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Sjukvården i Sverige är i dag inte jämlik, har brister i tillgänglighet och erbjuds inte på likvärdiga villkor trots Hälso- och sjukvårdslagens mål om en god hälsa och en vård på lika villkor för hela befolkningen.

För att bryta den pågående trenden och öka jämlikheten gjordes en överenskommelse mellan regeringen och SKL om lärandeprojektet Vård på lika villkor (under åren 2011–2014). Syftet med projektets har varit att inom socioekonomiskt resurssvaga bostadsområden öka jämlikheten i första linjens vård. Detta genom att testa, utveckla och identifiera effektiva arbetssätt och metoder vid sju primärvårdsverksamheter från fem landsting i Sverige.

Mälardalens högskola, Akademin för hälsa, vård och välfärd, fick av SKL i uppdrag att svara för forskarstöd och att genomföra en utvärdering av de metoder och arbetssätt som utvecklades och testades i lärandeprojektet.

Resultatet från den genomförda utvärderingen som belyser den genomförda processen, mål- och resultat samt hälsoekonomiska aspekter beskrivs närmare i denna rapport.

Abstract Introduction: To provide health care on equal terms has become a challenge for the health system. As the front line in health services, primary care has a key role to play in developing equitable health care, responsive to the needs of different population groups. Reducing inequalities in care has been a central and recurring theme in Swedish health reforms. The aim of this study is to describe and assess client/patient experiences and perceptions of care in four primary health care units (PHCUs) involved in Sweden's national Care on Equal Terms project. Methods: Mixed Method Research (MMR) was chosen to describe and assess client/patient experiences and perceptions of health care with regard to equity. There was a focus group discussion, and individual interviews with 21 clients/patients and three representatives of patient associations. Data from the Swedish National Patient Survey (NPS), conducted in 2011 and followed up in 2013, were also used. Results: The interview data were divided into two main categories and three subcategories. The first category "Perception of equitable health care" had two subcategories, namely "Health care providers' perceptions" and "Fairness and participation". The second category "To achieve more equitable health care" had four subcategories: "Encounter", "Access", "Interpreters and bilingual/diverse health care providers" and "Time pressure and continuity". Results from the NPS showed that two of the PHCUs improved in some aspects of patient perceived quality of care (PPQC) while two were not so successful. Conclusions: Clients/patients perceived health care providers' perceptions of their ethnic origin and mental health status as important for equitable health care. Discriminatory perceptions may lead to those in need of care refraining from seeking it. More equitable care means longer consultations, better accessibility in terms of longer opening hours, and ways of communicating other than just via voice mail. It also involves continuity in care and access to an interpreter if needed. Employing bilingual/diverse kinds of health providers is a way of providing more equitable primary health care.

Introduction: The Swedish Health Care Law requires the health system to provide good care on equal terms to all. However, several reports from different governmental agencies have revealed that health care is uneven in quality, lacking in accessibility, and not offered on equal terms to all people. Recent public health reports show that inequalities in health in the population have increased. To provide health care on equal terms has become a challenge for health care.

In order to apply methods for developing practice and policy in promoting health and equity the Swedish Association of Local Authorities and Regions developed and implemented a national project entitled Care on Equal Terms. The project began in 2011 and was completed in 2014 at seven Primary Health Care Units (PHCUs) in five regions. The aim of this study was to evaluate the outcomes of this project.

Methods: Based on a program theoretical approach an evaluation design was developed which included process, results and economical evaluation. In the data collection and analysis mixed methods were applied.

Results: According to the process evaluation, seven different strategies were applied in the process to develop primary health care on equal terms. One of the key observations was that in order to achieve health on more equal terms, health care needs to be provided on unequal terms, i. e. more needs to be done to reach those who need more assistance to access health services. Health promotion was one of the applied strategies and it was the most common strategy at some of the health care centers with the aim of developing patients' knowledge, awareness and understanding about health, care and self-care. The results evaluation showed that the PHCUs staff identified structural and organizational factors in health care as important factors for developing health promotion and equity in access. The health economic evaluation showed that the costs for implementing the activities for an improved equity were limited. Yet the majority of the PHCUs thought that the detailed regulation of their financing and reporting requirements were a limitation in their work for improved equity. Four of five county councils have recently introduced a primary care provider payment system (ACG) which may not be supportive of efforts to improve equity in access.

Conclusions: It is possible to develop and maintain practices that can contribute to more equitable care and increase health care personnel’s awareness about practice and policy in promoting health and equity.

To understand the development of inter-sectoral participation in the three intervention municipalities of Stockholm Diabetes Prevention Programme (SDPP) case studies with a longitudinal assessment were conducted using the spidergram method, document analysis and group discussions. At three time points, the members of the local steering committees assessed the extent of participation from narrow to wide inter-sectoral participation in five key areas: planning, resources, leadership, network and implementation. Wide participation of various interest groups was recognised in planning and implementing activities whereas local resources, the representation of the leadership and the extent of the network were perceived as more restricted. Expert involvement varied during the programme period but was not regarded as exerting control over the local programmes. Participation within the local steering committees decreased, with a stronger focus on the project co-ordinator and other local partners in latter years. The extent of partner engagement increased due to focusing on activities approaching multi-sector collaboration and institutionalisation. Overall, communication and shared responsibility appeared critical in influencing both the development and perception of participation. In conclusion, to understand the dynamic process of participation at different times, areas and levels, the development and use of evaluation designs combining different methods and information sources throughout the lifespan of a project are recommended. 

