Health promotion in local contexts and enabling factors : a study of primary healthcare personnel, local voluntary organizations and political decision makers

Municipalities are important arenas in health promotion as many of the determinants of health relate to, and exert their influence in, local contexts. Accordingly, one key question in public-health work is how to support health promotion on the local level. The present study explores and compares health promotion actions in four medium-sized municipalities, with an emphasis on factors influencing engagement. The point of departure is the health promotion strategies described in the Ottawa Charter (WHO 1986) – the focus being on community action for health, health-promoting health services and healthy public policy – and the multilevel health promotion model (Rütten et al. 2000). The overall aim is to further enhance understanding of health promotion action in local contexts. The specific aims are to explore the role of local voluntary associations in health promotion, to compare the emphasis on health promotion in four municipalities with different forms of primary healthcare service production, and, especially, to identify factors associated with comprehensive health promotion action and with health policy impact (effective health promotion actions). The study – part of an evaluation of the production model of primary healthcare in four municipalities in the southern part of Finland – is based on cross-sectional surveys conducted in the four municipalities in 2000, 2002 and 2004 and including all registered local voluntary associations (LVAs), primary healthcare (PHC) personnel (including services for older people) and local politicians. The data were analysed by means of descriptive statistics as well as logistic and linear regression analysis. The findings suggest that a fair proportion of LVAs are interested in action for community health and could be seen as a resource for health promotion in local contexts. There was agreement that the promotion of residents’ health requires cooperation between municipal agencies and LVAs, although cooperation was not particularly strongly emphasized in municipal budget and action plans according to the politicians. Cooperation with municipal agencies was independently associated with LVA engagement in health promotion. PHC personnel appear to be engaged in health promotion primarily on an individual basis. On all three levels (individual, group and population) it was most prevalent in ambulatory care. This was also true in the case of comprehensive action, as well as when health promotion was conceptualized as addressing risk behaviour. There were some differences between the municipalities in terms of level of engagement; the respondents' focus in health promotion and varying opportunities for cooperation are two potential explanations for these differences. Moreover, variables reflecting all the proposed determinants (organizational values, competence and opportunities) were independently associated with the PHC personnel’s engagement in comprehensive health promotion action. These included working conditions that are conducive to health promotion such as being able to use one’s skills and knowledge, and having possibilities for reflection and learning as well as collegial support; knowledge about residents’ health and living conditions; and opportunities to cooperate with partners outside the organization. Similarly, perceived competence and a value orientation towards health as well as opportunities for community participation were independently associated with LVA engagement in comprehensive health promotion action. In addition to the determinants in the theoretical model, the municipality had an influence. There were no inter-municipality differences in the politicians’ evaluations of health promotion actions and their effectiveness (health policy impact). In terms of impact, an emphasis on promoting health and quality of life among older people and the resources (in the form of capacity of PHC and care for older people) were among the most significant elements of health promotion policy on the local level. Contrary to expectations, opportunities for community participation were not associated with the evaluations. The findings reinforce the value of empowerment, community participation and intersectoral cooperation – in other words the principles of health promotion – in the context of Finnish municipalities, providing further evidence as well as highlighting their significance for engagement in health promotion action. The study also provides novel empirical confirmation concerning the applicability of the multilevel health promotion model to the actions of different actors in municipalities, in other words in local contexts. In support of action on the local level, the findings – the equally strong associations of organizational values, competence and opportunities with engagement in health promotion – suggest the need for a multilevel approach. However, local policy makers may need more evidence concerning the impact of cooperation and community participation.Väestön terveyden edistäminen on keskeinen terveyspoliittinen tavoite Suomessa. Kunnilla on tärkeä rooli tämän tavoitteen saavuttamisessa, sillä monet terveyden määrittäjät vaikuttavat väestön terveyteen lähiyhteisöissä. Näin ollen kansanterveystyön yksi tärkeä kysymys on se, miten terveyden edistämistä voidaan tukea paikallisella tasolla. Terveyttä ja hyvinvointia ja niihin yhteydessä olevia tekijöitä tutkitaan paljon. Sen sijaan vähemmän on tutkittu terveyden edistämisen toteuttamista ja toteutumista sekä niitä tukevia tekijöitä. Tässä tutkimuksessa tarkastellaan ja verrataan terveyden edistämistä sekä siihen yhteydessä olevia tekijöitä neljässä suomalaisessa keskikokoisessa kunnassa. Lähtökohtana ovat Ottawan julkilausuman (WHO 1986) terveyden edistämisen toimintalinjat sekä Rüttenin ja työtovereiden (2000) monitasoinen terveyden edistämisen malli. Tutkimuksen tavoitteena oli tarkastella paikallisten vapaaehtoisjärjestöjen roolia kuntien terveydenedistämistyössä ja verrata terveyden edistämisen suuntautumista ja painopisteitä eri kunnissa. Lisäksi tavoitteena oli tunnistaa niitä tekijöitä, jotka tukevat terveyden edistämistä ja jotka ovat yhteydessä paikallisten päättäjien näkemyksiin terveyden edistämisestä ja sen tuloksellisuudesta (terveyspolitiikan vaikuttavuus). Tutkimuksen aineistot koottiin neljästä eteläsuomalaisesta kunnasta osana perusterveyden- ja vanhustenhuollon palvelujen kokonaisarviointia. Tutkimusaineistoja kerättiin postikyselynä kolmesta eri lähteestä: paikallisten vapaaehtoisjärjestöjen edustajilta (vuosina 2000 ja 2002), perusterveyden- ja vanhustenhuollon ammattihenkilöiltä (vuonna 2002) sekä kunnallisten luottamuselinten poliittisesti valituilta jäseniltä (vuonna 2004). Kysely lähetettiin kuntien kaikille rekisteröidyille yhdistyksille, joista oli osoitetiedot yhdistysrekisterissä. Vuoden 2000 järjestökyselyyn vastasi 183 ja vuoden 2002 kyselyyn 182 järjestöä. Vastausprosentit olivat 46 % ja 40 %. Terveydenhuollon ammattilaisten kysely lähetettiin kaikille perusterveyden- ja vanhustenhuollon työntekijöille (n= 986), joista 57 % vastasi kyselyyn. Poliittisten päätöksentekijöiden kysely lähetettiin kaikille kunnanvaltuustojen, kunnanhallitusten ja sosiaali- ja terveyslautakuntien jäsenille (n= 195), joista 52 % vastasi kyselyyn. Tutkimus on poikkileikkaustutkimus, ja tilastomenetelminä käytettiin kuvailevia menetelmiä sekä logistista että lineaarista regressioanalyysiä. Tutkimuksen tulokset osoittivat, että kohtuullisen suuri osuus paikallisyhdistyksistä