Tine Tjørnhøj-Thomsen

The spirit of the intervention: reflections on social effectiveness in public health intervention research

This paper suggests that public health intervention research would benefit from more thorough considerations of the social dynamics in which public health interventions are embedded. Rather than simply asking ‘What works?’, researchers should examine the social effectiveness of intervention programmes; i.e. (i) the creation of shared understandings among researchers and practitioners and (ii) the ways in which programmes reconfigure social relationships. Drawing on the theoretical work of philosopher Charles Taylor and sociologist Marcel Mauss, we suggest that the term ‘the spirit of the intervention’ may enable researchers to further articulate – and hence discuss – the source of an intervention’s social effectiveness. The empirical impetus of the paper lies in our experiences as an interdisciplinary team of researchers, trained in social science and public health and now working within intervention research. We describe our attempts at reconciling the methodological requirements of an effect evaluation, modelled on the randomised clinical trial, with a process of intervention development grounded in ethnographic methods. In particular, we discuss how we have grappled with the schism between fidelity and adaptation, which is a key methodological issue in intervention research. While public health intervention research tends to conceptualise programmes as fixed and bounded entities, we argue that ‘the spirit of the intervention’ offers a conceptual starting point for reflections on programmes as on-going social processes. In order to capture and explore this dimension of public health interventions, a great deal of potential lies in a further engagement between intervention research, ethnographic methods and social theory.

What are the barriers to implementation of cardiopulmonary resuscitation training in secondary schools? A qualitative study

Objective Cardiopulmonary resuscitation (CPR) training in schools is recommended to increase bystander CPR and thereby survival of out-of-hospital cardiac arrest, but despite mandating legislation, low rates of implementation have been observed in several countries, including Denmark. The purpose of the study was to explore barriers to implementation of CPR training in Danish secondary schools. Design A qualitative study based on individual interviews and focus groups with school leadership and teachers. Thematic analysis was used to identify regular patterns of meaning both within and across the interviews. Setting 8 secondary schools in Denmark. Schools were selected using strategic sampling to reach maximum variation, including schools with/without recent experience in CPR training of students, public/private schools and schools near to and far from hospitals. Participants The study population comprised 25 participants, 9 school leadership members and 16 teachers. Results School leadership and teachers considered it important for implementation and sustainability of CPR training that teachers conduct CPR training of students. However, they preferred external instructors to train students, unless teachers acquired the CPR skills which they considered were needed. They considered CPR training to differ substantially from other teaching subjects because it is a matter of life and death, and they therefore believed extraordinary skills were required for conducting the training. This was mainly rooted in their insecurity about their own CPR skills. CPR training kits seemed to lower expectations of skill requirements to conduct CPR training, but only among those who were familiar with such kits. Conclusions To facilitate implementation of CPR training in schools, it is necessary to have clear guidelines regarding the required proficiency level to train students in CPR, to provide teachers with these skills, and to underscore that extensive skills are not required to provide CPR. Further, it is important to familiarise teachers with CPR training kits.

Recognition as care: a longitudinal study of Arabic immigrants’ experiences of diabetes training in Denmark

This longitudinal study provides critical insight into the social processes of municipal diabetes training for Arabic-speaking immigrants in Denmark focusing on participants’ experiences. Our study builds on observations of three diabetes courses and 36 interviews with participants at the start of, immediately following or 30–36 months after the courses. Lifestyle change and responsibility were dominant messages in the courses; over time and depending on their daily social context, participants selectively accepted and incorporated these messages. However, in retrospect, participants highlighted other meaningful benefits; these centred on reducing isolation and being met on their own terms regarding language and logistics. Most importantly, they remembered when treated with attention and respect by professionals and the mutual acknowledgement between participants. We use Axel Honneth’s notions of rights-based and solidarity-based recognition to analyse what was at stake in these experiences, and we engage Annemarie Mol’s concept of a logic of care to show how recognition unfolded practically during the training. We propose that participants’ wider social context and experiences of misrecognition situated the training experiences concerned with recognition. We also show exceptions. The sociality, which for some generated solidarity-based recognition, felt intimidating for others. We argue that the silent processes of recognition in the diabetes training carried significant meaning for participants, and that over time, many highlighted these as benefits rather than lifestyle change and responsibility.

