| 1. |
- Abbasi, Seyed
(författare)
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Determinants of social inequalities in cardiovascular disease among Iranian patients
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background and objectives: Cardiovascular disease (CVD) is the single largest cause of mortality in the world. Similar to other health issues, CVD is generally affected either by individual risk factors, which may influence the risk for developing an illness or its complications, or by social indicators (social determinants of health). There is evidence from developed countries which shows that the so-called "upstream factors"—including social determinants such as political, social, spiritual, cultural, and economic factors—may affect the prevalence and incidence of CVD. Scarce evidence from studies in low- and middle-income countries also suggests that social factors may affect the distribution of CVD across population groups. However, there is a dearth of such data in Iran, where only a few small-sizedstudies have focused on the social determinants of health. Therefore, the present thesis sought to fill this gap by assessing the effects of socioeconomic status (SES) on the distribution of CVD and the relevant inequalities within the Iranian context.Methods: This thesis is based on four studies, which used data from the Tehran Heart Center’s Databases. In Study I, a total of 44,820 patients who underwent coronary angiography at Tehran Heart Center between 2005 and 2010 were recruited. Then, their pre- and post-procedural data—including demographics, CVD risk factors, symptoms, and laboratory tests—were compared between men and women. In Study II, 6,246 patients with acutecoronary syndrome who were hospitalized between March 2004 and August 2011 were included and, based on their education and their employment status, were divided into high- and low-SES groups. Thereafter, the effect of SES on the in-hospital death of the patients was evaluated. In Study III, 20,165 patients with documented coronary artery disease who underwent coronary angiography at Tehran Heart Center were enrolled and CVD risk factors and severity (measured by the Gensini score) were assessed among the six major Iranian ethnic groups. In Study IV, 9,088 patients with acute coronary syndrome who were hospitalized at Tehran Heart Center between May 2007and June 2014 were recruited and the association between in-hospital death due to acute coronary syndrome and place of residence (rural/urban) was assessed using logistic regression adjusted for potential confounders.Results: In this thesis, the data analyses were based on the hypothesis that there is a potential association between the different socioeconomic indicators and the selected cardiovascular outcomes. In Study I, among the recruited participant, 25,363 men and 11,995 women had coronary artery disease and the women not only were significantly older, less educated, and more overweight but also had higher blood levels of triglyceride, cholesterol, low-density lipoprotein, high-density lipoprotein, and fasting blood sugar than the men. Moreover, hypertension and diabetes mellitus showed the strongest association in the women with coronary artery disease (OR=3.45, 95% CI: 3.28to 3.61 and OR=2.37, 95% CI: 2.26 to 2.48, respectively). In addition, the frequency of post-procedural recommendations for non-invasive procedures was higher in the women than in the men (20.1% vs 18.6%; P<0.001). In StudyII, of the 6,246 recruited patients with acute coronary syndrome, 3,290individuals were considered low-SES and 2,956 high-SES individuals. In-hospital death occurred in 79 (1.26%) patients: 1.9% in the low-SES and 0.6% in the high-SES groups. After adjustment for the possible cofounders, our multivariate analysis demonstrated a significant effect of the patients’ SES on their in-hospital death and a lower in-hospital mortality rate was shown in the high-SES patients (OR=0.30, 95% CI: 0.09 to 0.98; P=0.046). In Study III, the Fars (8.7%) and Gilak (8.6%) ethnic groups had the highest frequency of having at least four simultaneous risk factors. Additionally, the mean Gensini score was lowest in the Lurs (67.5±52.8) and highest among the Gilaks (77.1±55.9). The multivariable regression analysis indicated that the Gilaks showed the worst CVD severity (β: 0.056, 95% CI: 0.009 to 0.102; P=0.018), followed by the Turks (β: 0.032, 95% CI: 0.005 to 0.059; P=0.020), and the lowest CVD severity, was detected in the Lurs (β: -0.087, 95% CI: -0.146 to -0.027;P=0.004). Study IV showed that while smoking (P=0.002), positive family history of coronary artery disease (P=0.003), higher body mass index (P=0.013),and hyperlipidemia (P=0.026) were more prevalent in the urban patients, the rural patients showed lower educational levels (P<0.001) and higher frequency of unemployment (P=0.009). Meanwhile, in-hospital death occurred in 135 (1.5%) patients: 125 (1.5%) urban and 10 (1.2%) rural. To adjust the effects of the possible confounders, we utilized the Firth regression model, which showed no significant difference regarding in-hospital death betweenthe rural and urban patients (OR=1.57, 95% CI: 0.376 to 7.450; P=0.585).Conclusions: The aim of this thesis was to investigate the effects of social determinants (particularly SES) on CVD and its modifiable risk factors among Iranian patients. Results showed that medical treatment for CVD was more recommended (by treating physicians) to the women than the men, and the low-SES patients with acute coronary syndrome were more likely to die in the hospital than their high-SES counterparts. In addition, the thesis found heterogeneity in the distribution of the traditional risk factors for CVD as well as CVD severity in the major Iranian ethnic groups. Further, there were no differences concerning the in-hospital death rates due to acute coronary syndrome between the urban and rural patients after adjustment for the potential confounders.
