Search

Background: In 1938, J. Alison Glover published a study on incidence of tonsillecto-mies in school children, demonstrating variation in treatment rates across school districts. Consequently, it rates raised questions as to what determines when to treat a patient. After Wennberg and Gittelsohns’ paper ‘Small Area Variations in Health Care Delivery’ was pub-lished in 1973, it became clear that regional variation was not restricted to school districts nor surgical treatments. While the phenomenon of regional variation is well documented, there are still knowledge gaps on the cause and effect of this variation. Thesis fills in some of these omissions by ex-ploring the implications that regional variation has for patients, asking whether there are pat-terns in utilisation rates, and examining how treatment characteristics affect these patterns. Lastly, it considers how variation can be reduced. The original research provides new knowledge on the phenomenon, which hopefully can help policy makers construct a fair and efficient healthcare system. Materials and methods: The materials used in this thesis was gathered by the Norwegian Patient Register (NPR), the Norwegian Quality Register for Spine Surgery (NORSpine), and Statistics Norway. Data from NPR contains hospital administrative data on all treatments fitting the inclusion criteria for lumbar disc herniation-, spinal stenosis-, meniscus-, shoulder-, ear drain-, heavy eyelid- and cataracts -surgery, as well as tonsillectomies. For spine surgeries, NORSpine have developed a suitable inclusion criteria. NORSpine is a clinical quality register, containing clinical, demo-graphic and socioeconomic patient level data, as well as multiple patient reported outcome measures. For the six latter treatments, selection criteria was copied from the Norwegian Health Atlas. Data from NPR, NORSpine and Statistics Norway was used in Paper 1 and Paper 3. Data from NPR and Statistics Norway was used in Paper 2. The methods used to explore the research questions were, generalized estimation equations (Paper 1), principal component analysis (Paper 2), logistic regression and stochastic gradient boosting (Paper 3). Results: Relatively high regional utilisation rates were associated with reduced patient need. It was found that patients in high-rate regions were found to have better health at baseline and achieved lower health gain after treatment. For primarily elective treatments, high treatment rates are likely supply-driven, and there is a substitution effect across medical specialties. A suggested remedy to reduce this variation has been decision aid-tools. In the case of lumbar spine surgery, survey data alone is not enough to make accurate predictions on whom to treat. Conclusion: As a result of regional variation in treatment rates, region of residence affects patients’ likeli-hood of receiving treatment. The current method of financing hospital care is not designed to reduce the inequalities that arise from such variation. The most suitable approach to reduce variation is to increase focus on shared decision making between patient and physician, and facilitate experience sharing among physicians across hospital regions. Regional variasjon i bruk av helsetjenester eksisterer for nesten alle behandlinger i alle land. Mens noe av variasjonen er et resultat av mer sykdom i noen regioner, er det antatt at store deler av den totale variasjonen skyldes årsaker ikke relatert til pasienters helse. Selv om fenomenet er kjent, er det er fortsatt mye ukjent om hvorfor de oppstår, hva konsekvensen er for pasienter og hvordan man skal fjerne den uønskede variasjonen. I denne avhandlingen undersøkes derfor hvordan pasienter påvirkes av regional variasjon, hvorvidt vi kan lære noe ved å se på behandlingsrater for flere behandlinger samtidig, og det drøftes hvordan variasjonen kan reduseres. Ved å bruke unik data fra norske helse-, norske kliniske kvalitet- og administrative registre presenteres original forskning som kan brukes til å skape et bedre helsesystem.

Bakgrunn: Norske helseforetak er pålagt å drive kvalitetsforbedring for å bedre pasientsikkerhet ved norske sykehus. Det interne rapporteringssystemet er det viktigste formelle verktøyet for dette på lokalt nivå. Formål: studiens hensikt er å undersøke hvorvidt det interne avviksrapporteringssystemet bidrar til kvalitetsforbedring, og hvilke utfordringer helsepersonellet identifiserer ved bruk av systemet som læringsverktøy. Materiale og metode: Studien er basert på 8 semistrukturerte intervjuer med helsepersonell fra to avdelinger på et mellomstort norsk sykehus, analysert med tematisk analyse. Resultater: Avviksrapporteringssystemets bidrag til læring er omdiskutert og vanskelig målbart, da bidrag fra andre formelle og uformelle systemer for læring overlapper, samt at hendelser som forhindres ikke er målbare. Studien identifiserer at leder spiller en sentral rolle for avdelingenes meldekultur, og at en tydelig definisjon på avvik mangler. At avviksmeldinger kan føre til sanksjoner, og at meldekultur varierer mellom avdelinger fører til underrapportering. Informasjonshenting, analyse og problemløsning skjer ofte på siden av avvikssystemet. Avvikshåndtering er en ressurskrevende prosess, som i samspill med ressursknapphet og avvikenes kompleksitet, er hindre for kvalitetsforbedring. Tidligere kjente barrierer spiller også inn på avviksrapporteringen. Konklusjon: Basert på intervjuer av ansatte og ledere leger har vi beskrevet perspektivene på avvikssystemets bidrag til lokal pasientforbedring, og hvilke utfordringer de identifiserer med avvikssystemet som verktøy for dette. Dette er viktig for å skape et kunnskapsgrunnlag om de verktøyene vi bruker til lokal kvalitetsforbedring, og for å kunne gjøre justeringer i hvordan vi jobber med pasientforbedring i fremtiden. Videre forskning er nødvendig for å verifisere funnene.

Introduction: To provide more integrated care, several countries have implemented the Flexible Assertive Community Treatment (FACT) model. However, this model does not guarantee full integration, especially in complex and fragmented service systems like in Norway. Hence, we investigated which barriers that might reduce the potential for integrated care in the Norwegian system, as described by staff in FACT teams, and how they adjust their way of working to increase the opportunities for integration. Methods: Online focus group interviews involving 35 staff members of five Norwegian FACT teams were conducted using a semi-structured interview guide. The material was analysed using thematic text analysis. Results: Six themes described the barriers to integrated care in the service system: fragmentation, different legislation and digital systems, challenges in collaboration, bureaucracy and limited opening hours. Three themes described adjustments in the teams’ way of working to enhance integration: working as the responsible co-ordinator, being a collaborator, and the only entry channel into the service system. Conclusion: The FACT team staff described several barriers to integration within the system. However, they made some adjustments in their way of working that might provide opportunities for integrated care within complex and fragmented service systems.

There is a lack of studies on ethical responsibility in nursing. Nurses experience ethical responsibility in all settings where patients are exposed and vulnerable. The authors’ interest in public health and intensive care nursing provided a motivation to study these settings. The study aimed to explore how intensive care and public health nurses experience ethical responsibility. A qualitative design was chosen and 10 individual interviews were carried out. The data were analysed using hermeneutic phenomenological analysis. The study is reported in accordance with COREQ. Levinasian ethics provided the theoretical framework. The analysis resulted in four themes: Feeling alone, Feeling worried and uncertain, A sense of satisfaction, A personal commitment. Even though the settings differed, experiences of aspects of ethical responsibility were the same. Further in-depth studies in different settings can enhance an understanding of moral responsibility and facilitate the development of a theory of ethical responsibility in nursing practice.

In Finnmark, the northernmost county of Norway, many villages are remote and scattered between vast stretches of uninhabited land, with mountain crossings that are often closed in winter or where one can only drive in single file behind a snowplough. This may mean periodic total isolation and daily challenges with long distances to other professionals and hospitals. These special circumstances mean that nurses must act more independently than elsewhere. Objectives: The aim was to explore the challenges of rural nurses in palliative cancer care, and the prerequisites to maintain a suitable professional standard in their nursing. Methods: This study is qualitative with an explorative design and reports the results of the content analysis of interviews with five nurses, living in small, multi-ethnic villages. Findings: The main finding of the study is that the nurses experienced themselves as being alone geographically and professionally in their practice of palliative care. The established infrastructure for performing advanced nursing in patients’ homes is poorly adapted to the geographical and professional situation in rural areas such as Finnmark, and suboptimal information about patients arriving from hospitals can compromise the quality of care. Advanced nursing is performed when specialists are far away and there is no palliative team, and they care for patients who are often their family members, friends and acquaintances, which involves role ambiguity and a risk of over-involvement. Conclusion: The study shows that requirements to enhance palliative cancer care are to establish palliative teams, discharge summaries present in transition, the necessary drugs and medical equipment for several days, and relevant training of personnel.

Background: This article examines how staff delivering care (two groups of healthcare workers and leaders) in a newly established unit worked to sustain required performance levels through changes and disruptions. It highlights discrepancies between plans for the unit (work as imagined) and reality in the unit (work as done). Aim: The aim of this article is to explore the experiences of persons in the workplace in response to discrepancies between work as imagined and work as done. Methods: Case study methodology is used to give attention to context and complexity, to gain a deepened understanding of the topic and to unveil contradictions and commonalities. The data material includes notes, pictures and soundtracks, and was analysed using qualitative content analysis. Results: The findings show discrepancies between the plans and practical reality. Staff responses to these are presented as ‘being left to oneself’ ‘moving to new positions’ and ‘walking together’. Conclusion: The healthcare system consists of multiple interactive systems and subsystems. People working at the micro level need to deliver care under expected and unexpected conditions. For a workplace culture to be effective, staff need to experience being part of a community they can be proud of, as well as being acknowledged as persons contributing to that community. Involvement in decision making and opportunities to verbalise challenges make it possible for staff to make a map that fits the landscape, and thus make better plans for patient care. Implications for practice: Engagement in a project initiated by staff can provide direction for work and better quality of care A resilient healthcare system depends on health workers having the opportunity to develop as persons and be part of a community Changes in healthcare systems are demanding for both leaders and staff, and it takes time and effort to build resilient systems and cultures

We analyze the extent to which hospitality firms overuse staff using a production function model which considers firm heterogeneity and accounts for environmental variables in staff use. We decompose overall staff use inefficiency into transient and persistent inefficiency. To do this, we employ a state-of-the-art stochastic frontier model, which is estimated using daily data on 94 Norwegian hospitality firms from 2010 to 2014. The environmental variables, especially the annual time trend, seasonality, and days of the week are found to exert heterogeneous effects on staffing. The mean transient, persistent, and overall efficiencies of the hospitality firms are 69%, 67%, and 46%, respectively. We find that seasonality (days of the week) decreases (increases) transient inefficiency by about 4%, suggesting significant room for improvement in hospitality staff use.

