Citizens' digital footprints to support health promotion at the local level-PUHTI study, Finland

BACKGROUND

We aimed to explore to the possibilities of utilizing automatically accumulating data on health-owned for example by local companies and non-governmental organizations-to complement traditional health data sources in health promotion work at the local level.

METHODS

Data for the PUHTI study consisted of postal code level information on sport license holders, drug purchase and sales advertisements in a TOR online underground marketplace, and grocery sales in Tampere. Additionally, open population register data were utilized. An interactive reporting tool was prepared to show the well-being profile for each postal code area. Feedback from the tool's end-users was collected in interviews.

RESULTS

The study showed that buying unhealthy food and alcohol, selling or buying drugs, and participating in organized sport activities differed by postal code areas according to its socioeconomic profile in the city of Tampere. The health and well-being planners and managers of Tampere found that the new type of data brought added value for the health promotion work at the local level. They perceived the interactive reporting tool as a good tool for planning, managing, allocating resources and preparing forecasts.

CONCLUSIONS

Traditional health data collection methods-administrative registers and health surveys-are the cornerstone of local health promotion work. Digital footprints, including data accumulated about people's everyday lives outside the health service system, can provide additional information on health behaviour for various population groups. Combining new sources with traditional health data opens a new perspective for health promotion work at local and regional levels.

A qualitative study on multisector activities to prevent childhood obesity in the municipality of Seinäjoki, Finland

Background

Multisector activities are needed to prevent childhood obesity due to its multifactorial background. The first aim was to identify the activities that had been undertaken for obesity prevention and deduce their main targets. Second, we analyzed the public health policy approaches (upstream, midstream, and downstream) which were followed. Finally, we studied the perception of interviewees regarding their sectors’ roles in implementing the local obesity program.

Methods

Deductive content analysis was used to analyze semi-structured interviews with 34 key professionals (from seven administrative sectors) who had participated in multisector health promotion during 2009–2016 and five representatives of other core parties.

Results

Several midstream and upstream activities were targeted at making physical activity (PA) and healthy eating (HE) integral parts of children’s lifestyle. One long-term strategy was to create environments for PA accessible to every inhabitant and build and renovate the interiors and yards of schools and day-care centers. The healthiness of meals was increased progressively. In addition to midstream and upstream activities, as a downstream activity, an intervention targeting children at risk of obesity was implemented. The impact of management on the activities was considerable; childhood obesity prevention was included in the city strategy and systematically coordinated at the highest managerial level. Altogether, various sectors operated efficiently to promote obesity-preventing lifestyles; however, not all (important) sectors recognized their role in the multisector process.

Conclusion

Most of the activities to guide children towards obesity-preventing lifestyles were either at the midstream or upstream level. Among the latter, considerable work is aimed at creating opportunities to practice PA and making it a natural part of the daily life. The aim of familiarizing children with lifestyles that include PA and HE was shared across sectors, including sectors that had not yet acknowledged their role in obesity prevention. Strong support from city management and systematic coordination of the activity are important factors that contribute to the engagement of several administrative sectors in working towards a shared aim, such as the prevention of childhood obesity.

Dampness and student-reported social climate: two multilevel mediation models

BACKGROUND

Little previous research has analysed the relationship between schools' indoor air problems and schools' social climate. In this study, we analysed a) whether observed mould and dampness in a school building relates to students' perceptions of school climate (i.e. teacher-student relationships and class spirit) and b) whether reported subjective indoor air quality (IAQ) at the school level mediates this relationship.

METHODS

The data analysed was created by merging two nationwide data sets: survey data from students, including information on subjective IAQ (N = 25,101 students), and data from schools, including information on mould and dampness in school buildings (N = 222). The data was analysed using multilevel mediational models.

RESULTS

After the background variables were adjusted, schools' observed mould and dampness was not significantly related to neither student-perceived teacher-student relationships nor class spirit. However, our mediational models showed that there were significant indirect effects from schools' observed mould and dampness to outcome variables via school-level subjective IAQ: a) in schools with mould and dampness, students reported significantly poorer subjective IAQ (standardised β = 0.34, p < 0.001) than in schools without; b) the worse the subjective IAQ at school level, the worse the student-reported teacher-student relationships (β = 0.31, p = 0.001) and class spirit (β = 0.25, p = 0.006).