oli kiinnostunut toiminnasta yhteisön terveyden hyväksi, ja ne voidaan siten nähdä voimavarana terveyden edistämisessä paikallisella tasolla. Kunnissa oli yksimielisyyttä siitä, että väestön terveyden edistäminen edellyttää kunnallisten toimien ja paikallisten vapaaehtoisjärjestöjen yhteistyötä. Poliittisten päätöksentekijöiden mukaan yhteistyötä painotettiin jonkin verran kuntien talous- ja toimintasuunnitelmissa. Järjestöjen kannalta yhteistyö on tärkeää: yhteistyö kunnan eri toimien kanssa oli yhteydessä paikallisyhdistysten korkeampaan terveyden edistämisen aktiivisuuteen. Perusterveyden- ja vanhustenhuollon henkilöstö teki terveydenedistämistyötä pääasiallisesti yksilötasolla. Terveydenedistämistyötä tehtiin varsinkin terveysasemilla (ml. kouluterveydenhuolto). Verrattuna muuhun terveydenhuoltoon, terveysasemilla tehtiin enemmän yksilö-, ryhmä- ja väestötason terveydenedistämistyötä sekä osallistuttiin enemmän laaja-alaiseen terveydenedistämistyöhön sekä riskikäyttäytymisen ehkäisemiseen. Kuntien välillä oli jonkin verran eroja henkilökunnan terveyden edistämisen aktiivisuudessa. Mahdollisia selityksiä näille eroille ovat vastaajien kohderyhmät terveyden edistämisessä sekä mahdollisuudet tehdä yhteistyötä eri toimijoiden kanssa kunnassa. Tutkimustulokset ovat sopusoinnussa Rüttenin ym. (2000) monitasoisen terveyden edistämisen mallin kanssa. Terveydenhuollon ammattilaisten terveydenedistämistoiminnan aktiivisuutta lisäsivät organisaation arvot, oma osaaminen (tieto kuntalaisten terveydestä ja elinoloista) sekä mahdollisuudet yhteistyöhön organisaation ulkopuolella. Organisaation arvoihin liittyen, tulokset osoittivat, että työn koettu monipuolisuus ja haastavuus (työ jossa voi käyttää taitojaan ja tietojaan ja joka vaati osaamista, harkintaa ja päätöksentekoa sekä uusien asioiden oppimista) sekä kollegoiden sosiaalinen tuki olivat yhteydessä terveydenedistämistoiminnan aktiivisuuteen. Myös vapaaehtoisjärjestöjä koskevan tutkimuksen tulokset tukivat monitasoisen terveyden edistämisen mallin oletuksia. Paikallisyhdistysten terveydenedistämistoiminnan aktiivisuutta selittivät yhdistyksen pätevyys, yhdistyksen arvot – orientoituminen erityisesti lasten, nuorten ja aikuisväestön hyvinvoinnin edistämiseen – sekä osallistumisen mahdollisuudet (mahdollisuus tehdä yhteistyötä kuntatoimien kanssa ja seurata kuntalaisten terveydestä käytävää keskustelua sekä vaikuttaa päätöksentekoon). Näiden ohella kunnalla oli vaikutusta. Kuntien välillä ei ollut eroja siinä, miten luottamushenkilöt arvioivat terveydenedistämistoimintaa ja sen tuloksellisuutta (terveyspolitiikan vaikuttavuutta). Vaikuttavuutta selittivät, oletusten mukaisesti, tavoitteet ja resurssit. Oletusten vastaisesti yhteisöosallistumisen mahdollisuudet eivät olleet yhteydessä terveydenedistämistoimintaan ja sen tuloksellisuuteen. Vaikuttavuuden näkökulmasta tärkeimmiksi elementeiksi paikallispoliittisesti nousivat vanhusväestön terveyden ja elämänlaadun edistäminen sekä perusterveyden- ja vanhustenhuollon toimivuus. Tutkimuksen tulokset vahvistavat terveyden edistämisen periaatteiden eli voimaantumisen (empowerment), yhteisöosallistumisen ja sektorien välisen yhteistyön merkitystä suomalaisissa kunnissa. Tulokset antavat lisänäyttöä ja korostavat näiden periaatteiden merkittävyyttä terveydenedistämistoiminnan tukemisessa. Tutkimuksessa saatiin uutta tietoa teoreettisen mallin soveltuvuudesta eri toimijoiden terveyden edistämisen toimintaan kunnassa. Kun halutaan tukea terveyden edistämistä paikallistasolla, tämän tutkimuksen tulokset – organisaatioarvojen, osaamisen ja mahdollisuuksien yhtä vahvat yhteydet terveydenedistämistoimintaan – painottavat monitasoista lähestymistapaa. Poliittiset päättäjät tarvitsevat mahdollisesti enemmän näyttöä yhteistyön ja yhteisöosallistumisen vaikuttavuudesta terveyden edistämisessä

