Health-care climate, perceived self-care competence, and glycemic control among patients with type 2 diabetes in primary care.

This study showed, in line with self-determination theory, that glycemic control among patients with type 2 diabetes (n = 2866) was strongly associated with perceived self-care competence, which in turn was associated with autonomous motivation and autonomy-supportive health-care climate. These associations remained after adjusting for the effect of important life-context factors. Autonomous motivation partially mediated the effect of health-care climate on perceived competence, which fully mediated the effect of autonomous motivation on glycemic control. The results of the study emphasize health-care personnel's important role in supporting patients' autonomous motivation and perceived self-care competence.

Determinants of effective health promotion actions in local contexts: a study of the perceptions of municipal politicians.

OBJECTIVE: To compare municipal politicians' perceptions of health promotion policy and its impact, and whether these perceptions varied according to political variables. METHODS: A mail survey to all municipal politicians (N=195) in four municipalities in Finland. Response rate was 52%. Data were analysed by descriptive statistics and multivariate regression analyses. RESULTS: The politicians gave 'passable grades' when evaluating health promotion activities and their effectiveness in the municipalities. Three factors in a multivariate model explained 49% of the variance in this evaluation: emphasis on the promotion of health and quality of life of older people, capacity of primary health care and capacity of care for older people. There did not appear to be a consistent view on the local health promotion policies among the politicians. 'Terms in office' was more significant than political party affiliation to explain differences in the policy makers' perceptions. CONCLUSIONS: Paying attention to the possible impeding effects of structures, as well as enhancing institutional capacity, could open ways for a stronger focus on health promotion, including community participation, in local councils.

Does patients' choice of health centre doctor depend on the organization? A comparative study of four municipalities with different forms of service provision in Finland.

AIMS: The aim of the study was to examine the use of physician services and the willingness to choose an health centre (HC) doctor rather than an alternative (i.e. private, occupational healthcare, other doctor) by the working age population in four municipalities in Finland. In a Southern municipality primary health care was contracted out to a non-profit organization whereas Eastern, Western and South-Western municipalities mainly provided services themselves. METHODS: A mail survey of a random sample of the 15-64-age population was conducted in 2002 (n = 2,000, response rate 62%). Data were analyzed using descriptive statistics as well as bi- and multivariate logistic regression analyses. RESULTS: Of the respondents, 69% had visited an HC doctor during the past year, and of these, more than 40% had also visited another doctor outside the HC. The willingness to choose an HC doctor varied from 40% to 54% and was highest in the Southern municipality. When significantly associated variables - age, working status, perceived stress in life situation, access to an appointment, perceived interpersonal quality, and visits to doctors - were controlled for, the willingness to choose an HC doctor was, compared with the Southern municipality, less popular only in the Western municipality. CONCLUSIONS: The tendency to choose an HC doctor rather than an alternative was quite low, probably reflecting lack of attractiveness of HC to patients. However, contracting out service production did not additionally decrease patients' willingness to choose an HC doctor. More attention should be paid to improving access, interpersonal quality and continuity of care.

Job involvement of primary healthcare employees: does a service provision model play a role?

AIM: To investigate whether the development of job involvement of primary healthcare (PHC) employees in Southern Municipality (SM), where PHC services were outsourced to an independent non-profit organisation, differed from that in the three comparison municipalities (M1, M2, M3) with municipal service providers. Also, the associations of job involvement with factors describing the psychosocial work environment were investigated. METHODS: A panel mail survey 2000-02 in Finland (n=369, response rates 73% and 60%). The data were analysed by descriptive statistics and multivariate linear regression analysis. RESULTS: Despite the favourable development in the psychosocial work environment, job involvement decreased most in SM, which faced the biggest organisational changes. Job involvement decreased also in M3, where the psychosocial work environment deteriorated most. Job involvement in 2002 was best predicted by high baseline level of interactional justice and work control, positive change in interactional justice, and higher age. Also other factors, such as organisational stability, seemed to play a role; after controlling for the effect of the psychosocial work characteristics, job involvement was higher in M3 than in SM. CONCLUSION: Outsourcing of PHC services may decrease job involvement at least during the first years. A particular service provision model is better than the others only if it is superior in providing a favourable and stable psychosocial work environment.

Psychosocial work environment and emotional exhaustion--does a service provision model play a role?

OBJECTIVES: To investigate whether outsourcing of primary health care (PHC) services has affected the psychosocial work environment and emotional exhaustion. METHODS: Panel mail study 2000-2002 in Finland, 369 PHC employees. Comparison between Southern municipality (SM) after outsourcing PHC services to a not-for-profit organization and three municipalities with municipal service providers. RESULTS: Despite the positive development of the psychosocial work environment in SM, emotional exhaustion had increased there like in the comparison municipalities. However, in 2002 emotional exhaustion was at a lower level in SM than in one of the comparison municipalities. This difference could not be attributed to the production model itself but rather to baseline levels and changes in work demands and work resources. CONCLUSIONS: Outsourcing of PHC services may improve employee health and thus effectiveness of health care if a new service provider emphasizes employee health more than a previous one and is more flexible to improve the quality of the psychosocial work environment. However, change itself may be stressful, and frequent changes of service providers should be avoided.

Determinants of health promotion action in primary health care: comparative study of health and home care personnel in four municipalities in Finland.