CONCLUSIONS

Problems in a school's indoor environment may impair the school's social climate to the degree that such problems decrease the school's perceived IAQ.

Students' school-level symptoms mediate the relationship between a school's observed moisture problems and students' subjective perceptions of indoor air quality

Moisture damage can influence the subjective assessment of indoor air quality (subjective IAQ) in various ways. We studied whether the frequency of symptoms reported across students at school level mediates the relationship between observed mold and dampness in a school building and students' subjective IAQ. To answer this research question, we tested a multilevel path model. The analyzed data were created by merging two nationwide data sets: (a) survey data from students, including information on subjective IAQ (N = 24,786 students); (b) data from schools, including information on mold and dampness in a school building (N = 222). After the background variables were adjusted, schools' observed mold and dampness were directly and significantly related to poor subjective IAQ (standardized beta (β)= 0.22, P = .002). In addition, in schools with mold and dampness, students reported significantly more symptoms (β = 0.22, P = .023) than in schools without; the higher the prevalence of symptoms at school level, the worse the students' subjective IAQ (β = 0.60, P < .001). This indirect path was significant (P = .023). In total, schools' observed mold and dampness and student-reported symptoms explained 52% of the between-school variance in subjective IAQ.

Multisector prevention of childhood obesity in a Finnish municipality - factors perceived as crucial

Background

Obesity among children threatens health and life expectancy. Risk factors interact in complex ways on individual, household, and community levels. Interventions on lifestyle factors have been targeted at children. Although some have impacted weight gain positively, environment and policy approaches by multiple actors across the society, especially when integrated in everyday life could have longer lasting effects. In Finland, multisector collaboration is enabled by several institutional structures, such as child welfare clinics and student welfare services. We studied in a municipality how administrative sectors and some key NGOs contributed to the prevention of childhood obesity, and particularly, which were the factors seen as potentially crucial.

Methods

The informants were purposely selected, being those, who had operated in the process of health promotion in the City of Seinäjoki (Finland) in 2009-2016. They represented several administrative sectors, either as office holders at the managerial level or as working at the operational level or in NGOs. In total, 37 participated (1 refusal) the semi-structured interviews, which were recorded, transcribed verbatim (355 pages), anonymized, and analyzed with deductive content analysis.

Results

There emerged six entities of factors crucial for obesity prevention: strong and long-term commitment to health promotion both at the administrative and executive levels; activity aiming at well-being of all inhabitants; a shared view of the importance of preventive work and multiprofessional collaboration; competent and development minded personnel, appropriate administrative structure and the strong leadership role of the health promotion coordinator; the light administrative structure of the Finnish municipality; convenient size of the municipality.

Conclusions

There was a shared opinion among the interviewees about the crucial elements of multisectoral collaboration for obesity prevention.

Key messages

Multisectoral collaboration and strong commitment to long-term activity both at the administrative and executive levels form key elements in the prevention of childhood obesity. A supportive administrative structure in a municipality together with strong coordination of health promotion are important prerequisites for the prevention of childhood obesity.

Impact of an intervention to activate unemployed people on the use of primary health care services

Background

Promoting well-being and health is a key policy instrument in municipalities. There are many ways to support the work ability of long-term unemployed people. Short term subsidized employment (300-500 €/person/month) being one widely used measure. The purpose was to study what kind of influence a short term employment has on the use of social and health care services of long-term unemployed people in sparsely populated area. Specifically, the aim was to investigate the use of primary health care services among people in subsidized employment, intervention (n = 67) and control group (n = 85) during five years period (2012-2016).

Methods

Individual-level data were extracted from registers (age: 19-65 years old, gender: 61 % men, 39 % woman, N = 152). The use of primary health care was examined in the case study by means of annual averages, cumulative percentages and regression analysis.