BACKGROUND:

Over the past three decades, the capacity to develop and implement injury surveillance systems (ISS) has grown worldwide and is reflected by the diversity of data gathering environments in which ISS operate. The capacity to evaluate ISS, however, is less advanced and existing evaluation guidelines are ambiguous. Furthermore, the applied relevance of these guidelines to evaluate ISS operating in various settings is unclear. The aim of this paper was to examine how the World Health Organization (WHO) injury surveillance guidelines have been applied to evaluate systems operating in three different contexts.

METHODS:

The attributes of a good surveillance system as well as instructions for conducting evaluations, outlined in the WHO injury surveillance guidelines, were used to develop an analytical framework. Using this framework, a comparative analysis of the application of the guidelines was conducted using; the Aboriginal Community-Centered Injury Surveillance System (ACCISS) from Canada, the Shantou-Emergency Department Injury Surveillance Project (S-EDISP) from China, and the Yorkhill-Canadian Hospitals Injury Reporting and Prevention Program (Y-CHIRPP) imported from Canada and implemented in Scotland.

RESULTS:

The WHO guidelines provide only a basic platform for evaluation. The guidelines over emphasize epidemiologic attributes and methods and under emphasize public health and injury prevention perspectives requiring adaptation for context-based relevance. Evaluation elements related to the dissemination and use of knowledge, acceptability, and the sustainability of ISS are notably inadequate. From a public health perspective, alternative reference points are required for re-conceptualizing evaluation paradigms. This paper offers an ISS evaluation template that considers how the WHO guidelines could be adapted and applied.

CONCLUSIONS:

Findings suggest that attributes of a good surveillance system, when used as evaluation metrics, cannot be weighted equally across ISS. In addition, the attribute of acceptability likely holds more relevance than previously recognized and should be viewed as a critical underpinning attribute of ISS. Context-oriented evaluations sensitive to distinct operational environments are more likely to address knowledge gaps related to; understanding links between the production of injury data and its use, and the effectiveness, impact, and sustainability of ISS. Current frameworks are predisposed to disassociating epidemiologic approaches from subjective factors and social processes.

Background: In June 2011 the Swedish government signed an agreement with The Swedish Association of Local Authorities and Regions (SALAR), for a three year project to develop and implement “Health care on equal terms.” The project, which involved seven Primary Health Care Units (PHCU) from five county councils in different parts in Sweden, was completed in early 2014. The aim of the project was to develop methods and activities that could promote more equal health care provision in socio-economically disadvantaged areas.

Aim: To assess and compare health care providers’ experiences of and perceptions about equitable health care at the beginning and end of the national project “Health care on equal terms”.

Methods: A web survey was sent to all staff at the seven participating Primary Health Care Units (PHCU) at the beginning (2012) and the end (2013) of the project. Data were analyzed with descriptive statistics and the open issues with content analysis.

Results: In 2013, the percentage of health care providers who reported thinking patients’ ethnicity had no or very little impact on access to care increased, but the proportion of those who reported that they had “no idea” that patients’ gender, age, mental health and physical functioning were significant for access to care was lower in 2013 than in 2012. The results from analysis of the open-ended questions did not show meaningful changes in the respondents’ perceptions of the issues addressed in 2012-2013, but the analysis contributes to a deeper explanation of the answers.

Conclusion: The main conclusion is that it was possible to implement changes aiming for more equitable care through projects with a focus on learning.

Cervical cancer is one of the most common cancers among women worldwide, although cervical screening has reduced the incidence in many high-income countries. Low screening uptake among immigrant women may reflect differences in risk of cervical cancer. We investigated the degree of participation in cervical screening among immigrant and Swedish-born women and their concurrent risk of cervical cancer based on individual information on Pap smears taken both from organized and opportunistic screening. Mean degree of participation in cervical screening was estimated for women between 23 and 60 years from 1993 to 2005, stratified by birth region and age at migration. In Poisson regression models, we estimated relative risks (RRs), incidence rates and incidence rate ratios of cervical cancer for women adhering or not to the cervical screening program. We also assessed effect of adherence to screening on the risk of cervical cancer among immigrant groups compared to Swedish-born women. The degree of participation was 62% and 49% among Swedish-born and immigrant women, respectively, with large variations between immigrant groups. Participation was lowest among those immigrating at older ages. Swedish-born and immigrant women who where nonadherent to the cervical screening program had a fivefold excess risk of cervical cancer compared to adherent women. After adjustment for screening adherence, excess RRs of cervical cancer were statistically significant only for women from Norway and the Baltic States. Participation to screening is lower among immigrant than Swedish-born women, and adherence to the recommended screening intervals strongly prevents cervical cancer.

