Nordic responses to covid-19 from a health promotion perspective.

On 30 January 2020, the disease covid-19 was declared by the World Health Organization to be an international threat to human health and on 11 March 2020, the outbreak was declared a pandemic. The aim of this study was to analyse policy strategies developed by the five Nordic countries during the first 3 months of the pandemic from a health promotion perspective in order to identify Nordic responses to the crisis. Although the Nordic countries have a long tradition of co-operation as well as similar social welfare policies and legislation, each country developed their own strategies towards the crisis. The strategies identified were analysed from a health promotion perspective emanating from five principles: intersectorality, sustainability, equity, empowerment and a lifecourse perspective. Denmark, Finland and Norway had lockdowns to varying degrees, whereas Sweden and Iceland had no lockdowns. Iceland implemented a test and tracking strategy from the very beginning. All countries based their recommendations and restrictions on appeals to solidarity and trust in institutions and fellow citizens. The analysis showed that the strategies in all countries could be related to health promotion principles with some differences between the countries especially regarding equity and sustainability. The Nordic governments took responsibility for protecting their citizens by developing policy strategies based on restrictions and recommendations congruent with the principles of health promotion. The findings also identified issues that will pose challenges for future pandemic strategies.

Self-rated health over a two-year period after breast cancer surgery: prospective ratings and retrospective rating by means of a health-line.

BACKGROUND: There are difficulties in clinical assessment of patients' health, and there is a need for evaluating instruments that measures self-rated health over time and that are based on the patient's own experiences of their health situation. AIM: To describe the trajectory of self-rated health given in a retrospective health-line and its correspondence with the ratings of health given at six different time points during 2 years following a first breast cancer surgery. DESIGNS AND METHODS: An explorative prospective cohort study presented according to the STROBE guideline. At six time points, 459 women (26-63 years) completed assessments of self-rated health during 2 years following a first breast cancer surgery. Subsequently, the women retrospectively rated health month by month over the two years by means of a health-line. The women were included consecutively in 2007-2009, last data collection was performed in 2012. Statistical analyses were used to compare the health-line with previous ratings. RESULTS: Most women (74-88%) rated their health as good, very good or excellent at all six time points. Health-line ratings were somewhat lower than the ratings made at the actual time-point; however, the illustrated trajectories back in time followed the same patterns as the women had reported during the two years. The lowest ratings of self-rated health were reported at four months after surgery. The retrospective illustrations varied greatly, and poorer health was reported by women undergoing chemotherapy, with lower education and who reported more life events. CONCLUSIONS: Even if the retrospective ratings by the health-line were somewhat lower than the ratings at the actual time-point, the health-line captures the health trajectory. The individual graphic illustration by means of a health-line may serve as a basis for assessment and support patient health narratives. The findings indicate that life event, lower education and chemotherapy influence concurrent and retrospective self-assessment of health.

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.

The Nordic Health Promotion Research Network (NHPRN).

The Nordic Health Promotion Research Network (NHPRN) was established in 2007 at the Nordic School of Public Health (NHV). This article aims to describe the foundation of the NHPRN, the development and the present status of the work of NHPRN. The NHPRN consists of about 50 senior and junior researchers from all Nordic countries. It is a working network that aims to develop the theoretical understanding of health promotion, to create research cooperation in health promotion from a Nordic perspective and to extend the scope of health promotion through education. Network members meet biannually to discuss and further develop research within the field and are also responsible for the Nordic conference on Health Promotion, organized every 3 years. The NHV hosted the network between 2007 and 2014; and the World Health Organisation (WHO) will assume this role in 2015.

Swedish parents' activities together with their children and children's health: a study of children aged 2-17 years.

BACKGROUND: Nordic children's health has declined. Studies show that parents' engagement in children's leisure-time activities might provide beneficial health outcomes for children. AIM: The aim of the present study was to examine the association between Swedish parents' activities together with their children, the parents' experiences of time pressure and their children's health. METHODS: Data of 1461 Swedish children aged 2-17 years old that were collected in the NordChild study of 2011 were used. We analyzed physical health, diseases and disabilities, psychosomatic health and well-being, and the parents' experiences of time pressure; and we calculated the associations between parental activity together with the child and health indicators. RESULTS: Activities that were significantly and positively associated with children's health at ages 2-17 years of age were: playing and playing games; going to the cinema, theatre, and sporting events; reading books; playing musical instruments/singing; sports activities; watching TV/video/DVD. Playing video games or computer games, driving child to activities and going for walks were significantly and positively associated at age groups 7-12 years and 13-17 years. Activities that were negatively associated with health were: surfing/blogging on the Internet, going shopping and doing homework. Parents who were not experiencing time pressures had a higher level of activity together with their children. The parental experience of time pressure was associated with work time, with less homework activity and more symptoms in children. CONCLUSIONS: The family and home are important settings for the development of children's health we found eight parental activities together with their children that promoted the children's health parents' working time and their time pressure experiences affected their activities with their children there is a need for an increased focus on parental activities that are positively associated with children's health.

