Pathways to health : Determinants of health, health behaviour and health inequalities in early adulthood

There is increasing evidence that the origins of poor adult health and health inequalities can be traced back to circumstances preceding current socioeconomic position and living conditions. The life-course approach to examining the determinants of health has emphasised that exposure to adverse social and economic circumstances in earlier life or concurrent adverse circumstances due to unfavourable living conditions in earlier life may lead to poor health, health-damaging behaviour, disease or even premature death in adulthood. There is, however, still a lack of knowledge about the contribution of social and economic circumstances in childhood and youth to adult health and health inequalities, and even less is known about how environmental and behavioural factors in adulthood mediate the effects of earlier adverse experiences. The main purpose of this study was to deepen our understanding of the development of poor health, health-damaging behaviours and health inequalities during the life-course. Its aim was to find out which factors in earlier and current circumstances determine health, the most detrimental indicators of health behaviour (smoking, heavy drinking and obesity as a proxy for the balance between nutrition and exercise), and educational health differences in young adults in Finland. Following the ideas of the social pathway theory, it was assumed that childhood environment affects adult health and its proximal determinants via different pathways, including educational, work and family careers. Early adulthood was studied as a significant phase of life when many behavioural patterns and living conditions relevant to health are established. In addition, socioeconomic health inequalities seem to emerge rapidly when moving into adulthood; they are very small or non-existent in childhood and adolescence, but very marked by early middle age. The data of this study were collected in 2000 2001 as part of the Health 2000 Survey (N = 9,922), a cross-sectional and nationally representative health interview and examination survey. The main subset of data used in this thesis was the one comprising the age group 18 29 years (N = 1,894), which included information collected by standardised structured computer-aided interviews and self-administered questionnaires. The survey had a very high participation rate at almost 90% for the core questions. According to the results of this study, childhood circumstances predict the health of young adults. Almost all the childhood adversities studied were found to be associated with poor self-rated health and psychological distress in early adulthood, although fewer associations were found with the somatic morbidity typical of young adults. These effects seemed to be more or less independent of the young adult s own education. Childhood circumstances also had a strong effect on smoking and heavy drinking, although current circumstances and education in particular, played a role in mediating this effect. Parental smoking and alcohol abuse had an influence on the corresponding behaviours of offspring. Childhood circumstances had a role in the development of obesity and, to a lesser extent, overweight, particularly in women. The findings support the notion that parental education has a strong effect on early adult obesity, even independently of the young adult s own educational level. There were marked educational differences in self-rated health in early adulthood: those in the lowest educational category were most likely to have average or poorer health. Childhood social circumstances seemed to explain a substantial part of these educational differences. In addition, daily smoking and heavy drinking contributed substantially to educational health differences. However, the contribution of childhood circumstances was largely shared with health behaviours adopted by early adulthood. Employment also shared the effects of childhood circumstances on educational health differences. The results indicate that childhood circumstances are important in determining health, health behaviour and health inequalities in early adulthood. Early recognition of childhood adversities followed by relevant support measures may play an important role in preventing the unfortunate pathways leading to the development of poor health, health-damaging behaviour and health inequalities. It is crucially important to recognise the needs of children living in adverse circumstances as well as children of substance abusing parents. In addition, single-parent families would benefit from support. Differences in health and health behaviours between different sub-groups of the population mean that we can expect to see ever greater health differences when today s generation of young adults grows older. This presents a formidable challenge to national health and social policy as well as health promotion. Young adults with no more than primary level education are at greatest risk of poor health. Preventive policies should emphasise the role of low educational level as a key determinant of health-damaging behaviours and poor health. Keywords: health, health behaviour, health inequalities, life-course, socioeconomic position, education, childhood circumstances, self-rated health, psychological distress, somatic morbidity, smoking, heavy drinking, BMI, early adulthood

Psychosocial processes of health behaviour change in a lifestyle intervention : Influences of gender, socioeconomic status and personality

