Traditionally, research focus has been on school-aged children and school-based interventions and less on pre-school children and their families' engagement in promoting health in everyday life. The aim of the present study was to explore factors that parents of pre-school children in the Nordic countries experienced as influencing health lifestyles in their children's everyday lives. Semi-structured interviews were conducted with 25 parents of pre-school children in the five Nordic countries. Qualitative content analysis was used to analyse the data. The parents identified themselves as the primary shapers of their children's lifestyles and described influencing factors related to themselves as well as to their immediate surroundings and the larger society. Attaining a health lifestyle in everyday life of Nordic parents with pre-school children appeared to be all about the 'management of time when attempting to live up to expectations'. Pre-school children's lifestyles are to a great extent intertwined with their parent's lifestyles and should be approached, both in research and practice, accordingly. Parents of pre-school children in the Nordic countries appear to be living their everyday lives straining to adapt to norms prevailing in society and may need encouragement and support in managing time in order to promote health lifestyles for themselves and their children.

Relative deprivation in the Nordic countries-child mental health problems in relation to parental financial stress.

BACKGROUND: The Nordic welfare system has been acknowledged as favourable for children, successfully contributing to low child mortality and poverty rates. Nevertheless, mental health problems among children and adolescents are common and the economic situation of the family has been highlighted as an important determinant. In spite of similar social, political and cultural structures, the Nordic countries differ; Iceland was most affected by the global financial crisis in 2008. The aim of this study was to examine potential differences in parental financial stress and the associations to child mental health between the Nordic countries as well as age and gender differences. METHODS: The study sample consisted of 6330 children aged 4-16 years old included in the 2011 version of the Nordic Study of Children's Health, Wellbeing and Quality of life. The Strengths and Difficulties Questionnaire was used to measure mental health problems. RESULTS: In Iceland, 47.7% of the parents reported financial stress while ≤20% did so in the other countries except for Finland (33.5%). However, in case of parental financial stress the OR of mental health problems comparing children to parents with and without financial stress was significantly lower among the Icelandic children (OR 1.60, 95% CI 1.15-2.24) than among the others: Denmark OR 3.07 (95% CI 2.15-4.39), Finland OR 2.28 (95% CI 1.60-3.25), Norway OR 2.77 (95% CI 1.86-4.12), Sweden OR 3.31(95% CI 2.26-4.86). No significant age or gender differences in the ORs were observed. CONCLUSIONS: Besides socioeconomic situation, relative deprivation should be considered an important determinant of child mental health.

Health Promotion: A developing focus area over the years.

In 1953 when the Nordic School of Public Health was founded, the aim of public health programmes was disease prevention more than health promotion. This was not unusual, since at this time health usually was seen as the opposite of disease and illness. However, with the Ottawa Charter of 1986, the World Health Organization made a crucial change to view health not as a goal in itself but as the means to a full life. In this way, health promotion became a first priority and fundamental action for the modern society. This insight eventually reached NHV and in 2002 - 50 years after the foundation - an associate professorship was established with a focus on health promotion. Nevertheless, the concept of health promotion had been integrated with or mentioned in courses run prior to the new post. Subsequently, a wide spectrum of courses in health promotion was introduced, such as 'Empowerment for Child and Adolescent Health Promotion', 'Salutogenesis--from theory to practice' and 'Health, Stress and Coping'. More than half of all doctoral theses undertaken at NHV during these years had health promotion as their theme. As a derivative, the Nordic Health Promotion Research Network (NHPRN) was established in 2007 with bi-annual meetings at NHV.

Associations between parents' subjective time pressure and mental health problems among children in the Nordic countries: a population based study.

BACKGROUND: The home, the family and the parents represent a context of everyday life that is important for child health and development, with parent-child relationships highlighted as crucial for children's mental health. Time pressure is an emerging feature of modern societies and previous studies indicates that parents with children living at home experience time pressure to a greater extent than people with no children living at home. Previous studies of children's mental health in relation to parents' time pressure are lacking. Hence, the purpose of this study was to examine the association between parents' subjective time pressure and mental health problems among children in the Nordic countries as well as potential disparities between boys and girls in different age groups. METHODS: 4592 children, aged 4-16 from Denmark, Finland, Norway and Sweden, participating in the 2011 version of the NordChild study, were included. The Strength and Difficulties Questionnaire was used to measure children's mental health and associations to parents' time pressure were assessed by multiple logistic regression analysis. RESULTS: Among children of parents experiencing time pressure, 18.6% had mental health problems compared to 10.1% among children of parents experiencing time pressure not or sometimes. The odds of mental health problems were higher among both boys (OR 1.80 95% CI 1.32-2.46) and girls (OR 1.95 95% CI 1.42-2.66) if their parents experienced time pressure when adjusted for financial stress. The highest prevalence of mental health problems in the case of parental time pressure was found among girls 13-16 years old (23.6%) and the lowest prevalence was found among boys 13-16 years old (10.7%). CONCLUSIONS: In this study an association between parents' subjective time pressure and increased mental health problems among children was found. Given that time pressure is a growing feature of modern societies, the results might contribute to an explanation as to mental health problems are common among children in the Nordic countries in spite of otherwise favourable conditions. Additional research on the linkage between parents' experienced time pressure and children's and adolescents' mental health problems is needed to confirm the novel findings of this study.

Time pressure among parents in the Nordic countries: a population-based cross-sectional study.

AIMS: To estimate the prevalence of time pressure experienced by parents in the Nordic countries and examine potential gender disparities as well as associations to parents' family and/or living conditions. METHODS: 5949 parents of children aged 2-17 years from Denmark, Finland, Norway and Sweden, participating in the 2011 version of the NordChild study, reported their experience of time pressure when keeping up with duties of everyday life. A postal questionnaire addressed to the most active caretaker of the child, was used for data gathering and logistic regression analysis applied. RESULTS: The mother was regarded as the primary caregiver in 83.9% of the cases. Of the mothers, 14.2% reported that they experienced time pressure "most often", 54.7 % reported "sometimes" and 31.1 % reported they did "not" experience time pressure at all. Time pressure was experienced by 22.2 % of mothers in Sweden, 18.4% in Finland, 13.7% in Norway and 3.9% in Denmark, and could be associated to lack of support, high educational level, financial stress, young child age and working overtime. CONCLUSIONS: The mother is regarded as the child's primary caregiver among the vast majority of families in spite of living in societies with gender-equal family policies. The results indicate that time pressure is embedded in everyday life of mainly highly-educated mothers and those experiencing financial stress and/or lack of social support. No conclusion could be made about time pressure from the "normbreaking" fathers participating in the study, but associations were found to financial stress and lack of support.

A joint Nordic interdisciplinary education programme in infection control: a successful, but short-lived initiative.

INTRODUCTION: Prevention of healthcare-associated infections and a restrictive antibiotics policy in the Nordic countries have contributed to a low prevalence of multi-drug resistant microorganisms, compared to many other countries. This requires professional competences acquired through education in infection control, both in hospitals and in primary health care. METHODS: This paper describes a joint Nordic Interdisciplinary Education Programme in infection control, established at the Nordic School of Public Health NHV (NHV) in 2007. RESULTS: The education programme was considered highly relevant and successful by students and their employers. CONCLUSIONS: The paper describes the background and contents of the programme, which may serve as inspiration in the development of future educational initiatives in other countries.

Are equity aspects communicated in Nordic public health documents?

AIMS: To explore if the term equity was applied and how measures for addressing social inequalities in health and reducing inequity were communicated in selected Nordic documents concerning public health. METHODS: Documents from Denmark, Finland, Norway, and Sweden were collected and analysed by Nordic authors. Data included material from websites of ministries and authorities responsible for public health issues, with primary focus on steering documents, action programmes, and reports from 2001 until spring 2013. RESULTS: Most strategies applied in Danish, Finnish, and Swedish documents focused on the population in general but paid special attention to vulnerable groups. The latest Danish and Finnish documents communicate a clearer commitment to address social inequalities in health. They emphasise the social gradient and the need to address the social determinants in order to improve the position of disadvantaged groups. Norwegian authorities have paid increasing attention to inequity/social inequalities in health and initiated a new law in 2012 which aims to address the social gradient in a more clear way than seen elsewhere in the Nordic countries. CONCLUSIONS: In the Nordic countries, redistribution by means of universal welfare policies is historically viewed as a vital mechanism to improve the situation of vulnerable groups and level the social gradient. To establish the concept of equity as a strong concern and a core value within health promotion, it is important to be aware how policies can contribute to enable reduction of social health differences.