Results

According to preliminary results, there were differences in the prevalence of primary health care services use and how the use of services changed among intervention and control groups. The use of services in intervention group increased until the end of the intervention year, but decreased in the following year, 2016. The use of services in control group increased until 2016. Regression analysis was carried out to study the change; a year and an intervention for 2014-2016 were made as a predictor. It was found out that the number of visits increased each year by looking at both groups together (p = 0.012). The subsidized employment that started in 2014 had a statistically significant reducing effect on the use of services (p = 0.034) in intervention group in 2014-2016.

Conclusions

Municipalities’ health promotion and subsidized employment work can have positive impact on disadvantaged groups such as long-term unemployed people in sparsely populated area. Creating data for the use of services from local registers was very time consuming and challenging process, but possible.

Key messages

Promoting well-being and health is a key policy instrument in municipalities. Municipalities’ health promotion and subsidized employment work can have positive impact on disadvantaged groups such as long-term unemployed people in sparsely populated area.

Access to a school health nurse and adolescent health needs in the universal school health service in Finland

Universal school health services are expected to offer similar, needs‐based services to all students across schools, service providers and students’ socio‐economic statuses and health needs. This study investigates access to school health nurses in Finland. The objectives were to study the differences in access to school health nurse between service providers, schools, students’ characteristics and school health nurse resources. Access was examined through a nationwide School Health Promotion study, which is a self‐reporting, voluntary and anonymous survey for 8th and 9th graders (15 to 16‐year old, N = 71865). The ethical committee of the National Institute for Health and Welfare has approved procedure for the School Health Promotion study. Data on school health nurse resources and service providers were obtained from the national database (534 schools; 144 service providers). Multilevel logistic regression was used. Of the pupils, 15% of girls and 11% of boys reported difficult access to a school health nurse. The number of adolescents who reported difficult access ranged between service providers (0%–41%) and schools (0%–75%). Students with lower socio‐economic background, poorer well‐being at school, lack of support for studying and greater health needs reported difficult access more often. School health nurse resources were associated with difficult access only among boys, when resources were under the national recommendations. These findings raise concern about equality and unmet health needs in school health services.

Psychosocial Problems, Indoor Air-Related Symptoms, and Perceived Indoor Air Quality among Students in Schools without Indoor Air Problems: A Longitudinal Study

The effect of students' psychosocial problems on their reporting of indoor air quality (subjective IAQ) and indoor air-related (IA-related) symptoms has not been studied in schools in a longitudinal setting. Therefore, we analyzed whether changes in students' psychosocial problems (socioemotional difficulties and perceived teacher⁻student relations) between the beginning of seventh grade (age 12⁻13 years) and the end of ninth grade (15⁻16 years) predicted subjective IAQ and IA-related symptoms at the end of ninth grade. In order to explore the independent effect of psychosocial factors, we focused only on students in schools without observed indoor air problems. The analysis was of longitudinal data (N = 986 students) using latent change modelling. Increased socioemotional difficulties were related to more IA-related symptoms (standardized beta = 0.20) and deteriorated subjective IAQ (standardized beta = 0.20). Increased problems in teacher⁻student relations were related to deteriorated subjective IAQ (standardized beta = 0.21). Although students' psychosocial problems explained only 9⁻13% of the total variances, our findings support the notion that psychosocial factors also need to be taken into account in the evaluation of IAQ and the prevalence of IA-related symptoms in schools.

The comparative and objective measurement of health promotion capacity-building: from conceptual framework to operationalization

The aim of this study was to analyse and test a theoretical generic health promotion capacity-building framework with empirical data on primary health care. The framework consists of seven dimensions: commitment, management, monitoring and needs assessment, resources, common practices, participation and other core functions. The data were collected in 2014 from all the health centres in Finland, of which 156 (99%) submitted their data. The data were scored by the quality of activities on a scale from 0 to 100, where 100 stands for desirable quality. Individual indicators were nested into subdimensions, which in turn were nested into the dimensions of the theoretical framework. Variables were clustered using the dimensions and subdimensions as initial partitions. The internal consistency of dimensions and subdimensions was tested with standardized Cronbach's alpha both before and after the clustering analysis. The results showed that although the internal consistency of the dimensions was high in the initial classification, it is possible to get even more consistent dimensions. The internal consistency of the initial classification varied from 0.62 in participation to 0.93 in common practices. In the clustering analysis, 45 out of 203 indicators were assigned to a dimension different from the initial partition. The biggest gain in internal consistency was achieved in the subdimension of systematic mass communications by relocating two indicators. This study suggests that it is possible to assess the health promotion capacity-building of organizations in a coherent way with comparable and objective indicators. These analyses also show that the number of indicators can be reduced. It would be interesting to see how the framework works in other governmental structures or political contexts.