Patients' assessment of chronic illness care : a validation study among patients with type 2 diabetes in Finland

Background: To meet the challenges of the rising prevalence of chronic diseases, such as type 2 diabetes, new approaches to healthcare delivery have been initiated; among these the influential Chronic Care Model (CCM). Valid instruments are needed to evaluate the public health impact of these frameworks in different countries. The Patient Assessment of Chronic Illness Care (PACIC) is a 20-item quality of care measure that, from the perspective of the patient, measures the extent to which care is congruent with the CCM. The aim of this study was to evaluate the psychometric properties of the Finnish translation of the PACIC questionnaire, in terms of validity and reliability, in a large register-based sample of patients with type 2 diabetes. Method: The PACIC items were translated into Finnish in a standardized forward-backward procedure, followed by a cross-sectional survey among patients with type 2 diabetes (response rate 56%; n = 2866). We assessed the Finnish version of the PACIC scale for the following psychometric properties: content validity, internal consistency reliability, convergent and construct validity. We also present descriptive data on total scale as well as predetermined subscale levels. Results: The item-response on the PACIC scale was high with only small numbers of missing data (0.5-1.1%). Ceiling effects were low (0.3-5.3%) whereas floor effects were over 20% for two of the predetermined subscales (problem solving and follow-up/coordination). The total PACIC scale showed a reasonable distribution and excellent internal consistency (alpha 0.94) while the internal consistency of the subscales were at least acceptable (0.74-0.86). The principal component analysis identified a two-or three-factor solution instead of the proposed five-dimensional. In other respects, the PACIC scale showed the hypothesized relationships with quality of care and outcome measures, thus demonstrating convergent and construct validity. Conclusion: A Finnish version of the PACIC scale is now validated in the primary care setting among patients with type 2 diabetes. The findings suggest comparable psychometric properties of the Finnish scale as of the original English instrument and earlier translations, and reasonable levels of validity and reliability.Peer reviewe

Determinants of physical activity among patients with type 2 diabetes : the role of perceived autonomy support, autonomous motivation and self-care competence

Peer reviewe

Success in Weight Management Among Patients with Type 2 Diabetes : Do Perceived Autonomy Support, Autonomous Motivation, and Self-Care Competence Play a Role?

Based on self-determination theory (SDT), this study investigated whether the three central SDT variablesperceived autonomy support (from a physician), autonomous motivation and self-care competencewere associated with success in weight management (SWM) among primary care patients with type 2 diabetes when the effect of other important life-context factors was controlled for. Patients participated in a mail survey in 2011. Those who had tried to change their health behavior during the past two years in order to lose weight, either with or without success (n = 1433, mean age 63years, 50% men), were included in this study. The successors were more autonomously motivated and energetic than the non-successors. Moreover, male gender, younger age, taking oral medication only, and receiving less social support in diabetes care predicted better success. Autonomous motivation predicted SWM; self-care competence also played a role by partly mediating the effect of autonomous motivation on SWM. These results support the idea of SDT that internalizing the value of weight management and its health benefits is necessary for long-term maintenance of health behavior change. Perceived autonomy support was not directly associated with SWM. However, physicians can promote patients' weight management by supporting their autonomous motivation and self-care competence.Peer reviewe

Empowerment among adult patients with type 2 diabetes : age differentials in relation to person-centred primary care, community resources, social support and other life-contextual circumstances