Implementation of a multicomponent psychosocial programme for persons with dementia and their families in Norwegian municipalities: experiences from the perspective of healthcare professionals who performed the intervention.

BACKGROUND: A randomised controlled intervention study was conducted in 17 Norwegian municipalities to provide home-dwelling people with dementia and their families with knowledge and skills to cope with the emerging problems and stresses of everyday life. It included training health professionals to carry out the intervention. Since little is known about possible benefits for health professionals of participating in such a study in terms of knowledge and change of practice as well as their views on whether the intervention is useful, we carried out this study. AIM: To investigate the outcome of the study from the perspective of the healthcare professionals who participated in the intervention. METHOD: Interviews with 19 health professionals were performed during 2012, using three focus groups and six individual interviews. The sample was purposive and included informants aged 34-61 years from 13 municipalities. RESULTS: Three main categories emerged: challenges, new knowledge and service development. The category challenges details the challenges connected with professionals' participation in the intervention and how they dealt with them and is described in three subcategories. The category new knowledge demonstrates the knowledge the professionals achieved while conducting the intervention and is described through three subcategories. Service development presented how the informants' experiences could contribute to improve the provision of care and details in one subcategory. CONCLUSION: The results revealed a need for more knowledge among health professionals about the situation of home-dwelling persons with dementia and their families. The study indicated that health professionals must be more aware of these persons' abilities to find their own solutions to their problems. Structured individual interventions as well as group-based interventions in the early stages of dementia and throughout the course of the disorder seem beneficial. There is a need for better collaboration between the specialist health services, GPs and health workers in the municipalities.

Fathers of Children With Type 1 Diabetes: Perceptions of a Father's Involvement From a Health Promotion Perspective.

This study describes how fathers of children diagnosed with type 1 diabetes understand their involvement in their child's daily life from a health promotion perspective. Sixteen Swedish fathers of children living with type 1 diabetes were interviewed. Manifest and latent content analysis was used to identify two themes: the inner core of the father's general parental involvement and the additional involvement based on the child's diabetes. The former was underpinned by the fathers' prioritization of family life and the fathers being consciously involved in raising the child, and the latter by the fathers promoting and controlling the child's health and promoting and enabling the child's autonomy. The results highlight that the quality of the fathers' involvement is essential in the management of a child's chronic illness. It is important for pediatric diabetes health care professionals to assess the quality of fathers' involvement to promote the child's health.

Swedish pediatric diabetes teams' perception of fathers' involvement: A Grounded Theory study.

The purpose of this study was to analyze how Swedish pediatric diabetes teams perceived and discussed fathers' involvement in the care of their child with type 1 diabetes. It also aimed to discuss how the teams' attitudes towards the fathers' involvement developed during the data collection process. The Constructivist Grounded Theory design was used and data were collected during three repeated focus group discussions with three Swedish pediatric diabetes teams. The core category of the teams' perception of fathers' involvement emerged as: If dad attends, we are happy - if mom doesn't, we become concerned. Initially the teams balanced their perception of fathers' involvement on the mother's role as the primary caregiver. In connection with the teams' directed attention on fathers, in the focus group discussions, the teams' awareness of the importance of fathers increased. As a consequence, the team members began to encourage fathers' engagement in their child's care. We conclude that by increasing the teams' awareness of fathers as a health resource, an active health promotion perspective could be implemented in pediatric diabetes care.

Immigrant women's clubs in a health-promotion perspective.

AIMS: To gain a deeper understanding of the conditions for and perceived benefits of regular participation in an immigrant women's club, with special focus on the women's wellbeing and the club's potential for health promotion. METHODS: A qualitative research approach was applied, including semi-structured interviews, which were analysed using the constructivist Grounded Theory method. Individual interviews of 15 women aged 40-59 years and from various ethnic backgrounds were conducted in 2010/2011. FINDINGS: Four categories were identified during the analysis. These were labelled "Forming a place for coping with loneliness" (core category), "Learning the rules", "Social bonding and support", and "A space for wellbeing and health". The categories describe how the members deal with the club's status as a municipal association, the structure of the meetings, and the informants' perceptions of being members of a club, as well as the effects of the membership. CONCLUSIONS: Immigrant women may find support and perceive increased wellbeing from gathering in clubs with women from a similar background. In addition, the clubs may provide society an opportunity and a space for adapted health-promotion initiatives.