Background: The onset of many chronic diseases such as type 2 diabetes can be delayed or prevented by changes in diet, physical activity and obesity. Known predictors of successful behaviour change include psychosocial factors such as selfefficacy, action and coping planning, and social support. However, gender and socioeconomic differences in these psychosocial mechanisms underlying health behaviour change have not been examined, despite well-documented sociodemographic differences in lifestyle-related mortality and morbidity. Additionally, although stable personality traits (such as dispositional optimism or pessimism and gender-role orientation: agency and communion) are related to health and health behaviour, to date they have rarely been studied in the context of health behaviour interventions. These personality traits might contribute to health behaviour change independently of the more modifiable domain-specific psychosocial factors, or indirectly through them, or moderated by them. The aims were to examine in an intervention setting: (1) whether changes (during the three-month intervention) in psychological determinants (self-efficacy beliefs, action planning and coping planning) predict changes in exercise and diet behaviours over three months and 12 months, (2) the universality assumption of behaviour change theories, i.e. whether preintervention levels and changes in psychosocial determinants are similar among genders and socioeconomic groups, and whether they predict changes in behaviour in a similar way in these groups, (3) whether the personality traits optimism, pessimism, agency and communion predict changes in abdominal obesity, and the nature of their interplay with modifiable and domain-specific psychosocial factors (self-efficacy and social support). Methods: Finnish men and women (N = 385) aged 50 65 years who were at an increased risk for type 2 diabetes were recruited from health care centres to participate in the GOod Ageing in Lahti Region (GOAL) Lifestyle Implementation Trial. The programme aimed to improve participants lifestyle (physical activity, eating) and decrease their overweight. The measurements of self-efficacy, planning, social support and dispositional optimism/pessimism were conducted pre-intervention at baseline (T1) and after the intensive phase of the intervention at three months (T2), and the measurements of exercise at T1, T2 and 12 months (T3) and healthy eating at T1 and T3. Waist circumference, an indicator of abdominal obesity, was measured at T1 and at oneyear (T3) and three-year (T4) follow-ups. Agency and communion were measured at T4 with the Personal Attributes Questionnaire (PAQ). Results: (1) Increases in self-efficacy and planning were associated with three-month increases in exercise (Study I). Moreover, both the post-intervention level and three-month increases (during the intervention) in self-efficacy in dealing with barriers predicted the 12-month increase in exercise, and a high postintervention level of coping plans predicted the 12-month decrease in dietary fat (Study II). One- and three-year waist circumference reductions were predicted by the initial three-month increase in self-efficacy (Studies III, IV). (2) Post-intervention at three months, women had formed more action plans for changing their exercise routines and received less social support for behaviour change than men had. The effects of adoption self-efficacy were similar but change in planning played a less significant role among men (Study I). Examining the effects of socioeconomic status (SES), psychosocial determinants at baseline and their changes during the intervention yielded largely similar results. Exercise barriers self-efficacy was enhanced slightly less among those with low SES. Psychosocial determinants predicted behaviour similarly across all SES groups (Study II). (3) Dispositional optimism and pessimism were unrelated to waist circumference change, directly or indirectly, and they did not influence changes in self-efficacy (Study III). Agency predicted 12-month waist circumference reduction among women. High communion coupled with high social support was associated with waist circumference reduction. However, the only significant predictor of three-year waist circumference reduction was an increase in health-related self-efficacy during the intervention (Study IV). Conclusions: Interventions should focus on improving participants self-efficacy early on in the intervention as well as prompting action and coping planning for health behaviour change. Such changes are likely to be similarly effective among intervention participants regardless of gender and educational level. Agentic orientation may operate via helping women to be less affected by the demands of the self-sacrificing female role and enabling them to assertively focus on their own goals. The earlier mixed results regarding the role of social support in behaviour change may be in part explained by personality traits such as communion.

Periodontal and dental health and oral self-care among adults with diabetes mellitus.

