Strategier i kommunal helse- og omsorgstjeneste. Statlige styringsinstrumenter og lokale tilpasninger

Master i styring og ledelseSamhandlingsreformen brakte med seg føringer for statlige og kommunale helsetjenester, for å oppnå bedre koordinering mellom tjenestene. Flere politiske virkemidler ble tatt i bruk for å oppnå ønsket effekt med reformen og kommunene måtte respondere på dette innenfor de ressurser og det handlingsrom de hadde og ofte er bedre samhandling presentert som en strategi og en løsning for å redusere det offentliges ressursbruk. Dette utgjør bakteppet for min undersøkelse om strategier for koordinering av den kommunale helse- og omsorgstjenesten. Undersøkelsen beskriver de strategier jeg fant og belyser faktorer som kan ha hatt betydning for hvordan to kommuner har valgt å svare ut kravene om bedre koordinering. Undersøkelsen er en kvalitativ, komparativ casestudie med en kombinasjon av dokumentanalyse og semistrukturerte intervjuer. De to undersøkte kommuner er Nedre Eiker og Røyken (forkortet NE og R). Resultatene viser at kommunene har tatt i bruk virkemidler utledet i Samhandlingsreformen, slik som KAD, samarbeidsavtaler og samarbeidsmøter. De styringsinstrumenter jeg fant hyppigst benyttet for å koordinere helse- og omsorgstjenesten, var de strukturelle virkemidlene. Møtestrukturer, samlokalisering av ulike tjenester, kompetanseheving og teknologisk utvikling, er hva de observerte kommunene gjør mest av for å koordinere. Imidlertid viser to tilsynelatende like kommuner i stor grad variasjoner i sine strategier for koordinering av helse- og omsorgstjenesten. Dette understøtter at lokale forhold og det kommunale handlingsrommet har betydning for de strategiene som tas i bruk. Resultatene fra både dokumentanalysen og intervjuene gir inntrykk av at R har omfattende bruk av systematisk nedskrevne planer og bruk av virksomhetsanalyser. NE har i stor grad strategiske tiltak ved bruk av velferdsteknologiske løsninger, pakkeforløp for personer i korttids døgnopphold og stort fokus på tjenester i hjemmet. NE begrunner liten bruk av virksomhetsanalyser og strategisk og systematisk planarbeid med at de ikke har ressurser til dette. Min konklusjon er at svekket økonomisk handlingsrom gjør at NE omgir seg med strategier som tar utgangpunkt i konkrete handlinger ute i tjenesten, heller enn administrativt strategisk planarbeid.According to the Norwegian Coordination Reform the levels between state- and municipal health services had to be improved. Several political instruments were used to achieve the desired goals of the reform and municipalities had to respond to this within the framework presented. In addition collaboration is often presented as a strategy and solution to reduce public resource utilization. Following the coordination of the municipal primary health and care sevices, this paper presents a survey from two municpalities and the results on how these municipalties have solved the matter of 'better' coordination. The survey is a qualitative, comparative case study, with a combination of document analysis and semistructured interviews. The municipalities studied are Nedre Eiker and Røyken (accordingly NE and R). The results of the survey conducted shows that the two municipalities had many similar strategies for coordinating primary health- and care services. Both municipalities had taken advantage from governmental incentives to implement the reform. Meeting activities were a frequent means of coordination. Both had similar cooperation with the specialist healthcare, and both used inter-municipal cooperation. On the matter of variations, the study revealed that NE had goals affected by budget balance. R's goals were more detail oriented and they used several business analyses to develop goals, focus areas, plans and strategies. While NE only had statutory plans as municipal plan and budget, R had several recorded strategies for their primary health- and care services. Where R had several written strategies, NE demonstrated more strategic actions using welfare technology and training citizens in managing aging and one's own health. The largest variations were found in financial resources allocated in the budget to primary health- and care services, where the survey showed that NE deposited about 100 million (NOK) more than R. Based on the results I have concluded that the municipalities scope of action has affected how the two municipalities carry out strategic work, and that the municipal scope of action has been more important than the political incentives used in the reform.publishedVersio

Utilizing small nutrient compounds as enhancers of exercise-induced mitochondrial biogenesis.