Indoor air problems and the perceived social climate in schools: A multilevel structural equation analysis

Indoor air problems in schools appear to influence learning outcomes and absence rates. However, previous research has not investigated whether indoor air problems influence the social climate of schools. Therefore, we studied whether indoor air problems observed in schools associate with students' perceptions of the teacher-student relationship and class spirit. The nationwide sample of Finnish schools (N=194 schools/27153 students) was analyzed using multilevel structural equation modeling. Data on the schools' social climate collected from students were merged with independently collected data on observed indoor air problems from school principals. We found that the teacher-student relationship was reported to be worse in schools with observed indoor air problems compared to those without observed indoor air problems. Furthermore, the reported class spirit was worse in schools with observed indoor air problems, but only among students with a high grade point average. Our findings indicate that indoor air problems may affect the student-perceived social climate.

Health in All Policies: From rhetoric to implementation and evaluation - the Finnish experience

The principles of the Health in All Policies (HiAP) approach are not new. Their international roots can be traced back to 1978 and the Alma-Ata Declaration and the 1986 Ottawa Charter. In Finland, the roots of HiAP go back to 1972 when the Economic Council of Finland, chaired by the Prime Minister, launched the 'Report of the working group exploring the goals of health'. The paper discusses the history, rationale, and implementation of the principles underlying the umbrella concept of HiAP. A rationale for implementing a new concept - HiAP in 2006 during the Finnish European Union presidency - is given. The focus here will be on implementation of HiAP. International material supporting the implementation is introduced and practical examples from Finland presented. The Benchmarking System for Health Promotion Capacity Building is introduced, since it has been used as a primary source of information for monitoring and evaluating HiAP in Finland at the local level. The experience from Finland clearly indicates that HiAP as an approach and as a way of working requires long-term commitment and vision. For working across sectors it is crucial to have data on health and health determinants and analyses of the links between health outcomes, health determinants, and policies across sectors and levels of governance. Intersectoral structures, processes, and tools for the identification of problems and solutions, decisions, and implementation across sectors are prerequisites of HiAP. Legislative backing has proven to be useful, especially in providing continuation and sustainability.

The associations of indoor environment and psychosocial factors on the subjective evaluation of Indoor Air Quality among lower secondary school students: a multilevel analysis

Subjective evaluation of Indoor Air Quality (subjective IAQ) reflects both building-related and psychosocial factors, but their associations have rarely been studied other than on the individual level in occupational settings and their interactions have not been assessed. Therefore, we studied whether schools' observed indoor air problems and psychosocial factors are associated with subjective IAQ and their potential interactions. The analysis was performed with a nationwide sample (N = 195 schools/26946 students) using multilevel modeling. Two datasets were merged: (i) survey data from students, including information on schools' psychosocial environment and subjective IAQ, and (ii) data from school principals, including information on observed indoor air problems. On the student level, school-related stress, poor teacher-student relationship, and whether the student did not easily receive help from school personnel, were significantly associated with poor subjective IAQ. On the school level, observed indoor air problem (standardized β = -0.43) and poor teacher-student relationship (standardized β = -0.22) were significant predictors of poor subjective IAQ. In addition, school-related stress was associated with poor subjective IAQ, but only in schools without observed indoor air problem (standardized β = -0.44).

Quality of the contraceptive service structure: a pilot study in Finnish health centre organisations

OBJECTIVES

To evaluate the quality of the contraceptive service structure in health centre organisations (HCOs) in western Finland and to establish whether the characteristics of the HCOs are associated with the quality measured.