ABSTRACT Bakhshandeh, Soheila. Periodontal and dental health and oral self-care among adults with diabetes mellitus. Department of Oral Public Health, Institute of Dentistry, Faculty of Medicine, University of Helsinki, Helsinki, Finland. 2011. 49 pp. ISBN 978-952-10-7193-5(paperback). The aim of the present study was to assess oral health and treatment needs among Iranian adults with diabetes according to socio-demographic status, oral hygiene, diabetes related factors, and to investigate the relation between these determinants and oral health. Moreover, the effect of an educational oral health promotion intervention on their oral health and periodontal treatment needs was studied. The target population comprised adults with diabetes in Tehran, Iran. 299 dentate patients with diabetes, who were regular attendants to a diabetic clinic, were selected as the study subjects. Data collection was performed through a clinical dental examination and self-administered structured questionnaire. The questionnaire covered information of the subject s social background, medical history, oral health behaviour and smoking. The clinical dental examinations covered the registration of caries experience (DMFT), community periodontal index (CPI) and plaque index (PI). The intervention provided the adults with diabetes dental health education through a booklet. Reduction in periodontal treatment needs one year after the baseline examination was used as the main outcome. A high prevalence of periodontal pockets among the study population was found; 52% of the participants had periodontal pockets with a pocket depth of 4 to 5 mm and 35% had periodontal pockets with pocket depth of 6 mm or more. The mean of the DMFT index was 12.9 (SD=6.1), being dominated by filled teeth (mean 6.5) and missing teeth (mean 5.0). Oral self-care among adults with diabetes was inadequate and poor oral hygiene was observed in more than 80% of the subjects. The educational oral health promotion decreased periodontal treatment needs more in the study groups than in the control group. The poor periodontal health, poor oral hygiene and insufficient oral self-care observed in this study call for oral health promotion among adult with diabetes. An educational intervention showed that it is possible to promote oral health behaviour and to reduce periodontal treatment needs among adults with diabetes. The simplicity of the model used in this study allows it to be integrated to diabetes programmes in particular in countries with a developing health care system.

Finding space to mental health : promoting mental health in adolescents (12 to 14 year olds): preliminary results of the intervention's effectiveness

Resumen: La salud mental y el bienestar son fundamentales para nuestra capacidad colectiva y individual como seres humanos de pensar, de exteriorizar los sentimientos, de establecer y mantener relaciones, para estudiar, para perseguir las actividades de ocio, para tomar decisiones diarias y para disfrutar de una vida plena. Una adolescencia saludable es un prerrequisito para una vida adulta saludable. Sin embargo, la realidad actual presenta un panorama preocupante. La formación del capital mental individual y colectivo - especialmente en las primeras etapas de la vida - está siendo retenida por una serie de riesgos evitables para la salud mental (World Health Organization [WHO], 2013). Los adolescentes del sur de Europa (región que ha sido más severamente afectada por la crisis financiera; e.g., Portugal) son señalados como un grupo extremadamente vulnerable, ya que su salud mental fácilmente podría ser influenciada por las dificultades económicas de sus padres y la escasez de solidaridad social (European Parliament, 2012). La promoción de la salud mental de los adolescentes es considerada como una preocupación fundamental (WHO, 2005a, 2013). En este ámbito, las intervenciones centradas en la promoción de la literacía de la salud mental han revelado importantes ventajas en la prevención, reconocimiento, intervención precoz y la reducción del estigma (Pinfold, Stuart, Thornicroft & Arboleda-Florez, 2005; Pinfold, Toulmin, Thornicroft, Huxley, Farmer & Graham, 2003; Schulze, Richter-Werling, Matschinger & Angermeyer, 2003; Stuart, 2006). En consonancia con los marcos de promoción de la salud mentales propuestos por la Organización Mundial de la Salud (2005a), tenemos que involucrar a jóvenes en los ambientes donde interactúan (Burns, 2011). Las escuelas son implícitamente uno de los locales más importantes para la promoción de la salud mental de los adolescentes (Barry, Clarke, Jenkins & Patel, 2013; WHO, 2001). El proyecto “Abrir Espacio para la Salud Mental – Promoción de la salud mental en adolescentes (12-14 años)” tiene como objetivo incrementar literacía de la salud mental en los jóvenes. En el primer año se ha desarrollado un instrumento de evaluación - Mental Health Literacy questionnaire (MHLq) - y la intervención para la promoción de la salud mental. La intervención consiste en 2 sesiones, 90 minutos cada una, implementadas con intervalo de una semana. Siguen una metodología interactiva, utilizando dinámicas de grupo, videos, música y discusión. El estudio de la eficacia de la intervención se lleva a cabo mediante un análisis pre y pos-test con el MHLq, utilizando un grupo experimental y un grupo de control. Este artículo presenta los resultados preliminares de la eficacia de la intervención de promoción de la salud mental en una muestra de 100 adolescentes portugueses (12-14 años). El pos-test mostró un incremento de los niveles de conocimientos de salud mental y estrategias de autoayuda. Los resultados sugieren que la intervención desarrollada parece ser adecuada al objetivo propuesto y refuerzan la creencia de que intervenciones escolares, sistemáticas y sostenibles, para la promoción de la salud mental con jóvenes, es un enfoque prometedor para la promoción de la literacía de la salud mental (Schulze et al., 2003; Rickwood et al., 2005; Corrigan et al., 2007; WHO, 2010).