Introduction Danish and Norwegian immigrant women in Sweden have an increased risk of cervical cancer compared to Swedish-born women. In addition, Danish and Norwegian immigrant women follow the national recommendations for attendance at cervical screening to much lesser extent than Swedish-born women. The aim of this study was to explore how Danish and Norwegian immigrant women in Sweden reason about attending cervical screening, focusing on women's perceptions as to why they and their compatriots do not attend. Methods Eight focus group discussions (FGDs) were conducted with Danish and Norwegian immigrant women living in Stockholm. The women were between 26 and 66 years of age at the time of the FGDs, and were aged between <1 and 48 years old when they immigrated to Sweden. A FGD guide was used, which included questions related to cervical screening, and obstacles and motivators to attend cervical screening. The FGDs were tape recorded and transcribed, and the results analysed according to the principles of qualitative content analysis. Results The main theme was "Women have a comprehensive rationale for postponing cervical screening, yet do not view themselves as non-attenders". Investigation of women's rationale for non-attendance after being invited to cervical screening revealed some complex reasons related to immigration itself, including competing needs, organisational and structural factors and differences in mentality, but also reasons stemming from other factors. Postponing attendance at cervical screening was the category that linked all these factors as the reasons to why women did not attend to cervical screening according to the recommendations of the authorities. Conclusions The rationale used to postpone cervical screening, in combination with the fact that women do not consider themselves to be non-attenders, indicates that they have not actively taken a stance against cervical screening, and reveals an opportunity to motivate these women to attend.

In October 1997 the Swedish Parliament adopted a new road safety policy – Vision Zero. Vision Zero entails a fundamentally new division of responsibility for traffic safety between road users and the so called system designers such as road administrations, municipalities, and professional transport companies among others. In this study the implementation of a formal responsibility for system designers to prevent serious injuries in road traffic between 1997 and 2009 is evaluated. Two main research questions have guided this study namely: How has the legislative process of formalizing the responsibility of system designers progressed? and What important factors might explain the implementation outcome? The main sources of information for this study were official key documents. Based on a goal attainment model, an important conclusion is that the goal to legally formalize a responsibility has only been minimally realized and therefore this might be an example of a classic implementation failure. In order to explain and discuss this low level of achievement a process evaluation approach has also been used. Built on this process evaluation approach, it can be questioned if this is an example of implementation failure after all.

Aim: The Swedish Government has a long tradition of setting quantified time-bounded road safety targets. Thisarticle identifies and analyses these targets, and evaluates the national road safety targets adopted in 1989, 1996 and1998 in order to assess whether the different targets fulfil the SMART criteria of being specific, measurable, achievable,realistic and time bounded.

Methods: This study is a retrospective case study and in order to trace all relevant policy documents that containinformation on quantified targets, a snowball technique was applied. The searching process result in a total of 23 keydocuments and these were analyzed in two steps. The first step examined how the targets have been formulated andthe second step assessed whether the targets had been constructed according to the SMART criteria.

Results: This study shows that, although all the specified targets were theoretically achievable, those targetsadopted in 1996 and 1998 were, according to this evaluation, unrealistic.

Conclusion: This study raises the question as to the rationality of political leaders when adopting targets whichcould be difficult to achieve in reality. One explanation for their adoption is that unrealistic targets could serve as amanagement tool in that they could be rational from a road safety point of view because they could inspire stakeholdersto do more than they would otherwise have done. In this article, other motives behind the setting of unrealistic targetsare also discussed.

The aim of this paper is to examine Sweden's Vision Zero road safety policy. In particular, the paper focuses on how safety issues were framed, which decisions were made, and what are the distinctive features of Vision Zero. The analysis reveals that the decision by the Swedish Parliament to adopt Vision Zero as Sweden's road safety policy was a radical innovation. The policy is different in kind from traditional traffic safety policy with regard to problem formulation, its view on responsibility, its requirements for the safety of road users, and the ultimate objective of road safety work. The paper briefly examines the implications of these findings for national and global road safety efforts that aspire to achieving innovative road safety policies in line with the Decade of Action for Road Safety 2011-2020, declared by the United Nations General Assembly in March 2010.

Health impact assessments (HIAs) were first introduced in Sweden in the mid-to-late 1990s, with the aim of placing health issues on the political agenda and helping to reduce health inequalities. In the early 2000s, HIAs entered a second phase and the Swedish Parliament adopted a national public health policy. A national survey conducted in 2001 showed that 10/289 municipalities had begun to use HIA and 55/289 had decided to use HIA or had initiated an adoption process. In a 2013 follow-up study based on a strategic sample of municipalities, 9/36 municipalities reported using HIA and/or similar tools. Corresponding figures for the 21 Swedish regions were 10 regions in 2001 and four in 2013. HIA and similar tools (sustainability analyses, child impact assessments, and others) were applied to the same extent as HIA. Fifteen years after implementation began, HIA is still being used. Regions show a clear decrease in the use of HIA. There are several explanations for this development. One is the political context, and other explanations are shifts in which actors are responsible for HIA and for public health at the local/regional levels.

