Resept for et sunnere Norge1 Et foucaultsk blikk på norsk helsepolitikk

AbstractIn this article I use Michael Foucaultââ¬â¢s discussions of the relations between power and knowledge to explore the Norwegian health policy. It is mainly the intensifying of what we can call the prophylactic or preventive strategy that will be debated. I will argue that knowledge is not ââ¬Âinnocentââ¬Â or ââ¬Âneutralââ¬Â, but instead is related to and supports ââ¬Âtechniquesââ¬Â that can be interpreted as mechanisms of power; which means techniques that affect our bodies, that influence our way of acting and that form our senses. The body is an object for installing and extracting knowledge. In this perspective, power is not only seen as a repressive force, but will primarily be considered as a productive force: The state has developed different health initiatives that produce more information and knowledge about the population, and everybody can use this knowledge as a resource in their own ââ¬Âworkââ¬Â for constructing an identity. And because citizens always behave disobediently, incomprehensibly and unpredictably they produce a need for more knowledge and new initiatives from the government.Key words: Power, Foucault, prophylactic, health policy, knowledge

Trenerløftet. Evaluering av Olympiatoppens trenerutviklingsprosjekt

«Trenerløftet» er et trenerutviklingstiltak i regi av Olympiatoppen. Målgruppen er unge trenere med ambisjoner om en trenerkarriere, som jobber med morgendagens toppidrettsutøvere. I denne evalueringsrapporten undersøker vi hvordan trenernes verdier, perspektiver og praksis endres som en følge av systematisk veiledning og oppfølging. I kapittel 1 gjør vi rede for hvordan vi har samlet inn data til denne rapporten. I kapittel 2 diskuterer vi trenerrollen. Olympiatoppens tre kompetanseområder for en topptrener – idrettsfaglig kompetanse, ledelses- og relasjonskompetanse og kompetanse til å lede seg selv – legges til grunn for Trenerløftet. Kvintessensen er at trenerne skal utvikle en egen trenerfilosofi, gjennom refleksjon over egen rolle og praksis, og ved å bruke utøverne til sin egen læring. Dette krever at trenerne har evne til å kommunisere med og involvere utøverne, som både er avgjørende for et godt lederskap og et godt trenerskap. I kapittel 3 undersøker vi den metodikken veilederne har brukt i sitt «arbeid» med trenerne. Sentralt i diskusjonen står hvordan veilederne bruker lytting, spesifikke spørreteknikker og rådgiving for å utvikle trenernes forståelse av seg selv og av trenerrollen. Vi spør hva er det skapende og omskapende element i denne trenerutviklingsmodellen? Vi fant at Trenerløftet innebærer et slags perspektivskifte – eller i hvert fall et fokusskifte – som gjør at treneren oppdager hvordan «kommunikasjon, relasjon og væremåte» er svært virksomme variabler i trenergjerningen. Dette gjør at mange situasjoner avleses og oppfattes på en ny måte og at man da tenker annerledes om valgene man gjør som trener. Målsetningen med kapittel 4 er å vise hvordan noen utvalgte trenere jobbet med konkrete tema for å utvikle sitt trenerskap. Trenerens innsirkling av et utviklingsområde er i seg selv bevisstgjørende, samtidig som utviklingsprosessen bidrar til at treneren oppdaget hvordan en brikke kjedes sammen med en rekke andre brikker i treningsarbeidet. Gjennom å oppdage alle disse direkte og indirekte påvirkningskjedene har treneren et bedre utgangspunkt for å ta kloke valg og for å legge enda bedre til rette for et mer hensiktsmessig utviklingsarbeid for utøverne. I kapittel 5 oppsummerer vi ved å trekke fram noen av de dominerende kjennetegnene ved dette trenerutviklingsprosjektet, samtidig som vi vil peke på noen mulige implikasjoner av de tiltakene som ble valgt for Trenerløftet. En ting er å få treneren til «oppdage» det hun gjør og tenker (trenerens perspektiv), og å forstå og fortolke det som skjer. En annen ting er å overskride de etablerte forestillinger og praksiser. Kanskje treneren trenger innspill fra aktører som kan bringe inn helt andre begreper og perspektiver på de mulighetene og utfordringene hun står i

‘You create your own luck, in a way’ About Norwegian footballers’ understanding of success, in a world where most fail

The article is based on interviews with twelve young footballers who turned pro with the Norwegian top-flight club Odd BK. After asking why they succeeded in making the transition from promising talent to established top-level footballer, we investigate how the players’ own explanations tally with the two predominant theories in research on talent development, namely deliberate practice and successful talent development environments. We shall see that the basic elements of these theories resemble the players’ own recipes for success and more or less specify how the players and the club can achieve progress. However, neither of these theories relates to the structural situation that the players find themselves in, namely the fact that most hard-working players are never offered a professional contract. The looming uncertainty provides fertile ground for the development of notions of luck and the intricate workings of chance

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high‐HDI countries (risk difference −9·4 (95 per cent c.i. −11·9 to −6·9) per cent; P < 0·001), but the relationship was reversed in low‐HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30‐day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low‐ and middle‐HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low‐HDI countries was half that in high‐HDI countries

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with $222 for low FiO2 leading to a −$6 (95% confidence interval [CI]: −$13 to −$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a −$11 (95$15 to −$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with $1257 for low FiO2 leading to a −$93 (95% CI: −$132 to −$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this

Use of Telemedicine for Post-discharge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review with Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardised assessment tools are needed. Summary background data: Surgical site infection is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. Methods: The primary outcome of this study was surgical site infection reported up to 30-days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analysed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30-days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs. 11.1%, P&lt;0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval 0.63-0.84, P&lt;0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In nine eligible non-randomised studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. Conclusions: Use of telemedicine to assess the surgical wound post-discharge is feasible, but risks underreporting of SSI. Standardised tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially