Background: To achieve better health outcomes it is important to identify those aspects of health care delivery system that determines patient satisfaction. The health care planners must therefore be cognizant of the opinions and expectations of those who utilize health care facilities to achieve better health outcomes. This also applies to maternal satisfaction. The study aimed to measure mothers satisfaction with maternity care and its association with various socio-demographic characteristics. Method: The study presented here is a quantitative cross-sectional study that utilizes secondary data from facility-based survey conducted in 12 different tertiary hospitals of Nepal and included client exit interviews  (n=43756). The maternal satisfaction association with different exposures and potential confounders was determined using multivariate logistic regression analysis. Statistical Package for Social Sciences (SPSS) was used for data analysis. Results:. Better information and counselling is seen to be associated with higher satisfaction and recommendation [AOR: 1.67 [1.60-1.75]] and [1.68[1.57-1.80], respectively. Higher level of delivery preparation indicates lower overall satisfaction [AOR: 0.70 [0.66-0.74]]. Mothers were seen to be less satisfied with the religious and cultural aspects of the maternal health services. Mothers age and sex of child was not seen to be significant with any outcome. Conclusion: Better information and counselling indicates more satisfaction and recommendation. Mothers delivery preparation is seen as a significant predictor of their overall satisfaction; therefore, this should be a part of education and information strategy for mothers from the different backgrounds.

Introduction       Hypertension is the leading cause of cardiovascular disease, which is responsible for 9.4 million death per year. The characteristics of the physical environment of the workplace may influence exposure to the risk of hypertension. The aim of this study is to increase the knowledge of to what extent of physical workplace environment is associated with hypertension. Method A cross-sectional study was conducted using UK Biobank data including 256,617 participants, aged 39-71 years. The exposure variable included information about the physical aspects of the workplace environment. The outcome variable was hypertension, defined by the average of two blood pressure measurement, systolic blood pressure >140 mmHg and diastolic blood pressure >90 mmHg. The association was calculated using logistic regression. Result Both crude (OR 1.21, CI 1.14-1.28) and adjusted analysis (OR 1.07, CI 1.01-1.12) showed an association between exposure to chemicals in the workplace and hypertension. This association was constant when controlling for possible confounders in three models. Other physical aspects of the workplace environment did not show any statistically significant association with hypertension. To assess whether this association was modified by job satisfaction, the analysis was further stratified by work/ job satisfaction, but it was concluded that work/ job satisfaction does not act as an effect modifier of the association between workplace environment and hypertension. Conclusion Chemical exposure may increase the risk of hypertension in the workplace among the workers. This knowledge emphasizes the importance to formulate preventive measures in the workplace for better health outcome of workers.

On 26 April 1986 an accident occurred in the Chernobyl nuclear power plant resulting in the release of large amount of radionuclides. Almost five percent of the total released caesium-137 was deposited in Sweden. The incidence of malignancies in the most affected counties in Sweden was investigated in three epidemiological studies. In the first study the incidence of malignancies in children and adolescents was studied for the period 1978-1992. The parishes and their inhabitants were classified according to the ground deposition of caesium-137 on an analogue map provided be the Swedish Radiological Protection Authority. A continuous increase of brain tumour incidence observed during the time of the study had no clear relationship to the Chernobyl fallout. A somewhat decreased relative risk of ALL was observed in areas with increased deposition. Other malignancies showed no changes in incidence over time or with regard to the exposure of caesium-137. In study II and III we enlarged the study base by including adults. We improved the methodology by defining a cohort of subjects who lived in the same parish from 31 December 1985 to 31 December 1987. The inhabitants from seven counties were included. Parishes were classified the same way as in study I. Due to the large number of individuals six exposure categories could be created; <3, 3–29, 30–39, 40–59, 60–79, and 80–120 kBq caesium-137/m2. The inhabitants of the 117 non-affected parishes (<3 kBq/m2) served as reference. During the 1988-1996 followup, 22,409 malignancies were recorded. The MH-IRR in the fully adjusted model was 1.00 (reference), 1.05, 1.03, 1.08, 1.10 and 1.21, respectively. ERR was 0.11 per 100 kBq/m2 (95% CL 0.03;0.20). A more advanced method was used in Study III by ignoring the exposure classification for parishes, and instead matching the dwelling coordinate to a digital map of deposition of casesium-137. In spite of a more valid exposure classification the risk estimates were similar in study II and III. Also, the ERR during the longer follow-up of 1988-1999 was almost identical, 0.10 per 100 kBq/m2 (95% CL 0.00;0.23). The strongest dose-response relationship was seen in the first four years (1988-1991). No obvious excess for leukaemia or thyroid cancer was recognised in either study II or III. The estimated number of exposure related cases was calculated to 849 in study II and 1,278 in study III. Our interpretation is that we have shown an increased incidence of total malignancies with dose-response relationship for caesium-137, only a few years after the Chernobyl accident. In study IV we compared the two different ways of classifying the exposure in study II and III. Out of the 450 parishes 111 got a different classification. The similar risk estimates in study II and III could probably be explained by relatively homogenous exposure in the parishes making the intra-parish difference less influential, especially when included in categories. In study V we examined the urinary excretion of 8-OHdG in Belarussian children from areas with high and low fallout of caesium-137, respectively. We found significantly lower urinary 8-OHdG levels in children from rural contaminated areas compared to urban uncontaminated areas, suggesting an urban, rather than a radiation related, risk factor. Using the Hill criteria for causality there is support for a causal inference between the fallout of caesium-137 from the Chernobyl accident and the increased incidence in total malignancies in Northern Sweden.