Background Appointment no-show and early dropout from treatment represent major challenges in outpatient substance use disorder treatment, adversely affecting clinical outcomes and health care productivity. In this quasi-experimental study, we examined how a brief reminder intervention for new patients before their first appointment affected treatment participation and retention. No-shows (not attending any sessions) and dropouts (discontinuation of initiated treatment because of three consecutively missed appointments) were compared between a period with pre-admission telephone calls (intervention) and a period without such reminders (non-intervention). Methods Participants were all eligible patients (N = 262) admitted to a Norwegian specialist clinic for substance use disorder treatment. We used the Chi-square test for the no-show analysis. Of the eligible patients, 147 were included in a subsequent dropout analysis. We used the number of visits up to 10 appointments as a measure for time to event. Group differences were analyzed using a Kaplan–Meier plot and the log-rank test. To control for relevant sociodemographic variables, as well as substance use and mental distress severity, we used Cox regression. Results No-show rates did not differ between the two periods (12% for non-intervention vs. 14% for intervention; χ2 = 0.20, p = 0.653). Of those consenting to participate in the dropout analysis (n = 147), 28 (19%) discontinued treatment within the time frame of 10 appointments, with no differences between the two periods (log-rank test = 0.328, p = 0.567). Controlling for baseline characteristics did not alter this finding. In fact, of the registered covariates at baseline, only higher education level was associated with attrition, linked to a reduced risk for dropout (hazard ratio = 0.85, 95% CI = 0.74–0.98, p = 0.025). Conclusion These findings do not provide support for the systematic use of a brief pre-admission telephone reminder in the current treatment setting. Trial registration The study was retrospectively registered 13 Jan 2021 at ClinicalTrials.gov, NCT04707599.

Bakgrunn: Individuell plan er en lovfestet rettighet for de som har behov for langvarige og koordinerte tjenester. Formålet med ordningen er å sikre at tjenestemottakerne får et helhetlig, koordinert og individuelt tilpasset tjenestetilbud. Individuell plan skal både bedre samordningen av tjenester og sikre bedre brukermedvirkning. Det er imidlertid fortsatt få brukere/pasienter som får individuell plan. Formål og hensikt: Formålet med studien er å belyse praksis rundt individuell plan fra lederes ståsted. Dette kan gi økt kunnskap om hvorfor ordningen er så lite brukt, noe som igjen kan bidra til bedre løsninger i fremtiden. Problemstilling og forskningsspørsmål: Hvilke erfaringer har ledere i kommunal hjemmetjeneste med individuell plan? • Hvordan posisjonerer ledere i kommunal hjemmetjeneste seg selv og andre aktører når de forteller om praksis rundt individuell plan? • Hvordan kan ledernes posisjoneringer påvirke hvorvidt og hvordan individuell plan anvendes for brukere av kommunale hjemmetjenester? Metode: Studien har et kvalitativt og utforskende design. Det er gjennomført semi-strukturerte forskningsintervju. Informantene i studien er tre avdelingsledere i kommunal hjemmetjeneste, og de er alle tre sykepleiere. Det er gjort en narrativ posisjoneringsanalyse av intervjuene som beskrevet av Michael Bamberg (Bamberg, 2004). Resultater og konklusjon: Deltakerne posisjonerer gjennomgående seg selv og sine ansatte som aktive og autonome aktører, samtidig som brukerne får en passiv rolle, noe som er i konflikt med ideologien bak individuell plan. Lederrollen er tilpasset behovet for fleksibilitet og selvledelse i klinisk arbeid og dette kan påvirke bruken av individuell plan negativt. Materialet viser også manglende insentiver for implementering av ordningen, noe som også kan være med på å forklare den manglende bruken av individuell plan. Nøkkelord: Individuell plan, hjemmetjeneste, ledelse, myndiggjøring, samhandling.

Background: Health anxiety (HA) concerns worry of disease, and has mostly been examined in people with severe HA/hypochondriasis. However, HA can be conceptualised as a continuous construct, with levels ranging from low to severe. There is little knowledge on the distribution of HA as a continuous construct in the general population, nor the association between different levels of HA and healthcare use, physical disease and cardiovascular risk factors. Aim: To study the distribution of HA as a continuous construct in the general population, examine sociodemographic and social network factors associated with HA, and examine the association between HA and healthcare use, physical disease and cardiovascular risk factors. Methods: This thesis used cross-sectional data from the Tromsø study: Tromsø7 (2015-2016). 21 083 persons aged 40 years or older gave self-reported information on physical diseases, cardiovascular risk factors, and healthcare use in the last 12 months. HA was measured with Whiteley Index; possible scores ranged from 0-24. Sociodemographic and social network factors included age, gender, education, household income, friendship, and participation in organised activities. Results: HA was highly skewed in our sample of the general adult population, with an exponential distribution. Of the sociodemographic and social network variables, friendship had the highest association with HA level. HA as a continuous construct was associated with increased level of use of all types of healthcare services. HA was also consistently higher in the population reporting current or previous physical disease and cardiovascular risk factors, than in the healthy reference group. Conclusion: Our results support conceptualising HA as a continuous construct. Mean HA in the study sample was low, but all levels of HA were associated with increased healthcare use. Having physical disease and cardiovascular risk factors were consistently associated with increased HA. This indicates that all levels of HA deserve attention in future research. Bakgrunn: Forskning på temaet helseangst (HA) har i stor grad fokusert på alvorlig helseangst; personer som har symptombyrde likt de med hypokondri. HA er samtidig foreslått som et kontinuerlig fenomen, med alvorlighetsgrader som varierer fra lite til alvorlig. Alvorlig, eller høy grad av HA, er assosiert med høyt helsetjenesteforbruk og redusert livskvalitet. HA som et kontinuerlig fenomen har vi lite kunnskap om, heller ikke hvordan dette fordeler seg i den generelle befolkningen. I Norge og i verden er helsetjenesteforbruk økende, sammen med økende forekomst av fysisk sykdom og kardiovaskulære risikofaktorer. Sammenhengen mellom HA som et kontinuerlig fenomen og disse faktorene er derfor viktig å undersøke. Formål: Formålet med denne doktorgraden var å undersøke fordelingen av HA som et kontinuerlig fenomen i en voksen, generell befolkning, samt undersøke hvordan ulike faktorer var assosiert med HA; sosiodemografiske og sosiale faktorer, ulike typer helsetjenesteforbruk, fysisk sykdom og kardiovaskulære risikofaktorer. Metode: Doktorgraden brukte spørreskjemadata fra 21 083 personer som var 40 år eller eldre, som deltok på Tromsøundersøkelsen (Tromsø7) i 2015-2016, og hadde et tverrsnittdesign. HA ble målt med to versjoner av måleverktøyet Whiteley Index (WI-6 og WI-6-R), med en totalscore 0 til 24 der høyere score indikerer høyere HA. Sosiodemografiske faktorer inkluderte alder, kjønn, utdanning, husholdningsinntekt, vennskap og deltakelse i organisert aktivitet. Helsetjenesteforbruk inkluderte bruk av primærhelsetjenesten, somatisk spesialisthelsetjeneste og psykiatrisk spesialisthelsetjeneste de siste 12 måneder. Deltakerne rapporterte også om de hadde ulike somatiske sykdommer, nå eller tidligere, og om de hadde kardiovaskulære risikofaktorer. Resultat: HA var skjevfordelt i den generelle voksne befolkningen og hadde en eksponentiell fordeling. Av de sosiodemografiske variablene var vennskap den variabelen som var sterkest assosiert med HA. Alle grader av HA var assosiert med alle typer helsetjenesteforbruk. Grad av HA var gjennomgående høyere hos deltakere med fysisk sykdom sammenlignet med deltakere uten sykdom. Dette gjaldt både personer med nåværende og tidligere sykdom, samt de med kardiovaskulære risikofaktorer. Konklusjon: Våre resultater, med utgangspunkt i Tromsø7, viser HA som et kontinuerlig fenomen. Selv om gjennomsnittsscoren av HA var lav, var alle grader av HA assosiert med helsetjenesteforbruk. Sammenhengen mellom HA og fysisk sykdom var også konsekvent. Jeg mener våre funn indikerer at alle grader av HA er viktig og fortjener økt oppmerksomhet, både i fremtidig forskning og klinisk praksis.

BackgroundIn Scandinavia, various public reforms are initiated to enhance trust in the healthcare services and the public sector in general. This study explores experiences from a two-step service innovation project in municipal home care in Norway, coined as the Trust Model (TM), aiming at developing an alternative to the purchaser-provider split (PPS) and enhancing employee motivation, user satisfaction, and citizen trust. The PPS has been the prevalent model in Norway since the 1990s. There is little empirical research on trust-based alternatives to the PPS in healthcare. The overall objectives of this study were to explore facilitators and barriers to trust-based service innovation of municipal homecare and to develop a framework for how to support the implementation of the TM.MethodsThe TM elements were developed through a comprehensive participatory process, resulting in the decision to organize the home care service in small, self-managed and multidisciplinary teams, and trusting the teams with full responsibility for care decisions and delivery within a limited area. Through a longitudinal mixed methods case study design a) patients’ expressed values and b) factors facilitating or preventing the service innovation process were explored through two iterations. The first included three city districts, three teams and 80 patients. The second included four districts, eight teams and 160 patients.ResultsThe patient survey showed patients valued and trusted the service. The team member survey showed increased motivation for work aligned with TM principles. Both quantitative and qualitative methods revealed a series of facilitators and barriers to the innovation process on different organizational levels (teams, team leaders, system). The key message arising from the two iterations is to keep patients’ values in the centre and recognize the multilevelled organizational complexity of successful trust-based innovation in homecare. Synthesizing the results, a framework for how to support trust-based service innovation was constructed.ConclusionsTrust-based innovation of municipal homecare is feasible. The proposed framework may serve as a tool when planning trust-based innovation, and as a checklist for implementation and improvement strategies. Further research is needed to explore the validity of the framework and its replicability in other areas of healthcare.

