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Background: Dental caries is the most common chronic disease in children. In Norway there are government sponsored programs that give all children (0-18 years) free public dental treatment. This program seems to reduce the social gap in oral health compared to countries where dental treatment is paid out-of-pocket. There are indications that not all children in Norway benefit equally good from this program. Aims: The first aim of this thesis was to assess caries experience expressed as DMFT/dmft index among children in Northern Norway (Tromsø, Storslett and Mosjøen). The second aim was to investigate the association between children´s oral health and their parents´ socioeconomic position (SEP). Materials and method: This was a cross sectional study, that included 140 children and their parents. The children in the study were between 5 and 12 years old. The sample was recruited at University Dental Clinic in Tromsø (82, 30%), public dental clinic in Storslett (19, 76%) and public dental clinic in Mosjøen (39, 83%). Data was collected using a structured questionnaire asking about the child's gender, age, living area, number of people in the household, how long the child has lived in Norway, who the child lives with, last dental visit and the reason for the visit, rating of the child's oral health, frequency of tooth brushing, help with tooth brushing, use of dental cleaning products, chronic diseases, medication, intake of sugar, parents´ age/education/occupation, household income and residence. DMFT/dmft value was measured on a routinely dental examination by a dentist or a dental hygienist. Results: The total mean caries experience was higher among older children. It was lowest for children at 5 years old (0,1 (0,4)) compared to children at 6-, 7-, 8,- 9, 11- and 12 years old ((0,4 (1,0)), (0,3 (0,7)), (0,5 (1,0)), (0,5 (0,7)), (0,6 (1,2)), (1,1 (2,0)) and (1,0 (1,4)), respectively). This difference was not statistically significance. The odds for a child to have DMFT≥1 decrease by 0,8 with each 50000NOK higher income (p=0,058). Children with a father that only had completed primary school/ high school education had 10,4 times higher odds to have DMFT≥1 (adjusted OR: 10,435; 95% CI1,461-74,513). Conclusions: According to multivariable binary logistic regression analysis, having a father with low education was associated with DMFT≥1 of the child. Even in a rich country like Norway, social inequalities in oral health based on father's education and income already at the age of 5-12 years could be observed. More studies are needed in order to investigate social inequalities among children in Northern Norway.

Crowns, bridges, removable dentures and other dental appliances are custom-made medical devices and are subject to specific legislation. The EU directive 93/42 on medical devices constitutes the legislation that regulates dental laboratory custom-made medical devices. This paper investigates how importers of dental laboratory custom-made devices perform quality control and if the legal requirements for information about the medical device are being followed. Questionnaires were sent to eleven dental laboratories and conveyers who advertise import of dental laboratory custom-made devices. Seven replied. Statements that are to accompany dental laboratory custom-made medical devices were collected from Universitetstannklinikken at the University of Tromsø to investigate if they were filled out in accordance with the legal requirements. Although the legislation demands specific labeling of the custom-made devices, this is not adequately performed by the dental technicians. The law is general in its formulations and has its shortcomings in the daily clinical work of dentists and dental technicians. The existing Norwegian guidelines are outdated in some areas. Updated and more specific guidelines can be a helpful tool for dentists and technicians.

Background and purpose — In Norway all compensation claims based on healthcare services are handled by a government agency (NPE, Norsk Pasientskade Erstatning). We provide an epidemiological overview of claims within pediatric orthopedics in Norway, and identify the most common reasons for claims and compensations. Patients and methods — All compensation claims handled by NPE from 2012 to 2018 within pediatric orthopedics (age 0 to 17 years) were reviewed. Data were analyzed with regard to patient demographics, diagnoses, type of injury, type of treatment, reasons for granted compensation, and total payouts. Results — 487 compensation claims (259 girls, 228 boys) within orthopedic surgery in patients younger than 18 years at time of treatment were identified. Mean age was 12 years (0–17). 150 out of 487 claims (31%) resulted in compensation, including 79 compensations for inadequate treatment, 58 for inadequate diagnostics, 12 for infections, and 1 based on the exceptional rule. Total payouts were US$8.45 million. The most common primary diagnoses were: upper extremity injuries (26%), lower extremity injuries (24%), congenital malformations and deformities (12%), spine deformities (11%), disorders affecting peripheral joints (9%), chondropathies (6%), and others (12%). Interpretation — Most claims were submitted and granted for mismanagement of fractures in the upper and lower extremity, and mismanagement of congenital malformations and disorders of peripheral joints. Knowledge of the details of malpractice claims should be implemented in educational programs and assist pediatric orthopedic surgeons to develop guidelines in order to improve patient safety and quality of care. ; publishedVersion