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| 2. |
- Almén, Niclas, 1971-
(författare)
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Intervening Stress Recovery Behaviors in Everyday Life
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background. High levels of perceived stress and stress-related ill health, such as burnout, are common in many countries. Several theories postulate that stress behaviors promote adaption to environmental changes and if sustained they are potentially harmful for the body. In accordance, impaired stress recovery behaviors, i.e., psychophysiological deactivation after periods of stress behaviors, have been suggested to be a critical factor in explaining stress-related ill health. Whereas research shows that interventions targeting stress reactivity can have beneficial effects on stress-related variables, studies on interventions targeting stress recovery are surprisingly few. Also, the number of validated instruments for measuring behaviors important for stress recovery are few, in particular easily used self-rating scales. Aims. The primary aim of the thesis was to evaluate stress and health-related effects of an intervention targeting stress recovery behaviors in everyday life among people perceiving high levels of stress in life. A secondary aim was to validate a self-report scale measuring behaviors important for stress recovery in everyday life. Method. Three empirical studies were conducted to evaluate effects of the behavioral stress recovery intervention “balance in everyday life”, which solely aims at strengthening stress recovery behaviors in everyday life. First, a brief version of the intervention was investigated through a small pilot study in which a single-subject experimental design was used (study 1). After that, the intervention was exploratively tested in a group format in which a quasi-experimental design was used (study 2). Due to the positive results of these two studies, a larger scale study using a randomized controlled design was conducted in order to further investigate the effects of the intervention when delivered in a group format (study 3). To fulfill the secondary aim of the thesis, the Recovery Experience Questionnaire was translated into Swedish and analyzed using exploratory factor analysis and confirmatory factor analysis (study 4). Results. In study 1, data demonstrated immediate reduction of stress symptoms as a function of the intervention. The improvements were maintained at 1-year and 5-year follow-up assessments. In study 2, in comparison with a waiting-list-control group, the intervention yielded statistically significant improvements between pre- and postintervention assessment on eleven out of twelve stress and health-related variables. Medium to large between-groups effect sizes were demonstrated for the primary outcome measures covering (potential) recovery behaviors, perceived stress and rest and experiences of being recovered. In the third study, statistically significant improvements for all outcome measures at postintervention assessment and at the 3-month follow-up were demonstrated. The between-groups effect sizes for the primary measures - perceived stress, tension, and burnout - were medium-to-high at postintervention assessment and at follow-up. In addition, in all studies the intervention was associated with beneficial changes in levels of anxiety and depression. In the last study, support was found for the proposed four-factor structure of the Swedish version of the Recovery Experience Questionnaire. Conclusions. The results clearly indicate that the intervention “balance in everyday life” improves stress and health-related factors in a relatively satisfactory way among people perceiving high levels of stress in life. The empirical support is strongest for the reduction in tension, perceived stress, burnout, anxiety and depression, and to deliver the intervention in a group format. The studies demonstrated results that warrant further investigation of the effects of “balance in everyday life”, for example in different contexts, and to study other behavioral recovery interventions. To test (potential) recovery facilitating behaviors as mediators of intervention effects, such as reduction in burnout, the Swedish version of the Recovery Experience Questionnaire could be used.
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| 3. |
- Andréasson, Per, 1963-
(författare)
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Emotional Empathy, Facial Reactions, and Facial Feedback
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The human face has a fascinating capability to express emotions. The facial feedback hypothesis suggests that the human face not only expresses emotions but is also able to send feedback to the brain and modulate the ongoing emotional experience. It has furthermore been suggested that this feedback from the facial muscles could be involved in empathic reactions. This thesis explores the concept of emotional empathy and relates it to two aspects concerning activity in the facial muscles. First, do people high versus low in emotional empathy differ in regard to in what degree they spontaneously mimic emotional facial expressions? Second, is there any difference between people with high as compared to low emotional empathy in respect to how sensitive they are to feedback from their own facial muscles? Regarding the first question, people with high emotional empathy were found to spontaneously mimic pictures of emotional facial expressions while people with low emotional empathy were lacking this mimicking reaction. The answer to the second question is a bit more complicated. People with low emotional empathy were found to rate humorous films as funnier in a manipulated sulky facial expression than in a manipulated happy facial expression, whereas people with high emotional empathy did not react significantly. On the other hand, when the facial manipulations were a smile and a frown, people with low as well as high emotional empathy reacted in line with the facial feedback hypothesis. In conclusion, the experiments in the present thesis indicate that mimicking and feedback from the facial muscles may be involved in emotional contagion and thereby influence emotional empathic reactions. Thus, differences in emotional empathy may in part be accounted for by different degree of mimicking reactions and different emotional effects of feedback from the facial muscles.
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| 4. |
- Bjärtå, Anna, 1974-
(författare)
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FEAR - A process influenced by concurrent processing demands
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Fear is a central aspect in mammalian evolution, prompting escape from and avoidance of threat and dangers. Therefore, it is reasonable to believe that we have a well developed system to detect dangers and quickly respond to them. It has been shown that threatening information has an advantage in information processing; it seems to promote a rapid capture of selective attention and puts demand on processing resources. It has been suggested that the elicitation of fear occurs automatically, and that it is independent of and impenetrable to cognition.The idea with the present research is that fear processing is dependent on all concurrent internal or external processing demands. One visual search study (Study II) and two secondary task studies (Study I & III) have been conducted to investigate if external or internal distraction can interfere with fear processing. In order to provoke fear responses, spider or snake fearful individuals have been exposed to pictures of their feared stimulus. The aim of Study II was to investigate if the selective attention to fear stimuli could be influenced by contextual factors, such as the nature of the distracting stimuli in a visual search. Study I and III aimed to investigate manipulation of resources allocated to fear stimuli. In Study I, task demand was used as the manipulation, and in Study III an internal cognitive directive was used. The results from these studies indicate that fear is susceptible to manipulation by both external and internal means. By changing circumstances in the surrounding or in the individuals’ internal states, responses to threatening stimuli can be altered. This means that processing of threatening stimuli is influenced by other concurrent processing demands, suggesting that a fear response is not occurring as an isolated and impenetrable process. In an evolutionary perspective, a fear system that is easily triggered but has access to cognitive evaluation at all times ought to be far more flexible, thus creating a better chance for survival than a modular and impenetrable fear system.
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| 5. |
- Eriksson, Ann-Kristin Mimmi
(författare)
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Vid utmattningens gräns. Utmattningssyndrom som existentiellt tillstånd : Vårdtagares och vårdgivares erfarenheter av utmattningssyndrom och rehabilitering med en existentiell ansats i svensk vårdkontext
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background and objectives: Stress-related illness is a growing public health problem in Sweden and it is the most common reason for sick leave today. Stress-related illness causes suffering on a number of levels and affects the patient’s health and life in the long term. The stress-related ill health also leads to consequences for society, causing high costs for sick leave and health care as well as lost workforce since people partially or entirely lose their capacity to work. Research on stress-related ill health and rehabilitation often underline work-related conditions as crucial in dealing with the problem. There is also research that points out psychosocial factors in understanding stress-related ill health. What we know little about is the existential perspective of clinical burn-out. Therefore, it is of importance to investigate people’s existential experiences of clinical burn-out and the significance of an existential perspective in rehabilitation.Aim: The overall aim of this thesis is to gain insight into the existential experience of clinical burn-out as well as to highlight the significance of an existential perspective in rehabilitation. In addition, the thesis aims to reach a deeper understanding of clinical burn-out from an existential point of view and contribute to the field with knowledge of the existential dimension of health.Methods: The study, conducted in 2011, is based on qualitative interviews made with an inductive hermeneutic approach. Five patients and seven care givers were interviewed, focusing their existential experiences of clinical burn-out as well as their experiences of rehabilitation with an existential approach. A strategic selection was made of informants in the context of a rehabilitation program