Health and relationships with leisure time activities in Swedish children aged 2-17 years.

BACKGROUND: Three cross-sectional time series studies, randomised and stratified for age and gender, were performed on children aged 2-17, studying their health and well-being. The studies were performed in the Nordic countries in 1984, 1996 and 2011. Long-term illness (LTI) and psychosomatic complaints (PSC) increased during the period. Data were collected from mailed questionnaires. METHODS: Data of 1461 Swedish children from 2011 were used and compared with data from 1984 and 1996. Relationships between the health indicators (the absence of LTI, 13 diagnoses, the absence of PSC, six symptoms, six items of well-being) and 12 activities were analysed. RESULTS: A total of 83.2% of the children were healthy and 16.8% had at least one LTI, boys 19.1% and girls 14.5%. PSC increased from 18.6% in 1996 to 23.1% in 2011. The distribution was higher in girls. Girls were more active than boys during leisure time. 'Reading books', 'visiting friends', 'listening to music' and 'activity in organisations' were related to an absence of PSC, LTI and well-being. 'Surfing/blogging on the Internet' was negatively related to LTI, PSC and well-being. Multiple regression showed that that 'visits or is visited by friends' was related with a low probability for LTI and also with a high probability for well-being. In the logistic regression analyses, the following variables were seen as promoting health most: 'visits or is visited by friends' and 'is active in organizations' for children aged 2-17 years, especially for boys and well-being. CONCLUSIONS: The health of Swedish children declined between 1984 and 2011. Positive relationships were found between some activities and health as well as other activities related to ill health. The results suggest an increased focus on the activities that have positive relationships with health in order to promote health among children.

Children's experiences of a participation approach to asthma education.

AIM AND OBJECTIVES: To explore the participation and responses of children to an asthma education programme that was developed with the aid of children with asthma. In a larger perspective, the aim was to understand how educational approaches can be designed to help children learn to live and cope with asthma. BACKGROUND: A literature search showed that programmes where children participate in the development of educational materials or programmes are lacking. DESIGN: An exploratory descriptive design was chosen to get an in-depth understanding of the communication and collaboration between children and healthcare personnel. METHODS: Data were collected through observations, tape recordings of the conversations and notes of the interactions between the children and the healthcare personnel and analysed by content analysis. RESULTS: The significance of the asthma education programme emerged in four themes: (i) children are learning from each other: in a positive learning climate, the children were able to express emotional themes that they may not have communicated before; (ii) children are learning through an interaction with the educational material: the children discussed stories and pictures in a fellow interplay: when one child expressed something, another child would recognise it and continue the story; (iii) children are learning from their interaction with healthcare personnel and vice versa: adjusting the vocabulary according to the children's experiences, they were met on their level of understanding; and (iv) children can express and discuss their understanding of asthma. CONCLUSIONS: The unique aspect about this programme is that it emanates from children's perspectives. The children were actively involved and learnt from each other's shared knowledge and experiences, which is a good source of meaningful learning and empowering processes. RELEVANCE TO CLINICAL PRACTICE: Future educational approaches should use children's perspectives in a manner in which their questions, thoughts and daily challenges are emphasised.

Implementation of a standardised health education in a local context. A case study.

Educational interventions are generally poorly described and the active elements underlying several successful interventions have insufficient descriptions. The aim of the present study was to analyse and discuss the theoretical principles according to which a standardised health education programme originating from a Norwegian Learning and Mastery Centre was performed, and how these principles influence practice at a local Learning and Mastery Centre. A descriptive embedded multiple-case study, with two cases and three defined units, was chosen for the analysis. Data consisted of observations, documents and relevant theoretical literature. The findings indicate that both cases were organised and practised in a scholastic way. The professionals paid little attention to the participants' beliefs and ideas as part of the learning process. Professional knowledge and user knowledge did not appear to be considered to be of equal value. The professionals did not stress reflection as a main prerequisite for learning, therefore participants' learning potential was not utilised. Attention must be paid to improving the professional's educational competence. The educational competence of the professionals should not only include educational techniques but also knowledge about how to facilitate learning processes and an understanding of the concept of health literacy. The theoretical foundations of the Learning and Mastery Centre, as well as its learning philosophy and approach must be stated more explicitly. To benefit from a Learning and Mastery course, the participants should have a minimum understanding about their medical conditions before attending the course, and the professionals should have knowledge about the participants' pre-knowledge.