Parents' discursive resources: analysis of discourses in Swedish, Danish and Norwegian health care guidelines for children with diabetes type 1.

The incidence of diabetes type 1 in children, the most common metabolic disorder in childhood, increases worldwide, with highest incidence in Scandinavia. Having diabetes means demands in everyday life, and the outcome of the child's treatment highly depends on parents' engagement and involvement. The aim of this study was to explore and describe discourses in health care guidelines for children with diabetes type 1, in Sweden, Norway and Denmark during 2007-2010, with a focus on how parents were positioned. As method a Foucauldian approach to discourse analysis was applied, and a six-stage model was used to perform the analysis. The findings shows a Medical, a Pedagogic and a Public Health discourse embedded in the hegemonic Expert discourse. The Expert discourse positioned parents as dependent on expert knowledge, as recipients of education, as valuable and responsible for their child's health through practicing medical skills. This positioning may place parents on a continuum from being deprived of their own initiatives to being invited to take an active part and could result in feelings of guilt and uncertainty, but also of security and significance. From this study we conclude that guidelines rooted in the Expert discourse may reduce opportunities for parents' voices to be heard and may overlook their knowledge. By broadening the selection of authors of the guidelines to include patients and all professionals in the team, new discourses could emerge and the parents' voice might be more prominent.

The concept of ''equity'' in health-promotion articles by Nordic authors - a matter of some confusion and misconception.

AIMS: This paper focuses on equity in health, one of the key principles of the Ottawa Charter. It aims at analysing and discussing how the concept was defined, applied, and integrated in health-promotion articles by authors with a Nordic affiliation. METHODS: Abstracts were first identified by the search word ''health promotion'' as a key word. The search was limited to 1986-2008 and abstracts written in English by authors with a Nordic affiliation. Abstracts/articles for the present study were subsequently selected from these abstracts using the search word ''equity'' and analysed by quantitative and qualitative content analysis. FINDINGS: A majority of the 18 articles in the study did not include any proper definition of the term ''equity in health''. Most articles dealt with health in general or ''Health for All'' aspects and did not focus on specific strategies for vulnerable individuals or groups. The theoretical papers had a clear focus on equity aspects even though the concept of equity was sometimes included in an implicit way. In contrast, most papers reporting empirical studies did not specifically target equity aspects. Instead, the analysis gave the impression that many authors used the term ''equity'' synonymously with ''equality in health''. CONCLUSIONS: The findings may indicate that the concept of ''equity in health'' has been attenuated or even forgotten by Nordic health-promotion researchers and needs to be re-established as a strong concern within health promotion.

Holism in nursing and health promotion: distinct or related perspectives?--A literature review.

BACKGROUND: The concept of holism is central in health promotion as well as in nursing. Holism or a holistic view on health was identified as one of the key principles of the Ottawa Charter for Health Promotion and is linked to social ecology and the determinants of health. AIMS: To explore how the term holism was defined and/or described in Nordic articles with a health-promotion approach, and how holism aspects were related to nursing and health promotion, and to the other key principles of the Ottawa Charter. METHODS: Abstracts were first identified by the search word 'health promotion' as a keyword. The search was limited to 1986-2008 and abstracts written in English by authors with a Nordic affiliation. Abstracts/articles for this study were subsequently selected from these abstracts using the search words 'holism' and 'holistic' and analysed by quantitative and manifest qualitative content analysis. FINDINGS: The sample included 23 articles: one theoretical, two reviews and 20 empirical studies. Sixteen articles included a hospital setting or nursing perspective. A holistic perspective could be extracted from most articles. No larger but several minor differences were identified in the way holism aspects were related to nursing and health promotion respectively. CONCLUSION: There is a risk that the individual patient perspective of holism in nursing may result in less chance of reaching larger groups of patients with chronic diseases and mental health problems, not least the most vulnerable ones.

Learning to live with a child with diabetes--problems related to immigration and cross-cultural diabetes care.