Hensikten med artikkelen er å belyse en kommunes erfaringer med å samhandle og vurdere behov for pleie- og omsorgstjenester for samiske pasienter som tilhører reindriften og kommer til sommerhjemmet. Dette er en viktig problemstilling med tanke på reindriftssamenes rett til likeverdige helsetjenester uavhengig av hvor de oppholder seg.

Background: Projects initiated to transform and develop health services have to account for a variety of complex factors. There is a need to develop methods to handle this complexity, and in this article we present a flexible and adaptable framework for mapping projects that focus on involvement of persons receiving care and other stakeholders, with an integrated support structure. The method also considers elements in the local context. Aims: To present examples of project mapping, and to explore how the process can enhance quality in complex projects in healthcare services. Methods: The project mappings have been co-designed in processes of deliberate dialogue between the authors of this article, with involvement from other researchers and stakeholders. A three- dimensional version of project mapping was developed, and further refined by introducing a two-dimensional version and testing the framework in various settings such as a project leader course and the 2018 Enhancing Practice Conference in Basel. Analysis continued through the whole process as preliminary ideas were discussed and documented. We reflected, wrote notes, talked to people, took part in workshops that included a variety of creative methods, and did a qualitative content analysis of key findings to develop themes. Results: The examples of project mapping show that the process of mapping is as important as the map itself. The maps are flexible and can be combined. Project mapping can contribute to quality in projects by helping project facilitators and participants to stay on track. It can also enable co-creation and guide facilitation processes. Conclusion: Engaging in mapping processes represents an approach that can contribute to a shift in thinking and help even out power imbalances between project participants, as well as influencing the working culture in a health service. Mapping can facilitate transformation of practice while simultaneously creating new knowledge about that transformation. Implications for practice: Project mapping takes account of the complexity of changing practice in healthcare settings It offers project teams a novel way to engage in understanding project processes and outcomes It acts as a reminder that aims for quality improvement should be guided by health and wellbeing for persons receiving care, rather than being systems related

© 2019 Author(s). This is an open access article distributed under the terms of the Creative Commons CC-BY-NC 4.0 License (http://creativecommons.org/licenses/by-nc/4.0/) Hensikten med studien er å få mer kunnskap om hvordan utviklingssentrene for sykehjem og hjemmetjenester (USHT) opplever sin rolle som pådrivere for utvikling, implementering og spredning av ny kunnskap i de kommunale helse- og omsorgstjenestene, og hvordan de opplever samarbeidet med Senter for omsorgsforskning (SOF) når det gjelder forskningsfaglig bistand og veiledning. Vi søker gjennom dette å bidra til ny kunnskap om samarbeidsbasert innovasjonsarbeid i skjæringsfeltet mellom statlige føringer, forskning og praksis. Undersøkelsen er gjennomført som en questback-undersøkelse med både lukkede og åpne svaralternativer sendt til alle USHT. Resultatene viser at USHT er ulike når det gjelder oppbygging, organisering, antall ansatte, kompetanse og fagsammensetning. Disse ulikhetene har betydning for både deltakelse og fokus i innovasjons- og FoU-arbeidet som foregår i de ulike sentrene og for samarbeidet med SOF. En tettere dialog mellom Helsedirektoratet, USHT og SOF om forventninger og behov, samt en konkretisering av rammer for samarbeidet, vil kunne bidra til utvikling av en mer hensiktsmessig struktur for utvikling, implementering og spredning av ny kunnskap i helse- og omsorgstjenestene. Nøkkelord: Samarbeid, Innovasjon, FoU-arbeid, Senter for omsorgsforskning utviklingssentrene for sykehjem og hjemmetjenester Abstract: The aim of the study is twofold: First, it aims to investigate how the Centre for Development of Institutional and Home Care Services (CDIH) experiences their role as a driving force for the development, implementation and dissemination of new knowledge in the municipal health and care services. Second, it aims to explore how the CDIH experiences the collaboration with the Centre for Care Research (CCR) and the research-related assistance and supervision they provide. We seek to provide new insights into cooperation-based innovation efforts in the intersection between governmental leadership, research and practice. The study draws on data from a questback survey with both closed and open-ended questions distributed to all CDIH departments. The results show that the CDIH differs in terms of structure, organization, number of employees and competence. This is important for research & development work in the various CDIH departments, and for cooperation with the CCR. A closer dialogue between the Norwegian Directorate of Health, the CDIH and the CCR about expectations and needs, as well as a concrete framework for cooperation, can contribute to the development of a more appropriate structure for the development, implementation and dissemination of new knowledge in the municipal health and care services.

Source at https://doi.org/10.1016/j.childyouth.2019.02.037. Child welfare services are often scrutinized in media reports, but few comparisons of how services are represented in different countries are available. The aim of this article is to assess whether systematic differences in the representation of child welfare services in Norwegian, Danish and German newspapers can be documented. A content analysis of major newspapers in each country revealed considerable differences among the countries. While Norwegian and German child welfare services are mostly presented as implementing adequately severe and timed interventions, their Danish counterparts are heavily criticized for a complete lack of interventions and for implementing interventions too late or not at all. In none of the three countries, interventions of child welfare services are in the reviewed newspapers presented particularly as too severe or too early. The cooperation with other welfare services is described mostly as neutral or negative in Norwegian newspapers, as positive, neutral or negative in German ones and not at all in most Danish articles. Cultural sensitivity in interventions is in the newspaper coverage of all three countries characterized mostly by an omission of the topic altogether. The comparative indicators applied in this study are suggested as powerful tools for further comparisons.

Source at https://doi.org/10.18261/issn.1894-8693-2019-01-05. Casestudien undersøker hvordan samlokalisering av nødmeldingssentralene til politi, brann og helse påvirker læring og utvikling av transaksjonsminnesystem (TMS) på operativt nivå horisontalt mellom etater. Datamaterialet er innhentet fra ni norske nødmeldingssentraler med ulike samarbeidsbetingelser og geografi og er kategorisert i modellene SAMLOK, SPREDT og NÆR. Analysen av kvalitative intervjudata, observasjons- og medlyttdata viser at læring i de ulike etatenes nødmeldingssentraler skjer situert i et praksisfellesskap mellom operatører under og i etterkant av hendelser. Samlokalisering i SAMLOK ga et teknisk-organisatorisk læringsmiljø horisontalt mellom nødmeldingssentralene som utvidet praksisfellesskapet og økte operatørenes TMS relatert til de andre nødetatenes behov, kompetanse og oppgaver. Nødmeldingssentraler som er SPREDT- eller NÆR-lokalisert, har et etatsspesifikk praksisfellesskap og begrensede muligheter til systematisk erfaringslæring og refleksjon på tvers av etatene. Ledere som møtes regelmessig, kan være pådrivere for erfaringsdeling og kunnskapsdeling horisontalt mellom nødmeldingssentraler. The case study investigates how co-location of police, fire and health emergency coordination centrals (ECCs) affects learning and development of transactional memory systems (TMS) at operational level between agencies. The data come from nine Norwegian ECCs with different cooperation conditions and geography, categorized in the models SAMLOK, SPREDT and NEAR. The analysis of qualitative interview data, observation and compliance data revealed that ECCs are communities of practice where learning takes place between operators during and after events. Co-location in SAMLOK provided a technical organizational learning environment that included the ECCs in an expanded community of practice that increased operators 'TMS on the needs, competencies and tasks of the other agencies’ emergency services. ECCs that are SPREDT or NEAR located have an agency’s practice community and limited opportunities for experience based learning between the agencies. SPREDT and NEAR did not systematic share experiences and reflect for development between agencies.

Bakgrunnen for studien er et ønske om å øke kunnskapen om hvilke årsaker som ligger til grunn for frivillig turnover blant mellomledere i spesialisthelsetjenesten, og hva som kan gjøres for å forebygge dette. Det finnes lite dybdekunnskap om fenomenet, og studien har en åpen tilnærming til mulige årsaksforhold. Den teoretiske redegjørelsen belyser ytre og indre rammebetingelser, hva som kjennetegner mellomledere i spesialisthelsetjenesten og kjente mellomlederutfordringer. Forskningsspørsmålene jeg har brukt er: 1) Hvilke faktorer har hatt betydning for turnover blant tidligere mellomledere i UNN? Og 2) Hva mener mellomlederne må til for å redusere turnover av mellomledere i spesialisthelsetjenesten? Forskningen er gjennomført som en casestudie ved Universitetssykehuset Nord-Norge. Datamaterialet er bygget på semistrukturerte intervjuer av 8 tidligere mellomledere i UNN. Funnene viser at det er tre hovedårsaker til turnover: for stor arbeidsbelastning, mangel på støtte og karriereskifte. De mest sentrale tiltakene for å forebygge turnover handler om tilgang til støtte. Alle ønsket seg en større grad av praktisk administrativ støtte og ulike former for organisatorisk støtte. Noen hadde også et ønske om individuell støtte, spesielt i startfasen som mellomleder. Datafunnene viser også at faglig rolleidentitet og intensjonen med å gå inn i lederrollen henger sammen med frivillig turnover. I konklusjonen tilbys en anbefaling for rekruttering og oppfølging av mellomledere for å forebygge frivillig turnover av denne gruppen.