‘Like a soccer camp for boys’. A qualitative exploration of gendered activity patterns in children’s self-organized play during school recess

Boys are more physically active than girls and the greatest gender difference in children’s physical activity is found in institutional settings such as school recess. However, research on gender relations, performances and practices that maintain gendered differences in physical activity during recess is still limited. Drawing on a qualitative dataset and a social constructivist gender view, the aim of this study was to investigate how construction of gendered activity patterns and social positions in the schoolyard lead to gendered practices in self-organized play during recess. At 17 Danish schools a total of 460 minutes of recess were observed and 17 go-along group interviews (one at each school), including in total 111 fourth graders (58 girls), were conducted. We found six gender typologies with varying behaviours, needs and power relations. The majority of children were prejudiced in their play, reinforcing gender binarism with boys being more physically active than girls. However, we also found groups such as soccer-playing girls and sedentary computer gaming boys who defied the gender stereotypes. These groups felt limited in their activities because of a hierarchy where not being skilled and sporty implied a lesser status in the hegemonic masculinity and even exclusion from play. More detailed research into what is required for particularly the least active groups is needed to successfully increase both the girls’ and overall physical activity levels.

Cardiopulmonary Resuscitation Training in Schools Following 8 Years of Mandating Legislation in Denmark: A Nationwide Survey

Background School cardiopulmonary resuscitation (CPR) training has become mandatory in many countries, but whether legislation has translated into implementation of CPR training is largely unknown. We assessed CPR training of students following 8 years of legislative mandates in Denmark. Methods and Results A nationwide cross‐sectional survey of Danish school leadership (n=1240) and ninth‐grade homeroom teachers (n=1381) was carried out for school year 2013‐2014. Qualitative interviews and the Theory of Planned Behavior were used to construct the survey. Logistic regression models were employed to identify factors associated with completed CPR training. Information from 63.1% of eligible schools was collected: 49.3% (n=611) of leadership and 48.2% (n=665) of teachers responded. According to teachers, 28.4% (95% CI 25.0% to 32.0%) and 10.3% (95% CI 8.1% to 12.8%) of eligible classes had completed CPR and automated external defibrillator training, respectively. Among leadership, 60.2% (95% CI 56.2% to 64.1%) reported CPR training had occurred during the 3 years prior to the survey. Factors associated with completed CPR training included believing other schools were conducting training (odds ratio [OR] 9.68 [95% CI 4.65‐20.1]), awareness of mandating legislation (OR 4.19 [95% CI 2.65‐6.62]), presence of a school CPR training coordinator (OR 3.01 [95% CI 1.84‐4.92]), teacher feeling competent to conduct training (OR 2.78 [95% CI 1.74‐4.45]), and having easy access to training material (OR 2.08 [95% CI 1.57‐2.76]). Conclusions Despite mandating legislation, school CPR training has not been successfully implemented. Completed CPR training was associated with believing other schools were conducting training, awareness of mandating legislation, presence of a school CPR training coordinator, teachers teacher feeling competent to conduct training, and having easy access to training material. Facilitating these factors may increase rates of school CPR training.