The characteristics of a welfare state is largely related to social justice and welfare reforms. This is mainly in the form of legislation, economic transfers and services that help to ensure that all citizens receive a basic economic security and access to services such as health care and nursing. A key factor for this is a country's economy and political will. In Thailand, there was a strong economic growth during the 1970s. The corresponding development in Sweden took place in the mid 1940's. Health and welfare is the main area of collaboration between the Ministry of Health in Thailand and Mälardalen University. The aim of this study is from a welfare perspective, a comparison of the similarities and differences in the basic elements of the health care systems in Thailand and Sweden.

The study is based on analysis of national policy documents from Thailand and Sweden as well as from United Nations Agency.

Both countries emphasize health and welfare from a social rights perspective in constitutions and other laws. E.g. the Thailand Constitution of 2007 states that a person shall enjoy an equal right to receive standard public health service, and the indigent shall have the right to receive free medical treatment from State's infirmary. The Swedish Constitution recognizes that the personal, economic and cultural welfare should be the fundamental goal of public activity through, among other things promote social care and social security, and good conditions for health. In the Swedish Health Care Act of 1982, the goal is a good health and care on equal terms for the entire population.

Both Thailand and Sweden have a national system of Universal Health Coverage (UHC), which is defined according to World Health Organization (WHO) as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

In terms of selected indicators shows for the year 2012 that the Total health expenditure (THE) % of Gross Domestic Product (GDP) amounts in Thailand 4% and 10% in Sweden, general government expenditure on health as % of GDP are 3% resp. 8%, prevention and public health services are 9 resp. 4%, physician density per 1,000 population 0.3 resp. 3.9. The proportion of beds at public/private hospitals are 78/21% resp. 99/1%.

The example from the health care system shows that the two countries have legislation that emphasizes health as a social right and a public financing of health care. In terms of specific indicators, there are wide variations in terms of costs to society and the individual including prevention and public health services, access to doctors and proportion of beds in public and private hospitals.

A Non Smoking Generation (NSG) utvecklade, tillsammans med Landstinget Kronoberg, Gotlands och Järfälla kommuner, under åren 2003 till 2005 ett tobakspreventivt flerkomponentsprogram för grundskolan. År 2010 fick NSG nya medel för att utvärdera vad som fortfarande fanns kvar av programmet på de skolor som var med i projektet. Långtidsuppföljningen, fem år efter det projektet var avslutat, visar att grundskolorna åtminstone delvis fortsatt att använda programmet, men både programföljsamheten och vidmakthållandet minskat. Vid implementering av tobaksförebyggande program i grundskolan är det av betydelse att beakta både yttre strukturella faktorer som påverkar skolornas arbete som inre faktorer som lärarnas synsätt på hälsofrämjande arbete i skolan, personalkontinuitet och andra stödjande faktorer som främjar ett vidmakthållande av tobaksförebyggande arbete som implementeras i skolan.

Background: Thailand is 18th out of the 22 countries with the highest tuberculosis (TB) burden. It will be a challenge for Thailand to achieve the UN Millennium Development target for TB, as well as the new WHO targets for eliminating TB by 2035. More knowledge and a new approach are needed to tackle the complex challenges of managing the DOT program in Thailand. Contextual factors strongly influence the local implementation of evidence in practice. Using the PARIHS model, the aim has been to explore district leaders' perceptions of the management of the DOT program in Trang province, Thailand. Methods: A phenomenographic approach was used to explore the perceptions among district DOT program leaders in Trang province. We conducted semi-structured interviews with district leaders responsible for managing the DOT program in five districts. The analysis of the data transcriptions was done by grouping similarities and differences of perceptions, which were constructed in a hierarchical outcome space that shows a set of descriptive categories. Results: The first descriptive category revealed a common perception of the leaders' duty and wish to comply with the NTP guidelines when managing and implementing the DOT program in their districts. More varied perceptions among the leaders concerned how to achieve successful treatment. Other perceptions concerned practical dilemmas, which included fear of infection, mutual distrust, and inadequate knowledge about TB. Further, the leaders perceived a need for improved management practices in implementing the TB guidelines. Conclusion: Using the PARIHS framework to gain a retrospective perspective on the district-level policy implementation of the DOT program and studying the leadership's perceptions about applying the guidelines to practice, has brought new knowledge about management practices. Additional support and resources from the regional level are needed to manage the challenges.

To develop a conceptual framework of adherence to treatment among Thai people living with tuberculosis, a grounded theory approach was used. A purposive sample of 20 Thai people living with tuberculosis, aged from 23 to 85years, was interviewed. From the participants' perspective, a core category of social belonging was highlighted, with three categories of conditions connected: personal barriers, personal resilience, and social facilitation. Personal barriers encompassed fear of stigma, concealing the illness, and lack of knowledge and motivation to complete the treatment regime. Personal resilience encompassed positive thinking and self-awareness. Social facilitation encompassed the ease of access to health services, continuity in the health service's ability to choose a directly-observed therapy observer, and social support. This study contributes a deeper understanding of the perspective of Thai people living with tuberculosis with regards to adherence to tuberculosis treatment. It might improve how local healthcare workers provide tuberculosis care, and inspire them to tailor care to people living with tuberculosis in a local community to increase personal resilience and reduce stigma.

