Suchergebnisse

There is still a debate concerning the evidence base for community interventions. The randomised clinical trial design (RCT) is increasingly challenged as a gold standard for their evaluation. This thesis takes the Norsjö health programme in Västerbotten as the starting point for a discussion about the ethical platform of community interventions and for exploring the role of self-rated health. The specific objectives are: 1) to better understand barriers to community participation and to assess the role of ethical premises among decision-makers, 2) to explore how health related norms and attitudes interact with self-rated health and the risk factor outcome of an intervention and 3) to analyse the gender and socio-cultural interplay of self-rated health with biomedical risk factors for cardiovascular disease. The participation and views of different actors in the planning and implementation phases of the intervention were studied by contrasting information between official documents, interviews with decision makers and professionals and questionnaires to community members. The role of basic values in setting priorities and choosing intervention strategies utilised a questionnaire design with hypothetical scenarios sent to a representative sample of Swedish health care politicians. Qualitative research interviews were used to explore health related norms and attitudes. Health examination measurements and questionnaire data formed the basis for analysis of the development of self-rated health and risk factor load during a 10-year follow-up of the intervention. Access to a stroke registry enabled a case-referent approach for studying the interaction between bio-medical risk factors, socio-demographic factors and self-rated health. Data from the Västerbotten Intervention Programme (VIP) could be utilised for a cross-country comparison with a "sister project" in Otsego, U.S.A. The results point to both strengths and limitations of the efforts made to involve people in the intervention. The problem definition mainly remained with the professionals and participation as a goal in itself, strengthening local democracy was felt to be an exaggerated ambition. However, there was an overall agreement about the seriousness of the health problem, the need to intervene and about the implementation mode. Self-rated health and reported behavioural change were important indicators of participation and young men with bad health seemed to have been least involved. Among Swedish health care politicians there was an overall agreement to allocate resources for prevention directed towards communities when there are serious health problems. The majority preferred an intervention strategy that involved primary health care. The risk of harm by creating some degree of anxiety or stigma was for many considered an acceptable drawback of a successful intervention. The follow-up study revealed a positive risk factor reduction accompanied by a positive development of self-rated health, especially for men. Additional support for an intervention effect was given through a comparison with a reference area. The interaction pattern between risk reduction and self-rated health was more polarised for men than for women, with a corresponding pattern for the lower compared to the higher educated. These results could be linked to a transition in the health related norm system and to "ideal types" representing attitudinal sets towards the intervention. The case-referent analysis suggested an interaction effect between self-rated health and bio-medical risk factor load in predicting stroke that was greater for men than for women. The cross-country comparison revealed a stronger influence of education in the U.S.A. The lower educated, with a high risk load, had a greater risk of self-rated poor health than their Swedish counterparts. The thesis suggests that self-rated health is an unexplored indicator, potentially important for understanding the complexity of community interventions. Self-rated health may predict disease development as well as modify the impact of established risk factors.

Since the launch of a Zero Tolerance Policy in Indonesia, several policies to address domestic violence have been enacted. The obligation of local governments to establish service units for women survivors of domestic violence is one of them. Since domestic violence is a sensitive and complex issue in Indonesia it is important to understand how governmentally regulated services function in practice. This case study aimed to explore challenges faced by a local service agency in managing service provision for women survivors of domestic violence in rural Indonesia. Data from one focus group discussion (12 participants), four individual interviews, six short narratives, two days of participant observation, as well as archive reviews were collected. All data were analyzed using Grounded Theory Situational Analysis. The major challenge faced by the local agency was the low priority that was given them by the local authorities, mirrored also in low involvement by the assigned volunteers in the daily service. The study also identified a gap between the socio-cultural arena and the law & policy arena that needs to be bridged to avoid that the two arenas address domestic violence in a contradictory way. Budget allocation to support the sustainability of the daily routines of service agencies has to be given priority. There is also a need for careful considerations regarding the composition of personnel involved within daily management of service agencies addressing domestic violence. To bridge the gap between the legal systems and traditional cultural values, culturally adjusted alternative justice systems could be developed to increase women's access to legal support.

Since the launch of a Zero Tolerance Policy in Indonesia, several policies to address domestic violence have been enacted. The obligation of local governments to establish service units for women survivors of domestic violence is one of them. Since domestic violence is a sensitive and complex issue in Indonesia it is important to understand how governmentally regulated services function in practice. This case study aimed to explore challenges faced by a local service agency in managing service provision for women survivors of domestic violence in rural Indonesia. Data from one focus group discussion (12 participants), four individual interviews, six short narratives, two days of participant observation, as well as archive reviews were collected. All data were analyzed using Grounded Theory Situational Analysis. The major challenge faced by the local agency was the low priority that was given them by the local authorities, mirrored also in low involvement by the assigned volunteers in the daily service. The study also identified a gap between the socio-cultural arena and the law & policy arena that needs to be bridged to avoid that the two arenas address domestic violence in a contradictory way. Budget allocation to support the sustainability of the daily routines of service agencies has to be given priority. There is also a need for careful considerations regarding the composition of personnel involved within daily management of service agencies addressing domestic violence. To bridge the gap between the legal systems and traditional cultural values, culturally adjusted alternative justice systems could be developed to increase women's access to legal support. ; Originally included in thesis in submitted form.