In Norway, the incidence of invasive meningococcal disease (IMD) is higher among 16–19-year-olds than in the general population. Most IMD cases among teenagers are caused by serogroup Y. Since 2011, one dose of meningococcal ACWY conjugate vaccine (MCV4) has been recommended for teenagers with out-of-pocket payment. The teenagers are usually vaccinated through the school health service at age 18. This study aimed to estimate costs and health gains of introducing MCV4 to Norwegian teenagers through the national immunization program (NIP). A Markov model was used to analyze the cost-effectiveness of universal MCV4 vaccination of either 15-year-olds or 18-years-olds. Occurrences of IMD were simulated from 15 until 23 years of age. Costs were estimated from a healthcare perspective. Sensitivity analyses evaluated the impact of vaccine price, vaccination uptake, IMD incidence and discount rate. Compared to today’s practice of vaccinating 18-year-olds with out-of-pocket payment, introducing MCV4 to 15-year-olds in a NIP-setting, with 90% vaccine uptake and 50% rebate on vaccine price, prevented 3.2 hospitalizations, 0.20 sequelae and 0.47 deaths among 15–23-year-olds, annually. Total costs were reduced by €30,000 and 9.7 quality-adjusted life-years (QALYs) were gained per birth cohort. The probability of cost-effectiveness was 99.0%, assuming a willingness-to-pay threshold of €86,000/QALY for severe diseases in Norway. Cost-effectiveness was highly dependent on vaccine price. Vaccination of 18-year-olds in a NIP-setting was also cost-effective, but less than NIP-vaccination of 15-year-olds. Introduction of MCV4 to the 15-year-olds in the Norwegian NIP is likely to be cost-effective given a rebate on the vaccine price.

While expectations are well-known drivers of electronic health record (EHR) adoption, the drivers of expectations are more elusive. On the basis of interviews with general practitioners (GPs), we investigate how the early implementation process drives their expectations of an EHR that is being implemented in Norway. The GPs’ expectations of the prospective EHR are driven by (a) satisfying experiences with their current system, (b) the transfer of others’ experiences with the prospective EHR, (c) a sense of alignment, or lack thereof, with those in charge of the implementation process, (d) uncertainty about the inclusion of GP needs, and (e) competing technological futures. To manage expectations, starting early is important. Mismanaged expectations produce a need for convincing people to reverse their expectations. This appears to be the situation in Norway, where the GPs are currently skeptical of the prospective EHR.

Background Physicians who perform unsafe practices and harm patients may be disciplined. In Norway, there are five types of disciplinary action, ranging from a warning for the least serious examples of malpractice to loss of licence for the most serious ones. Disciplinary actions always involve medical malpractice. The aims of this study were to investigate the frequency and distribution of disciplinary actions by the Norwegian Board of Health Supervision for doctors in Norway and to uncover nation-wide patient safety issues. Methods We retrospectively investigated all 953 disciplinary actions for doctors given by the Board between 2011 and 2018. We categorized these according to type of action, recipient’s profession, organizational factors and geographical location of the recipient. Frequencies, cross tables, rates and linear regression were used for statistical analysis. Results Rural general practitioners received the most disciplinary actions of all doctors and had their licence revoked or restricted 2.1 times more frequently than urban general practitioners. General practitioners and private specialists received respectively 98.7 and 91.0 disciplinary actions per 1000 doctors. Senior consultants and junior doctors working in hospitals received respectively 17.0 and 6.4 disciplinary actions per 1000 doctors. Eight times more actions were received by primary care doctors than secondary care doctors. Doctors working in primary care were given a warning 10.6 times more often and had their licence revoked or restricted 4.6 times more often than those in secondary care. Conclusion The distribution and frequency of disciplinary actions by the Norwegian Board of Health Supervision clearly varied according to type of health care facility. Private specialists and general practitioners, especially those working in rural clinics, received the most disciplinary actions. These results deserve attention from health policy-makers and warrant further studies to determine the factors that influence medical malpractice. Moreover, the supervisory authorities should assess whether their procedures for reacting to malpractice are efficient and adequate for all types of physicians working in Norway.

Akseptert manusversjon av en artikkel publisert av Universitetsforlaget i Tidsskrift for psykisk helsearbeid.

Tittel: Jordmødres opplevelser av traumatiske hendelser i fødsel. Hensikt: Å studere jordmødres opplevelser av traumatiske hendelser i yrkesutøvingen, i forbindelse med fødsel, og hvilken støtte de har hatt behov for i ettertid. Forskningsspørsmål: «Hvordan oppleves traumatiske hendelser for jordmødre?» «Hvilken hjelp fikk jordmødrene etter hendelsen og hva må til for å komme seg videre etter en traumatisk opplevelse?» Metode: Kvalitativ metode med semistrukturert dybdeintervju som design. Analysert i henhold til Malterud. Fem jordmødre som hadde erfaring med traumatiske hendelser, ble intervjuet. Resultater: Resultatet presenteres med fire hovedkategorier; overveldende følelser som påvirker; behovet for å bli sett, bekreftet og ivaretatt; et ønske om omsorg og veiledning; erfaringens motgang og styrke. Jordmødrene opplevde hendelsene som følelsesmessig belastende. Følelser som redsel, angst, skyld, skam og bekymring kom fram i studien, samt lite støtte og oppfølging. Jordmødrene hadde behov for støtte fra kollegaer og ledelse for å komme seg videre. Det kom fram et ønske om og en mangel på oppfølging satt i system. Konklusjon: Jordmødre kan oppleve hendelser som traumatiske, noe som gir utslag i følelsesmessige stressreaksjoner som påvirker dem både privat og hvordan de utøver yrket. Over tid kan problemene føre til at jordmor forlater yrket. Det ønskes derfor fokus på støtte og oppfølging satt i system, samt forebyggende tiltak både i utdanning og i praksis. Nøkkelord: Jordmor, traume, opplevelser, stress, krise, mestring, støtte.

Foreldre har behov for omsorg og informasjon av høy kvalitet allerede ved jordmors første mistanke om fosteravvik på rutineultralyd. Hensikten med denne studien var å utforske hvordan jordmødre opplever at foreldres informasjonsbehov blir møtt etter oppdaget avvik på rutineultralyd. Klassisk grounded theory med konstant sammenligningsanalyse ble brukt. Det ble utført semistrukturert dybdeintervju med dem jordmødre som har spesialisering innen ultralyd og utfører rutineultralyd regelmessig. De ble rekruttert fra både lokalsykehus og universitetssykehus. Studiens resultat viser at jordmødrene ikke kan svare direkte på denne problemstillingen, da de har en begrenset og uklar rolle i en større prosess med tverrfaglig samarbeid. De arbeider på en slags «mellomstasjon». Jordmødrenes hovedutfordring ble identifisert som at de har en begrenset, uklar rolle på en mellomstasjon i det øyeblikket et føtalt avvik er oppdaget. Kjernekategorien, tilpasser seg en begrenset, uklar rolle på en mellomstasjon, beskriver forskjellige måter jordmødrene tilpasser seg hovedutfordringen. De tilpasser seg rammene som er satt for rollen deres med ulike strategier for hvordan de tilpasser seg. Ultralydjordmødrene ser verdi i jobben de gjør og beskriver rollen sin som viktig. De legger til rette for å styrke foreldres tilknytning til det ufødte barnet, med fokus på hele familien, og på å beskytte svangerskapet. Studien retter perspektivet mot kvinnesentrert omsorg, og viser til at dette begrepet har sin plass innen ultralyddiagnostikk. Jordmødrenes beskrivelse av egen rolle, tyder på at de etterstreber å jobbe kvinnesentrert. Dette sees i deres beskrivelser av å ville beskytte svangerskapet, tilpasse informasjon som legger til rette for empowerment og at de tilstreber kontinuitet i omsorgen. Nøkkelord – Fosteravvvik, Informasjon, Jordmødre, Rutineultralyd, Grounded theory

Master's thesis in Public health science (ME516) Background: The recommended procedure for achieving health promotion in Norwegian municipalities is a "Healt-in-All-Policies" approach. This is because the factors that affect the population's health also include areas outside the health sector. The municipalities are recommended to employ a public health coordinator to bring together the various parties in cross-sectoral public health work. Collaborative processes with several stakeholders in different sectors depend on a unifying key person to achieve acceptable cross-sectoral involvement, understanding and continuity. This is according to the "boundary spanner" theory and Kingdon's theory of the "policy entrepreneur". The aim of this study is to investigate the public health coordinators' contact pattern, and factors of importance to increase their cross-sectoral contact. Conclusion: The fact that public health coordinators ́ contact with the municipality's top management and civil society is low may indicate a lack of exchange of knowledge with keypersons and decision-makers, as well as a small degree of inclusion of the civil society in the systematic public health work. The public health coordinators cannot run their mission for public health without clear guidelines and time at hand. Keywords: Health-in-all-policies, wicked problems, municipal public health work, public health coordinator, boundary spanners, policy entrepreneur

Tittel: Jordmødres første møte med den vonde stillheten. Hensikt: Økt innsikt og forståelse for jordmødres opplevelse av det første møte med intrauterin fosterdød. Problemstilling: Hvordan mestrer jordmor sitt første møte med intrauterin fosterdød? Metode: Kvalitativt design med en fenomenologisk hermeneutisk tilnærming. Datainnsamling gjennom individuelle semistrukturerte forskningsintervju av fem jordmødre. Analyse av resultatene gjennom Malteruds systematisk tekstkondensering. Resultater: Jordmødrene beskrev deres første møte med intrauterin fosterdød som følelsesmessig utfordrende. De var både sårbare og takknemlig i møte med foreldrene, parallelt med at de følte på utrygghet, usikkerhet og frykt. Ulike motstandsressurser hadde en viktig betydning for jordmødrene, herunder følelsesorientert- og problemorientert mestring, kunnskap, profesjonalitet og sosial støtte. Ønsket om å hjelpe foreldrene sto sentralt, og fungerte som en motivasjon for å håndtere deres første møte med intrauterin fosterdød. Konklusjon: Jordmødrene mestret sine første møter med intrauterin fosterdød ved å finne mening og motivasjon i å hjelpe foreldrene, og ved å benytte et bredt spekter av motstandsressurser som ga dem styrke og kraft. Nøkkelord: Intrauterin fosterdød, dødfødsel, erfaring, jordmor, OAS

Master's thesis in Clinical health sciences (ME520) Background and purpose In the health-promoting work in the municipalities and in the health services, there is a purpose to improve, by developing the services and moving them closer to where the service recipients live. One intervention that can contribute to fulfill this purpose, the municipalities responsibilities and contribute to an increased experience of mastering ones life, may be systematic health-promoting and preventive home visits in the municipalities (HFHB) (Helse –og omsorgsdepartementet, 2016). My intentions with this survey was to increase awareness on how the elderly home residents experience the health-promoting home visits, through their own stories. Method A qualitative study with a descriptive and exploratory design based on individual qualitative interviews. The sample consisted of a total of 7 elderly people aged 78-88 years. 2 single women, 1 single man and two married couples. Everyone included in the study has had a health-promoting home visit within the last 2 years. The interviews were analyzed in light of Granheim and Lundemann, 2014's understanding of content analysis.