Background: The study is based in post-apartheid South Africa and looks at the health and well being of households in the rural northeast. Temporary migration remains important in South Africa because it functions as a mainstay for income and even survival of rural communities. The economic base of rural South Africans is surprisingly low because there is high inequity at a national level, within and between racial groups. There has now been a democratic system in place for 15 years and there is no longer restriction of mobility, but there remain high levels of poverty in rural areas and rising mortality rates. Migration patterns did not change after apartheid in the manner expected. We need to examine consequences of migration and learn how to offset negative impacts with targeted policies. Aims: To determine a relevant typology of migration in a typical rural sending community, namely the Agincourt sub-district of Mpumalanga, South Africa, and relate it to the urban transition at a national level – Paper (I) . To evaluate the dynamics of socio-economic status in this rural community and examine the relationship with migration – Paper (II). To explore, using longitudinal methods, the impact of migration on key dimensions of health, including adult and child mortality, and sexual partnerships, over a period of an emerging HIV/AIDS epidemic – Papers (III), (IV) and (V). Methods: The health and socio-demographic surveillance system (HDSS) is a large open cohort where the migration dynamics are monitored as they unfold. They are recorded as temporary or permanent migration. Settled refugees are captured using nationality on entry into the HDSS. Longitudinal methods, namely a household panel and two discrete time event history analyses, are used to examine consequences of migration. Results: Migration features prominently and different types have different age and sex profiles. Temporary migration impacts the most on socio-economic status (SES) and health, but permanent migration and the settlement of former refugees are also important. Remittances from migrants make a significant difference to SES. For the poorest households the key factors improving SES are government grants and female temporary migration, while for less poor it is male temporary migration and local employment. Migration has been associated with HIV. Migrants that return more frequently may be less exposed to outside partners and therefore less implicated in the HIV epidemic. There are links between migration and mortality including a higher risk of dying for returnee migrants compared to permanent residents. A mother’s migration can impact on child survival after accounting for other factors. There remains a higher mortality risk for children of Mozambican former refugee parents. Interpretation: Migration changes the risks and resources for health with positive and negative implications. Measures such as improved transportation and roads should be seen as a positive, not a negative intervention, even though it will create more migration. Health services need to adapt to a reality of high levels of circular migration ranging from budget allocation to referral systems. Data should be enhanced at a national level by accounting for temporary migration in national censuses and surveys. At individual level we can offset negative consequences by treating migrants as persons striving against adversity, instead of unwelcome visitors in our better-off communities.