Sociopoetizando a construção das ações de autocuidado no envelhecimento saudável: uma aplicação da teoria de Nola Pender

O envelhecimento populacional no Brasil sobreleva a necessidade de organização de serviços de saúde, sendo a estimulação do autocuidado uma estratégia privilegiada para orientar programas de promoção da saúde para pessoas idosas. Face à busca das mais variadas formas de viver bem, abrem-se fronteiras possibilitando o surgimento de modelos de envelhecimento saudável. Partindo do pressuposto de que as pessoas possuem uma dimensão imaginativa no acrescentar qualidade aos anos de vida, delimitou-se como objeto de estudo o imaginário de um grupo da terceira idade na construção das ações de autocuidado. Objetivos: descrever a poética sobre as ações de autocuidado construídas por um grupo de pessoas idosas; e analisar os significados (conceitos/confetos) atribuídos por essas pessoas ao envelhecer. Utilizou-se como marco referencial a Teoria de Promoção da Saúde de Nola Pender. Trata-se de pesquisa descritiva, qualitativa, considerando o paradigma naturalista. Foi aplicado o método sociopoético por meio do dispositivo analítico Grupo Pesquisador, composto por 11 idosos participantes da Unati da Universidade do Estado do Rio de Janeiro, que desenvolveram a investigação no período de outubro a dezembro de 2008, mediante as técnicas de pesquisa: Dinâmica de Corpo como Território Mínimo e a Vivência de Lugares Geomíticos. Foram questões norteadoras do estudo, respectivamente: Como vocês se cuidam para o caminho do bom envelhecer? E Como é o autocuidado para o envelhecer saudável se ele for um lugar geomítico?. Os dados produzidos foram submetidos à análise categorial, dos estudos sociopoéticos. No estudo filosófico, observou-se haver coexistência da autoimagem realista revelando que os idosos estão mais aptos aos desafios da vida, pois seu comportamento é coerente com a ideia que faz de si, além de intenções, aspirações e tendências. O classificatório ressaltou as dicotomias das ações de autocuidado tendo: O Autocuidado através dos Limites e Possibilidades; e Transcender para Experienciar o Dom do Envelhecer; O transversal revelou O Autocuidado como Reconhecimento das Necessidades de Saúde, enquanto no surreal sobrelevam-se Aceitar o Novo para um Renascer Saudável; Perseverança para Conviver com o Envelhecimento; e Procurar Assistência pode Desvelar Temores para a Finitude do Viver. Conclui-se que a compreensão do imaginário dos sujeitos de pesquisa mediada pela teoria de Pender permitiu identificar fatores que influenciam e motivam o autocuidado para comportamentos saudáveis. Assim, o grupo vislumbra para seu futuro uma imagem de envelhecer mais dinâmica, adotando para si próprio um viver mais autônomo, ativo e bem-sucedido. À contribuição do estudo, propõe-se aos enfermeiros a apropriação de conceitos teóricos como forma de traduzir a realidade e demonstrar alternativas viáveis de ações de cuidado/saúde, bem como a utilização das práticas de dinâmicas de criatividade e sensibilidade nas atividades assistenciais.