The aim of this mixed-method study was to explore the trajectories of leaving home, and views and experiences among children and youth in the Kagera region in Tanzania, who have lived on the streets or been domestic workers. The main results showed that orphanhood and mistreatment were the main reasons for leaving home: few children lived with their parents before they left, and leaving home was a complex process over several years where three trajectories were identified. The children who had left home showed strong agency and competency but lived in vulnerable conditions, especially young children living on the streets.

BACKGROUND: Mass screening could identify those with unrecognized celiac disease (CD), but the experience of being detected through screening and living with screening-detected CD should be explored before considering this as acceptable intervention. For this study we invited screening-detected adolescents to describe their experience living with screening-detected CD five years after diagnosis with the aim to explore how their perceptions, practices, and beliefs evolved. METHODS: Adolescents who were diagnosed through a population-based CD screening were invited to write narratives after being diagnosed. Of 153 adolescents who were eventually diagnosed through the screening, 91 wrote narratives one year after diagnosis and 72 five years after diagnosis. A qualitative content analysis resulted in a theme and categories that describe the experience living with screening-detected CD five years after diagnosis. RESULTS: The overall theme - "Internalizing the threat of risk" - illustrates that being detected through screening and the internalized threat of future health complications have impacted how these adolescents felt about the diagnosis, coped with the gluten-free diet (GFD), and thought about CD screening. This theme is supported by four categories: maintaining an imposed disease identity describes how they continued to define their diagnosis in relation to the screening. They also expressed moving from forced food changes to adapted diet routines by describing habits, routines, coping strategies, and the financial burden of the GFD. They had enduring beliefs of being spared negative consequences, however, even after five years, some doubted they had CD and worried that being detected and eating a GFD might not be beneficial, i.e. "continuing to fear it is "all in vain". CONCLUSIONS: There was maintenance and evolution in the perceptions, practices, and beliefs of the adolescents after five years. Some have adjusted to the disease and adapted new habits and coping strategies to deal with the GFD, while others still doubt they have CD or that being detected was beneficial. The transition to adapting to the disease and GFD is ongoing, illustrating the importance of providing ongoing support for those with screening-detected CD as they adjust to this chronic disease and the GFD. ; Originally included in thesis in manuscript form.

Socioeconomic development initiatives (SDIs) have become a controversial issue. In giving skill trainings and credit supports, practitioners assume that SDI participation will enhance women's income/dignity. Some studies have indicated that SDIs reduce women's exposure to marital violence (MV), while others have shown that they increase spousal conflicts/MV. Our study explains how SDI participation may influence women's marital life. This explorative study adopted a grounded theory design. Data included 17 participating-women's interviews. It revealed that many women experienced further marital subordination, spousal conflicts, and MV. Yet women with strong motivation increased marital dignity/safety. Caring husbands facilitated this. If men can be involved in supporting women, impacts of SDIs will be substantial.

Faced with the problems of HIV/AIDS, people have to find ways to communicate around them. The aim of this paper is to mirror changes over time in the Kagera people's social cognition regarding HIV/AIDS, using their own language as a tracer of this process. Focus group discussions and personal and group interviews conducted during 1992 to 1995 in urban Bukoba, Kagera, constitute the basis for an analysis of metaphorical expressions in use since 1985. Pronounced uncertainty is later transformed into a deeper understanding of the pandemic and an increased disposition to cope with the situation. Knowledge about the socio-linguistic expressions mapped out in this article can be of help when developing guidelines on how to communicate about interventions.

This article describes a formative strategy for developing effective tractor safety messages aimed at small crop and livestock farmers in New York. This population accounts for the highest proportion of tractors lacking rollover protective structures (ROPS), which reduce the risk of overturn injury or death. To encourage ROPS installation on unprotected tractors, persuasive messages were developed to be used as part of a social marketing intervention. The message development process involved evaluating concepts in small group discussions (triads) with the target audience. Participants were asked to review and provide feedback on 15 concepts, select two favorites, and discuss influential message channels. Results indicate that messages should address existing concerns for family safety or a permanently disabling injury and should realistically depict the lives of participants. Messages featuring financial incentives must clearly state the cost to the farmer. Although the data from the pilot test of intervention components has not yet been analyzed, data from the program hotline indicates concept development messages and rebates generated a greater demand for ROPS than generic messages and rebates. In conclusion, by employing the target population in the message development process it was possible to increase the efficacy of ROPS social marketing messages.

This paper presents an initiative to revive the previous Somali-Swedish Research Cooperation, which started in 1981 and was cut short by the civil war in Somalia. A programme focusing on research capacity building in the health sector is currently underway through the work of an alliance of three partner groups: six new Somali universities, five Swedish universities, and Somali diaspora professionals. Somali ownership is key to the sustainability of the programme, as is close collaboration with Somali health ministries. The programme aims to develop a model for working collaboratively across regions and cultural barriers within fragile states, with the goal of creating hope and energy. It is based on the conviction that health research has a key role in rebuilding national health services and trusted institutions.