Background: The challenge of research in resource-poor settings remains a profound concern and is closely linked to African social development. Work of this thesis spans the end of apartheid and first decade of the democratic era in South Africa, along with emergence of the HIV/AIDS pandemic. It also covers the founding decade of the INDEPTH Network. Aims: Through appraising health and population research in a rural southern African sub-district over the past decade, to evaluate the utility of health and socio-demographic surveillance in rural African settings for: • capturing the dynamics of health, population and social transitions • supporting a mix of research designs, and • contributing to policy and programme development and evaluation. To extend this appraisal by examining the multi-site opportunities offered by the INDEPTH Network. Methods: Work was sited in the Agincourt sub-district, a heavily populated border area of rural north-eastern South Africa. Health and socio-demographic surveillance, introduced in 1992, involved prospective follow-up of the entire sub-district population of 70,000 people (including some 30% Mozambican immigrants) who lived in 11,700 households and 21 villages. Annual census rounds systematically updated household membership and recorded all vital events (births, deaths and migrations) since the previous census. A maternity history was asked of women of reproductive age and a verbal autopsy carried out on all deaths registered. The resulting ‘data and research platform’ – a core feature of all INDEPTH field sites – provided data for computation of trends in vital events and supported an extensive interdisciplinary project portfolio. The population under surveillance can be disaggregated into cohorts selected by age, sex or other criteria. Analyses are possible at multiple levels (individual, family/household or neighborhood) and can include socioeconomic factors. Findings: The Agincourt community experienced a serious worsening of mortality among most age-sex groups, rapidly declining fertility to near replacement level, and changing patterns of labour migration. This resulted in major changes in population structure and household composition. The rising burden of chronic disease involved both chronic infectious illness (HIV/AIDS and tuberculosis) and non-communicable disorders (such as stroke and related vascular disease). The burden of illness requiring chronic care increased disproportionately to that needing acute care. Potential contributions of field sites based on health and socio-demographic surveillance to local and national health policy are considerable yet remain underexploited. Interpretation: Rural South and southern Africa is in the midst of multiple, interrelated transitions with implications for health, social and development sectors. Health and socio-demographic surveillance systems are effective research instruments that can capture the rapidly-changing dynamics of health and social transitions in developing settings. Similarly, they can support a range of observational and intervention study designs including policy evaluations. The INDEPTH Network should boost much-needed comparative research; yet singly, and as a group, many of these sites have yet to fulfil their undoubted potential.

The overall aim of this thesis is to evaluate the risk for increased morbidity and mortality due to long-term arsenic exposure via drinking water by use of epidemiological and spatial approaches in studies performed in Matlab, Bangladesh. A total of 166,934 individuals aged 4 years and above were screened for skin lesions in 2002-2003. Another sample of 115,903 adults aged 15 years or more and a third sample of 26,972 pregnancies in 1991-2000 were considered in a historical cohort and an ecological study, respectively, where risk of adult mortality and spatial clusters of foetal loss and infant death were analysed in relation to arsenic exposure. More than 70% of the tube-wells in the study area exceeded the threshold for arsenic contamination according to the WHO guideline (10 µg/L). The prevalence of arsenic-induced skin lesions was 3/1000 and men had significantly higher prevalence of skin lesions (SMR 158, 95% CI: 133-188) compared to women. There was an increased risk for death in adulthood due to all non-accidental causes (hazards ratio = 1.16, [95% CI 1.06-1.26]) even at a low level of arsenic contamination (10-49 µg/L). Slightly lower risks were observed for death in cancers (1.44 [1.06-1.95]) and infectious diseases (1.30 [1.13-1.49]) at 50-149 µg/L, but for cardiovascular diseases, it was evident (1.23 [1.01-1.51]) from the level 150-299 µg/L. A dose-response relationship was observed for each of these causes. We identified high and low risk clusters of foetal loss and infant death that coincided with identified high and low clusters of arsenic exposure. Water arsenic concentration of the reported main water source was significantly correlated with arsenic concentration in urine, which reflects current arsenic intake from all sources (R2=0.41, ρ< 0.0001), and the influence of neighbouring water sources was minimal. The study findings underlines that the ongoing arsenic exposure has resulted in a series of severe public health consequences in Bangladesh that call for reinforcement in the mitigation efforts. Knowledge about the spatial distribution of exposure and health effects may be of value in that process.