Background

Workplace violence (WPV) is an occupational health hazard in both low and high income countries. To design WPV prevention programs, prior knowledge and understanding of conditions in the targeted population are essential. This study explores and describes the views of drivers and conductors on the causes of WPV and ways of preventing it in the road passenger transport sector in Maputo City, Mozambique.

Methods

The design was qualitative. Participants were purposefully selected from among transport workers identified as victims of WPV in an earlier quantitative study, and with six or more years of experience in the transport sector. Data were collected in semi-structured interviews. Seven open questions covered individual views on causes of WPV and its prevention, based on the interviewees' experiences of violence while on duty. Thirty-two transport professionals were interviewed. The data were analyzed by means of qualitative content analysis.

Results

The triggers and causes of violence included fare evasion, disputes over revenue owing to owners, alcohol abuse, overcrowded vehicles, and unfair competition for passengers. Failures to meet passenger expectations, e.g. by-passing parts of a bus route or missing stops, were also important. There was disrespect on the part of transport workers, e.g. being rude to passengers and jumping of queues at taxi ranks, and there were also robberies. Proposals for prevention included: training for workers on conflict resolution, and for employers on passenger-transport administration; and, promoting learning among passengers and workers on how to behave when traveling collectively. Regarding control and supervision, there were expressed needs for the recording of mileage, and for the sanctioning of workers who transgress queuing rules at taxi ranks. The police or supervisors should prevent drunken passengers from getting into vehicles, and drivers should refuse to go to dangerous, secluded neighborhoods. Finally, there is a need for an institution to judge alleged cases of employees not handing over demanded revenues to their employer.

Conclusions

The causes of WPV lie in problems regarding money, behavior, environment, organization and crime. Suggestions for prevention include education, control to avoid critical situations, and a judicial system to assess malpractices. Further research in the road passenger transport sector in Maputo City, Mozambique and similar settings is warranted.

During the last decade, Health Impact Assessment (HIA) has been discussed worldwide as being an important tool for the development of healthy public policy. In Sweden, the Swedish Federation of County Councils and the Swedish Association of Local Authorities have taken the initiative to and are responsible for the development of an HIA tool concerning proposed policy decisions at local and regional levels. The HIA tool was developed as three different templates to be adapted to local conditions and needs: the Health Question, the Health Matrix and the Health Impact Analysis. In this paper we present a feasibility study of the experiences of implementing this HIA tool at regional level in a Health Care District (SWHCD) of Stockholm County Council, based on an inductive approach and on principles of data triangulation. The main findings include the need for continuous revision of the HIA templates during the pilot period. The following factors were instrumental in successfully using the HIA tool in local policy making and management: political consensus, agreement between politicians and public officials on political intentions, a clear-cut decision from management, and offering an opportunity for training. Respondents felt that all public officials should use the HIA as part of their normal work routines. In conclusion, the HIA tool has to be locally adapted and the implementation process has to include close collaboration between politicians and public officials and be followed by continuing education, providing possibilities for a dialogue around the HIA tool, in order to ensure the quality of the instrument. Implications of the study are that the process of developing the tool has worked well but that the possible impacts of its use in this case remain an open question. However, this was not the focus of our study.

The trend away from a health and medical care-based policy to a healthy public policy has taken place in Sweden rather later than in other West European countries. One of the first county councils to establish health-promotion plans was Västernorrland. The aims of this study are to describe the contents of and analyze the changes over time in the five public-health plans in the county. The object of study for the policy analysis consists in these plans between 1978 and 2004. A deductive thematic content analysis was performed for each plan on the basis of the central determinants of health promotion. The positioning of the plans was determined using a theoretical framework (Beattie's modified model) founded in the dimensions of power (individual and collective) and governance (local, i.e. the municipalities, and central, i.e. the county council). The results show that the value attributed to good health was consistently high, but the means for attaining this goal have varied over time. The policy focus of the measures in the plans have taken a cyclical path-from individual empowerment to empowerment from a societal perspective, and back prioritizing of actions at an individual level. On the governance dimension, there has been a corresponding positional change over time-from regional to local and then back to regional. Promoting the health of a population requires mutual interaction between the regional and local levels, in which both societal and individually oriented actions are prioritized.

Background

Since the Ottawa Charter (1986) the Nordic countries have been in the forefront in developing health promotion (HP) theory, research, policy and practice. An informal network of Nordic researchers organized five Nordic HP research conferences since 1996. In 2007, the NHPRN was established in cooperation with the Nordic School of Public Health, and three more conferences have been established.