Endurance exercise, when performed regularly as part of a training program, leads to increases in whole-body and skeletal muscle-specific oxidative capacity. At the cellular level, this adaptive response is manifested by an increased number of oxidative fibers (Type I and IIA myosin heavy chain), an increase in capillarity and an increase in mitochondrial biogenesis. The increase in mitochondrial biogenesis (increased volume and functional capacity) is fundamentally important as it leads to greater rates of oxidative phosphorylation and an improved capacity to utilize fatty acids during sub-maximal exercise. Given the importance of mitochondrial biogenesis for skeletal muscle performance, considerable attention has been given to understanding the molecular cues stimulated by endurance exercise that culminate in this adaptive response. In turn, this research has led to the identification of pharmaceutical compounds and small nutritional bioactive ingredients that appear able to amplify exercise-responsive signaling pathways in skeletal muscle. The aim of this review is to discuss these purported exercise mimetics and bioactive ingredients in the context of mitochondrial biogenesis in skeletal muscle. We will examine proposed modes of action, discuss evidence of application in skeletal muscle in vivo and finally comment on the feasibility of such approaches to support endurance-training applications in humans

The effect of different training modes on skeletal muscle microvascular density and endothelial enzymes controlling NO availability

It is becoming increasingly apparent that a high vasodilator response of the skeletal muscle microvasculature to insulin and exercise is of critical importance for adequate muscle perfusion and long-term microvascular and muscle metabolic health. Previous research has shown that a sedentary lifestyle, obesity, and ageing lead to impairments in the vasodilator response, while a physically active lifestyle keeps both microvascular density and vasodilator response high. To investigate the molecular mechanisms behind these impairments and the benefits of exercise training interventions, our laboratory has recently developed quantitative immunofluorescence microscopy methods to measure protein content of eNOS and NAD(P)Hoxidase specifically in the endothelial layer of capillaries and arterioles of human skeletal muscle. As eNOS produces NO and NAD(P)Hoxidase superoxide anions (quenching NO) we propose that the eNOS/NAD(P)Hoxidase protein ratio is a marker of vasodilator capacity. The novel methods show that endurance training (ET) and high intensity interval training (HIT) generally regarded as a time efficient alternative to ET, increase eNOS protein content and the eNOS/NADP(H) oxidase protein ratio in previously sedentary lean and obese young men. Resistance exercise training had smaller but qualitatively similar effects. Western blot data of other laboratories suggest that endurance exercise training leads to similar changes in sedentary elderly men. Future research will be required to investigate the relative importance of other sources and tissues in the balance between NO and O2- production seen by the vascular smooth muscle layer of terminal arterioles

Muscle fiber-type distribution predicts weight gain and unfavorable left ventricular geometry: a 19 year follow-up study

BACKGROUND: Skeletal muscle consists of type-I (slow-twitch) and type-II (fast-twitch) fibers, with proportions highly variable between individuals and mostly determined by genetic factors. Cross-sectional studies have associated low percentage of type-I fibers (type-I%) with many cardiovascular risk factors. METHODS: We investigated whether baseline type-I% predicts left ventricular (LV) structure and function at 19-year follow-up, and if so, which are the strongest mediating factors. At baseline in 1984 muscle fiber-type distribution (by actomyosin ATPase staining) was studied in 63 healthy men (aged 32–58 years). The follow-up in 2003 included echocardiography, measurement of obesity related variables, physical activity and blood pressure. RESULTS: In the 40 men not using cardiovascular drugs at follow-up, low type-I% predicted higher heart rate, blood pressure, and LV fractional shortening suggesting increased sympathetic tone. Low type-I% predicted smaller LV chamber diameters (P ≤ 0.009) and greater relative wall thickness (P = 0.034) without increase in LV mass (concentric remodeling). This was explained by the association of type-I% with obesity related variables. Type-I% was an independent predictor of follow-up body fat percentage, waist/hip ratio, weight gain in adulthood, and physical activity (in all P ≤ 0.001). After including these risk factors in the regression models, weight gain was the strongest predictor of LV geometry explaining 64% of the variation in LV end-diastolic diameter, 72% in end-systolic diameter, and 53% in relative wall thickness. CONCLUSION: Low type-I% predicts obesity and weight gain especially in the mid-abdomen, and consequently unfavourable LV geometry indicating increased cardiovascular risk

