| 1. |
- Brohede, Sabina
(författare)
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Body Dysmorphic Disorder : Capturing a prevalent but under-recognized disorder
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundIndividuals with body dysmorphic disorder (BDD) are highly distressed due to defects they perceive in their physical appearance that are not noticeable to others. The condition often leads to impaired functioning in relationships, socialization, and intimacy and a decreased ability to function in work, school, or other daily activities. Although BDD seems to be relatively prevalent, it is under-recognized by people in general and by health care professionals. Individuals with BDD are secretive about their symptoms, and they usually do not recognize that they are suffering from a psychiatric disorder. Instead, in an attempt to relieve their symptoms by correcting their perceived defects, they commonly seek dermatological treatment or cosmetic surgery. However, such interventions usually do not result in any decrease in BDD symptom severity, but can rather aggravate the symptoms. Therefore, it is crucial that health care professionals recognize BDD in order to offer adequate care. Prior to the studies conducted for this thesis, there were no known data regarding the prevalence of BDD in Sweden.Main aims(i) To translate a screening questionnaire for BDD (the Body Dysmorphic Disorder Questionnaire, BDDQ) into Swedish and validate the questionnaire in a community sample. (ii) To estimate the prevalence of BDD in the general population of Swedish women and in female dermatology patients. (iii) To explore BDD patients’ experiences of living with the disorder, including their experiences of the health care system.MethodsThe BDDQ was validated using the Structured Clinical Interview for DSM-IV (SCID) as the gold standard for diagnosing BDD (Study I). The validated BDDQ was used to estimate the prevalence of BDD in a randomly selected population-based sample of Swedish women (n=2 885) (Study II) and in a consecutive sample of female dermatology patients (n=425) (Study III). In Studies II and III, the Hospital Anxiety and Depression Scale was used to assess symptoms of depression and anxiety. In Study III, quality of life was evaluated by the Dermatology Life Quality Index. BDD patients’ lived experiences were explored using a qualitative research design (Study IV). Fifteen individuals with BDD were interviewed, and the interviews were analysed using Interpretive Description.ResultsThe Swedish translation of the BDDQ displayed a sensitivity of 94%, a specidicity of 90% and a (positive) likelihood ratio of 9.4. The prevalence of women screening positive for BDD was 2.1% (95% CI 1.7–2.7) in the population-based sample of women and 4.9% (95% CI 3.2–7.4) in the dermatology patients’ sample. The positive predictive value of the BDDQ (71%) gave an estimated BDD prevalence of 1.5% (95% CI 1.1–2.0) in the female Swedish population. Women screening positive for BDD had signidicantly more symptoms of anxiety and depression compared to those screening negative for BDD in both samples. In the dermatology patients, quality of life was severely impaired in patients with positive BDD screening. The overarching concept found in Study IV was that patients with BDD felt imprisoned and were struggling to become free and to no longer feel abnormal. The participants had encountered difdiculties in accessing health care and had disappointing experiences of the health care system.ConclusionThe findings of this thesis indicate that BDD is a relatively common disorder in the Swedish female population, and that it is more prevalent in dermatology patients. BDD patients struggle to be free from a feeling of imprisonment, and in this struggle they encounter difficulties in accessing health care. Therefore, it is important to increase awareness and recognition of BDD among health care professionals to ensure that patients with BDD receive the appropriate care.
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| 2. |
- Brüggemann, A. Jelmer
(författare)
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Toward an Understanding of Abuse in Health Care : A Female Patient Perspective
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background. High numbers of incidents of abuse in health care (AHC) have been reported by patients in Sweden. In questionnaire studies (n=9600), every fifth Swedish woman and every tenth Swedish man reported any lifetime experience of AHC, and a majority reported suffering from their experiences. Female patients with experiences of AHC described them as experiences of being nullified, and male patients as experiences of being mentally pinioned. Little is known about why AHC occurs and how it can prevail in a health care system that aims to relieve patients’ suffering.Aim. The overall aim of the thesis was to bring understanding to what AHC is and to start exploring what contributes to its occurrence, focusing on a female patient perspective.Methods. In study I, a concept analysis of AHC was conducted based on the concept’s appearance in scientific literature and through case studies. Also, AHC was demarcated against the related concepts patient dissatisfaction, medical error, and personal identity threat, in order to analyze differences and similarities with these concepts. For studies II and III the Transgressions of Ethical Principles in Health Care Questionnaire (TEP) was developed to measure to what extent female patients remain silent toward the health care system after having experienced abusive or wrongful ethical transgressions in the Swedish health care system. It was hypothesized that to a high degree female patients remain silent toward the health care system after such experiences, and this lack of feedback may in turn contribute to the hampering of structural change toward better encounters. The questionnaire was answered by female patients recruited at a women’s clinic in the south of Sweden (n=530). Study IV built on a constructed grounded theory design and included informants who reported experiences of AHC in TEP (n=12). The interviews focused on the informants’ stories of what contributed to their experiences of AHC.Results.Results. Based on the concept analysis, AHC was described as patients’ subjective experiences in health care of encounters devoid of care, in which they experienced suffering and loss of their human value. Study II showed that a majority of the female patients who perceived one or more transgressions as abusive or wrongful remained silent about at least one of them (70.3%). In 60% of all cases, patients remained silent about abusive or wrongful events. In study III it was examined whether patients remaining silent could be associated with any patient characteristics. Remaining silent was only found to be associated with younger age and a lower self-rated knowledge of patient rights. In study IV, female patients’ stories of what contributed to their experiences of AHC were analyzed. This was best characterized as a process where the patient loses power struggles. According to these patients, not only their vulnerability, but also their level of competence contributed to staff’s unintended use of domination techniques by which they felt abused.Conclusions. As AHC is defined from patients’ subjective experiences it is necessary for the prevention of AHC to listen to patients’ stories and complaints. The prevalence of female patients’ silence after abusive events could be worrying, as it constitutes a loss of essential feedback for the health care system. Patients do not bear responsibility for the quality of health care processes, but their knowledge may be very valuable for structural improvement of these processes and could be valued as such. Clinical interventions that stimulate these patients to speak up, accompanied by health care staff’s reflections on how to respond to patients speaking up, must therefore be explored.
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| 3. |
- Elmerstig, Eva, 1969-
(författare)
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Painful Ideals : Young Swedish women´s ideal sexual situations and experiences of pain during vaginal intercourse
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Many young women today are concerned about their sexual health; an increasing number of them consult gynaecologists, youth centres (YCs) and general practitioners with vulvar problems such as painful sensations associated with vaginal intercourse (VIC). It is known that some women continue to have VIC despite pain. Theoretically, repeated painful VIC might elicit vaginistic reactions, which may increase the pain and induce vicious circles. Since many clinicians and researchers nowadays notice that pain during VIC often starts at young age, it is important to investigate how pain during VIC starts and is maintained in younger populations. The overall aim of this thesis was to investigate young women’s experiences of ideal sexual situations and pain during VIC.Women aged 13-22 years participated in our studies, which used both quantitative (study I and IV) and qualitative (study II and III) methods. For paper I, a questionnaire was developed and used in a YC sample (n=300); informants for paper II were selected from that sample to participate in qualitative interviews (n=16). Another qualitative interview study for paper III with a complimentary research question was conducted in a different YC sample (n=14). For paper IV, a questionnaire was developed based on the results from study I, II and III to test the hypotheses derived from study II in a sample of female high school students (n=1566).The findings revealed that 65% of the women reported pain related to first VIC. Among those who reported VIC during the previous month, 49% had experienced pain and/or discomfort during VIC during that same period (paper I). In paper IV, 47% of the women reported experience of pain and/or discomfort during VIC, and among those, 47% continued to have VIC, 22% feigned enjoyment, and 33% omitted telling the partner about their pain. In paper II, the women’s reasons for continuing to have VIC despite pain were: striving to reach their ideal image of a woman, characterized as always willing to have VIC; being perceptive of their partner’s sexual needs; and being able to satisfy their partner. In paper IV the hypotheses derived from study II were confirmed and showed, for example that a significantly higher proportion of women who continue to have VIC despite pain than women who did not had difficulty refusing sex when the partner wants it, felt inferior to the partner during sex, regarded the partner’s satisfaction as more important than their own, felt dissatisfaction with their sex life, and feigned enjoyment despite pain. In a multivariate model, continuing to have VIC despite pain was associated with feelings of being inferior to the partner during sex (adjusted OR 1.82; CI 1.10-3.02), dissatisfaction with their own sex lives (adjusted OR 1.76; CI 1.14-2.72) and feigning enjoyment while having pain (adjusted OR 7.45; CI 4.37-12.69).The major reason for continuing to have VIC was that the partner’s enjoyment was prioritized higher than their own (paper IV). In paper III, we found that women without pain during VIC also felt pressure from social norms and demands and had experienced partners “driving their own race”. However, they managed to some extent to resist these unequal gender norms because of their urge to experience pleasure.In conclusion, pain during VIC is a common complaint among young Swedish women, and a high proportion of them continue having VIC despite pain. The women’s notion of prioritizing the partners´ enjoyment before their own illustrates that unequal gender regimes affect young women’s (hetero)sexuality negatively.
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| 4. |
- Engman, Maria
(författare)
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Partial vaginismus : definition, symptoms and treatment
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Vaginismus is a sexual pain disorder, where spasm of musculature of the outer third of the vagina interferes with intercourse. Vaginismus exists in two forms: total vaginismus, where intercourse is impossible, and the more seldom described partial vaginismus, in which intercourse is possible but painful.The aim of the thesis was to develop a useful definition of partial vaginismus for both clinical and scientific purposes; to describe the prevalence of partial vaginismus among women with superficial coital pain; to report on symptoms and clinical findings in women with partial vaginismus; and to present treatment results for women with vaginismus.In a clinical sample of 224 women with superficial coital pain, we found a great overlap of the clinical diagnoses of partial vaginismus (PaV) and vulvar vestibulitis (VVS) (nowadays called provoked vestibulodynia); 102 women had both PaV and VVS. All women with VVS had vaginismus. Partial vaginismus was more common in all our samples than total vaginismus.sEMG of pelvic floor muscles was found to be of no value in distinguishing women with partial vaginismus with or without vulvar vestibulitis (PaV+/-VVS) (n=47) from each other or from an asymptomatic group (n=27).Women with PaV+/-VVS (n=53) reported not only burning pain but also itch during a standardized penetration situation (sEMG of pelvic floor muscles), while asymptomatic women (n=27) did not. In most cases, the appearance of burning pain preceded the appearance of itch.In a retrospective interview study, 24 women with PaV+/-VVS reported pain after intercourse more often than pain during penetration at the onset of the problem. When the women ceased having intercourse, both symptoms were equally common. Intensity of pain during penetration increased dramatically from very low at onset of the problem to very high when the women ceased having intercourse, while intensity of pain after intercourse was already high at onset of the problem and increased to very high when the women ceased having intercourse.Pain after intercourse in women with PaV+/-VVS was described as burning and/or smarting and lasted in mean for two hours, while pain during penetration was described with words like sharp/incisive/bursting and lasted for one minute.At long-term follow-up (more than three years) of a group of women treated with cognitive behaviour therapy for vaginismus (n=59, response rate 44/59 on a questionnaire), a majority were able to have and enjoy intercourse. The proportion of women with positive treatment outcome was, however, associated to the definition of treatment outcome. An ability to have intercourse at end of therapy was maintained at follow-up. Every tenth women with vaginismus healed spontaneously after thorough assessment.Conclusion: Partial vaginismus was more common in our studies than total vaginismus, and all women with vulvar vestibulitis had partial vaginismus. Women with PaV+/-VVS reported not only burning pain during standardized penetration but also itch. When the problem started in women with PaV+/-VVS, pain after intercourse was more common than pain during penetration. Pain after intercourse was described as longlasting and burning and/or smarting, while pain during penetration was described as short and sharp/incisive/bursting. Long-term follow-up results of a series of women treated with CBT for vaginismus show good treatment outcome.
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| 5. |
- Oscarsson, Marie, 1956-
(författare)
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Healthy women or risk patients? : Non-attendance in a cervical cancer screening program
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Women afflicted with cervical cancer who have the highest morbidity and mortality rates have been the least likely to be screened. The overall aim of this research project was to investigate non-attendance in a cervical cancer screening (CCS) program among women with no registered cervical smear during the previous five years. Both quantitative (I,III) and qualitative methods (II) as well as costeffectiveness analysis (IV) were used in this research project. In Kalmar County women (aged 23-65 years) are invited to CCS every third year. All cervical smears taken both in opportunistic and organised CCS are coordinated in a register called Sympathy. The coverage is 88.4 %. From Sympathy, a random sample of 400 women served as a study group and another 400 women as a control group (III,IV). From the study group, 133 women participated in study I and 14 women in study II. Data was collected by telephone interviews based on a questionnaire (I), qualitative face-to-face interviews (II), questionnaire, promotive efforts and outcome (III), costs and effectiveness (IV). Quantitative data was analysed by descriptive and analytic statistics (I,III), qualitative data was analysed by content analysis. In study IV, cost-effectiveness analysis was used.The women believed that CCS was a good idea for all other women, but tended to refer to various circumstances resulting in their own non-attendance. One of the most common reasons for non-attendance was the feeling of being healthy. The women prioritized family and work commitments, and the invitation to attend CCS was sometimes experienced as a stressful disturbance. The feeling of discomfort was related to the gynaecologic examination, or to health care visits in general (I,II). Of 133 women, 120 could consider having a cervical smear taken and their two most common requirements for doing so were to be assured they would be treated in a friendly way (19%) and to find a suitable time (18%) for having the cervical smear. Fifty women wanted to be helped to have a cervical smear taken. Promotive efforts ranged from making a simple telephone call to arranging an appointment time to a combination of promotive efforts including repeated encounters in order to create a trusting relationship with respect to taking the smear. In the study group, 29.5% (n=118) had a registered cervical smear at follow-up compared to 18.5% (n=74) in the control group, (p<0.001) (III). In the study group, the cost per cervical smear taken was 66.87 €, and in the control group it was 16.62 €. The incremental cost per additional cervical smear taken was 151.36 € (IV). In conclusion, women’s reasons for not attending CCS are complex and are influenced by both present and earlier circumstances. In settings with high coverage, further contact in order to promote women’s attendance at CCS seems to be associated with high costs in relation to the number of additional cervical smears taken.
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| 6. |
- Samelius, Charlotta, 1964-
(författare)
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Abused Women : Health, Somatization, and Posttraumatic Stress
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aims of this thesis were to estimate the lifetime prevalence of physical, sexual, and psychological abuse in a random population-based sample of women aged 18-60 years; to estimate current suffering thereof; and to investigate associations between abuse and health problems, more specifically to study abuse related variables associated with somatization and PTSD, respectively.The studies had a cross-sectional design. Studies I and II comprised 4150 women 18-60 years. Study III included 547 women, and study IV consisted of 213 women, randomly selected from the population-based sample of the first two studies.The first study found lifetime prevalence rates of 19.4% for physical abuse, 9.2% for sexual abuse, and 18.2% for psychological abuse. Abused women reported more ill-health and a less advantageous social situation than non-abused women. There was an association between magnitude of abuse and health problems. Even a low magnitude of abuse was substantially associated with ill-health. In the second study we found that of the 27.5% of women who had reported any kind of abuse in the first study, 69.5 % reported current suffering thereof. Abused suffering women reported more health problems than abused non-suffering women and non-abused women, and abused non-suffering women reported more health problems than non-abused women. In study three, psychological abuse and sexual abuse without penetration were found to be associated with somatization. Physical abuse and sexual abuse with penetration were not associated with somatization, when adjustments for other kinds of abuse were made. In study four, PTSD and somatization were found to be separately reported phenomena in abused women, although PTSD was positively associated with having somatic symptoms. Women with PTSD reported higher total magnitude of abuse and a higher number of perpetrators than women with somatization. Sexually abused women with PTSD more often described their experience as an act of abuse compared with sexually abused women with somatization.The present thesis demonstrates that even a low magnitude of abuse is associated with health problems. It also shows that a majority of the abused women, when investigating lifetime history of abuse, reported current suffering thereof, which warrants considering abuse an important societal problem. The relationship between somatization and posttraumatic stress in abused women is discussed in relation to abuse variables. Other factors than severity of abuse, such as whether the abused woman herself perceives her experience as abuse, seem to be more decisive for development of somatization in abused women. The findings suggest that PTSD is not a necessary mediator between abuse and somatization.
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| 7. |
- Siwe, Karin, 1953-
(författare)
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Learning the Pelvic Examination
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The inspiration for the present studies was the learning concept that used professional patients (PP) as instructors for medical students in learning how to perfom the pelvic examination (PE).Interviews performed with women who were PPs showed that they experienced a continuous beneficial increase in knowledge. This promoted personal development related to bodily awareness and affirmed their femininity, making them less vulnerable and reversing their approach to their own body of being an object to becoming a subject. The growing ability to contribute to students’ learning and the feeling of being valuable enhanced the PPs self-esteem and well-being and promoted independence in the learning situation. Being a PP was rewarding and contributed to the feeling of being empowered and growing as a woman in the examination chair.Two models of teaching the PE to medical students were compared: with PPs or with clinical patients (CP). The outcome showed that the PP students were more skilful in palpating the terus and ovaries and performed more PEs during the clinical clerkship than did CP students.Female and male medical students were interviewed after they had performed their first PE with PPs as instructors. The female students’ most obvious concern was about looking and touching another women’s vulva whereas male students were concerned about how to establish rapport with the PP. The interactive and supportive feedback from the PPs enabled the students to overcome their hesitation and encouraged creative learning of interpersonal and palpation skills. The LS positively enhanced the female students’ awareness of own bodies and promoted a deeper interest in PEs, both as an examiner and as patients. The male students became aware of the importance of creating a beneficial interaction with the woman and gained an insight into a previously “unknown” female world that deepened their understanding of women’s possible vulnerability during a PE.Women at an outpatient clinic participated in individual LSs about the female anatomy and the PE, and performed a PE on a mannequin prior to visiting the gynaecologist. Following the visit interviews were performed to gain a deeper understanding of the impact of the LS. The womens’ active participation during the LS generated increased self-confidence and knowledge, triggered emowerment and promoted a creative ability to interact subsequently during their own PE.Part of the studies involved developing a questionnaire to measure the fear of performing the pelvic examination, the Fear of Pelvic Examination Scale (F-PEXS). The questionnaire was shown to have a very good reliability (e.g. Cronbach alpha is .96) and good construct validity.Engaging voluntary, healthy and knowledgeable women as instructors in the PE situation creates a safe and ethical learning environment and promotes interaction with students. Immediate constructive feedback enables students to integrate communication and behavioural skills in a professional manner whilst learning to palpate the uterus, facilitating an inner security as a future examiner.The learning sessions were of benefit to the PPs, the female students in the PP model, and the women in the clinical study. The acquired knowledge started something positive within the women; a will to act and find out more about themselves. The LSs initiated empowerment in the sense that an empowered person has increased capacity to act in goal-directed ways.
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| 8. |
- Zbikowski, Anke
(författare)
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Counteracting Abuse in Health Care from a Staff Perspective : Ethical Aspects and Practical Implications
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Abuse of patients by health care staff (AHC) is a cause of unnecessary suffering, which is inconsonant with the premise in medicine of not doing harm to the patient. The understanding of AHC in this thesis is considered two-dimensional: as a patient’s subjective experience and as violation of a patient’s dignity. Patients’ experiences of these events are rather well studied and are characterized by feelings of neglect and a loss of their human value. However, little is known about staff’s perspectives on AHC and what they can do to counteract it.Aim: The overall aim of this thesis is to approach AHC from the perspective of health care staff in order to develop and test a model for enabling health care staff to recognize and take action in situations where AHC is about to happen and to handle it professionally once it has happened.Methods: To explore professionals’ formal perspectives on AHC, five sets of ethical guidelines for staff working within gynecology and obstetrics were examined in study I, using an analytical framework based on empirical studies regarding issues related to AHC. Data for studies II and III were collected at a women’s clinic that had chosen to host an intervention model based on Forum Play (FP) as a method for counteracting AHC. In FP, an improvisational theater method, based on Boal’s Forum Theater, staff together stage problematic situations from their own experience and test different ways of acting. In study II, qualitative interviews with 21 staff members from the target clinic were conducted, to capture the staff’s perception of AHC before the intervention. Study III evaluated the impact of 16 FP workshops by means of questionnaires focusing on the occurrences of AHC and the perceived effects of FP, sent to all staff (n=137) before, during, and after the intervention. In study IV, ten participants of an FP course, consisting of a mixed group of employees working within health care, were interviewed about their experiences of the FP course.Results: In study I, it was shown that all guidelines failed to address issues related to AHC, mainly structural issues such as power imbalances between professionals. In study II, the staff’s described perception of AHC was best categorized as ethical lapses, integrating theoretical descriptions of AHC with a defensive staff-centered position that rejected responsibility for AHC. In study III, no indication of an increased awareness of AHC was found, but an increase in the staff’s ability to act in situations with a moral dilemma was confirmed, even one year after the intervention. The findings of study IV suggest that FP has the potential to develop a response ability, enabling staff to become active in AHC situations. The power to intervene when witnessing AHC was emphasized.Conclusions: Assuming that clinical practice is a moral activity with the good of the patient as its end, it is important for staff to be able to understand AHC from the patient’s perspective. To accomplish this, even structural aspects such as power imbalances between professionals have to be considered. By failing to address these important aspects, ethical guidelines appear to be a limited resource for helping to counteract AHC. FP enables staff participants to adopt a patient’s perspective and to develop an understanding of their power and responsibility to act when in a situation involving AHC. Furthermore FP seems to provide a useful tool for staff learning to display and overcome structural obstacles in order to intervene when witnessing AHC. If counteracting AHC is understood as a matter of acting professionally, practical training such as FP needs to be prioritized.
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