Aplicabilidade da Norma Regulamentadora 32: visão dos trabalhadores de enfermagem de um hospital público do RJ

Pesquisa de natureza descritiva e abordagem quantitativa de dados sobre a Aplicabilidade da Norma Regulamentadora-32 (NR 32) do Ministério do Trabalho e Emprego (MTE), visando mobilizar os trabalhadores de enfermagem para reduzir a exposição aos riscos inerentes do trabalho em estabelecimentos de saúde. Problema de pesquisa: Quais os fatores que interferem na implantação da Norma Regulamentadora-32 nas enfermarias de um Hospital Público Estadual do Rio de Janeiro, na visão dos trabalhadores de enfermagem? Teve como objetivo geral analisar os fatores que interferem na aplicabilidade da NR 32 pela enfermagem, em um hospital público do Rio de Janeiro. A população foi composta de 138 trabalhadores de enfermagem das enfermarias de clínica médica, cirúrgica e ortopédica. Utilizou-se para a coleta de dados um questionário estruturado com perguntas fechadas. Os dados foram coletados no período de 28 de janeiro a 14 de fevereiro de 2009, e analisados através do Programa Statical Package for the Social Sciences (SPSS) versão 13 for Windows e Microsoft Office Excel 2003. Os resultados apontaram que os trabalhadores de enfermagem desse hospital estão, em sua maioria, na faixa etária de 30-49 anos, com pelo menos 1 ano de atuação no mesmo setor e formaram-se há 15 anos ou mais, além disso, 68,1% são estatutários. Constatou-se que há recomendações da NR-32 e precauções-padrão não são seguidas pelos participantes da pesquisa. Os fatores que interferem no cumprimento da atual legislação vão desde o desconhecimento dos riscos ocupacionais e comportamento dos trabalhadores, até a falta de uma ação efetiva de Educação Continuada e da Comissão de Controle de Infecção Hospitalar (CCIH). Destacaram-se, entre outros, o uso de adornos (51,8%); calçado aberto (48,9%); alimentação no posto de trabalho (46,3%); uso da pia para outras finalidades (44,9%), reencape ou desconexão manual de agulhas (36,4%); sair do local de trabalho com uniforme ou Equipamento de Proteção Individual - EPI (21%); limite de recipiente de descarte de perfurocortantes não respeitado (11,8%), falta de uso de EPI quando auxilia no exame com Raios-X (32,6%) e na manipulação de quimioterápicos (7,8%). A instituição não fornece uniformes nem calçados. Outros fatores institucionais foram a falta de equipamentos, a falta de um política de prevenção e promoção da saúde, inexistência de serviço de saúde ocupacional e instalações físicas inadequadas. Tal descumprimento expõe, de forma excessiva, os trabalhadores de enfermagem aos mais variados fatores de riscos ocupacionais, podendo refletir na sua saúde e no processo de trabalho. Recomenda-se um trabalho efetivo e integrado dos Programas de Educação Continuada e CCIH para esclarecimento dos trabalhadores de enfermagem, e implantação do Serviço de Saúde do Trabalhador. Sugere-se aos gestores expandirem este estudo para os demais setores das unidades hospitalares e outras instituições públicas de saúde para o conhecimento da situação de trabalho, bem como a criação de espaços de discussão para a busca de soluções dos problemas com a participação dos trabalhadores.

Operacionalização das políticas de atenção ao idoso: um olhar avaliativo sobre algumas experiências no município do Rio de Janeiro

Diante do crescente envelhecimento populacional, a operacionalização das políticas de atenção à pessoa idosa torna-se um desafio. Há que se propor estratégias que possam melhor nortear as ações e serviços. Neste sentido, este trabalho propôs-se a avaliar algumas iniciativas em andamento no município do Rio de Janeiro, considerando o Projeto Longevidade e o Programa de Atenção Básica à Saúde do Idoso (PSI), desenvolvidos pela Secretaria Extraordinária de Qualidade de Vida (SEQV) e pela Gerência de Programas de Saúde do Idoso (GPI), respectivamente. Como parâmetros estruturantes da pesquisa foram considerados os pressupostos da análise de intervenção e, de modo a oferecer respaldo teórico para a avaliação proposta, as concepções de velhice e promoção de saúde defendidas pelos projetos foram ressaltadas sob a ótica da Gerontologia. O material empírico consistiu na análise do conteúdo de entrevistas semiestruturadas com os representantes dos projetos, objetivando configurar o direcionamento dado às ações desenvolvidas. O relato dos gestores pareceu denotar certa fragilidade estrutural, dificultadora da efetivação da assistência. Constatou-se, a partir da contextualização dos projetos, que mediante maior articulação interinstitucional e construção de espaços de discussão onde a velhice seja prioridade, o estabelecimento de estratégias em consonância com os princípios legais instituídos poderá tornar-se uma realidade.