Developing lay health worker policy in South Africa: a qualitative study.

BACKGROUND: Over the past half decade South Africa has been developing, implementing and redeveloping its Lay Health Worker (LHW) policies. Research during this period has highlighted challenges with LHW programme implementation. These challenges have included an increased burden of care for female LHWs. The aim of this study was to explore contemporary LHW policy development processes and the extent to which issues of gender are taken up within this process. METHODS: The study adopted a qualitative approach to exploring policy development from the perspective of policy actors. Eleven policy actors (policy makers and policy commentators) were interviewed individually. Data from the interviews were analysed thematically. RESULTS: Considerations of LHW working conditions drove policy redevelopment. From the interviews it seems that gender as an issue never reached the policy making agenda. Although there was strong recognition that the working conditions of LHWs needed to be improved, poor working conditions were not necessarily seen as a gender concern. Our data suggests that in the process of defining the problem which the redeveloped policy had to address, gender was not included. There was no group or body who brought the issue of gender to the attention of policy developers. As such the issue of gender never entered the policy debates. These debates focused on whether it was appropriate to have LHWs, what LHW programme model should be adopted and whether or not LHWs should be incorporated into the formal health system. CONCLUSION: LHW policy redevelopment focused on resolving issues of LHW working conditions through an active process involving many actors and strong debates. Within this process the issue of gender had no champion and never reached the LHW policy agenda. Future research may consider how to incorporate the voices of ordinary women into the policy making process.

Provider experiences of the implementation of a new tuberculosis treatment programme: a qualitative study using the normalisation process model.

BACKGROUND: Tuberculosis (TB) is a major contributor to the global burden of disease. In many settings, including South Africa, treatment outcomes remain poor. In contrast, many antiretroviral treatment (ART) programmes are achieving high levels of adherence and good outcomes. The ART programme model for maintaining treatment adherence may therefore hold promise for TB treatment. Changing treatment models, however, requires an assessment of how staff receive the new model, as they are responsible for programme implementation. Using the normalization process model as an analytic framework, this paper aims to explore staff perceptions of a new TB treatment programme modelled on the ART treatment programme. METHODS: A qualitative approach was used. Interviews and focus group discussions were conducted with clinic staff from five intervention clinics. Data were analysed initially using qualitative content analysis. The resulting categories were then organised under the constructs of the normalization process model. RESULTS: Staff recounted a number of challenges with implementing the programme. Interviews and focus group discussions identified factors relating to the main categories of the normalization process model. The key issues hindering the normalisation of the programme within clinics related to the interactional workability, relational integration and skill-set workability constructs of the model. These included hierarchical relationships, teamwork, training needs and insufficient internalisation by staff of the empowerment approach included in the programme. Logistical and management issues also impacted negatively on the normalization of the programme at the clinics. CONCLUSION: The normalization process model assisted in categorising the challenges experienced during implementation of the intervention. The results suggest that issues remain that need to be resolved before the programme is implemented more widely. Considerable work is needed in order to embed the intervention in routine clinic practice.

Children's experiences of living with asthma: fear of exacerbations and being ostracized.

The aim of the study was to explore children's experiences of asthma to tailor a learning program based on their perspectives. Fifteen children (7-10 years) were interviewed, and they narrated the meaning behind their drawings; a phenomenological hermeneutical approach was used in the analysis. The findings are described in two themes with five subthemes: fear of exacerbation (bodily sensations, frightening experiences, and loss of control) and fear of being ostracized (experiences of being excluded and dilemma of keeping the asthma secret or being open about it). Drawings are a good tool for initiating a dialogue with children.

Taking charge of communication: adults' descriptions of growing up with a cleft-related speech impairment.

OBJECTIVE: To obtain descriptions of the experience of growing up with a cleft-related speech impairment and how it was dealt with. DESIGN: Semistructured interviews were tape-recorded, transcribed verbatim, and analyzed using a qualitative approach inspired by grounded theory methodology. SETTING: Interviews took place at participants' homes or workplaces or at the university. PARTICIPANTS: Thirteen young adults (25 to 34 years of age) born with cleft palate with or without cleft lip. RESULTS: The analysis resulted in the core category Taking charge of communication, which comprised three main categories: Forming an idea of one's speech, Learning about one's communication, and Taking responsibility for communication. The first main category was made up of three subcategories and the other two had two. The categories emerged as parallel processes in the understanding and active handling of communicative interaction. CONCLUSIONS: The participants described the processes that had enabled them to take charge of their communication. Seeing things from the listener's perspective and being open about the cleft and the speech disorder emerged as important parts of taking active responsibility for communication, as well as accepting their present speech and communication. Communicative participation should be assessed more thoroughly to understand the individual needs of people born with a cleft who have a speech impairment into adolescence.