Aims

The aims of the NHPRN is to develop: the theoretical understanding of HP; Nordic research cooperation; cooperation within education on a master and PhD level; and to organize the Nordic Health Promotion Research

Conferences

Organization

The network members constitute a balanced representation of the Nordic countries: It is interdisciplinary with junior and senior researchers. It organizes biannual meetings at WHO’s premises in Copenhagen. The network is organized in working groups engaged in topics central for HP research and practice. Current working groups are Healthy aging; Health literacy; Equity in health; Empowerment; and Workplace health promotion. Working groups are not static and may change depending on the interests for the network members.

Mode of working

In the biannual meetings, lectures on state-of-the art issues are given by leading researchers and policy makers. Participants engage in theoretical discussions in plenum and working groups. The working groups perform research. Collaboration finds place at the meetings and through e-mail correspondence and web meetings. The working groups take part in the planning of conferences and organize workshops in line with their research interests.

Production

The network has published the book Health literacy: teori och praktik i hälsofrämjande arbete (Ringsberg KC Olander E, Tillgren P. 2015), two supplements in Scandinavian Journal of Public Health (2010 and 2014) and several scientific articles. The network has organized three scientific conferences with a Nordic perspective: 2009;

The role of health promotion in the transition of the Nordic welfare states (Gothenburg, Sweden); 2013: Promoting health in everyday settings (Vestfold, Norway); 2016: 20 years of health promotion research in the Nordic countries (Jyväskylä, Finland). A fourth conference is planned for 2019 with the topic Sustainable health promotion (Roskilde, Denmark).

Future

The network is open for PhD students and HP researchers working in the Nordic countries. The NHPRN is a working network and all participants must therefore commit to the work of the network and participate in its meetings. Researchers interested in participating in the network may obtain further information by contacting the network chairman Sami Kokko (sami.p.kokko@jyu.fi) or 1.1.2017 onwards Anne Liveng (aliveng@ruc.dk); seeing the website http://nhprn.wordpress.com; and/or reading Ringsberg KC., The Nordic Health Promotion Research Network, Scand J Publ Health 2015;43(Suppl 16):51-56.

Den andra nationella utvärderingen av samtliga 23 utbildningsprogram på kandidat-, magister- och masternivå i folkhälsovetenskap genomfördes 2011-2012. Här presenteras en översikt av de examensarbeten som utvärderingen baserades på. Det är 218 slumpmässigt utvalda uppsatser, 67 från kandidatnivå, 55 från magisternivå och 76 från mastersnivå. Högskoleverkets hårt reglerade format medgav inte någon innehållsmässig analys av hur folkhälsovetenskapen speglades i uppsatserna. Vi åtta i bedömargruppen var dock eniga om att vidga ramarna. Vår fördjupning kom att fokuseras på vilka tillämpningsområden som studenterna valde, vilka forskningsdesigner som tillämpades och hur kvaliteten bedömdes i relation till ämne, metod och fakultetsområde. Av de nio folkhälsovetenskapliga områden som förekommer i uppsatserna var de vanligaste Hälsofrämjande och Hälsans bestämningsfaktorer. Ämnesinnehåll och olika examensnivåer varierade stort mellan de olika lärosätena. En slutsats är att utbildningen i folkhälsovetenskap har svårigheter att balansera det flervetenskapliga med att nå ett fördjupat kunskapsinnehåll.

Lärandeprojektet Vård på lika villkor har varit en överenskommelse mellan staten och Sveriges Kommuner och Landsting som pågått mellan 2011 och 2014. Målet med projektet har varit att utveckla arbetssätt och metoder som kan främja en mer jämlik första linjens vård. Inom ramen för projektet har SKL uppdragit åt forskare vid Mälardalens högskola att göra områdesbeskrivningar för de sju medverkande vårdverksamheterna.

Syftet med områdesbeskrivningarna är försöka ge en jämförbar beskrivning av de medverkande sju verksamheterna i projektet. Beskrivningen är gjord utifrån relevant statistik och demografi ska data på patientnivå, samt utifrån organisatoriska förutsättningar och resurser. Förhoppningen är att dessa uppgifter kan ge ökad förståelse för vilka patienter som fi nns i området och fungera som ett stöd i arbetet för en mer jämlik vård.

Developing a program theory for a project and evaluate the project based on this program theory has both its merits and limitations. These merits and limitations in turn may be depend on the existing attitude towards a particular program theory. This study is about exploring how different phases and parts of the national learning project Care on equal terms (2011-2014) functioned in relation to the program theory developed in the beginning of the project. The result shows that the program theoretical perspective on the project contributed to a better structuring of the various forms of evaluation, given a broader understanding of the project's components and provided better opportunities to improve monitoring of the project by the research team in collaboration with the project management of the Swedish Association of Local Authorities and Regions (SALAR) and the participating health care units.

Public health science has been an established subject within Swedish universities for two decades, all three levels of higher education. Over the years, the number of courses has varied and the subject is in 2017 available at 18 universities. At the undergraduate level there are nine programmes and at advanced level 18 different programmes, with each nine as master’s (60 credits) respectively and master’s programmes (120 credits). Postgraduate studies in the subject are conducted at ten universities. While there has been a decline in the number of students at undergraduate level, there has been a vigorous expansion in advanced and postgraduate level. The content of the education clearly reflects the interdisciplinary nature of the subject and its anchoring in epidemiology. Undergraduate studies show a broad alignment and the master programmes are available with several specific foci, including Global Health, Health Economics and Epidemiology.