A qualitative study to identify barriers to deployment and student training in the use of automated external defibrillators in schools

BackgroundStudent training in use of automated external defibrillators and deployment of such defibrillators in schools is recommended to increase survival after out-of-hospital cardiac arrest. Low implementation rates have been observed, and even at schools with a defibrillator, challenges such as delayed access have been reported. The purpose of this study was to identify barriers to the implementation of defibrillator training of students and deployment of defibrillators in schools.MethodsA qualitative study based on semi-structured individual interviews and focus groups with a total of 25 participants, nine school leaders, and 16 teachers at eight different secondary schools in Denmark (2012–2013). Thematic analysis was used to identify regular patterns of meaning using the technology acceptance model and focusing on the concepts of perceived usefulness and perceived ease of use.ResultsSchool leaders and teachers are concerned that automated external defibrillators are potentially dangerous, overly technical, and difficult to use, which was related to their limited familiarity with them. They were ambiguous about whether or not students are the right target group or which grade is suitable for defibrillator training. They were also ambiguous about deployment of defibrillators at schools. Those only accounting for the risk of students, considering their schools to be small, and that time for professional help was limited, found the relevance to be low. Due to safety concerns, some recommended that defibrillators at schools should be inaccessible to students. They lacked knowledge about how they work and are operated, and about the defibrillators already placed at their campuses (e.g., how to access them). Prior training and even a little knowledge about defibrillators were crucial to their perception of student training but not for their considerations on the relevance of their placement at schools.ConclusionsIt is crucial for implementation of automated external defibrillators in schools to inform staff about how they work and are operated and that students are an appropriate target group for defibrillator training. Furthermore, it is important to provide schools with a basis for decision making about when to install defibrillators, and to ensure that school staff and students are informed about their placement.

Space, body, time and relationship experiences of recess physical activity: a qualitative case study among the least physical active schoolchildren

BackgroundIncreasing recess physical activity has been the aim of several interventions, as this setting can provide numerous physical activity opportunities. However, it is unclear if these interventions are equally effective for all children, or if they only appeal to children who are already physically active. This study was conducted to explore the least physically active children’s “lived experiences” within four existential lifeworlds linked to physical activity during recess: space, body, time, and relations.MethodsThe study builds on ethnographic fieldwork in a public school in Denmark using a combination of participatory photo interviews and participant observation. Thirty-seven grade five children (11–12 years old) were grouped in quartiles based on their objectively measured daily physical activity levels. Eight children in the lowest activity quartile (six girls) were selected to participate in the study. To avoid stigmatising and to make generalisations more reliable we further recruited eight children from the two highest activity quartiles (four girls) to participate.ResultsAn analysis of the least physically active children’s “lived experiences” of space, body, time and relations revealed several key factors influencing their recess physical activity: perceived classroom safety, indoor cosiness, lack of attractive outdoor facilities, bodily dissatisfaction, bodily complaints, tiredness, feeling bored, and peer influence.ConclusionWe found that the four existential lifeworlds provided an in-depth understanding of the least physically active children’s “lived experiences” of recess physical activity. Our findings imply that specific intervention strategies might be needed to increase the least physically active children’s physical activity level. For example, rethinking the classroom as a space for physical activity, designing schoolyards with smaller secluded spaces and varied facilities, improving children’s self-esteem and body image, e.g., during physical education, and creating teacher organised play activities during recess.

Implementing a free school-based fruit and vegetable programme: barriers and facilitators experienced by pupils, teachers and produce suppliers in the Boost study