Source: doi:10.3945/ajcn.115.120873 ; Background: Vitamin D deficiency has been described as being pandemic, but serum 25-hydroxyvitamin D [25(OH)D] distribution data for the European Union are of very variable quality. The NIH-led international Vitamin D Standardization Program (VDSP) has developed protocols for standardizing existing 25(OH)D values from national health/nutrition surveys. Objective: This study applied VDSP protocols to serum 25(OH)D data from representative childhood/teenage and adult/older adult European populations, representing a sizable geographical footprint, to better quantify the prevalence of vitamin D deficiency in Europe. Design: The VDSP protocols were applied in 14 population studies [reanalysis of subsets of serum 25(OH)D in 11 studies and complete analysis of all samples from 3 studies that had not previously measured it] by using certified liquid chromatography–tandem mass spectrometry on biobanked sera. These data were combined with standardized serum 25(OH)D data from 4 previously standardized studies (for a total n = 55,844). Prevalence estimates of vitamin D deficiency [using various serum 25(OH)D thresholds] were generated on the basis of standardized 25(OH)D data. Results: An overall pooled estimate, irrespective of age group, ethnic mix, and latitude of study populations, showed that 13.0% of the 55,844 European individuals had serum 25(OH)D concentrations <30 nmol/L on average in the year, with 17.7% and 8.3% in those sampled during the extended winter (October–March) and summer (April–November) periods, respectively. According to an alternate suggested definition of vitamin D deficiency (<50 nmol/L), the prevalence was 40.4%. Dark-skinned ethnic subgroups had much higher (3- to 71-fold) prevalence of serum 25(OH)D <30 nmol/L than did white populations. Conclusions: Vitamin D deficiency is evident throughout the European population at prevalence rates that are concerning and that require action from a public health perspective. What direction these strategies take will depend on European policy but should aim to ensure vitamin D intakes that are protective against vitamin D deficiency in the majority of the European population.

Whether genetic and familial factors influence the association between cardiorespiratory fitness (CRF) and cardiovascular disease (CVD) is unknown. Two cohorts were formed based on data from 1,212,295 men aged 18 years who were conscripted for military service in Sweden during 1972–1996. The first comprised 4,260 twin pairs in which the twins in each pair had different CRF (≥1 watt). The second comprised 90,331 nonsibling pairs with different CRF and matched on birth year and year of conscription. Incident CVD and all-cause mortality were identified using national registers. During follow-up (median 32 years), there was no difference in CVD and mortality between fitter twins and less fit twins (246 vs. 251 events; hazard ratio (HR) = 1.00, 95% confidence interval (CI): 0.83, 1.20). The risks were similar in twin pairs with ≥60-watt difference in CRF (HR = 0.96, 95% CI: 0.57, 1.64). In contrast, in the nonsibling cohort, fitter men had a lower risk of the outcomes than less fit men (4,444 vs. 5,298 events; HR = 0.83, 95% CI: 0.79, 0.86). The association was stronger in pairs with ≥60-watt difference in CRF (HR = 0.65, 95% CI: 0.59, 0.71). These findings indicate that genetic and familial factors influence the association of CRF with CVD and mortality.