METHODS

Survey data were collected from all HCOs in a university hospital area in western Finland (N = 63). Quality was evaluated using a score of ten indicators. Associations between the score and the characteristics of the HCOs were studied using rank correlation analysis and a multivariate ordered logit model.

RESULTS

Among 51 HCOs yielding complete data for the evaluation, the quality score ranged from 3 to 10, the mean being 5.8. From 25 variables studied, 'a chief nursing officer or leading nurse engaged in the HCO' (p = 0.001) and 'an appointed person responsible for management of health promotion' (p = 0.006) were found to be associated with a good score in the rank correlation analysis, and they also remained significant in multivariate analysis (Odds Ratio [OR] = 11.5, 95% confidence interval [CI] 2.3-56.5 and OR = 5.9, 95% CI 1.6-21.5, respectively).

CONCLUSIONS

In the majority of the HCOs involved, the quality of service structure was rated average, but there was much variation between the HCOs. The results of the multivariate analysis emphasise the importance of good management of services.

Health in all policies-the Finnish initiative: background, principles, and current issues

Many historical developments, such as the Alma Ata Declaration or the Ottawa Charter, have drawn attention to the need for intersectoral work and for considering the health aspects of different policy proposals. In the 1970s, Finland started broad actions to change national diets to reduce the high mortality associated with cardiovascular diseases (CVDs). This and other work in Finland have involved many sectors and policies, resulted in significant public health improvements, and paved the way for the Health in All Policies (HiAP) initiative started during the Finnish European Union (EU) presidency in 2006. The initiative and the principles have encouraged further developments in Finland and have been linked with related developments within the EU and the World Health Organization (WHO).

From innovation to practice: initiation, implementation and evaluation of a physician-based physical activity promotion programme in Finland

In 2001, a collaborative Physical Activity Prescription Programme (PAPP) was started in Finland to increase physical activity (PA) counselling among physicians, especially in primary care. This article describes the initiation, implementation and evaluation of PAPP. Five actions were implemented to reach the programme goal: (i) developing a counselling approach for physicians; (ii) providing easy and open access to counselling material; (iii) facilitating physicians' uptake and adoption of the counselling approach; (iv) disseminating information about the counselling approach to physicians, health and exercise professionals and decision-makers and (v) raising financial resources to cover programme expenses. Evaluation was based on the dimensions of the RE-AIM framework: reach, effectiveness, adoption, implementation and maintenance. Effectiveness and adoption were evaluated with two questions added to the annual survey of the Finnish Medical Association to all practising physicians in the year 2002 (n = 16 692) and 2004 (n = 17 170). The 4-year PAPP was successful in reaching health care units (Reach), accomplishing most of the implementation actions (Implementation) and initiating local projects for institutionalizing the prescription-based counselling approach, 'Prex' (Maintenance). However, at the national level, the programme was not effective in increasing the frequency of asking about patients' PA habits (Effectiveness) or the frequency of using 'Prex' or other written material in PA counselling among physicians (Adoption). To improve the latter two, the duration of the programme would have had to be extended with more effort at strengthening physicians' confidence in PA counselling and knowledge about its effectiveness. Also, a more systematic approach would have been necessary to facilitate inter-sectoral network for adopting 'Prex' as a counselling tool at the local level.

The importance of policy orientation and environment on physical activity participation--a comparative analysis between Eastern Germany, Western Germany and Finland