New relative intensity ambulatory accelerometer thresholds for elderly men and women: the Generation 100 study

BACKGROUND: Public health initiatives world-wide recommend increasing physical activity (PA) to improve health. However, the dose and the intensity of PA producing the most benefit are still debated. Accurate assessment of PA is necessary in order to 1) investigate the dose–response relationship between PA and health, 2) shape the most beneficial public health initiatives and 3) test the effectiveness of such initiatives. Actigraph accelerometer is widely used to objectively assess PA, and the raw data is given in counts per unit time. Count-thresholds for low, moderate and vigorous PA are mostly based on absolute intensity. This leads to largely inadequate PA intensity assessment in a large proportion of the elderly, who due to their declining maximal oxygen uptake (VO(2max)) cannot reach the moderate/vigorous intensity as defined in absolute terms. To resolve this issue, here we report relative Actigraph intensity-thresholds for the elderly. METHODS: Submaximal-oxygen-uptake, VO(2max) and maximal heart rate (HR(max)) were measured in 111 70–77 year olds, while wearing an Actigraph-GT3X+. Relationship between VO(2max) percentage (%), counts-per-minute (CPM) and gender (for both the vertical-axis (VA) and vector-magnitude (VM)) and VO(2max)% and HR(max)% was established using a mixed-regression-model. VM-and VA-models were tested against each other to see which model predicts intensity of PA better. RESULTS: VO(2max) and gender significantly affected number of CPM at different PA intensities (p < 0.05). Therefore, intensity-thresholds were created for both men and women of ranging VO(2max) values (low, medium, high). VM-model was found to be a better predictor of PA-intensity than VA-model (p < 0.05). Established thresholds for moderate intensity (46−63 % of VO(2max)) ranged from 669–3367 and 834–4048 CPM and vigorous intensity (64−90 % of VO(2max)) from 1625–4868 and 2012-5423CPM, for women and men, respectively. Lastly, we used this evidence to derive a formula that predicts customized relative intensity of PA (either VO(2max)% or HR(max)%) using counts-per-minute values as input. CONCLUSION: Intensity-thresholds depend on VO(2max), gender and Actigraph-axis. PA intensity-thresholds that take all these factors into account allow for more accurate relative intensity PA assessment in the elderly and will be useful in future PA research. TRIAL REGISTRATION: (ClinicalTrials.gov Identifier: NCT02017847, registered 17. December 2013

Gender differences in the physiological responses and kinematic behaviour of elite sprint cross-country skiers

Gender differences in performance by elite endurance athletes, including runners, track cyclists and speed skaters, have been shown to be approximately 12%. The present study was designed to examine gender differences in physiological responses and kinematics associated with sprint cross-country skiing. Eight male and eight female elite sprint cross-country skiers, matched for performance, carried out a submaximal test, a test of maximal aerobic capacity (VO2max) and a shorter test of maximal treadmill speed (Vmax) during treadmill roller skiing utilizing the G3 skating technique. The men attained 17% higher speeds during both the VO2max and the Vmax tests (P < 0.05 in both cases), differences that were reduced to 9% upon normalization for fat-free body mass. Furthermore, the men exhibited 14 and 7% higher VO2max relative to total and fat-free body mass, respectively (P < 0.05 in both cases). The gross efficiency was similar for both gender groups. At the same absolute speed, men employed 11% longer cycles at lower rates, and at peak speed, 21% longer cycle lengths (P < 0.05 in all cases). The current study documents approximately 5% larger gender differences in performance and VO2max than those reported for comparable endurance sports. These differences reflect primarily the higher VO2max and lower percentage of body fat in men, since no gender differences in the ability to convert metabolic rate into work rate and speed were observed. With regards to kinematics, the gender difference in performance was explained by cycle length, not by cycle rate