Background: The epidemic of chronic diseases is largely neglected. Although a threatening burden of chronic diseases is emerging, developing public health efforts for their prevention and control is not yet a priority for trans-national and national health policy makers. Understanding the population burden of risk factors which predict chronic diseases is an important step in reducing the impact of the diseases themselves. Objective: This thesis responds to the increasing burden of chronic diseases worldwide, and aims to illustrate the gap in chronic disease risk factor research in developing countries. The thesis describes and analyses the distribution of chronic disease risk factors in a rural setting in Indonesia. It also describes how smoking, one of the most common risk factors, is viewed by rural Javanese boys. Ultimately, therefore, this thesis aims to contribute to policy and programme recommendations for community interventions in a rural setting in Indonesia Methods: The studies were conducted in Purworejo District, where a Demographic Surveillance System (DSS) has been running since 1994. The Purworejo DSS is part of the INDEPTH network (International Network of field sites for continuous Demographic Evaluation of Populations and Their Health in developing countries). Two representative cross-sectional studies (in 2001 and 2005) were conducted to assess the chronic disease risk factors (including smoking, elevated blood pressure, and overweight and obesity). The first cross-sectional study was followed up in 2002 and 2004. In each study, a total of 3 250 participants (approximately 250 individuals in each sex and age group among 15–74 year olds stratified into 10-year intervals) were randomly selected from the surveillance database from each enumeration area in the surveillance area. Instruments were adopted from the WHO STEPS survey and adapted to local setting. Since many Indonesians start to smoke at an earlier age, a qualitative study using a focus group discussion approach was conducted among school boys aged 13-17 years old to describe and explore beliefs, norms, and values about smoking in a rural setting in Java. Result: Both the rural and urban populations in Purworejo face an unequal distribution of risk factors for chronic diseases. The burden among the most well-off group in the rural area has already reached a level similar to that found in the urban area. Most of the risk factors increased in all age, sex and socioeconomic groups during the period of 2001 to 2005. However, women and the poorest group experienced the greatest increase in risk factor prevalence. The qualitative study showed that cultural resistance against women smoking in Indonesia remains strong. Smoking is being viewed as a culturally internalised habit that signifies transition into maturity and adulthood for boys. Smoking is utilised as a means for socialisation and signifies better socioeconomic status. The use of tobacco in the construction of masculinity underlines the importance of gender specific interventions. National tobacco control policy should emphasise a smoking free society as the norm, especially among boys and men, and regulations regarding the banning of smoking should be enforced at all levels and areas of the community. Within the demographic surveillance setting, it is possible to assess the population and health dynamics. Utilisation of a standardised methodology across sites in INDEPTH will produce comparable population-based data in developing countries. Such comparisons are important in global health. A comparison of smoking transition patterns between a Vietnamese DSS and an Indonesian DSS shows that Indonesian men started smoking regularly earlier and ceased less than Vietnamese men. Compared with Vietnam, which has already signed and ratified the Framework Convention on Tobacco Control, tobacco control activities in Indonesia are still deficient. Conclusion: The thesis concludes that the rural population is not spared from the emerging burden of chronic disease risk factors. The patterning of risks across different socioeconomic groups provides a macro picture of the vicious cycle between poverty and chronic diseases. Understanding of risk factors in a local context through a qualitative study provides insight into cultural aspects relating to risk factor adoption, and will allow the fostering and tailoring of culturally appropriate interventions. Combining data from demographic surveillance sites with the WHO STEP approach to chronic disease risk factor Surveillance addresses basic epidemiological questions on chronic diseases. The use of such data is a powerful advocacy tool in public health decision-making for chronic disease prevention in developing countries. With substantial existing evidence on the effectiveness of chronic disease prevention and intervention programmes, it is vital that Indonesia to starts planning intervention programmes to control the impending chronic disease epidemic, and most importantly, to translate all this evidence into public health action. Keywords: chronic disease, risk factor, demographic surveillance system, smoking, elevated blood pressure, overweight and obesity, population-based intervention