Being involved in an everlasting fight--a life with postnatal faecal incontinence. A qualitative study.

UNLABELLED: The prevalence of women suffering from faecal incontinence as a complication to childbirth has been estimated to 0.6-6%. The aim of this study was to elucidate the life situation and the psychosocial processes of women suffering from this injury and to find out how they cope with being in that situation. Nine women were strategically and consecutively selected from a surgery outpatient department at a hospital, to be the participants of this study. Data collection and analysis were made according to the grounded theory approach. In the analysis a core category Being involved in an everlasting fight was identified. Three main categories Fighting to be like others, Fighting against attitudes and Striving for confirmation with six sub categories depict the constant struggle to not only keep up an appearance of a normal, healthy person, but also to feel like one. The women described feelings of shame and marginalization and expressed a strong need of support and confirmation from husbands and private network in order to cope better with their lives. CONCLUSIONS AND CLINICAL IMPLICATIONS: Health care professionals must inform women at risk about the effects of the injury and inform them about treatment in case of future problems in order to prevent physical, psychological and social suffering. They should also, as a routine, question the patients with regard to problems with incontinence of urine, faeces and flatulence.

Health-related quality of life among Danish patients 3 and 12 months after TIA or mild stroke.

AIM: This paper aimed to describe health related quality of life three and 12 months after mild stroke or transient ischemic attack, TIA, to describe the perceived changes from pre to post stroke status and to examine sociodemographic determinants for health related quality of life. METHODS: 105 patients with mild stroke or TIA delivered self reported data on health related quality of life using the Stroke Specific Quality of Life Scale Danish Version, SSQOL-DK. The main outcome was perceived change in over all quality of life from pre to post stroke status. Non-parametric tests were used to examine change over time and differences between groupings of gender, age and life conditions. Logistic regression was used to model the change of all over quality of life changed at 12 months compared to pre stroke status. RESULTS: Fifty seven percent (57%) of the patients felt that their pre stroke status concerning quality of life was regained. Those that rated all over quality of life deteriorated 12 months post stroke were more often working (48.9% vs. 31.7%), fewer had a diagnosis of TIA (13.3% vs. 30%), functional level was lower and the consumption of antidepressive medication was more frequent. In the regression model male sex (OR 3.77), working outside home (OR 2.84) and less than 5.00 (maximum score) on the domains Mood and Work/productivity at three months were significant predictors for rating health related quality of life deteriorated after stroke. CONCLUSION: Rehabilitation efforts should include employment alternatives of a less demanding nature for male patients.

Conflicting accountabilities: Doctor's dilemma in TB control in rural India.

OBJECTIVE: The aim of this study was to analyse how the implementation strategy of direct observed treatment short course (DOTS) has shaped and influenced patient-provider encounters in a district tuberculosis centre (DTC) in a rural district of India. METHOD: Qualitative methods, combining observations and interviews, were carried out in a DTC focusing on the medical encounters between a TB doctor and his patients. RESULTS: The findings showed that the TB doctor seemed to be working with a dilemma, defined as conflicting accountabilities, in the medical encounters. In an organization perceived as inefficient and resource-constrained, the doctor struggled to find a balance between meeting the obligations of the DOTS programme and meeting the needs and expectations of the patients. Strategies to deal with these conflicting accountabilities were identified as limiting patients' involvement, struggling to maintain authority, and transferring responsibility. CONCLUSION: Professional involvement and patient participation were seen as part of a linked process in this study, and the importance of empowering doctors and health care workers who are implementing DOTS is emphasized. The development of DOTS guidelines needs to be based on the actual process of health care delivery, and staff empowering efforts should also include strengthening of public health care infrastructure.

Health-related quality of life after stroke: reliability of proxy responses.

A Danish version of the Stroke-Specific Quality of Life Scale (SSQOL-DK) has been developed for self-reporting; it contains 12 physical and psychosocial domains. The purpose of this study was (a) to assess the reliability of the proxy version of the SSQOL-DK and (b) to evaluate the influence of frequency of proxy contact on agreement. In all, 143 patients completed the SSQOL-DK 1 to 5 years post-stroke. A patient chosen proxy completed a proxy version of the same questionnaire. The proxy version showed satisfactory internal consistency (Cronbach's alpha = .85-.95). Agreement was generally high. Proxies rated the amount of trouble significantly smaller (higher score) than the patients only in the domain Social Roles. The amount of trouble in the domain Family Roles received significantly higher ratings from noncohabitant proxies when compared with patients (lower score). The proxy version of the SSQOL-DK appears to be reliable for use with stroke patients up to a few years following a stroke.

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.