Background : With recent changes in legislation regulating recreational and medical cannabis use around the globe, increased use in pregnancy is to be expected. Objectives : To investigate the association between cannabis use during pregnancy and birth outcomes. Method : Data from the Norwegian Mother and Child Cohort Study (MoBa), a prospective pregnancy cohort, were used. Participants were recruited from all over Norway between 1999 and 2008: 9,312 women with 10,373 pregnancies who reported use of cannabis before or in pregnancy. Women reported on their illegal drug use before pregnancy and at pregnancy weeks 17/18 and 30 and at 6 months postpartum. Linear regression was used to estimate crude and adjusted effects of prenatal cannabis exposure on birth outcomes. Results : In 10,101 pregnancies, women had used cannabis before pregnancy but not during pregnancy. In 272 pregnancies, women had used cannabis during pregnancy, and among these, in 63 pregnancies, women had used cannabis in at least 2 periods. In adjusted analyses for potential confounders, only cannabis use during at least 2 periods of pregnancy showed statistically significant effects on birth weight. The effect was observed in the complete cohort ( B = −228 g, 95% CI = −354 to −102, p < 0.001) and for the subgroup where information about the child's father was available ( B = −225 g, 95% CI = −387 to −63, p = 0.01). Our results may indicate that prolonged use causes more harm, whereas short-term use did not indicate adverse effects on birth outcomes. Conclusions : There was a statistically significant and clinically relevant association between the use of cannabis during pregnancy and reduced birth weight. Clinicians should screen not only for cannabis use but also for the length and intensity of use as part of a comprehensive substance use screening.

Master in International Social Welfare and Health Policy ; The total prohibition on therapeutic abortion is an issue that prevents the delivery of quality medical care to women that are pregnant. Subsequent maternal mortality is one of the outcomes on this policy. The aim of this literature review is to address and explore how this ban on abortion will influence maternal mortality. There are two research questions: 1. How has the total ban on therapeutic abortion affected Maternal Mortality in El Salvador and Nicaragua? 2. How will the total ban on therapeutic abortion influence the achievement of the UN Millennium Development Goals for 2015 in Nicaragua and El Salvador, specifically MDG target number 5 for improving maternal health? The methodological approach of this thesis is qualitative by a literature review of academic documents dealing with the topic before and after the legislation on abortion changed. The thesis was constructed with primary and secondary sources that were read and analyzed critically then they were compared within the country and between them. The core findings were that maternal mortality was not affected by the prohibition on abortion, in addition it has been reduced on both countries, but it is still high compared to other nations. The legislation on abortion, among others, is one of the causes of maternal mortality. The United Nations Millennium Development Goal five was achieved by El Salvador, according to the government, while in Nicaragua the progress towards it remains slow. Within each of these categories there are similarities, differences and ongoing debates, since abortion, either therapeutic or not, is still a controversial issue in many countries.