BackgroundRising prevalence of type 2 diabetes (T2D), also among younger adults, constitutes a growing public health challenge. According to the person-centred Chronic Care Model, proactive care and self-management support in combination with community resources enhance quality of healthcare and health outcomes for patients with T2D. However, research is scarce concerning the importance of person-centred care and community resources for such outcomes as empowerment, and the relative impact of various patient support sources for empowerment is not known. Moreover, little is known about the association of age with these variables in this patient-group. This study, carried out among patients with T2D, examined in three age-groups (27-54, 55-64 and 65-75years) whether person-centred care and diabetes-related social support, including community support and possibilities to influence community health issues, are associated with patient empowerment, when considering possible confounding factors, such as other quality of care indicators and psychosocial wellbeing. We also explored age differentials in empowerment and in the proposed correlates of empowerment.MethodIndividuals from a register-based sample with T2D participated in a cross-sectional survey (participation 56%, n=2866). Data were analysed by descriptive statistics and multivariate logistic regression analyses.ResultsRespondents in the youngest age-group were more likely to have low empowerment scores, less continuity of care, and lower wellbeing than the other age-groups, and to perceive less social support, but a higher level of person-centred care than the oldest group. Community support, including possibilities to influence community health issues, was independently and consistently associated with high empowerment in all three age-groups, as was person-centred care in the two older age-groups. Community support was the social support variable with the strongest association with empowerment across age-groups. Moreover, vitality was positively and diabetes-related distress negatively associated with high empowerment in all age-groups, whereas continuity of care, i.e. having a family/regular nurse, was independently associated in the youngest age-group only.ConclusionPerson-centred care and community support, including possibilities to influence community health issues, supports empowerment among adults with T2D. Findings suggest that age is related to most correlates of empowerment, and that younger adults with T2D have specific healthcare needs.Peer reviewe

Health care climate, perceived self-care competence and glycemic control among patients with type 2 diabetes in primary care.

Peer reviewe

The meaning of dignity for older adults : A meta-synthesis

Dignified care is a central issue in the nursing care of older adults. Nurses are expected to treat older adults with dignity, and older adults wish to be treated in a dignified manner. Researchers have recommended investigating the concept of dignity based on specific contexts and population groups. This meta-synthesis study aims to explore the understandings of dignity from the perspective of older adults in the Nordic countries. Synthesising findings from qualitative studies on older adults? experiences of dignity has provided important insight into what can be essential for dignified care in a Nordic context. The importance of visibility and recognition for the experience of dignity is an overarching theme in all the studies. The participants? descriptions mostly implicated an existence dominated by a lack of recognition. The older adults do not feel valued as people or for their contribution to society and strive to tone down their illnesses in an attempt to become more visible and acknowledged as people. Toning down their illnesses and masking their needs can protect their independence. At the same time, becoming less visible can leave them without a voice. The metaphorical phrase protected and exposed by a cloak of invisibility is used to express the authors? overall interpretation of the findings. Lack of recognition and being socially invisible is a genuine threat to older adults? dignity.Peer reviewe

Phenylketonuria as a protein misfolding disease: The mutation pG46S in phenylalanine hydroxylase promotes self-association and fibril formation

AbstractThe missense mutation pG46S in the regulatory (R) domain of human phenylalanine hydroxylase (hPAH), associated with a severe form of phenylketonuria, generates a misfolded protein which is rapidly degraded on expression in HEK293 cells. When overexpressed as a MBP-G46S fusion protein, soluble and fully active tetrameric/dimeric forms are assembled and recovered in a metastable conformational state. When MBP is cleaved off, G46S undergoes a conformational change and self-associates with a lag phase and an autocatalytic growth phase (tetramers≫dimers), as determined by light scattering. The self-association is controlled by pH, ionic strength, temperature, protein concentration and the phosphorylation state of Ser16; the net charge of the protein being a main modulator of the process. A superstoichiometric amount of WT dimers revealed a 2-fold enhancement of the rate of G46S dimer self-association. Electron microscopy demonstrates the formation of higher-order oligomers and linear polymers of variable length, partly as a branching network, and partly as individual long and twisted fibrils (diameter ~145–300Å). The heat-shock proteins Hsp70/Hsp40, Hsp90 and a proposed pharmacological PAH chaperone (3-amino-2-benzyl-7-nitro-4-(2-quinolyl)-1,2-dihydroisoquinolin-1-one) partly inhibit the self-association process. Our data indicate that the G46S mutation results in a N-terminal extension of α-helix 1 which perturbs the wild-type α–β sandwich motif in the R-domain and promotes new intermolecular contacts, self-association and non-amyloid fibril formation. The metastable conformational state of G46S as a MBP fusion protein, and its self-association propensity when released from MBP, may represent a model system for the study of other hPAH missense mutations characterized by misfolded proteins