AIMS: The purpose of this paper is to contribute to understanding which factors influence health promotion action in primary health care (PHC) on the municipal, i.e. local, level. METHODS: A cross-sectional mail survey of all PHC personnel in four municipalities in Finland in 2002. The data were analysed by descriptive statistics, and univariate and multivariate logistic regression analyses. RESULTS: A total of 417 (response rate 57%) healthcare professionals participated in the study; 65% of the personnel working in ambulatory care, 52% working in home care and 44% working in inpatient care were engaged in health promotion action (=higher than median engagement). Factors independently associated with engagement in health promotion were organizational values, reflected in perceived skill discretion and social support from coworkers, and the personnel's competence, reflected in knowledge about the health and living conditions of the population served. Further, the opportunities, reflected in cooperation with partners outside the organization were strongly associated with engagement in health promotion action. CONCLUSIONS: The results suggest that working conditions such as possibilities for skill usage, reflection and development as well as collegial support enable higher engagement in health promotion action in PHC. However, access to data on the local population's health and living conditions, in addition to opportunities to cooperate with decision makers and partners in the community turned out to be as important. This should be taken into consideration when striving to reorient health services to health promotion.

Outsourcing primary health care services--how politicians explain the grounds for their decisions.

OBJECTIVE: To explore outsourcing of primary health care (PHC) services in four municipalities in Finland with varying amounts and types of outsourcing: a Southern municipality (SM) which contracted all PHC services to a not-for-profit voluntary organization, and Eastern (EM), South-Western (SWM) and Western (WM) municipalities which had contracted out only a few services to profit or public organizations. METHODS: A mail survey to all municipality politicians (response rate 52%, N=101) in 2004. Data were analyzed using cross-tabulations, Spearman correlation and linear regression analyses. RESULTS: Politicians were willing to outsource PHC services only partially, and many problems relating to outsourcing were reported. Politicians in all municipalities were least likely to outsource preventive services. A multiple linear regression model showed that reported preference to outsource in EM and in SWM was lower than in SM, and also lower among politicians from "leftist" political parties than "rightist" political parties. Perceived difficulties in local health policy issues were related to reduced preference to outsource. The model explained 27% of the variance of the inclination to outsource PHC services. CONCLUSIONS: The findings highlight how important it is to take into account local health policy issues when assessing service-provision models.

Determinants of health promotion action: comparative analysis of local voluntary associations in four municipalities in Finland

The World Health Organization makes a case for the importance of voluntary organizations in promoting health at local levels. The purpose of this paper is to contribute to understanding which factors explain local voluntary associations (LVAs) participation in health promotion in local contexts. It does so through (i) identifying indicators that represent determinants of health promotion action which were reported by LVAs and by (ii) comparaing their actions with these determinants. The data reported are from a questionnaire survey of all registered LVAs in four municipalities in Finland. Principal component analysis revealed four determinants of health promotion action. Four factors in the final multivariate model explained over half of the variance of LVAs engagement in health promotion action: competence, values healthy and also opportunities and municipality. There is some evidence to support a model of health promotion action which has not been tested empirically in relation to these types of organization. More detailed studies of determinants of health promotion action are needed to shape strategies in local communities. (AU)

Client perceptions of the performance of public and independent not-for-profit primary healthcare.

AIMS: To compare primary healthcare (PHC) provided by an independent not-for-profit organization (INPO) with that provided by two public municipal organizations (MO1 and MO2), in terms of clients' perceptions of performance, acceptance, and trust. METHODS: A survey using a pre-tested questionnaire to all clients visiting a health centre (HC) doctor or nurse during one week in 2000 (n = 511, 51% response rate) and 2002 (n = 275, 47%). The data were analysed by descriptive statistics and cumulative logistic regression analysis. RESULTS: The INPO differed from both publicly provided services in accessibility, consistency of service, and outcomes. Clients reported lower trust in HC provided by public organizations compared with the INPO. Trust was higher if clients also reported experiencing "very good" or "moderate" organizational access--or if general satisfaction was "very high" or "moderate" or if they experienced outcomes as "very good" or "moderate" compared with the "very poor or low" situation. Women reported lower trust in HC than men. When the family doctor was included in the same logistic regression model with the service provider, only the family doctor was a significant explanatory variable. Reported acceptance of private alternative service providers among clients was similar between the study organizations. CONCLUSIONS: Clients of the INPO generally rated the service more positively than clients of publicly provided services. The results indicate that trust in HC depends more on a family doctor system than a service provider.

Determinants of health promotion action: comparative analysis of local voluntary associations in four municipalities in Finland.

The World Health Organization makes a case for the importance of voluntary organizations in promoting health at local levels. The purpose of this paper is to contribute to understanding which factors explain local voluntary associations (LVAs) participation in health promotion in local contexts. It does so through (i) identifying indicators that represent determinants of health promotion action which were reported by LVAs and by (ii) comparing their actions with these determinants. The data reported are from a questionnaire survey of all registered LVAs in four municipalities in Finland. Principal component analysis revealed four determinants of health promotion action. Four factors in the final multivariate model explained over half of the variance of LVAs engagement in health promotion action: competence, values 'healthy' and also opportunities and municipality. There is some evidence to support a model of health promotion action which has not been tested empirically in relation to these types of organization. More detailed studies of determinants of health promotion action are needed to shape strategies in local communities.