This work is a synthesis of experiences gained during ten years of helping healthcare providers improve their service to victims of injury and acute disease. This work is based on my participation in two programs: The Trauma Care Foundation's Mine Injury Management Program in Kurdistan, northern Iraq, and the BEST Foundation: Better & Systematic Trauma Care's trauma team training program in Norwegian hospitals. My experience with both programs took place from 1996 to 2006-7. The purpose of the thesis was to: 1. Describe and assess the effects of trauma team training in Norway, and summarize health personnel's experience from implementation, and 2. Describe and assess the adaptation and maturation of a pre-hospital trauma care system in northern Iraq, and determine the impact of this system on villagers in mine-affected areas. I have summarized these experiences in order to enable health workers with a need for training and system improvement to draw upon our experiences. The thesis consists of five papers. In the first paper, the team training method from Norway is described as a solution to the team members' perceived lack of team skills (communication, leadership, and cooperation). In the second paper, the effects of team training are described in terms of perceived quality of care during multi-trauma resuscitation and individual knowledge and confidence. The feasibility of team training was also assessed. The third study is a follow-up of a program that trained paramedics and first responders in Kurdistan in northern Iraq, with an evaluation of the adaptation and maturation of the trauma system. The fourth study examined the impact of the development of chains of paramedics and first responders on Kurdish villages. Finally, the fifth paper examined how Norwegian healthcare personnel manage to maintain team training in their institutions. In these projects, we found that short-term educational activities are effective if they are targeted carefully, which indicates that they should be planned and adapted with cooperation between the local healthcare workers and the external teachers. We found that it is possible to transfer knowledge that continues to live and grow in some organizations, but that this is dependent on support to enthusiasts in the organizations in question. In both locations, the healthcare providers adapted their new knowledge and skills to different patient groups and different medical situations. Treatment quality seemed to remain at a high level. System maturation in northern Iraq resulted in a reduced time interval between injury and the first medical response, and improved physiological function after transportation. In areas where demanding medical challenges, such as severe trauma, occur infrequently, it seems useful to share experiences among health workers. In both settings, we found that health workers take responsibility for further development of their services, and that they are able and willing to apply their experience to other areas of patient care. Healthcare providers will act responsibly and employ what they believe are useful training methods provided they receive some sort of support. Responsible health personnel can be a powerful force of change. The training methods described here have great potential for application in similar areas. Medical training in low-income countries is a political act that has implications for the trainees and the societies in which they live that reach beyond the medical arena. In Norway, the decision on where to devote ones energy is also a political matter. However, trauma does not occur indiscriminately, neither should trauma training. ; Avhandlingen er basert på deltakelse i to programmer: Trauma Care Foundations mineskadeprogram i Kurdistan, Nord-Irak, og Stiftelsen BEST: Bedre & systematisk traumebehandlings treningsprogram for traumeteam på norske sykehus, begge i perioden 1996 til 2006-7. I begge programmene var formålet å gi helsepersonell praktisk og teoretisk opplæring for å forbedre behandlingen av pasienter med skader og akutt sykdom. Formålet med avhandlingen var å: 1. Beskrive og evaluere effekten av traumeteamtrening i Norge, og oppsummere helsepersonellets erfaringer fra implementeringen. 2. Beskrive og evaluere hvordan det prehospitale traumesystem i Nord-Irak modnet og tilpasset seg, og betydningen av systemet for landsbyboerne i mineområdene. Avhandlingen består av fem artikler. I den første beskrives treningsprogrammet for traumeteam som en løsning på teammedlemmenes opplevde mangel på teamferdigheter (kommunikasjon, ledelse og samarbeid). I den andre artikkelen evalueres effekten av treningen på opplevd behandlingskvalitet under resuscitering av multitraumatiserte, individuell viten og fortrolighet. Vi evaluerte også muligheten for å gjennomføre teamtrening. Det tredje studien er en oppfølging av mineskadebehandlere og førstehjelpere i Nord-Irak med vekt på hvordan det prehospitale system modnet og tilpasset seg endrede behov. Betydningen traumesystemet hadde for landsbyboerne i mineområdene ble undersøkt i artikkel fire. Den femte artikkelen undersøkte hva som avgjør om norsk helsepersonell lykkes med implementering av teamtrening på sine sykehus. Vi fant at korte treningskurser er effektive hvis de er målrettet og planlegges nøye etter deltakernes behov. Vi fant også at kunnskapen fortsetter å gro i organisasjonene og kan videreføres, men dette avhenger av at det finnes entusiaster som driver implementeringen, og i hvilken grad de får støtte. I begge områder tok helsepersonellet selv ansvar for å tilpasse viten og kunnskaper til nye pasientgrupper. Behandlingskvaliteten ser ut til å holde seg når kunnskapene blir brukt på nye grupper. I Nord-Irak førte modningen av traumesystemet til at tidsintervallet fra skade til første medisinske hjelp ble redusert og at den fysiologiske effekten av behandlingen økte gjennom studieperioden. I områder med sjeldne, krevende traumepasienter ser det ut til å være nyttig å dele erfaringer mellom helsepersonell ved nettverksmøter eller månedlige møter. Vi fant at helsepersonell tar ansvar for å forbedre sine tjenester, og at de er i stand til å overføre sine er faringer til andre områder i pasientbehandling. Studiene viser at helsepersonellet er ansvarlige, og bruker hva de opplever som nyttige læringsmetoder dersom de får en viss støtte. Denne typen helsepersonell har en sterk endrings- og utviklingskraft. De beskrevne treningsmetodene ser ut til å ha stort potensial for spredning til beslektede områder. Medisinsk opplæring i fattige land er en politisk handling. Opplæringen har ikke bare konsekvenser for de skadde, mineskadebehandlere, og førstehjelpere, men også for samfunnet, og betydningen rekker utover det medisinske. Også i Norge er beslutningen om hvor man som utdannet med spesialkompetanse skal bruke sin energi et politisk spørsmål. Personskade rammer ikke tilfeldig. Det bør treningen ikke heller.