BackgroundMulti-component interventions which combine educational and environmental strategies appear to be most effective in increasing fruit and vegetable (FV) intake in adolescents. However, multi-component interventions are complex to implement and often poorly implemented. Identification of barriers and facilitators for implementation is warranted to improve future interventions.This study aimed to explore implementation of two intervention components which addressed availability and accessibility of FV in the multi-component, school-based Boost study which targeted FV intake among Danish 13-year-olds and to identify barriers and facilitators for implementation among pupils, teachers and FV suppliers.MethodsWe conducted focus group interviews with 111 13-year-olds and 13 teachers, completed class observations at six schools, and conducted telephone interviews with all involved FV suppliers. Interviews were transcribed, coded and analysed using qualitative analytical procedures.ResultsFV suppliers affected the implementation of the FV programme at schools and thereby pupils’ intake through their timing of delivery and through the quality, quantity and variety of the delivered FV. Teachers influenced the accessibility and appearance of FV by deciding if and when the pupils could eat FV and whether FV were cut up. Different aspects of time acted as barriers for teachers’ implementation of the FV programme: time spent on having a FV break during lessons, time needed to prepare FV and time spent on pupils’ misbehaviour and not being able to handle getting FV. Teacher timing of cutting up and serving FV could turn into a barrier for pupils FV intake due to enzymatic browning. The appearance of FV was important for pupils’ intake, especially for girls. FV that did not appeal to the pupils e.g. had turned brown after being cut up were thrown around as a part of a game by the pupils, especially boys. Girls appreciated the social dimension of eating FV together to a larger extent than boys.ConclusionsLimited time and pupils’ misbehaviour were barriers for teachers’ implementation. Establishing FV delivery to schools as a new routine challenged FV suppliers’ implementation. Food aesthetics were important for most pupils’ FV intake while the social dimension of eating FV together seemed more important to girls than boys.Trial registrationCurrent Controlled Trials ISRCTN11666034.

Ambiguous expectations for intersectoral action for health: a document analysis of the Danish case

Abstract Ideas about intersectoral action and policy-making for health (ISA) are prominent among public health professionals. They are often presented as effective ways to address root causes of poor health and health inequality, and as such the best way to promote population health. The implementation of such ideas has proven difficult though. In this paper we argue that neo-institutional theory can help us conceptualize implementation challenges by pointing to implicit expectations and contradictions associated with the ISA idea itself. With Denmark as empirical case, we conducted a document analysis of recommendations for municipal ISA. The analysis shows how the recommendations provide a very abstract conceptualization of ISA that does not give much practical guidance for action. We show how ISA is discursively constructed with buzzword qualities as the natural way to organize health promotion, by being presented as a means to produce better quality services, more cost-effective operations and ensure the future of the welfare state, while at the same time hardly changing much at all. By applying the lens of institutional logics we show how ISA, although being vaguely defined, offer ambiguous normative and symbolic repertoires for action. We discuss the implementation challenges associated with this advocacy rhetoric and suggest that the domination of the corporation logic may appear to reduce the political character of ISA and potentially conflict with the ideals of health as a matter of social justice and human rights.

Lay bystanders' perspectives on what facilitates cardiopulmonary resuscitation and use of automated external defibrillators in real cardiac arrests

Background Many patients who suffer an out‐of‐hospital cardiac arrest will fail to receive bystander intervention (cardiopulmonary resuscitation [CPR] or defibrillation) despite widespread CPR training and the dissemination of automated external defibrillators (AEDs). We sought to investigate what factors encourage lay bystanders to initiate CPR and AED use in a cohort of bystanders previously trained in CPR techniques who were present at an out‐of‐hospital cardiac arrest. Methods and Results One‐hundred and twenty‐eight semistructured qualitative interviews with CPR‐trained lay bystanders to consecutive out‐of‐hospital cardiac arrest, where an AED was present were conducted (from January 2012 to April 2015, in Denmark). Purposive maximum variation sampling was used to establish the breadth of the bystander perspective. Twenty‐six of the 128 interviews were chosen for further in‐depth analyses, until data saturation. We used cross‐sectional indexing (using software), and inductive in‐depth thematic analyses, to identify those factors that facilitated CPR and AED use. In addition to prior hands‐on CPR training, the following were described as facilitators: prior knowledge that intervention is crucial in improving survival, cannot cause substantial harm, and that the AED will provide guidance through CPR; prior hands‐on training in AED use; during CPR performance, teamwork (ie, support), using the AED voice prompt and a ventilation mask, as well as demonstrating leadership and feeling a moral obligation to act. Conclusions Several factors other than previous hands‐on CPR training facilitate lay bystander instigation of CPR and AED use. The recognition and modification of these factors may increase lay bystander CPR rates and patient survival following an out‐of‐hospital cardiac arrest.