Based on the storytelling tradition and analyses of conference material, this article provides an overview of the evolving Nordic Health Promotion Research Network (NHPRN) and its conferences over the last 20 years. The story goes from the planning of the first conference in Bergen, Norway, back in 1996 to the eighth conference in Jyväskylä, Finland, in 2016. There have been three phases of development. During the first phase, 1996–2007, the five first conferences were initiated and implemented by departments of public health in the Nordic countries. The World Health Organization (WHO) collaborative centres of Health Promotion in Bergen University and a group at Karolinska Institute, Department of Social Medicine, creating supportive environments for health in Stockholm played key roles in initiating and supporting NHPRN. During the second phase, 2007–2014, the network was strengthened and supported by the Nordic School of Public Health (NHV) in Gothenburg. The third phase started when NHV closed down in 2015 and networking activities were transferred to the European Office of WHO in Copenhagen. The Nordic Health Promotion Research Conference series has served several purposes and will continue to do so. They are important Nordic meeting places, stimulating Health Promotion research, as well as explicitly managing ongoing concerns in the international Health Promotion community. This is reflected in the shift of foci over time. The content of the conferences has been highly responsive to whatever challenges are particularly relevant at different points in time, while also contributing to developing Health Promotion as a discipline, given that every conference has built on the previous ones.

The aim of this study was to explore and describe the Swedish social workers’ experiences in caring for addicted clients in the middle-sized municipality with a population of about 130,000 inhabitants. Qualitative descriptive study was applied. Purposive sampling was used to recruit the participants. Seven Swedish social workers participated in the study. These participants had extensive experiences and were able to communicate in English. The structured interviews, field notes, and the tape recorder were used during data collection process during February 21 st to March 23rd 2011. Content analysis was used for data analysis. The results disclose that two themes emerged including ways of encountering and ways of caring. The first theme way of encountering, social workers encourage their drug addicted clients to sustain abstinence by using motivation talk and showing respect for human rights. In another theme, way of caring, social workers applied standardize methods in the caring process and collaboration between the health care and social welfare systems.

I ett drygt decennium har det varit möjligt för statliga och enskilda högskolor i Sverige att ansöka om att få inrätta forskarutbildning inom ett specifikt område. Fram till 2020 har 38 tillstånd beviljats och åtta av dessa har koppling till området hälsa och/eller välfärd. Sedan läsåret 2012/13 finns vid Mälardalens högskola (MDH) forskarutbildning inom detta område. Syftet med denna artikel är att beskriva och diskutera en granskning av hur området hälsa och välfärd återspeglas i de första 15 avhandlingarna. En kvalitativ deduktiv innehållsanalys genomfördes samt en bibliometrisk undersökning av innehållet i avhandlingarnas introduktion och diskussion. Utifrån granskningen diskuteras resultatet men också hur den metodik som tillämpats kan vara relevant för granskning av avhandlingar även vid andra högskolor med ett specifikt forskarutbildningsområde.   

Objectives

The aim was to study the occurrence and how equality in health was expressed in policy and activities in four Swedish municipalities in the years 2006 and 2012.

Methods

A deductive content analysis of interviews with local municipal key persons, politicians and chief executives and policy documents in the form of annual reports, in four strategically selected municipalities in the region of Mälardalen in Sweden.

Results

In the documents, terms of equality, justice and vulnerable groups did not occur. However, these themes were mentioned by politicians and officials in most of the municipalities studied, and the issues of vulnerability and exclusion occur in both documents and interviews in most municipalities. These issues were conceptualized as various support measures, such as social and economic support, integration efforts, appropriate housing, promotion of employment and to provide security and a safe childhood. These issues occurred in all the documents and in some of the interviews. Priority groups in all municipalities were children, young people and older people but also immigrants. Barriers mentioned were the lack of qualified personnel such as social workers and support staff in schools.

Conclusions

Equality, health equity and reducing the gaps are not explicitly stated in the study of the municipalities. But the insight that disadvantaged groups needs support through actions and tailored training programs and work based on the individuals’ different conditions was emphasized.

The local perspective on the implementation of a national public health policy in Sweden – a case study from two municipalities

Author names (surname, initials): Elisabeth Jansson^a,b, , Elisabeth Fosse^c, Per Tillgren^a,b

Affiliations:

School of  Health, Care and Welfare, Mälardalen University, Box 883, SE-721 23 Västerås, Sweden

^b Department of Public Health Sciences, Karolinska Institutet, Norrbacka, SE-171 76 Stockholm, Sweden

^c Department of Health Promotion and Development, University of Bergen, Christiegt. 13, 5015 Bergen, Norway

 Background:

 In 2003 the Swedish parliament adopted a wide-ranging national objective for public health, focusing specifically on health determinants. It is envisaged that the overall objective will be achieved through the efforts of different bodies, including agencies, county councils and municipalities. Responsibility for implementation is located at regional and local level, without any specified guidelines or, for example, economic incentives for how the work should be performed.