The present study addresses one of the limitations of the JD-R model, namely, that analyses of the outcomes of the motivational process have largely focused on organizational outcomes and have neglected to investigate the associations between job resources, work engagement and health-related outcomes. Specifically, the aim of this paper is to show that health-related indicators may be outcomes of the motivational process in the job demands-resources (JD-R) model. We achieve this through a two-wave panel study with a two-year time lag. The results provide longitudinal evidence that two well-established job resources (i.e., social support and feedback) predicted work engagement, that work engagement was negatively related to sick leave and that this relation was mediated by subjective health. By showing that health-related indicators could also be outcomes of the motivational process in the JD-R model, we have strengthened the model.

Akutt hjerteinfarkt, hvorav STEMI er den farligste formen, er den hyppigst forekommende alvorlige sykdommen i Norge. I oppgaven har jeg tatt for meg behandling av STEMI i akuttsituasjonen med trombolyse og perkutan koronar intervensjon (PCI). Jeg har sett på ulikheter i håndtering og utkomme innad i Norge og sammenlignet med andre nordiske land som har lignende geografiske og demografiske forhold. Tema som tidsforsinkelse og mortalitet står sentralt i oppgaven. Innledningsvis har jeg brukt de nyeste europeiske retningslinjene for å beskrive anbefalt håndtering av STEMI. Jeg har anvendt nasjonale medisinske kvalitetsregistre for å skissere håndtering av tilstanden i Norge. Videre har jeg etter systematisk litteratursøk inkludert artikler fra Sverige og Finland, for så å sammenligne resultater fra disse med behandling og utkomme i Norge. Litteratursøket ble komplementert av nyeste årsrapport fra svensk STEMI-register. Andre relevante forskningsartikler ble inkludert blant annet for perspektiv på håndtering av tilstanden globalt. I Norge baseres STEMI-behandling på sentraliserte PCI-sentre og prehospital trombolyse i de tilfeller hvor det er lang transporttid til PCI-sentre. Reperfusjonsbehandling med trombolyse og PCI varier mellom de ulike regionale helseforetakene i Norge. Noe av grunnen er geografiske utfordringer med lange avstander til PCI-sentre. Det er stort forbedringspotensial når det gjelder tidsforsinkelser til behandling med prehospital trombolyse i alle regioner. Vi ser også muligheter for forbedring når det gjelder tidsforsinkelser til primær PCI (pPCI), og flere pasienter burde heller fått prehospital trombolyse ifølge retningslinjer. Det er store forskjeller i bruk av reperfusjonsstrategier og tidsforsinkelse til behandling mellom Norge, Sverige og Finland. Sverige bruker betydelig mer pPCI enn trombolyse sammenlignet med Norge og har i mye mindre grad tidsforsinkelse til denne behandlingsformen. 30 dagers overlevelse etter STEMI er tilnærmet lik landene imellom og varierer lite mellom de regionale helseforetakene i Norge. Finland har betydelig større andel PCI-sentre per innbygger enn Norge. Finske studier viser lengre tid til pPCI og kortere tid til trombolyse sammenlignet med Norge, men disse studiene er eldre enn norske registerdata. Felles for alle landene er stagnering i positiv utvikling når det gjelder tidsforsinkelser til reperfusjonsbehandling og overlevelse. Selv om manglende reduksjon av tidsforsinkelser kan være en bidragende faktor, er det viktig å ta endringer i pasientkarakteristikker i betraktning når en tolker data vedrørende mortalitet ved STEMI.

Decisions on uptake of medicines and medical devices on health insurance schemes are increasingly based ona health technology assessment (HTA) process. In Norway, the process has included reimbursement of outpatientmedicines for two decades. During the past years, in-patient medicines, medical devices and morerecently vaccines are all included in the HTA system. In the present article, we outline the Norwegian HTAsystem including its central components and partners. HTA as a scientific approach puts evidence on efficacy,safety and value of interventions into a broader perspective, explicitly considering relevant factors, among theselegal, ethical and organisational aspects of the intervention. Although several combinations of aspects arepossible, the most common is an assessment of the relative effectiveness and cost-effectiveness of theintervention. Randomised controlled trials have long been considered the mainstay for assessment of clinicaleffectiveness pre-launch, while registry data have been used to inform safety post-lunch, by pharmacovigilance.Recently, we have seen a move towards more use of “real world evidence”, i.e. data from non-RCT sources,mainly from registries. A model-based approach is often used to assess cost-effectiveness, in this context,different types of evidence from different sources are often synthesized. In this paper we describe the centralcomponents of HTA with special emphasis on different observational data sources, such as the unique Norwegianhealth registries. We finally speculate on future directions for use of observational data in HTA, both in aglobal and Norwegian setting.

Bakgrunn Det er kjente sosiale ulikheter i helse i Norge, og myndighetene introduserte i 2006 helseforskjellsstrategien, med mål om å utjevne disse helseulikhetene. Ett av hovedpunktene i strategien er å redusere sosiale ulikheter i bruk av helsetjenester. Imidlertid viser norske studier at det fremdeles er ulik bruk av helsetjenester mellom grupper med forskjellig utdanning og inntekt. Denne oppgavens formål er å undersøke om det var sosioøkonomiske ulikheter i helsetjenestebruk i Tromsø ved å svare på problemstillingen «Er det sammenheng mellom utdanningsnivå og bruk av fastlege, legevakt og alternativ behandler hos personer 40 år og eldre i Tromsø?». Materiale og metode Vi har utført en tverrsnittstudie med datamateriale på 21083 deltakere 40 år og eldre fra Tromsø kommune. Datamaterialet var innhentet gjennom spørreskjema fra Tromsøundersøkelsen: Tromsø7 (2015-2016). Vi estimerte sammenheng mellom utdanning og helsetjenestebruk med multivariat logistisk regresjonsanalyse på henholdsvis 19416 deltakere for fastlegebruk, 18917 for legevaktbruk og 18849 for bruk av alternativ behandler. Vi justerte for egenvurdert helse, kjønn, alder i 10-års-intervaller og sivilstatus. Analysene ble gjort for begge kjønn samlet, og separat for kvinner og menn. Resultater Vi fant at 80.2% hadde brukt fastlege, 13.3% legevakt og 8.4% alternativ behandler i løpet av det foregående året. Lav utdanning var assosiert med signifikant høyere odds for bruk av fastlege. Det var ingen signifikant sammenheng mellom utdanning og bruk av legevakt. Lav utdanning var signifikant assosiert med høyere odds for bruk av alternativ behandler hos menn, men ikke kvinner. Menn hadde lavere odds for bruk av fastlege (OR 0.53, p

Background: Traditionally, health intervention evaluations provide long-term evidence of efficacy and safety via validated protocols, following a positivist paradigm, or approach, to research. However, modern mobile health (mHealth) technologies develop too quickly and outside of medical regulation, making it challenging for health research to keep pace. Objective: This thesis explored and tested how research can incorporate mHealth approaches and resources to evaluate mHealth interventions comprehensively, which follows the pragmatism paradigm. The works described herein were part of a larger project that designed, developed, and tested a data-sharing system between patients and their healthcare providers (HCPs) during diabetes consultations. Methods: The pragmatism paradigm underpins the mixed-methods, multi-phase design approach to exploring this overall objective. The following methods were performed using a sequential exploratory strategy. First, co-design workshops invited individuals with diabetes and HCPs to design an mHealth data-sharing system. Next, a scoping literature review identified research practices for evaluating mHealth interventions to-date. Then, app usage-logs, collected from a previous longitudinal study, were analyzed to explore how much additional information they could provide about patients’ self-management. Finally, a mixed-method study was designed to test the feasibility of combining both traditional and mHealth approaches and resources to evaluate an intervention. Results: Using the pragmatist paradigm as a scaffolding, these works provide evidence of how research can provide more comprehensive knowledge about mHealth interventions for diabetes care and self-management. Nine individuals with diabetes and six HCPs participated in the co-design workshops. Feedback included how a data-sharing system should work between patients and providers. The literature review identified how both traditional and mHealth-based approaches (n=15 methods, n=21 measures) were used together to evaluate mHealth interventions. Usage-log analysis revealed that changes in Glycosylated haemoglobin (HbA1c) differed between groups organized by usage patterns and duration of use of mHealth. The mixed-method study demonstrated how to collect comprehensive and complementary information when combining traditional and mHealth-centered approaches and resources. Conclusion: Traditional positivist approaches and resources are not adequate, on their own, to comprehensively understand the impact of mHealth interventions. The presented studies demonstrate that it is both feasible and prudent to combine traditional research with mHealth approaches, such as analyzing usage-logs, arranging co-design workshops, and other patient-centered methods in a pragmatist approach to produce comprehensive evidence of mHealth’s impacts on both patients and HCPs.

Introduction: This article addresses the pro­vision of rehabilitation services for torture victims with a refugee background in Norway. It engages the topic from the outset of relevant rehabilitation rights and duties, presenting the organisation of rehabilitation services within the Norwegian health care system, and ex­ploring the challenges and opportunities pro­fessionals see and experience as they seek to provide adequate treatment and rehabilitation for torture victims. Methods and material: Qualitative inter­views with 46 experts and practitioners that contribute to or otherwise focus on treat­ment and rehabilitation for torture victims in Norway, conducted between March and August 2019, and an email-based educational programme survey. Results and discussion: Re­habilitation services for torture victims suffer from the absence of a systematic approach to identification and documentation of torture injuries. Moreover, the quality of rehabilitation services suffers from a lack of coordination and inclusion of actors that can contribute to com­prehensive rehabilitation processes. Students of relevant professions, such as medicine, psy­chology, nursing, law, and policing, are to a large extent not exposed to knowledge about torture injuries and rehabilitation for torture victims during their professional studies. Conclusion: Rehabilitation services for torture victims in Norway are fragmented, and the resulting practice is highly person depen­dent. Three recommendations are proposed in order to ensure minimum standards in reha­bilitation services for this group: 1) develop­ing and implementing a national plan of action on torture rehabilitation; 2) knowledge and capacity-building within relevant educational programmes, the national health services and other relevant public sector services; and 3) strengthening and institutionalising interdisci­plinary communities of practice with special­ised expertise on the topic at all relevant levels.