Does chronic pain hinder physical activity among older adults with type 2 diabetes? : Health Psychology and Behavioral Medicine

ABSTRACT Background: Physical activity (PA) is a key component in management of type 2 diabetes (T2D). Pain might be a barrier to PA especially among older adults with T2D, but surprisingly few studies have investigated the association between chronic pain and PA. Our aim was to evaluate the prevalence of chronic pain among older adults with T2D and to examine the association between chronic pain and PA while taking important life-contextual factors into account. Methods: Data of this register-based, cross-sectional study were collected in a survey among adults with T2D (n=2866). In the current study, only respondents aged 65?75 years were included (response rate 63%, n=1386). Data were analysed by means of descriptive statistics and multivariate logistic regression analysis. Results: In total, 64% reported chronic pain. In specific groups, e.g. women and those who were obese, the prevalence was even higher. Among respondents experiencing chronic pain, frequent pain among women and severe pain among both genders were independently associated with decreased likelihood of being physically active. Moreover, the likelihood of being physically active decreased with higher age and BMI, whereas it increased with higher autonomous motivation and feelings of energy. Among physically active respondents suffering from chronic pain, neither intensity nor frequency of pain explained engagement in exercise (as compared with incidental PA). Instead, men were more likely to exercise regularly as were those with good perceived health and higher autonomous motivation. Conclusions: The prevalence of chronic pain is high among older adults with T2D. This study shows that among those suffering from chronic pain, severe pain is independently and inversely associated with being physically active, as is frequent pain, but only among women. Moreover, the findings show the importance of autonomous motivation and health variables for both incidental PA and exercise among older adults with T2D experiencing chronic pain.Peer reviewe

Treatment with 24 h-delayed normo- and hyperbaric oxygenation in severe sepsis induced by cecal ligation and puncture in rats

Abstract Background Septic shock remains a leading cause of death worldwide. Hyperbaric oxygen treatment (HBO2) has been shown to alter the inflammatory response during sepsis and to reduce mortality. A therapeutic window of HBO2 treatment has been demonstrated experimentally, but optimal timing remains uncertain. We investigated the effects of 24 h delayed normobaric oxygen (NBO2) and HBO2 treatment on the endogenous production of the inflammatory markers interleukin (IL)-6, tumor necrosis factor (TNF)-α and IL-10, and on mortality in rats with cecal ligation and puncture (CLP) induced sepsis. Method Fifty-five male Sprague-Dawley rats underwent CLP and were randomized to the following groups: 1) HBO2 2.5 bar absolute pressure (pabs); 2) NBO2 1.0 bar pabs; 3) Control (no-treatment), and they were individually monitored for 72 h with intermittent blood sampling. Results IL-6, TNF-α, and IL-10 were increased 24 h after the procedure, and IL-6 was significantly higher in non-survivors than in survivors. The level of IL-10 was significantly higher at hour 48 in the HBO2 group compared to control (p = 0.01), but this was not the case at other time points. No other significant differences in cytokine levels were found for any group comparisons. Delayed NBO2 and HBO2 treatment failed to change the mortality in the animals. Conclusion High levels of IL-6 in non-surviving animals with sepsis suggest that IL-6 is a potential biomarker. We found a significantly higher concentration of IL-10 in the HBO2 group at hour 48 vs. control animals. However, 24 h–delayed treatment with HBO2 did not change the levels of pro-inflammatory cytokines and survival, suggesting that earlier intervention may be required to obtain an anti-inflammatory effect