Política Carioca Rindo a Toa e o Programa Saúde e Cidadania Dentescola: análise da política de saúde bucal no município do Rio de Janeiro e sua trajetória rumo à implementação considerando a interface com o Brasil Sorridente

A presente dissertação constituiu um estudo da política na Área de Saúde Bucal em um município de grande porte através dos seus processos - de formulação e implementação - seus atores e sua interface com a Política Nacional Brasil Sorridente. Tomando como referência a experiência do Rio de Janeiro no período de 2001 a 2006, optou-se por um estudo de caso por tratar-se de descrever a unidade a política - em profundidade e em detalhe. A condução de listas livres possibilitou um maior discernimento das mudanças político-organizacionais e principalmente de dois momentos consecutivos: a suposta centralidade da Saúde Bucal na agenda municipal com o decreto do Programa Saúde e Cidadania Dentescola e a oportunidade de se estabelecer uma política de Saúde Bucal contextualizada no acolhimento, no acesso e na universalidade da atenção. O processo de implementação da Política Carioca Rindo à Toa e do Programa Saúde e Cidadania Dentescola dependeu principalmente do aumento de recursos humanos e da aproximação desses com as propostas de Integralidade e Transversalidade.

A política pública Saúde da Família e a permanência fixação do profissional em medicina: um estudo de campo em Pernambuco

A proposta Saúde da Família surge em 1994, como um modelo assistencial com equipes multiprofissionais, visando à promoção, prevenção e assistência primária em Saúde. Em 2001 é lançado o PITS (Programa de Interiorização do Trabalho em Saúde), e mais recentemente o PROESF (Projeto de Expansão e Consolidação da Saúde da Família), em vigência até 2009, com verbas provenientes do governo federal e do BIRD, destinando-se à ampliação da atenção básica. A pesquisa objetiva trazer dados capazes de auxiliar a solução do problema da fixação dos profissionais de saúde no PSF. Elucidando dilemas, preenchendo a distância existente entre a Política Oficial da Saúde da Família e os recursos humanos, no caso, especificamente, o médico. Buscando contribuir, de maneira efetiva, com informações capazes de auxiliar o enfrentamento das questões do Sistema Público de Saúde.

Prevalence of overweight and obesity among nurses in Scotland: A cross-sectional study using the Scottish Health Survey.

Background Increasing prevalence of overweight and obesity represents a global pandemic. As the largest occupational group in international healthcare systems nurses are at the forefront of health promotion to address this pandemic. However, nurses own health behaviours are known to influence the extent to which they engage in health promotion and the public's confidence in advice offered. Estimating the prevalence of overweight and obesity among nurses is therefore important. However, to date, prevalence estimates have been based on non-representative samples and internationally no studies have compared prevalence of overweight and obesity among nurses to other healthcare professionals using representative data. Objectives To estimate overweight and obesity prevalence among nurses in Scotland, and compare to other healthcare professionals and those working in non-heath related occupations. Design Cross-sectional study using a nationally representative sample of five aggregated annual rounds (2008-2012) of the Scottish Health Survey. Setting Scotland. Participants: 13,483 adults aged 17 to 65 indicating they had worked in the past 4 weeks, classified in four occupational groups: nurses (n = 411), other healthcare professionals (n = 320), unqualified care staff (n = 685), and individuals employed in non-health related occupations (n = 12,067). Main outcome measures: Prevalence of overweight and obesity defined as Body Mass Index ≥ 25.0. Methods Estimates of overweight and obesity prevalence in each occupational group were calculated with 95% confidence intervals (CI). A logistic regression model was then built to compare the odds of being overweight or obese with not being overweight or obese for nurses in comparison to the other occupational categories. Data were analysed using SAS 9.1.3. Results 69.1% (95% CI 64.6,73.6) of Scottish nurses were overweight or obese. Prevalence of overweight and obesity was higher in nurses than other healthcare professionals (51.3%, CI 45.8,56.7), unqualified care staff (68.5%, CI 65.0,72.0) and those in non-health related occupations (68.9%, CI 68.1,69.7). A logistic regression model adjusted for socio-demographic composition indicated that, compared to nurses, the odds of being overweight or obese was statistically significantly lower for other healthcare professionals (Odds Ratio [OR] 0.45, CI 0.33,0.61) and those in non-health related occupations (OR 0.78, CI 0.62,0.97). Conclusions Prevalence of overweight and obesity among Scottish nurses is worryingly high, and significantly higher than those in other healthcare professionals and non-health related occupations. High prevalence of overweight and obesity potentially harms nurses’ own health and hampers the effectiveness of nurses’ health promotion role. Interventions are therefore urgently required to address overweight and obesity among the Scottish nursing workforce.

An investigation of the utilisation of health impact assessments (HIAs) in Irish public policy making

It is the aim of this thesis to investigate Health Impact Assessment (HIA) use in public policy formulation in Northern Ireland and in the Republic of Ireland. The influences affecting the use of HIAs will be examined in this study. Four case studies, where HIA has been conducted, will be used for research analysis. This includes HIAs conducted on traffic and transport in Dublin, Traveller accommodation in Donegal, a draft air quality action plan in Belfast and on a social housing regeneration project in Derry. HIA aims to identify possible intended and unintended consequences that a project, policy or programme will have on the affected population’s health. Although it has been acknowledged as a worthwhile tool to inform decision-makers, the extent to which it is used in policy in Ireland is subject to scrutiny. A theoretical framework, drawing from institutionalist, impact assessment and knowledge utilisation theories and schools of literature, underpin this study. The investigation involves an examination of the unit of analysis which consists of the HIA steering groups. These are made up of local authority decision makers, statutory health practitioners and community representatives. The overarching structure and underlying values which are hypothesized as present in each HIA case are investigated in this research. Chapters 2 and 3 outline the main literature in the area which includes theories from the public health and health promotion paradigm, the policy sciences and impact assessment techniques. Chapter 4 describes the methodology in this research which is a multiple case study design. This is followed by an analysis of the cases and then concludes with practical recommendations for HIA in Ireland and theoretical conclusions of the research.

Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda.

BACKGROUND: The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249-584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda. METHODS: Using census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities. RESULTS: Analysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery. CONCLUSIONS: The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.

The life of leaders: an intensive health program for clergy.

Clergy suffer from chronic disease rates that are higher than those of non-clergy. Health interventions for clergy are needed, and some exist, although none to date have been described in the literature. Life of Leaders is a clergy health intervention designed with particular attention to the lifestyle and beliefs of United Methodist clergy, directed by Methodist LeBonheur Healthcare Center of Excellence in Faith and Health. It consists of a two-day retreat of a comprehensive executive physical and leadership development process. Its guiding principles include a focus on personal assets, multi-disciplinary, integrated care, and an emphasis on the contexts of ministry for the poor and community leadership. Consistent with calls to intervene on clergy health across multiple ecological levels, Life of Leaders intervenes at the individual and interpersonal levels, with potential for congregational and religious denominational change. Persons wishing to improve the health of clergy may wish to implement Life of Leaders or borrow from its guiding principles.

Spousal concordance in health behavior change.

OBJECTIVE: This study examines the degree to which a married individual's health habits and use of preventive medical care are influenced by his or her spouse's behaviors. STUDY DESIGN: Using longitudinal data on individuals and their spouses, we examine changes over time in the health habits of each person as a function of changes in his or her spouse's health habits. Specifically, we analyze changes in smoking, drinking, exercising, cholesterol screening, and obtaining a flu shot. DATA SOURCE: This study uses data from the Health and Retirement Study (HRS), a nationally representative sample of individuals born between 1931 and 1941 and their spouses. Beginning in 1992, 12,652 persons (age-eligible individuals as well as their spouses) from 7,702 households were surveyed about many aspects of their life, including health behaviors, use of preventive services, and disease diagnosis. SAMPLE: The analytic sample includes 6,072 individuals who are married at the time of the initial HRS survey and who remain married and in the sample at the time of the 1996 and 2000 waves. PRINCIPAL FINDINGS: We consistently find that when one spouse improves his or her behavior, the other spouse is likely to do so as well. This is found across all the behaviors analyzed, and persists despite controlling for many other factors. CONCLUSIONS: Simultaneous changes occur in a number of health behaviors. This conclusion has prescriptive implications for developing interventions, treatments, and policies to improve health habits and for evaluating the impact of such measures.