In the context of current and expected demographic changes, the issues of which services the welfare state should offer and, ultimately, the very function of the welfare state are currently debated in Norway. The political discourse on health and care services for older adults has morphed into an accepted reality in which the system must be altered, prompting policy makers and stakeholders to find new and novel solutions to problems associated with population ageing. In this paper, we discuss one such proposed solution: the transformation of health and care services for the older adult population through the increased involvement of volunteers. We ask how volunteer efforts are articulated and delineated through official accounts and discuss the implications of such an articulation and delineation. We seek answers to these questions through a critical discourse analysis of recent governmental white papers. We investigate, in other words, volunteer efforts as a political instrument. We argue that the official representation of how efforts in health and care services should be re-aligned take the form of a distinct discourse of ‘voluntarism’. Within this ‘voluntarism’, volunteer efforts have been altered from a third sector comprising charity and non-profit organisations that contribute within or as a supplement to the largely public-run welfare system to a limitless and extensive concept that is blurring the boundaries to informal care.

I dette kapittelet ønsker vi å belyse hvordan systematisk refleksjon over praksiserfaringer bidrar til viktig kunnskapsdannelse i jordmorstudiet. Vi har utviklet reflekterende team (RT) som en undervisningsform der studentens praksiserfaringer danner grunnlag for personlig og profesjonell kunnskapsutvikling. Bevissthet om og trening i kommunikasjon og veiledning er sentrale tema i arbeidet. For å lykkes med dette er det vesentlig at studenten med egne ord får fortelle frem og dele det vesentlige i erfaringen, og undersøke hvordan hennes forståelse former hennes yrkespraksis. Studentenes refleksjonslogger etter hver arbeidsøkt er analysert med tanke på å forstå hvilken kompetanse RT som undervisningsform kan bidra til.

Tema for denne oppgaven er krysspress og rollekonflikt. I oppgaven undersøkes disse fenomenene for apotekerne som jobber som daglige ledere i apotek. Videre er det interessant å finne ut om det finnes en rollekonflikt mellom krav fra førstelinjearbeidere og ledelsen, som påvirker apotekernes arbeidssituasjon. For å undersøke dette ble følgende problemstilling formulert: «Fører rollekonflikt til krysspress hos apotekere i Norge?». For å nyansere problemstillingen er den delt inn i fire underordnende forskningsspørsmål: 1. Opplever apotekere i norske apotek at de har flere roller? 2. Opplever apotekere i norske apotek at det er en konflikt mellom de ulike rollene han/hun har, og er det noen rollesammensetninger som er mer konfliktfylte enn andre? 3. Opplever apotekere i norske apotek at noen rollekonflikter fører til større opplevd krysspress enn andre? 4. Har alder, kjønn, erfaring som farmasøyt, ansiennitet som apoteker, avstand til nærmeste konkurrent eller kjedetilhørighet noe å si for opplevd rollekonflikt og krysspress? Vi valgte kvantitativ metode og gjennomførte en spørreundersøkelse. For å belyse vår problemstilling målte vi begrepene krysspress og rollekonflikt. Dette er abstrakte begrep som må gjøres målbare, eller operasjonaliseres. Spørreundersøkelsen besto av 20 spørsmål som målte demografiske verdier, roller, rollekonflikter og krysspress. Resultatene av undersøkelsen var firedelt etter forskningsspørsmål. 1. Apotekere har flere roller på lik linje med ledere og mellomledere i andre bransjer. 2. Det ser ut til at de som har deltatt i vår undersøkelse har funnet en balansegang mellom rollene. Generelle rollekonflikter som mellomledere opplever (Belasen & Belasen, 2016), er også mest krevende for apotekerne. 3. Personalansvarlig – økonomiansvarlig er den rollesammensetningen flest apotekere synes gir krysspress. Rollekonflikter som er mer knyttet til stillingen som mellomleder har størst innvirkning på opplevd krysspress. 4. Demografiske verdier gav lite eller ingen signifikante korrelasjoner med spørsmålene knyttet til rollekonflikt og krysspress.

Kommunal barneverntjeneste sees på å være et av Norges mest kompliserte arbeidsfelt. Den typiske arbeidshverdagen til saksbehandlerne er preget av å forvalte krevende saker, samt at de er tett på vold, overgrep og omsorgssvikt mot barn. Det kreves stor indre motivasjon og gode mestringsstrategier for å holde ut over tid som saksbehandler i kommunalt barnevern. Problemstilling i denne kvalitative studien er følgende: «Hvordan kan indre motivasjon fremme kontinuitet blant saksbehandlere i kommunalt barnevern» Hensikten med undersøkelsen er å få informasjon om hvordan erfarne saksbehandlere i kommunalt barnevern opprettholder sin motivasjon og hva de selv mener er av betydning for at de blir i jobben som saksbehandler. Metoden jeg benyttet for å belyse problemstillingen var av kvalitativ tilnærming med dybde intervjuer. Utvalget besto av seks informanter som alle er ansatt som saksbehandlere i kommunal barneverntjeneste, med minimum fem års ansiennitet i tjenesten. Funnene er hovedsakelig drøftet i lys av Deci og Rayans (1985) Self- determination theory tre psykologiske behov; Autonomi, kunnskap og tilhørighet og teorien om anerkjennelse. Funn fra undersøkelsen viste at saksbehandlernes indre motivasjon ble forsterket gjennom tilførelsen av selvbestemmelse/autonomi, kunnskap, tilhørighet og anerkjennelse. Deres personlige verdier i forhold til å hjelpe, gi omsorg og bidra ovenfor andre mennesker ble forsterket av deres indre motivasjon. Motivasjonen syntes å bli stimulert og opprettholdt gjennom blant annet kollegastøtte, autonomi, en opplevelse av at barnevernfaget er spennende og at faget oppleves som utviklende. Funnene viser at deres personlige egnethet til å ivareta seg selv og ta ansvar for egen opplæring som nyansatt, har stor betydning for at de fortsatt er i jobben. Samtidig er det en jobb mange slutter i før to år er gått. Studien beskriver viktigheten av at barnevernsansatte får anledning til å samarbeide med sine kollegaer, i saker der kollegastøtte er viktig. Videre kan studien vise at personlig og faglig utvikling er viktig for utvikling av indre motivasjon, og for å fremme kontinuiteten blant saksbehandlere. Konklusjonen viser at oppgavens informanter blir indre motivert av selve jobben i barnevernet. Samtidig setter de organisatoriske forholdene begrensninger for saksbehandlernes opplevelse av å få gjort en tilfredsstillende, grundig og god barnevernfaglig jobb. The Child Welfare Service is considered to be one of Norway's most complicated fields to work in. A typical day at work for the child welfare worker in the municipality Child Welfare is characterized by managing demanding cases, as well as witnessing violence, abuse and neglect of children. Great internal motivation and good coping strategies are required to endure time as a case manager in the Child Welfare System in the municipality. Issue: Issues in this qualitative study is the following: "How can inner motivation promote continuity among employees in the Child Welfare services?” Purpose: The purpose of the survey is to obtain information about how experienced employees in the Child Welfare community maintain their motivation and what they think is important for themselves to stay in the job as case manager. Method: The method used to elucidate the problem was of a qualitative approach with partially semi-structured, individual interviews. The committee consisted of six informants who are employed as case workers in municipal Child Welfare Service with a minimum of five years of seniority in the service. The findings are mainly discussed in light of Deci and Rayan's (1985) self-determination theory's three psychological needs: Autonomy, knowledge and belonging and the theory of recognition. Findings: Findings from the study showed that the caseworkers' inner motivation was enhanced by the addition of self-determination / autonomy, knowledge, belonging and recognition. And their personal values when it comes to helping, caring and contributing to other people. This seems to be stimulated and maintained through, among other things, collegial support, autonomy and the fact that the child welfare profession itself is exciting and experienced as developing. The findings show that their personal suitability to example; look after themselves and take responsibility for their own training as a new employee, is of great importance for them to still stay in their job. A job that many quit before two years has passed. The study also shows the importance of giving the employees the opportunity to collaborate with their colleagues in cases where collegial support is important in a demanding day at work. Furthermore, personal and professional development is important for developing inner motivation and for promoting continuity among employees in the Child Welfare system. Conclusion: Conclusions shows that the employees are intrinsically motivated by the job itself in the Child Welfare, but the organizational conditions impose restrictions on the employees to feel that they get to do a satisfactory, thorough and a good, professional job.

Background: At the beginning of the 2000s, Norwegian research in nursing and allied health disciplines was described as weak. Since 2007, the Northern Norway Regional Health Authority has had a strategic focus on enhancing health research. Objective: The objective of this project was to evaluate whether the Northern Norway Regional Health Authority’s research investment has given results. We have examined research activity, the allocation of research funding, research outputs and facilitating factors for research to be conducted by health researchers (excluding doctors and dentists) in the health trusts. Method: The survey took place in four health trusts under the Northern Norway Regional Health Authority. In the survey, we used a multi-method approach and a variety of data sources. Quantitative mapping based on research administrative data and systematic searches for published scientific output registered in journal databases were used together with data from a survey conducted among health researchers and research fellows in 2015. Results: In the period 2008–2015, there was an increase in the number of research fellows, researchers and published scientific output in the health trusts. Competence enhancement has been greatest in nursing and physiotherapy. Researchers and research fellows have contributed to multi-disciplinary research, using a broad range of methodological approaches with a preponderance of qualitative methods. On average, 29 per cent of the articles published in the period were published in level 2 journals. The Northern Norway Regional Health Authority has been the main funding source for the research. The respondents reported time pressure, lack of funding, research culture and adaptation for research as obstacles to conducting research. Conclusion: There has been a positive development in and strengthening of health research and research-based competence in the Northern Norway Regional Health Authority during the relevant period of time. The results indicate that strategic investment in health research has had a positive effect, and that a similar focus is also recommended for other health authorities.