Environmental and policy interventions are seen as boosting physical activity because they are designed to influence large groups. However, they have not been much researched and the evidence on their role is still quite limited. The purpose of this study was to investigate differences in and relationships between policy orientation, the objective and perceived physical environment, and physical activity between Finland, Eastern Germany and Western Germany. The data are taken from a public telephone survey carried out as part of the international MAREPS project (Methodology for the Analysis of Rationality and Effectiveness of Prevention and Health Promotion Strategies; Eastern Germany, n = 913; Western Germany, n = 489; Finland, n = 400), statistics of sports facilities and policy documents. Results from the survey showed that Finns are more active than Germans and that they differ in their way of practising physical activity from Germans. Finns were more satisfied with their opportunities for physical activity and were better informed about physical programmes and measures. Finland also has the best opportunities in indoor sports facilities and outdoor sports grounds per number of inhabitants (excluding indoor swimming pools). Analysis of policy orientations showed that Finland had the most extensive 'Sport for All' policy, although West Germany's policy orientation did not differ that much from Finland's. East Germany's policy orientation was characterized by competitive sports. A policy orientation that places emphasis on the physical activity of the whole population seems to be related to better opportunities and a better infrastructure for sports and physical activity. This study suggests that there is a relationship between policy orientation, physical environment and physical activity participation.

[Health promotion by sports and physical activity: politics, behavior and infrastructures in a European comparison]

OBJECTIVES

The focus of physical activity promotion is moving from measures to increase health-enhancing physical activity on the individual level to higher-level strategies including policy and environmental approaches. Scientific evidence, traditionally related to individual-based strategies, calls for adaptation and refinement when environmental and policy changes become more relevant.

METHODS

This paper investigates differences in physical activity promotion and public policy among six European countries. Data from a European study on public health promotion policy and health behaviours (MAREPS) is analysed to study behaviour, community-based opportunities for physical activity, and populations' perception of the effectiveness of their national policies in promoting physical activity.

RESULTS

Analyses show significant differences in both involvement in and perceived opportunities for physical activity among the investigated countries. Populations in Finland, Switzerland, and The Netherlands show comparably higher participation and, at the same time, perceive better opportunities for physical activity within the residential environment than people in East Germany, Belgium, and Spain. Moreover, respondents from the former group of nations report considerably greater contribution of health policy in their country to the promotion of physical activity than respondents from the latter group.

CONCLUSIONS

In conclusion, the results provide empirical support for the significance of environmental and policy approaches with regard to physical activity. Opportunities created by implementing such approaches may enable populations to develop more active lifestyles conducive to health. Further research employing longitudinal designs could be especially helpful to explore the causalities of the relationship between policy, environment and physical activity.

The importance of the social environment for physically active lifestyle--results from an international study

Physically active lifestyles are regularly associated with improved health and quality of life. Differences in lifestyles in society can partly be understood through the differences in the social and physical environment. This study examines the relationships between reported physical activity, and the extent of perceived support for physical activity in the physical and policy environment (e.g. facilities, programmes and other opportunities), and in the social environment. The data for the study come from a cross-cultural health policy study called MAREPS. In total, 3342 adults, 18 years or older, from six countries (Belgium, Finland, Germany, The Netherlands, Spain, Switzerland) were interviewed via telephone. Respondents were categorised as active or inactive according to self-reported physical activity. Social environmental factors and physical and policy environmental factors were also assessed. The analysis of the data was informed by social cognitive theory, although the study was not originally designed for this purpose. Sixty-eight percent of females and 70% of males were active. The proportions of active and inactive varied by countries to a great extent. The strongest independent predictor of being physically active was social environment. Those who perceived low social support from their personal environment (i.e. family, friends, school and workplace) were more than twice as likely to be sedentary compared to those who reported high social support from their personal environment. Specific knowledge of the programmes and actions for physical activity and sport was also a strong predictor of being active. A supportive physical and policy environment was not associated with participation in physical activity as strongly as had been anticipated. The variation between countries was stronger predictor of being active than the physical and policy environment variables. This study generates the hypotheses and raises the questions that in a preliminary way, there appears to be some relationships between aspects of physical and social environment and physical activity participation. However, future research is needed to refine and clarify this.

The MuPSi project--a learning environment for multiprofessional collaboration

Students studying for different professions within the field of health care need to practice both multiprofessional collaboration and use of HIS and EPR software. The MuPSi concept utilizes computer-mediated communication to provide students access to a EPR software to enable the students to act collaboratively as members of a virtual health care team. The students are given a fictive patient case and use the EPR software to plan and document the care they provide. In order to achieve a higher grade of authenticity the case is presented as segments--the teachers direct the simulation by recording events that change the situation into the patient record.