Aim To synthesize what is known about elder abuse and relationship factors associated with abuse between caregivers and older people with memory disorders at home. Background Concerns about abuse in the caring relationship between older people with memory disorders and family caregivers have increased. Abuse is associated with negative outcomes on older people's health, quality of life, and zest for life. Abuse in the caring relationship manifests in financial exploitation, neglect, mistreatment, and physical issues. Design Systematic review. Data Sources Databases including Scopus, PubMed/Medline, SveMed+, Cinalh, SonINDEX, and ProQuest were searched using keywords about abuse in the caring relationship between older people with memory disorders and family caregivers at home. Articles published between 2005–2019 were retrieved and underwent data analysis and knowledge synthesis. Review Methods The review was presented under the categories of the dyadic approach of elder abuse in connection with the role of caregiver (risk) and care recipient (vulnerability) by Fulmer et al. (2005). Results The search process led to 12 quantitative studies, including an intervention, a prospective, nine surveys, and a cross‐sectional structural interview. Findings were synthesized and presented under 'personal', 'physical and psychological', and 'social' domains indicating the bilateral roles of caregiver and care recipient leading to abuse. Conclusion This review depicted factors influencing abuse in the caring relationship between older people with memory disorders and their family caregivers at home. They included family caregivers' psychological issues, knowledge of memory disorders and modifications, previous caring relationship, social support, number of care recipients, and care recipients' functional level. Impact This review identifies what influences elder abuse by family caregivers using the dyadic approach and explains how abuse can be prevented through suggested strategies. The review findings are relevant to multidisciplinary healthcare providers and can guide the provision of support, screening and assessment, educational programs, and legislative initiatives. ; publishedVersion ; Paid Open Access

Background: Mobile phone has been one of the most technologically ubiquitous influences over the past decade. Mobile phone use has changed from a perceived item of luxury to an everyday necessity for many people. Given the widespread availability of mobile technology, there is increasing interest in the potential of interventions utilising these technologies to enhance medical treatment. Smartphones are therefore changing many industries, including the medical industry. Africa as a whole lags far behind compared to the richer regions of the world. Africa often have challenges in medical information, access to healthcare, treatment excellence and affordability. However, the speedy spread of mobile phones in so many of its countries is an extraordinary phenomenon, exclusively in the framework of their enormous economic and social challenges. Mobile technology is an example of such technologies that are readily available, accessible and affordable worldwide that can help African countries to solve their healthcare delivery challenges. This study explored and addressed the possible use of smartphones in providing basic health services in Ghana using health professionals at the 37 Military Hospital as a reference group. Method: A cross-sectional survey was conducted involving 101 healthcare professionals at the 37 Military Hospital. The study used primary data, however, secondary data were also employed where necessary. Data was gathered by administering structured closed-ended questionnaires to respondents who were sampled using convenience sampling technique. Findings: It was found that all the participants owned and used their smartphones for health purposes. It was particularly found that majority of the participants used their smartphones to communicate with patients. Specifically, applications (like whatsapp, imo, viber) was the most used medium of communication by the nurses, SMS was the most used medium the doctors and pharmacist use to communicate with patients according to the result. The radiologist/laboratory technicians preferred communicating with patients through two or more of the listed options as provided in the questionnaire. The data also revealed that it is only the doctors who admitted that their smartphones helped them in the diagnosis of diseases although majority said otherwise. The study also revealed that majority of the health professionals searched for health information using search engines like google, medline and pubmed. Moreso, internet access problems was the major challenge health professionals at the 37 Military Hospital faced in using their smartphones for health purposes. Conclusion: The use of smartphones by health care professionals is rising in popularity especially in less financially advanced countries). The use of mobile technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery. The Government and health policy makers in Ghana can make use of the potentials of this technology in the health care delivery of Ghana.

The Internet, given its availability and affordability, is increasingly being used for different purposes, including health-related purposes. In this context, the Internet serves as a medium for people to interact frequently with the health care professionals, access health information online, and form and participate in online support groups. Yet, the extant literature has focused mostly on the use of the Internet for health purposes in developed countries. To bridge this gap and to ascertain the utility of the Internet for health purposes in developing countries, a cross-sectional survey was conducted involving 363 students at the University of Ghana, using self-reported methodology. The study revealed that all the participants reported to use the Internet for health purposes. Particularly, the study found evidence that the participants use the Internet to seek for information online, interact with health professionals, engage in social support and group communication via popular social networks-Facebook and WhatsApp. Interestingly, the study also found that the majority of the participants own two or more electronic devices, used to access the Internet. More so, the availability of the Internet on campus, and easy access, motivated participants to use it. While the majority of the participants had indicated that they acquired knowledge and changed their lifestyle after accessing health information online, few had stated otherwise. The general implication of the study is that the use of the Internet for health purposes is not limited to developed countries. Government and policy makers in Ghana can make use of the Internet to provide relevant health information and services. The extent of the Internet usage raises the optimism that geographical and physical barriers to seeking health care information can be overcome. The findings are briefly discussed and also, the implications of the findings for promoting access to health information discussed.

Background and purpose — In Norway all compensation claims based on healthcare services are handled by a government agency (NPE, Norsk Pasientskade Erstatning). We provide an epidemiological overview of claims within pediatric orthopedics in Norway, and identify the most common reasons for claims and compensations. Patients and methods — All compensation claims handled by NPE from 2012 to 2018 within pediatric orthopedics (age 0 to 17 years) were reviewed. Data were analyzed with regard to patient demographics, diagnoses, type of injury, type of treatment, reasons for granted compensation, and total payouts. Results — 487 compensation claims (259 girls, 228 boys) within orthopedic surgery in patients younger than 18 years at time of treatment were identified. Mean age was 12 years (0–17). 150 out of 487 claims (31%) resulted in compensation, including 79 compensations for inadequate treatment, 58 for inadequate diagnostics, 12 for infections, and 1 based on the exceptional rule. Total payouts were US$8.45 million. The most common primary diagnoses were: upper extremity injuries (26%), lower extremity injuries (24%), congenital malformations and deformities (12%), spine deformities (11%), disorders affecting peripheral joints (9%), chondropathies (6%), and others (12%). Interpretation — Most claims were submitted and granted for mismanagement of fractures in the upper and lower extremity, and mismanagement of congenital malformations and disorders of peripheral joints. Knowledge of the details of malpractice claims should be implemented in educational programs and assist pediatric orthopedic surgeons to develop guidelines in order to improve patient safety and quality of care. ; publishedVersion

Master's thesis in Global Development and Planning (UT505) ; The main objective of the study was to elucidate why thereis a gap between medical research conducted on the neglected tropical disease Female Genital Schistosomiasis (FGS) and work-related knowledge about the disease amongst professional nurses in the Ugu District, South Africa. The study is based on qualitative field work in three local governmental clinics in this area, and the purpose is to explore why there is such a gap and why the development of knowledge concerning FGS seems to stagnate despite a relatively high level of awareness related to its "twin disease", Urological Schistosomiasis which is commonly referred to as Bilharzia or Isichenene in Zulu.

Little is known about medical consequences of losing arm(s) or leg(s) in military attacks. Many Palestinians in Gaza have suffered loss of one or more limbs during recurrent Israeli military incursions. Such serious physical trauma pose grave health problems not only for the amputee, but also for their families and for the society at large. The problem is increasing. Hanne Heszlein-Lossius, MD, from UiT The Arctic University of Tromsø has together with her supervisor professor Mads Gilbert (UiT) and Palestinian research colleagues in Gaza conducted a study of 254 patients with war-related traumatic extremity amputations in Gaza. The patients attended Gaza's main rehabilitation center, The Artificial Limb and Polio Centre (ALPC) in Gaza City for prosthesis and rehabilitation. The studies, published in The Lancet, BMJ and BMC found that the majority of the amputated Palestinians were young, well-educated men with large financial responsibilities, and often the family's sole breadwinner. Most traumatic amputations were major and will cause life-long disability. To lose the ability to work and thus loose income and the ability to care for one's family and put food on the table seemed to be an important trauma adding to the pain and loss of arms or legs. A variety of military weapons had caused the loss of limb(s) among the studied patients. Unarmed military airplanes carrying explosive weapons (drones) were the most common. Those who had been hit during drone-attacks suffered the most severe extremity amputations. The patients needed more surgical operations after drone strikes than amputations caused by other weapons.

The papers of this thesis are not available in Munin. Paper 1. Silsand, L., Ellingsen, G. (2014). Generification by Translation: Designing Generic Systems in Context of the Local. Available in: Journal of Association for Information Systems, vol. 15(4): 3. Paper 2. Christensen, B., Silsand, L., Wynn, R. and Ellingsen, G. (2014). The biography of participation. In Proceedings of the 13th Participatory Design Conference, 6-10 Oct. Windhoek, Namibia. ACM Digital Library. Paper 3. Silsand, L. and Ellingsen, G. (2016). Complex Decision-Making in Clinical Practice. In: Proceedings of the 19th ACM Conference on Computer-Supported Cooperative Work & Social Computing (CSCW '16). ACM Digital Library. ISBN: 978-1-4503-3592-8. Paper 4: Silsand, L., Ellingsen, G. (2017). Governance of openEHR-based information Infrastructures. (Manuscript). Paper 5. Silsand, L. (2017). The 'Holy Grail' of Interoperability of Health Information Systems: Challenges and Implications. Available in: Stigberg S., Karlsen J., Holone H., Linnes C. (eds) Nordic Contributions in IS Research. SCIS 2017. Lecture Notes in Business Information Processing, vol 294. Springer, Cham. ; This thesis provides empirical insights about socio-technical interdependencies affecting the making and scaling of an Information Infrastructure (II) for healthcare based on the development of large-scale Electronic Patient Records. The Ph.D. study is an interpretive case study, where the empirical data has been collected from 2012 to 2017. In most developed countries, the pressures from politicians and public in general for better IT solutions have grown enormously, not least within Electronic Patient Record (EPR) systems. Considerable attention has been given to the proposition that the exchange of health information is a critical component to reach the triple aim of (1) better patient experiences through quality and satisfaction; (2) better health outcomes of populations; and (3) reduction of per capita cost of health care. A promising strategy for dealing with the challenges of accessibility, efficiency, and effective sharing of clinical information to support the triple aim is an open health-computing platform approach, exemplified by the openEHR approach in the empirical case. An open platform approach for computing EPR systems addresses some vital differences from the traditional proprietary systems. Accordingly, the study has payed attention to the vital difference, and analyze the technology and open platform approach to understand the challenges and implications faced by the empirical process. There are two main messages coming out of this Ph.D. study. First, when choosing an open platform approach to establish a regional or national information infrastructure for healthcare, it is important to define it as a process, not a project. Because limiting the realization of a large-scale open platform based infrastructure to the strict timeline of a project may hamper infrastructure growth. Second, realizing an open platform based information infrastructure requires large structural and organizational changes, addressing the need for integrating policy design with infrastructure design.