Source at https://www.tannlegetidende.no/i/2020/9/m-1912. The original research paper that is discussed is available in Munin at https://hdl.handle.net/10037/18994. Tannhelsetjenestens kompetansesenter Øst (TkØ) har gjennomført en spørreundersøkelse om tannhelsepersonells erfaringer under nedstenging i perioden 13. mars–17. april 2020. Første del av studien er nå publisert i International Journal of Environmental Research and Public Health og er den første norske studien som omhandler håndtering av covid-19-pandemien i tannhelsetjenesten.

Background: In Norway, due to demographic challenges with an ageing population and lower fertility rates, current government policies have encouraged municipalities and volunteers to collaborate. Moreover, present policies recommend an increase in volunteer activities within care services. Co-production is advocated as a functional and innovative method of activating resources when citizens and public employees interact in the care sector. Method: This study has scrutinised ongoing volunteer activities in nursing homes and home care facilities by utilising the results from a survey targeting employees in public care services. Aim: The aim has been to identify the extent to which long-term care units (LTC units) in Norwegian municipalities and voluntary organisations collaborate in the coordination of volunteer activities at the local level by answering the following research questions: when LTC units and voluntary organisations collaborate in coordinating voluntary activities within caring services: are they sharing tasks, dividing the tasks between them or both? Findings: The results show that LTC units often coordinate volunteer activities that correspond to statutory public care services. Additionally, LTC units also contribute considerably in coordinating other volunteer activities, either alone or to a small extent in collaboration with voluntary organisations. This limited task sharing when coordinating volunteer activities in municipal care services can be seen as a suboptimal way of using the resources. Hence, a large part of this paper concerns a discussion of the theory of co-production in public care services, drawing on the findings of the survey.

“First, do no harm” is a fundamental element of health care and considered indistinguishable from the delivery of quality in health care. While cancer care has become more effective, it has also become more complex consequently increasing the risk for harm. We have assessed the extent and severity of treatment related adverse events in hospitalised cancer patients and elucidated how adverse events can be used as a measure of quality and safety in cancer care. All three studies are retrospective cohort studies, using the Global Trigger Tool to identify adverse events in hospitalised cancer patients. We find that hospitalised cancer patients more often than other patients experience adverse events, but this is due to older age and longer length of stay rather than the cancer itself. Especially medication related harm and healthcare associated infections are safety hazards of concern to cancer patients. Patients dying in hospitals differ in several ways from a general hospitalised population and experience seven times the rate of severe adverse events. For nearly one in three deceased cancer patients an adverse event contributes to death. Despite strong recommendations limiting use of aggressive anticancer treatments for cancer patients near the end of life, we found that one third of deceased hospitalised cancer patients received some kind of anticancer treatment during the last 30 days of their lives. Anticancer treatment given during the last 30 days of life is associated with a significantly increased rate of adverse events with twice the odds of having an adverse event contributing to death. A thorough understanding of specific adverse events in cancer care is clearly warranted and can enhance of quality and patient safety in cancer care.

Masteroppgaven tar utgangspunkt i Helseforetaksloven (2002). Lov om helseforetak organiserte sykehusene i foretak, som egne rettssubjekter utenfor den statlige forvaltningen. Samtidig ble lederskapet og ansvaret for spesialisthelsetjenesten fullt og helt lagt på staten. Problemstillingen tar for seg de kriterier (redskap) for ledelse og effektivitet som ligger nedfelt i lov om helseforetak. Problembestillingen belyses gjennom et instrumentelt perspektiv og et (historisk) institusjonelt perspektiv. Det rasjonelle, instrumentelle perspektivet preges av NPM inspirerte ledelseskriterier og ledelsesidealer. Her fremstår det offentlige rigid, lite effektivt og utdatert. Det private markedet er idealet det styres etter, med vekt på mål- og resultatstyring, rammebudsjettering og stykkprisfinansiering. Helseforetakene skal tilpasses markedsmekanismer gjennom sterkere brukerorientering, fritt sykehusvalg, innsatsstyrt finansiering og rapportering på resultatindikatorer. Valgfrihet og konkurranse skal gi bedre kvalitet og ressursutnyttelse. (Byrkjeflot og Grønlie, 2005; Christensen et. al., 2016; Hippe og Trygstad, 2012; Nerskogen 2013; Opedal og Stigen, 2008; Ot.prp. nr. 66 (2000-2001); Styringsdokument, 2002-2020). Andre del av problemstillingen ser på utviklingen av styringsredskapene, da sett i lys av overordnet eller detaljert grad av statlig styring. Et instrumentelt perspektiv på den NPM-inspirerte reformen indikerer at Staten skal styre gjennom prinsipielle, overordnede retningslinjer. Sykehusene skulle få økt autonomi i daglig virke, gjennom å sørge for sykehustjenester til befolkningen i sin region. (Hippe og Trygstad, 2012; Opedal og Rometvedt, 2005; Ot.prp. nr. 66 (2000-2001)). Det historiske, institusjonelle perspektivet vil derimot tyde på, foretaksorganisering til tross, økt statlig kontroll og styringen av spesialisthelsetjenesten. Ved at eierskap, myndighetsrolle og finansieringsansvar nå plassers på staten alene, gis staten stor makt til å utøve kontroll og sikre at helsetjenesten også i fremtiden utvikles i samsvar med overordnede helsepolitiske mål. (Bang, 2015; Byrkjeflot og Grønlie, 2005; Christensen et al., 2016; Christensen et. al., 2017; Christensen & Lægreid, 2010; Jabobsen & Thorsvik, 2013; Opedal og Rommetvedt, 2005).

Introduksjon: Nasjonale og europeiske retningslinjer anbefaler i dag at et hvert sykehus som har akutt traumefunksjon har en massiv transfusjonsprotokoll (MTP). I denne studien undersøkes utbredelse og innhold av massive transfusjonsprotokoller ved norske sykehus med akutt traumefunksjon og deres respektive blodbankers beredskap. Metode: To separate spørreundersøkelser på henholdsvis 26 og 15 spørsmål ble sendt til traumekoordinatorer og blodansvarlige ved alle norske sykehus med akutt traumefunksjon og tilhørende blodbankene. Dataene ble deskriptivt analysert ved hjelp av regnearket Excel. Resultater: 35/38 traumekoordinatorer og 36/38 blodbankansvarlige besvarte hele eller deler av spørreundersøkelsene. Ved 4/35 sykehus forelå ingen MTP. Åtte (29%) av protokollene var sist revidert i 2017 eller tidligere. Klinisk mistanke om stor blødning (93%) og avvikende hemodynamiske parametere (80%) var hyppigste aktiveringskriterier. Monitorering utover avvikende hemodynamiske parametere som aktiveringskriterium, var i liten grad anført i MTP. 10/31(34%) protokoller manglet føringer for monitorering av temperatur. I 11/29 (38%) protokoller forelå ingen føringer for hyppighet av laboratoriske prøver. Ved 12 lokalisasjoner mangler trombocyttberedskap til vanlig. Fire sykehus transfunderer fullblod, tre av disse har også muligheten til komponentbasert transfusjon. 33/37 (89%) sykehus og blodbanker anga i sin MTP transfusjon av erytrocytter og plasma i forhold 1:1. Tranexamsyre (22/26, 85%) og fibrinogen (19/26, 73%) var hyppigst anførte medikamentell støttebehandling i MTP. Kun 23/35 (66%) blodbanker hadde anbefalte mengder erytrocytter av typen O Rh(D) positiv jamfør nasjonal traumeplan. Konklusjon: Fire sykehus mangler MTP. Innholdet i MTP varier i form av monitorering av vitale parametere, i tillegg til føringer for laboratorieundersøkelser og medikamentell støttebehandling. Trombocytter er til vanlig ikke tilgjengelig ved 12 blodbanker. Blodbankberedskapen i øyeblikkundersøkelsen tilfredsstiller i liten grad anbefalingene fra Nasjonal Kompetansetjeneste for Traumatologi. Økt fokus på massive blødninger og nye revisjoner av MTP bør vurderes ved flere lokalisasjoner. Nye studier hvor pasientdata integreres vedrørende prehospital og intrahospital transfusjonsbehandling vil gi en bedre kartlegging av MTP i Norge.

Background There is a gap in the literature regarding what takes place between the announcement of a regulatory intervention, such as an external inspection of a health care organisation, and the inspecting body’s site visit. This study aimed to explore inspecting bodies’ expectations of how inspected organisations should prepare before an external inspection and to elucidate how inspected health care organisations prepare before site visits. Methods This qualitative study was based on data from 17 group interviews with a total of 75 participants representing inspection teams, organisation leaders and clinicians in inspected health care organisations. The data were analysed using a qualitative content analysis method. Results We identified two approaches to how the inspection teams expected that the inspected organisations should prepare before site visits. In the first approach the inspection teams did not expect any improvement activities to be initiated during this period and focused on identifying inadequacies that the inspected organisations should subsequently improve. In the second approach the inspection teams expected organisations to review their own practices and begin improvement activities if necessary. The inspected organisations responded in different ways to an upcoming site visit, and the organisations’ leaders were important in determining which activities would be initiated. Organisations in which leaders involved clinicians in assessing care delivery tended to initiate action to improve and expected inspection teams to assess their ongoing improvement work and provide guidance on further improvements. Leaders who did not involve clinicians in assessing the quality of care tended to perceive the current quality of care as adequate on the basis of reviewing written guidelines. They did not initiate action to improve care delivery apart from updating written guidelines describing how care should be delivered, and they expected the inspection team to confirm that their current practices were in line with the guidelines and external standards. Conclusions To promote anticipatory effects in inspected organisations, inspecting bodies should stress the importance of assessing clinical practice and involving frontline clinical staff and leaders in the assessment and in improvement work before the site visit.