Integrering i den finske og den norske skolen En analyse av de lange utdanningspolitiske styringslinjene

Sammendrag Mange land har introdusert sammenlignbare mål for vurdering i stor skala. De forutsetter kartlegging av elever, skoler og lærere gjennom blant annet nasjonale prøver, standardiserte tester som ansvarliggjør lærere gjennom offentliggjøring av sammenligninger mellom skoler. Hva har så finsk spesialundervisning med dette systemet å gjøre? Finland skiller seg fra andre land som har utviklet omfattende vurderingssystemer som er laget for å ansvarliggjøre lærere i det offentlige rom. Samtidig fremkommer det av forskning at Finland kan vise til langt bedre PISA-resultater enn land som bruker standardiserte tester som et styringsverktøy (Sørreime, 2012). Finland er dessuten det landet hvor det er minst sprik i karakterene mellom de sterkeste og svakeste elevene. Dessuten får mange elever tidlig støtteundervisning/spesialundervisning dersom de ikke klarer å følge tempoet i den normale undervisningen. Men det er også en mørkere side ved de finske elevenes skolehverdag. I Dagbladet skriver Hølleland (2008) at elevtrivselen i Finland ikke er like høy som i Norge, trass i at de har færre skoletimer per uke og lengre ferie enn norske elever. I 2013 kunne vi lese at Finland hadde en kultur for segregering som form av egne skoler for evneveike På bakgrunn av denne dystre statistikken har finske myndigheter endret skoleloven for å øke den indre differensieringen, som vil si at elevene gis ekstra støtte på skolen i sitt nærmiljø Det er derfor interessant å finne ut av hvilke føringer som ligger i finske styringsdokumenter vedrørende spesialundervisning, som er forskjellig fra de nye tendensene som preger politikkutformingen på området. I denne oppgaven har jeg oppsummert forskning og analysert utdanningspolitiske dokumenter om tilpasset opplæring og støtteundervisning i Finland og Norge. Jeg har også oppsummert generelle tendenser basert på offisielle statistikk som kan si noe om i hvilken grad Finland har sikret faglig og sosial integrering blant elevene med indre differensiering som utgangspunkt. Ettersom indre differensiering er et sentralt fagbegrep i oppgaven, vil jeg vise til hva det innebærer med utgangspunkt i Wolfgang Klafkis teori (Klafki, 2016). Analysen min viser at den finske skolen fungerer bra på flere punkter fordi likhetsidealer ivaretas gjennom et enhetlig styringssystem og et strengt regulert lovverk som ivaretar sosial og faglig integrering. For det første er eierskapet til skolene i all hovedsak statlige i Finland, til forskjell fra i Norge der mye ansvar er desentralisert. Styringen av den finske skolen er hierarkisk og de faste rammene som ny forskning og reformideer må innordne seg etter, er støttet av over 90 prosent av landets velgere (Sahlberg, 2013b). Styringen av den norske skolen er mer desentralisert og fragmentert – og samarbeidskulturen i systemet har vesentlige svakheter. De norske lovene og forskriftene representerer en svakere byråkratis-profesjonell koordinering av sosial og faglig integreringspraksis. Det har paradoksalt sett medført økte kontroller, konkurranse og en ansvarligjøring av skoler og lærere i Norge. En slik praksis kan sikre enkeltes rettigheter, men gå på bekostning av fellesskapende løsninger som sikrer faglig og sosial integrering. Den faglige forankringen i finske styringsdokumenter og finsk forskning er i stor grad bestemt av lærerstanden og profesjonsfaglige interesser som sikrer det autonome fagfeltet. Den tilsvarende faglige forankringen i Norge er i stor grad influert av politikere og faggrupperingeringer som har til dels ulike syn på integrering og måter å ivareta elever med ulike behov. Det fører til at beslutningsprosessene i det finske utdanningssystemet preges av et godt samarbeid mellom staten og lærerstanden. I Norge synes det å være andre betingelser for organisering og samarbeid om elver med spesielle behov. Sammenliknet med Finland, synes den formålsorienterte integreringskulturen å være mindre fremtredende