This study’s intention is, from a bottom-up perspective, to investigate public-health policies in two municipalities, and to see whether municipal policies can be related to the national objective.  The bottom-up perspective focuses on the actors, the people responsible for implementation, and on the process as seen from their own perspective. The implementers play a key role, as mediators of empirical knowledge and bases for decisions to the national decision-makers. Thus, in the implementation of national policy at local level, decision-makers are dependent on the decisions made and priorities set by the municipalities in their own local settings, as these are related to competing or similar laws, policies, stakeholders and needs. Local and committed actors have an important function in the implementation process. Serious commitment and occupying a position of power are important aspects of success, but so too is professional expertise. At the same time, local actors’ opportunities to act and implement national targets within their own organization is restricted by surrounding structures, e.g. the party-political (partisan) composition of the municipality and its administrative organization, and also the presence or not of formal or informal support networks.

Methods:

 Scrutiny of documents and interviews provided a foundation for a qualitative case study.

Results:

The results reveal a loose fit between policy implementation and the national public health policy. The local level does not regard the national objective as implementable; instead, it has, to varying degrees, chosen to redefine its goals according to municipal needs and conditions. A success-promoting factor in the two municipalities was the presence of committed and knowledgeable actors/implementers. Also, the municipality with a more centrally controlled and stable party-political leadership succeeded better in implementing structural and intersectoral community-wide policies for coordinated local public-health promotion.

Discussion /Conclusions:

Problems that accompany major, ambitious and non-specific goals, like those in the Swedish public health policy, are that they risk being integrated into a solely symbolic structure, entailing formal adoption but with only a superficial finish.  Below the surface, the informal, original organization remains in the administrations, which hinders implementation.

Swedish municipal self-governance, with its enhanced scope for local action, offers an opportunity for communities to shape their own politics and policies. But, at the same time, this acts as a barrier to opportunities for decision-makers at national-government level to influence and guide the municipalities towards the national objective of more organized and structured health promotion focusing on the determinants of health enhanced knowledge of the policy, and of its specific focus on health determinants, is needed to increase understanding/motivation to implement the national policy locally.

Objective: Gain knowledge about municipalities’ setting approaches by studying four Swedish municipalities’ and how they practices settings in their organized and conducted local health promotion.Methods: A multiple case study design with content analysis of key person interviews and documents. Results: The municipalities stressed the importance of enable the inhabitants’ and staffs’ possibilities to maintain and achieve better health. In the case an explicit local health policy existed the focus was on specific target groups e.g. children, problem areas e.g. alcohol or on health outcomes as e.g. decreases in days of sick leave. Dependent on the nature of the problem, the strategies implicitly focused on intersectoral collaboration within the municipal administration and sectors or/and with external actors as official authorities, private companies, NGOs and neighboring municipalities, as well as between different levels and professions. Health promotion actions implemented were mainly established in more traditional and locally well-known local settings as schools, workplaces, family centers or libraries, but there were examples on efforts to create new venues to enable social wellbeing and supportive settings. Conclusions: The setting approach is consistent with the municipalities’ views and possibilities to handle complex public health issues, hence the setting approach is still going strong. Locally prioritized health issues based on local needs and prerequisites are preferably performed in traditional settings. The development and sustainability is seen as possible and achievable by intersectoral collaborations with engaged and committed actors in established arenas. Challenges in the municipalities’ setting approaches are related to factors like sectorial pipe-line organizations and e.g. confidentiality regulations in collaborations between the municipality and health care sector.

OBJECTIVES: In 2003 the wide-ranging Swedish National Public Health Policy (SNPHP), with a focus on health determinants, was adopted by the Swedish parliament. In the context of multilevel governance, SNPHP implementation is dependent on self-governed municipalities and counties. The aim of the study is, from a municipal perspective, to investigate public-health policies in two municipalities. METHODS: Content analysis of documents and interviews provided a foundation for an explorative case study. RESULTS: The SNPHP at national level is overriding but politically controversial. At local level, a health-determinants perspective was detectable in the policies implemented, but none regarding to health equality. At local level, the SNPHP is not regarded as implementable; rather, limited parts have, to varying degrees, been reconciled with local public-health goals, according to municipal needs and conditions. A success-promoting factor in the two municipalities was the presence of committed and knowledgeable actors/implementers. Also, the municipality with a more centrally controlled and stable party-political leadership succeeded better in implementing structural and intersectoral community-wide policies for coordinated local health promotion. CONCLUSIONS: The contents of national and local public-health policies differ, and municipalities that have implemented their own local health policies do not seem to regard the SNPHP as justifiable or adoptable. If the SNPHP overall aim regarding equal health is to be achieved homogeneously in Swedish municipalities, its contents and purpose need clearer management and negotiation, so that implementation of the national policy locally is understandable and motivated.