Formål: Bestemme omfangen, typen, udløsende årsager, bagvedliggende faktorer og konsekvenser af vold og trusler om vold mod behandlere i Københavns Amts Behandlingscenter for Stofbrugere samt at udvikle kliniske retningslinier for håndtering og minimering af vold og trusler om vold. Metode: Omfanget af voldsepisoder blev vurderet ved to metoder: 1) Retrospektiv anonym tværsnitsspørgeskemaundersøgelse af samtlige 84 fastansatte medarbejder 2) Kohorte undersøgelse med prospektiv registrering af alle psykiske og fysiske voldsepisoder i en tre måneders periode i 2001-2002. Årsager, faktorer og konsekvenser blev undersøgt i semi-strukturerede interviews med den voldsramte medarbejder og den voldelige klient. Håndteringen af voldsepisoderne blev vurderet i en audit procedure og kliniske retningslinier i relation til håndtering af arbejdsrelateret vold og trusler om vold blev udviklet . Resultat: I tværsnitsundersøgelsen svarede 73 (87%), 45% (n=33) af medarbejderne havde været udsat for vold af psykisk eller fysisk karakter indenfor det sidste år, 48% (n=35) indenfor de sidste fem år. Hyppigheden var uafhængig af medarbejderens alder, køn og arbejdserfaring. Kohorteundersøgelsen afslørede, med en svar procent på 57%, 16 tilfælde af ren psykisk vold medførende en incidens på 0.77 pr. arbejdsår pr. medarbejder eller 0.24 psykisk voldsepisode pr. dag, 11 tilfælde af kombineret psykisk/fysisk vold medførende en incidens 0.53 pr. arbejdsår pr. medarbejder eller 0.17 psykisk/fysisk voldsepisode pr. dag (ca. een ugentligt). Politi blev tilkaldt 5(19%) gange. Bagvedliggende faktorer inkluderede dybe frustrationer mod behandlersystemet, lavt selvværd og dårlig kommunikationsevne hos klienterne. Hovedparten af medarbejderne oplevede efterfølgende angstreaktioner. Sygemelding og psykologisk krisehjælp forekom kun i få tilfælde. På basis af audit-panelets rekommandationer blev der udviklet kliniske retningslinier for håndtering af vold og trusler om vold. Konklusion: Prævalenses og incidensen af vold og trusler om vold i arbejdet med stofbrugere er højere end i andre fagområder både i og uden for sundhedsvæsenet med væsentlige konsekvenser for både medarbejderen og specielt for den voldelige klient. Resultaterne i dette studie kvantificerer arbejdsrelateret vold som ikke fremgår af officielle registre (”mørketal”) / Purpose: To determine the extent, type, precipitating factors, causality and consequences of work related threats and violence at the Copenhagen County Substance Abuse Treatment Centre and to develop clinical guidelines in order to minimise threats and violence. Methods: The extent of violent episodes was estimated using two methods: 1) Retrospective anonymous questionnaire issued to all (n=84) full-time employed staff-members. 2) In a tree months period 2001-2002 prospective registration of all physical and psychological violent episodes at the Copenhagen County Substance Abuse Treatment Centre was performed. Precipitating factors, causality and consequences were investigated in semi-structured interviews including all abused staff-members and violent clients. The management of violent episodes was audited in an audit panel and clinical guidelines regarding work related threats and violence were developed. Results: 73 (87%) staff-members completed the questionnaire. 33(45%) staff-members had experienced work related violence in the last year, 35(48%) in the last 5 years. There were no sub-group differences. The prospective registration identified 16 episodes of psychological violence, constituting an incidence of 0.77 pr. work-year pr. staff-member or 0.24 psychological violent episodes pr. day at the centre. 11 combined physical and psychological violent episodes were identified ending up with an incidence of 0.53 violent episode pr. work-year pr. staff-member or 0.17 violent episodes at the centre pr. day. Police was called in 5(19%) of the cases. The clients were characterized by harboring deep frustrations towards the system, low self-esteem and poor communication skills. The majority of the abused staff-members experienced anxiety reactions. Only a few required sick-leave and psychological crises counseling. On the basis of the audit-panel’s recommendations clinical guidelines regarding threats and violence were developed. Conclusions: The prevalence and incidence of work related threats and violence is higher among staff-members treating substance users than in other fields both in- and outside the Health Service. There are consequences of significance for both the abused staff-member and the violent client. The results of this study quantify the extent of violence not registered in official registers. / <p>ISBN 91-7997-109-1</p>

Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 4 uppsatser.

The purpose of the study is to investigate midwife's work towards pregnant women.  The method of the study had a qualitative approach and the data collection was done using semistructured interviews. Three phoneinterviewes and an interview face to face.    The method used had a qualitative approach and semi structured telephone interviews as well an interview with a personal meeting was the results implementation. The participants in the survey were four midwives recruited by telephone. The interviews were recorded, transcribed and analyzed with a manifest thematic content analysis, with a phenomenological element.   The Result gave four different themes: The health call - a good foundation for maternity health care, trust and trust, diet and exercise, insufficient knowledge and midwives experience of support. The result showed that midwives work on the same guidelines, that is the BAS program. They felt short of time and wished that the visits with the women could be a bit more flexible.   The conclusion is that more time for each visit would be necessary and that cooperation with other actors would make the work more efficient and fair.