with an existential approach for people diagnosed with clinical burn-out. The data was analysed in two steps. In the first step the data was interpreted with an inductive hermeneutic approach. In step two of the analysis, the data was interpreted with a deductive hermeneutic approach, using Karl Jasper’s concept of limit situation as a way of interpreting the existential experience. Aaron Antonovsky’s concept sense of coherence was used as a tool for understanding components that can contribute to restoring health.Results: In this study, the patients describe clinical burn-out as a comprehensive existential experience that can be perceived as being in between life and death, in a shadow world, trapped in a dead end. It’s a situation characterized by being powerless. It creates a need to comprehend one’s situation in order to be able to regain control and manage it. It’s a struggle to make sense of the life situation. When not being met with understanding, the patients lose hope. Existential issues in terms of meaning, existence and life choices become urgent. Working with the existential perspective requires trust, openness from both caregiver and patient, distinctness, a way to communicate it and courage to take on the challenge of dealing with existential issues. The perspective also requires that the existential suffering can be contained. Dealing with existential questions leads to self-knowledge and insights that enables a possibility to make different choices and leave negative behavioural patterns. Also, it can lead to a discovery of spirituality and religion as a resource in life. Besides their personal struggle for meaning, the patients see an existential void in society, leaving people without tools to handle existential needs. This is understood as something that affects people’s ability to handle stressful times in life.The care providers understand burn-out as a manifestation of a way of living that is not sustainable. It is an existential experience embodied in body and mind that can be experienced as being drained of life. It’s an existential challenge, causing grief when realizing one’s limitations as a human being. Also, loss of meaning and sense of existential vulnerability due to an experience of being annihilated is crucial for understanding the deep existential crisis that clinical burn-out can induce. This situation makes the patient ask existential questions about identity, meaning, values and direction. In the burnout-process the patients have distanced themselves from their own self and therefore need to reconnect with themselves. This makes the existential questions central in the rehabilitation as a way to reconnect to inner strength and resources, which are prerequisites for starting a health promoting, sustainable process which is empowering, making it possible to see oneself as a human being who experience meaning, not only as a patient with a diagnosis. Instead of finding meaning in the diagnosis, the patient’s existential questions and the existential experience is a key to moving forward, out of the situation. Meaning-making is therefore important in the rehabilitation.A holistic-existential approach and view of man makes it possible to work with the complexity of the situation. The holistic-existential approach creates synergies and offers an extra tool both for the caregiver and the patient. Focusing on the patient’s resources and competence makes it possible to see the crisis as a way to learn from it.The existential perspective in health care and rehabilitation is enabled by competence, openness, reliance, empathy and respect when meeting the patient. It also requires courage to take on the challenge of dealing with existential issues. It can be hard for both the patient and the care giver to confront existential suffering. It is the responsibility of the care giver to enable the existential perspective by acknowledging and making the existential perspective possible to communicate and work it through.The care providers understands values in modern society as contributing to people’s experience of feeling alone with existential needs, which intensifies their existential aloneness.The care providers’ experience is that the biomedical paradigm aggravates an existential perspective. The perspective is not associated with the care situation. There is a lack of knowledge about and understanding of the value of the existential perspective, all the way from the decision-making level to the clinical meeting with the patient. In addition, the paradigm affects how the patients express their illness. Also, the perspective requires time. Existential perspectives, therefore, tend to be concealed in the health care context.Applying Karl Jasper’s concept of limit situation, clinical burn-out can be interpreted as a defining existential experience. It can be understood as a limit situation when humans realize their limitations and at the same time get insights that are crucial for their lives. It’s an experience they wish they had not gone through, but on the other hand, it has led to insights they do not want to be without. The meaning-making process is health promoting by recreating meaning, the fundamental part of sense of coherence, which is crucial for a salutogenic direction.Conclusion: The existential state that the clinical burnout patients go through can, using Karl Jasper’s concept, be understood as a limit situation. According to Jasper’s reasoning, the limit situation can be perceived as facing an abyss, making it clear one has limitations as a human being. At the same time, the experience can be perceived as reaching a limit where humans can get insights about human life that can enhance life. Clinical burn-out, using Aaron Antonovsky’s concept, can be understood as a loss of the components that create sense of coherence. Loss of meaning is particularly central for understanding burn-out.Consequently, it is crucial to acknowledge the existential challenge that the patient is facing, as well as the importance of the meaning-making process for facilitating a movement in a health promoting manner. It gives a deeper understanding of the challenges and needs of patients suffering from clinical burn-out.The existential dimension of health has been highlighted in health promotion, but gets little attention in practice. This is especially significant in the health care context. This points out the need for a discussion about how the existential health dimension can be used as a resource in health care and rehabilitation and how this resource for health can be applied in a better way in health promotion and public health.