Diabetes in childhood is a serious chronic disease. Having a different ethnic background is described as a risk factor for poor metabolic control and quality of life. The aim of the study was to explore variations in how parents living as immigrants in Denmark and in their native country had perceived learning to live with a child with diabetes. This was done in order to identify potential problems related to immigration and cross-cultural care which should be considered in the provision of diabetes care to immigrant families. Data were collected by semi-structured interviews with Arabic-speaking immigrant parents of six children with diabetes in Denmark and matched Egyptian parents of six children in Cairo. The children were 7-16 years old and had been diagnosed in 2003-2005. Data were analysed using a phenomenographic approach, focussing on describing variations in the parents' perceptions of the phenomenon 'Learning to live with a child with diabetes'. The findings show that the parents in the two countries shared many reactions and concerns, but that they responded and were affected in different ways. Above all, the immigrant parents experienced their parental role and the life of the child with diabetes, in a more doubtful and negative way. The findings further indicate that the establishment of a trustful relationship between the immigrant families and the health-care professionals should be given high priority. The study concludes that parents with an immigrant background are likely to require special pedagogic, psychological and social support to learn to adapt and come to terms with the diagnosis of a chronic disease in a child.

Learning to live with type 1 diabetes from the perspective of young non-western immigrants in Denmark.

AIMS AND OBJECTIVES: To explore how young adults with a non-western immigrant background and type 1 diabetes since childhood/adolescence have perceived learning to live with the disease, with special focus on health education and support. BACKGROUND: A national Danish study found significantly poorer metabolic control in non-western immigrant children and adolescents as compared with ethnic Danes. Subsequent studies have primarily focused on immigrant parents, whereas little is known about how immigrant children/adolescents have perceived the diagnosis and the diabetes care and support provided. DESIGN: A mixed quantitative and qualitative design was applied. This included data on metabolic control for 2002-2006 and semi-structured interviews in 2006 with eleven strategically selected young immigrants. Data were analysed using qualitative content analysis. FINDINGS: The findings are described in three thematic categories: Perceptions and reactions at the time of diagnosis; Learning to manage the disease; Present and future life with diabetes. Some findings were similar to those in studies describing children and adolescents of western origin, but the participants also shared perceptions which appeared to be related to their immigrant background. Above all, they described their parents as having difficulty coping with the disease and providing them with sufficient support. CONCLUSIONS: The diagnosis of diabetes in immigrant children and adolescents requires special pedagogic and psychosocial approaches to bridge the gaps related to culture and traditions and introduce the concept of diabetes management, not least to the parents, in a more optimum way. RELEVANCE TO CLINICAL PRACTICE: Diabetes care should be a continuous and holistic process, constantly aiming to explore existing knowledge and the need for additional education and support for both the patient and his/her family. Special attention should be paid to the fact that immigrants may have limited pre-knowledge of chronic diseases in childhood, including the concept of selfcare.

Adolescents' knowledge and opinions about smoking: a qualitative study from the Jhaukhel-Duwakot Health Demographic Surveillance Site, Bhaktapur District, Nepal.

BACKGROUND: The use of tobacco products among adolescents in Southeast Asia represents a major public health burden. Two out of ten adolescents attending school are tobacco users and several factors influence them to initiate tobacco use. Most studies related to tobacco use are quantitative, whereas qualitative studies exploring adolescents' smoking behavior and their views, knowledge and experiences are scarce. OBJECTIVE: To gain a deep understanding of Nepalese adolescents' knowledge and opinions about smoking and reasons for smoking initiation. SUBJECTS: Adolescents from four secondary schools in the Bhaktapur district, Nepal. METHODS: Eight focus-group discussions were conducted with 71 adolescents aged 13-16 years and from grades 8-10. Data were analyzed using manifest qualitative content analysis. RESULTS: The participants knew that smoking represents health risks as well as socio-economic risks, but few described the addictive nature of tobacco and health risks related to passive smoking. Most participants related smoking initiation to the smoking behavior of peers and family members, but easy accessibility to cigarettes, ineffective rules and regulations, and exposure to passive smoking also created environments for smoking. Some expressed confidence to resist peer pressure and refuse to start smoking, but also expressed the need for prevention strategies in schools and for governmental initiatives, such as more strict implementation of tobacco control and regulations to prevent and reduce smoking. CONCLUSION: Curbing the tobacco epidemic in Nepal requires healthy public policies and multifaceted interventions to address the knowledge gap on health consequences associated with smoking among adolescents, teachers and parents/adults.