ObjectivesOur primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel’s safety culture perceptions.SettingA longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital.ParticipantsWe invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017.Primary and secondary outcome measuresPrimary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded.ResultsSurvey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ‘Hospital managers’ support to patient safety’ from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07–0.21).ConclusionThe National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.

Ved å intervjue 2 vernepleiere og 2 sykepleiere som ansatt i spesialisthelsetjenesten har jeg fått større innsikt i hvilket behov de har for å forebygge sekundærtrauamtisering i arbeid med traumatiserte pasienter. Helsepersonell som arbeider med andres grusomme historier med vold, tap og sorg kan selv oppleve de samme symptomene som pasienten selv. Prosjektet hadde fokus på hvilke faktorer og strategier deltakerne hadde for å forebygge sekundærtraumatisering. Tre kategorier utpekte seg som betydningsfulle. 1. Det psykososiale arbeidsmiljø: her ble det viktig med støttende kolleger, samt mulighet for veiledning, debrifing og refleksjonsmøter, jevnlig. 2. Strategier for selvivaretakelse: i arbeidstida og på fritida. Her ble både bevisste og ubevisste strategier delt. 3. Den siste faktoren var en mestringsstrategi som gikk ut på å se det friske hos pasienten, og fokusere på de områdene som pasienten mestrer. Dette ga mot for helsepersonell til å fortsette i jobben med andres detaljerte traumeopplevelser.

Background Several publications have addressed the need for a systematic integration of oncological care focused on the tumor and palliative care (PC) focused on the patient with cancer. The exponential increase in anticancer treatments and the high number of patients living longer with advanced disease have accentuated this. Internationally, there is now a persuasive argument that introducing PC early during anticancer treatment in patients with advanced disease has beneficial effects on symptoms, psychological distress, and survival. Methods This is a national cluster-randomized trial (C-RCT) in 12 Norwegian hospitals. The trial investigates effects of early, systematic integration of oncology and specialized PC in patients with advanced cancer in six intervention hospitals compared with conventional care in six. Hospitals are stratified on the size of local catchment areas before randomization. In the intervention hospitals, a three-part complex intervention will be implemented. The backbone of the intervention is the development and implementation of patient-centered care pathways that contain early, compulsory referral to PC and regular and systematic registrations of symptoms. An educational program must be completed before patient inclusion. A total of 680 patients with advanced cancer and one caregiver per patient are included when patients come for start of last line of chemotherapy, defined according to national treatment guidelines. Data registration, clinical variables, and patient- and caregiver-reported outcomes take place every 2 months for 1 year or until death. The primary outcome is use of chemotherapy in the last 3 months of life by comparing the proportion of patients who receive this in the intervention and control groups. Primary outcome is use of chemotherapy in the last 3 months before death, i.e. number of patients. Secondary outcomes are initiation, discontinuation and number of cycles, last 3 months of life, administration of other medical interventions in the last month of life, symptom burden, quality of life (QoL), satisfaction with information and follow-up, and caregiver health, QoL, and satisfaction with care. Discussion Results from this C-RCT will be used to raise the awareness about the positive outcomes of early provision of specialized palliative care using pathways for patients with advanced cancer receiving medical anticancer treatment. The long-term clinical objective is to integrate these patient-centered pathways in Norwegian cancer care. The specific focus on the patient and family and the organization of a predictable care trajectory is consistent with current Norwegian strategies for cancer care. Trial registration ClinicalTrials.gov, NCT03088202. Registered on 23 March 2017.

The importance of e-health to citizens, patients, health providers, governments, and other stakeholders is rapidly increasing. E-health services have a range of advantages. For instance, e-health may improve access to services, reduce costs, and improve self-management. E-health may allow previously underserved populations to gain access to services. Services utilizing apps, social media, or online video are rapidly gaining ground in most countries. In this special issue, we present a range of up-to-date studies from around the world, providing important insights into central topics relating to e-health services.

Background Electronic health (eHealth) services may help people obtain information and manage their health, and they are gaining attention as technology improves, and as traditional health services are placed under increasing strain. We present findings from the first representative, large-scale, population-based study of eHealth use in Norway. Objective The objectives of this study were to examine the use of eHealth in a population above 40 years of age, the predictors of eHealth use, and the predictors of taking action following the use of these eHealth services. Methods Data were collected through a questionnaire given to participants in the seventh survey of the Tromsø Study (Tromsø 7). The study involved a representative sample of the Norwegian population aged above 40 years old. A subset of the more extensive questionnaire was explicitly related to eHealth use. Data were analyzed using logistic regression analyses. Results Approximately half (52.7%; 9752/18,497) of the respondents had used some form of eHealth services during the last year. About 58% (5624/9698) of the participants who had responded to a question about taking some type of action based on information gained from using eHealth services had done so. The variables of being a woman (OR 1.58; 95% CI 1.47-1.68), of younger age (40-49 year age group: OR 4.28, 95% CI 3.63-5.04), with a higher education (tertiary/long: OR 3.77, 95% CI 3.40-4.19), and a higher income (>1 million kr [US $100,000]: OR 2.19, 95% CI 1.77-2.70) all positively predicted the use of eHealth services. Not living with a spouse (OR 1.14, 95% CI 1.04-1.25), having seen a general practitioner (GP) in the last year (OR 1.66, 95% CI 1.53-1.80), and having had some disease (such as heart disease, cancer, asthma, etc; OR 1.29, 95% CI 1.18-1.41) also positively predicted eHealth use. Self-rated health status did not significantly influence eHealth use. Taking some action following eHealth use was predicted with the variables of being a woman (OR 1.16, 95% CI 1.07-1.27), being younger (40-49 year age group: OR 1.72, 95% CI 1.34-2.22), having a higher education (tertiary/long: OR 1.65, 95% CI 1.42-1.92), having seen a GP in the last year (OR 1.58, 95% CI 1.41-1.77), and having ever had a disease (such as heart disease, cancer or asthma; OR 1.26, 95% CI 1.14-1.39). Conclusions eHealth appears to be an essential supplement to traditional health services for those aged above 40 years old, and especially so for the more resourceful. Being a woman, being younger, having higher education, having had a disease, and having seen a GP in the last year all positively predicted using the internet to get health information and taking some action based on this information.

Community health-care services for older, home-dwelling persons with dementia tend to be underutilised. Family care-givers provide substantial care, and they often arrange for and co-ordinate health-care services on behalf of persons with dementia. The aim of this study was to examine family care-givers’ knowledge of unused services and their self-reported reasons for non-use of such services. We gathered cross-sectional survey data from 430 family care-givers of older persons with dementia in Northern Norway. Multinomial logistic regression analysis was used to identify predictors of family care-givers’ knowledge of unused services. An open-ended question regarding reasons for non-use of services was analysed by thematic text analysis. Characteristics of family care-givers (e.g.education level) and factors related to the care-giving circumstances (e.g.negative impact of care-giving) predicted family care-givers’ knowledge of unused services. Reasons for non-use of services were multifaceted and complex, and were related to attributes of the person with dementia and/or the family care-giver (e.g.reluctance to use services) and/or the health-care services (e.g.low quality). Although services were unused, several family care-givers indicated substantial needs for the services. Strategies aimed at addressing the non-use of services should emphasise individuals’ and families’ needs and the adaptation of information about available services and their benefits for both care recipients and family care-givers. A relationship-centred care approach is thus recommended in dementia care.

Background - Family planning counseling is critical for women to make informed reproductive and sexual health decisions. Despite Ethiopia's success in expanding access to family planning services, information on the quality of family planning counseling is limited. The objectives of this study were to assess whether the quality of counseling from the female client´s perspective has changed over time (2014 to 2018) and to investigate determinants associated with the quality of counseling to provide a more nuanced understanding of disparities in sexual and reproductive health outcomes in Ethiopia. Methods - Data were obtained from five rounds of the Ethiopian Performance Monitoring and Accountability 2020 female survey questionnaire. Quality of counseling was categorized into four levels based on the responses of the questions that compose the Method Information Index, a core Family Planning 2020 indicator that serves as a proxy for quality of counseling and reflects the extent to which women are informed about side effects and alternate methods. The proportion of female contraceptive users that received good counseling were examined over time by each region, demographic characteristics, and contraception method type and source. Ordinal logistic regression was applied to the last survey round (2018) to investigate determinants associated with counseling quality. Results - The proportion of female contraception users that reported receiving information on all three questions did not significantly change over the period 2014 to 2018. Overall quality of counseling on family planning was low, with only 30% of women reporting receiving sufficient information during counseling. The likelihood of good quality counseling was the least among those who had no formal schooling when compared to those who had higher educational attainment (OR = 0.70, 95% CI: 0.50, 0.97). Women from the wealthiest quintile were 1.72 times more likely (95% CI: 1.10, 2.69) to receive good quality counseling when compared to women in the lower wealth quintile. Women from rural areas were 1.51 times more likely to have received good counseling when compared to those in urban areas (95% CI: 1.04, 2.18). Amhara residents were less likely to receive good counseling when compared to the SNNPR (OR: 0.51, 95% CI: 0.32, 0.81). Women who acquired their method from the private sector had worse counseling (OR: 0.31, 95% CI: 0.23, 0.41) when compared to the public sector. Those using short-acting methods were more at risk of receiving lesser quality counseling when compared to users of long-acting methods (OR: 0.58, 95% CI: 0.46, 0.72). Conclusion - The results of this analysis indicated that Ethiopia’s overall progress in modern contraceptive use has not been accompanied by a corresponding increase in the quality of family planning counseling. Improving the quality of contraception counseling for women across all demographics, including wealth quintiles and education, is a crucial strategy to support positive reproductive health outcomes with a rights-based focus. Based on the findings of this study, it is essential to emphasize the need to do proper counseling for all methods including short-acting methods especially for those working the private sector and some of the regions which have lower prevalence of good counseling. Further community-based participatory and qualitative research should focus on understanding the root causes and barriers to the delivery of high-quality counseling in Ethiopia.