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| 6. |
- Eriksson, Lina J. K.
(författare)
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An Exploration of the Behavioral Inhibition System (BIS), Response Inhibition, and Possible Implications in Sports
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Large parts of human behaviors are oriented towards achieving a particular goal. Motivational factors in the form of approach and avoidance motivated behavior and executive functions (EFs) such as inhibition are central for goal-directed behavior. There are individual differences in the inhibition of prepotent behavior and the Behavioral Inhibition System (BIS) can be viewed as a neuropsychological system that has been proposed to be a personality trait that explains those individual differences. Inhibition is an EF that is involved in the control of impulses and enable us to choose how to react and behave. Sport is a context in which the cognitive demands can be high and there is a growing body of research trying to pinpoint the cognitive mechanisms behind superior athletic performance. Response inhibition is suggested to be one of the mechanisms that is of importance for performance in sport.The general aim of this thesis was to explore the BIS, response inhibition and the possible implications in sports. A theoretical framework of approach and avoidance motivation, the revised RST (Gray & McNaughton, 2000; McNaughton & Corr, 2004) was combined with a paradigm for assessment of response inhibition; the stop-signal paradigm (Logan & Cowan, 1984). In addition, different instruments for assessment of the BIS was investigated and designs of the stop-signal task for assessment of response inhibition was used. Study I and III aimed to examine the relationship between response inhibition and the BIS. Study I used a sample of non-athletes and Study III used a sample of non-athletes, and athletes from two different interceptive sports, biathlon and alpine skiing. The aim of Study II was to test the factor structure of a Swedish version of the Reinforcement Sensitivity Theory of Personality Questionnaire (RST – PQ; Corr & Cooper, 2016). The results from Study I indicated that when the ability to inhibit prepotent response and behavioral precision (i.e., accuracy) is central for task performance, higher levels of BIS could be a vulnerability factor when the individual’s inhibitory ability simultaneously is poor. Due to ceiling effects in the variable accuracy, this was not possible to replicate in Study III. The results in Study II suggest that the RST-PQ has considerable promise since it, for example, provides an opportunity to distinguish between the individual differences between fear and anxiety, although there were issues concerning the convergent validity. Study III showed that athletes with experience in interceptive sports do not outperform non-athletes on response inhibition. The implications of these results are that it is possible that other aspects than being an athlete or non-xathlete need to be considered and that individual differences in the BIS could be one of these aspects.Taken together, results from these three studies indicated that that it is possible to combine a theoretical framework of approach and avoidance motivation and a paradigm for the assessment of response inhibition, the stop-signal paradigm, with the purpose of exploring the BIS, response inhibition and possible implications in sport. It has also showed the complexity with using self-report instruments for assessment of neuropsychological systems that, in theory, underlies personality and the difficulties with using SSTs for assessment of an estimated measure (i.e., SSRT) of response inhibition. By exploring the BIS and response inhibition, this thesis offers an approach to view sport expertise and show the value of focusing on individual differences in the personality trait BIS since, at least theoretically, the BIS has the potential to serve as an explanation for variations in response inhibition and the possible association with behavioral precision (i.e., accuracy).
