1. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori OPPORTUNITIES FOR PHYSICAL ACTIVITY PROMOTION IN PRIMARY HEALTH CARE FOR CHILDREN AS PERCEIVED BY THE FINNISH PUBLIC HEALTH NURSES PHD TARJA JAVANAINEN-LEVONEN

2. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Background: Physical activity (PA), as one of health determinants, has become a global issue in health promotion – even in early childhood. PA is a concern for health care for all age groups because of its preventative and promotive nature. (Cavill et al. 2006; European Commission 2007, 7; WHO 2007.) Child health clinic (CHC) service represents primary health care based on family nursing practice with scheduled check-ups with every child under the school-age (i.e.,7 years). The aim is to promote the health and general well-being of the child and the family. Public health nurses (PHNs) are considered in Finland as the most important resource in the team of health professionals in CHC. Therefore, this qualitative research aims to shed some light on the important role of PHNs in physical activity promotion as part of total child and family health care in Finland. In this particular context, it reflects experiences in professional practice in primary care.

3. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Research questions: 1.What are the facilitators for physical activity promotion in CHC? 2.What are the restrictors of physical activity promotion in CHC? 3.What are PHNS’ developmental ideas concerning physical activity promotion in CHC?

4. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Methods: The data were gathered by five regional focus groups (FG). Topic quide is demonstrated in Table 1. Deliberate sampling was carried out in Satakunta Region. Finally, CHCs in 8 municipalities out of 24 were selected based on the characteristics of the municipality (number of inhabitants, urban/suburban and rural areas included, the number of PHNs working in certain area 6-8). Verbatim transcripts were analysed by qualitative content analysis by categorizing PHNs´ statements dealing with the research questions. The qualitative analysis was complemented by simple counting of frequencies of statements in order to highlight the factors mostly emphasized in FGs. In research findings, this emphasis is described by an index: (e.g. 4 - 12% - statements falling into the certain category were addressed in 4 focus groups, and the percentage of the statements was 12% out of all statements for the specific research question)

5. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Table 1. Topic guide with main questions (Krueger and Casey, 2000; Morgan, 1997) in focus groups Topics and main questions Physical activity promotion in daily routines of public health nurses in child health clinics – general approach “How is physical activity promotion of the child manifested in your daily routines?” Challenges for physical activity promotion according to a preliminary research (Javanainen-Levonen et al. 2003) – more detailed approach “How is [the following theme] manifested in your daily routines?” Assessment of motor development Assessment of physical activity Activation of physical activity Exercise counselling Collaboration “How would [theme under discussion] be manifested at its best?” “What are the restrictors of this?”

6. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Table 2. Characteristics of the ”experienced” sample (N = 24) Background informationn% Local recruitment of PHNs Small rural municipality Middle-sized municipality City center of a big municipality Residential surburb of a big municipality (* 92.3% out of all PHNs working in the CHCs of the recruitment area) 75667566 29 21 25 Gender Female24100 Age 31-40 years 41-50 years ! 51-50 years (Mean 46.2 years) 4 16 4 17 66 17 Working experience 3 years or less 4-10 years 11-17 years ! 18-24 years 25 years or more (Mean 13.9 years) 3 2 12 6 1 13 8 50 25 4 Professional training Nurse PHN 20 24 83 100 PE lessons/sports scientific training ! Included in nursing training ! Included in PHN training ! 20 9 83 38

7. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Results: Firstly, the results will be demonstrated according to the research questions. In this context, even the statements mentioned only in one FG will be reported. Later on (Table 3.) the results are collated in one table demonstrating those issues PHNs emphasized most in discussions. Therefore, only the issues brought up at least in four FGs will be reported.

8. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Facilitators (N=85 statements) The nature of daily work in CHC (40%): - population principle (5 - 21%); including individual knowledge of clients particularly announced in the rural groups - the number of scheduled check-ups (3 - 11%) - regular assessment and documentation of motor development, strategies focusing on physical activity The personal characteristics and abilities of the PHN (33%): - PHN as a local worker (4 - 11%) - PHN´s activity in searching for information and knowledge of service- delivery in PA, PHN´s attitude towards PA and PHN´s own PA, length of work experience in CHC Collaboration and information on service delivery (27%): - PA organisers (4 - 11%) - day-care centre, health care actors

9. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Restrictors (N=81 statements) The personal characteristics and abilities of the PHN (47%) -- the limited knowledge on PA and service-delivery in PA (4 - 22%) -- scepticism about the effects of counselling (4 - 20%) -- readiness for electronic searches and documentation The nature of daily work in CHC (36.5%) - time and material resources (4 - 12%) - difficulties in assessing motor development, deficiency in documentation and in transfer of information, wide scope of duties, obscurity of referral practices, shortage of check-ups in toddler age Collaboration and information on service delivery (16.5%) - insufficient information on service-delivery in PA (3 - 11%) - resources for collaboration, heavy work load

10. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Developmental ideas (N=75 statements) The nature of daily work in CHC (45%) -- documentation concerning PA of the child and the family as well as motor - development of the child (4 - 17%) - production of material (3 - 15%) - integration of PA to community oriented methods, clarification of referral systems Collaboration and information on service delivery (39%) -- better information and coordination of service-delivery in PA (4 - 32%) -- PA as part of collaborative events The personal characteristics and abilities of the PHN (16%) - interaction skills (e.g., courage, inspiration), systematization of work, better argumentation, development of basic and in-service training of PHNs

11. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Table 3. Determinants of promotion showing the most emphasized issues with specific focus on collaboration Main categoryFACILITATORS (n=85 statements) % RESTRICTORS (n=81 statements) % DEVELOPMENTAL IDEAS (n=75 statements) % THE PERSONAL CHARACTERISTICS AND ABILITIES OF PHNS -PHN as a local worker 4 – 11% * -Activity 5 – 8% -Attitude and physical activity 4 – 8% 33-Limited knowledge on PA and service delivery in PA 4 – 22% -Scepticism about counselling 4 – 20% 4716 THE NATURE OF DAILY WORK IN CHC -Population principle 5 – 21% 40-Time and material resources 4 – 12% -Difficulties in assessment of motor development 4 – 4% 36-Documentation 4 – 17% -Integration of PA to community oriented working methods 4 – 9% 45 COLLABORATION INCLUDING INFORMATION ON SERVICE DELIVERY IN PA -PA service providers 4 - 11% -Day care services 5 – 8% -Health care professionals 4 – 8% 27-Insufficient information on services -Resources for collaboration 17-Coordination of information on service delivery in PA within health care and dissemination of information 4 – 32% 39 * Number of groups (max. 5) with statements concerning the specific issue – percentage out of the column percentage 100

12. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Discussion: The personal characteristics and abilities of PHNs, the nature of daily work in CHC, and collaboration within health care and in the community were listed as determinants of physical activity promotion. PHNs stressed the importance of population responsibility as a facilitator for physical activity promotion within health care in every group. Particularly rural PHNs highlighted their possibility to get to know the child and the family individually, which facilitates client- centred working methods. Evidently, even experienced PHNs - such as in this study - with some education in physical activity during their professional training, do not feel capable of promoting physical activity according to the guidelines and recommendations for health care. Therefore, the following recommendations are presented:

13. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori The professional training of PHNs: Apart from the general skills in health promotion, the specific skills in physical activity promotion including content concerning PA of the child and the family, as well as introduction to service delivery in physical activity in community should be included in the training of nurses. Working methods in CHC: a) Instructions should be prepared for implemention and documentation of physical activity promotion in different phases of childhood, b) clear instructions for counselling and referral systems, c) instructions for assessment of PA of the child and the family, d) material for support of motor development and physical activity both for PHNs and families. Inclusion of time resources (even cross-municipal) for collaboration in the work load of PHNs. Sharing information concerning service-delivery in PA [for children, families and persons with special needs] should be developed.

14. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori Even experienced nurses, like in this sample, identified several restrictors and developmental issues for physical activity promotion in health care. Therefore, there the training of nurses as well as the working methods in CHC should be evaluated and developed. Despite the fact that the focus of this qualitative research was on health promotional issues in primary health care for children and the family, the issues related to collaboration (between health professionals or in community with physical activity service providers/day care) became an interesting topic. According to the findings of a recent research (N=417 health professionals) in primary care by Simonsen-Rehn et al. (2009), the opportunities, reflected in cooperation with partners outside the organization were strongly associated with engagement in health promotion action. Based on research findings, more focus on collaboration should be placed in primary care for children and their families. Conclusion:

15. Satakunnan ammattikorkeakoulu | Sosiaali- ja terveysala Pori Satakunta University of Applied Sciences | Faculty of Social Services and Health Care Pori References: Javanainen-Levonen, T. 2009. Terveydenhoitajat liikunnanedistäjinä lastenneuvolatyössä [Public health nurses as physical activity promoters in Finnish child health clinics]. Dissertation. University of Jyväskylä. Studies in Sport, Physical Education and Health 138. Cavill, N. et al. 2006. An evidence-based approach to physical activity promotion and policy development in Europe: contrasting case studies. Promotion & Education 13(2), 104-111. European Commission. 2007. Healthier together in the European Union. Health and consumer protection. Brussels: Directorate-General, European Communities. Krueger, R. A. & Casey, M. A. 2000. Focus groups: a practical guide for applied research. (3rd ed.) London: Sage. Morgan, D. L. 1997. Focus groups as qualitative research. (2nd ed.) Newbury Park, CA: Sage. Simonsen-Rehn, N. et al. 2009. Determinants of health promotion action in primary health care: Comparative study of health and home care personnel in four municipalities in Finland. Scandinavian Journal of Public Health 37(1), 4-12. WHO. 2007. Steps to health. A European framework to promote physical activity for health. Copenhagen: WHO Regional Office for Europe. Other publications: Javanainen-Levonen, T., Poskiparta, M., Rintala, P. & Satomaa, P. 2009. Public health nurses’ approaches to early childhood physical activity in Finland. Journal of Child Health Care 13(1), 30-45. Javanainen-Levonen, T., Rintala, P. & Poskiparta, M. 2007. Physical activity promotion in public health nursing practice with children. Primary Health Care research & Development 8, 355-366.