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| 7. |
- Eslami, Bahareh, 1978-
(författare)
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The Psychosocial Situation of Adults with Congenital Heart Disease in Iran
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background and objectives:Adults with congenital heart disease (CHD) are a new group of patients with a prevalence of 4 per 1000. They have evolved as a result of significant improvements in medical management during the past decades. However, adults with CHD experience various medical and social challenges that may influence their psychosocial functioning. Providing appropriate medical, rehabilitation and social care for adults with CHD, and indeed improving their well-being require the evaluation of their current psychosocial situation. This thesis aims to increase the understanding of the mental health, somatic symptoms, social support, style of coping, quality of life and life satisfaction of adults with CHD and to examine the possible contributing factors in the context of a developing country; issues not addressed in the current literature.Methods:This thesis is based on four studies. Study I recruited 347 consecutive CHD patients (18-64 years) from two heart hospitals in Tehran, Iran. The study iscross-sectional and focused on sex differences in socio-economic status, lifestyle and medical characteristics of adults with CHD. Studies II, III and IV havea cross-sectional case-control design comparing the aforementioned CHD patients with 353 non-CHD participants, matched by sex and age. Outcome variables were anxiety, depressive and somatic symptoms (Study II), styles of coping (Study III), and life satisfaction/quality of life (Study IV). The data were analysed with bivariate and multivariate methods. Multivariate linear regression analyses were performed to scrutinize the association of demographic/socio-economic variables, social support, mental health, and medical variables with the aforementioned outcome variables among adults with CHD (Studies II, III, IV). Results:Study I showed that women with CHD were more often married and had children and were less often employed, but had healthier behaviour compared to men. Even though most of the patients received regular medical viiicare from different typesof medical professionals, half of them had no knowledge about the type of their cardiac defect. Study II showed that CHD patients experienced more anxiety and somatic symptoms than the healthy controls, whereas there were no differences in depressive symptoms. Perceived financial strain, lower social support and low annual income were positively associated with worse outcome in mental health and somatic symptoms. None of the medical variables were related to anxiety, depressive and somatic symptoms. Study III showed that the styles of coping of the CHD patients were comparable to those of the control group and CHD per se was not associated with a certain style of coping, except for palliative reaction pattern. Problem-focused styles of coping were associated with being never married, parenthood, higher level of anxiety and somatic symptoms, lower level of depressive symptoms and higher social support. Emotion-focused styles of coping were associated with annual income and higher level of anxiety. None of theadopted coping strategies were related to the heart disease variables. Study IV showed that adults with CHD had poorer quality of life and lower life satisfaction than the control group. However, CHD was associated only with decreased overall quality of life and its physical health domain, and life and health satisfaction. Among CHD patients, higher quality of life was associated with female sex, younger age, employment status, having less emotional distress and higher social support, while life satisfaction was associated with female sex, being employed, less emotional distress and higher social support. Conclusions:The results support the notion that psychosocial factors contribute to the well-being of adults with CHD.Socio-economic factors, emotional health and social support are significant determinants in nearly all outcomes of interest which need to be considered by health care providers and policy makers in their efforts to improve the health ofadults with CHD. However, longitudinal studies are warranted to establish causal linksand qualitative studies are recommended to deepen the understanding of coping and quality of life.
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| 8. |
- Hiswåls, Anne-Sofie
(författare)
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Employment Status and Inequalities in Health Outcomes : Population-based Studies from Gävleborg County
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background and objectives: From a public health perspective, it is important not only to improve and maintain health, but also to promote equality in health. Epidemiological research has showed the importance of work and unemployment in the development of socio-economic health inequalities, and peoples life chances are suggested to be conditioned by participation or exclusion from the labour market. The most recent economic recession has brought further changes to the labour market that might have aggravated the already multifaceted image of inequalities in health. Gävleborg County was one of the hardest hit counties in Sweden, which experienced a myriad of changes in the labour market that went beyond those of the Swedish national average, in terms of increase in flexible forms of employment, factory closures, and lay-offs. The overall objective of this thesis was to investigate the relationship between employment status and health-related inequalities in Gävleborg County, Sweden. In addition, the Specific objectives for the thesis were to: assess the relationship between employment status and self-reported health in Gävleborg (Study I); to estimate the relationship between employment status and suicidal ideation during the economic recession in Gävleborg (Study II); to estimate the prevalence of anxiety and depression among economically active people living in the Municipality of Gävle (Study III) and to assess experiences and perceptions of well-being after involuntary job loss in Gävle (Study IV).Methods: Study I and II in this thesis used data from the 2010 Health in Equal Terms survey, a cross-sectional survey carried out in Gävleborg County in Sweden. A total of 4,245 individuals, aged 16–65 years were included in the analyses. Study III was performed in Wave 1 (baseline survey) of the Gävle Household, Labour Market Dynamics and Health Outcomes survey (GHOLDH), a panel survey with household as the follow-up unit. A total of 241 persons completed a self-administered postal questionnaire which collected information on the employment status and psychological health (anxiety and depression) among persons aged 18–65 years. The thesis used descriptive analyses and logistic regression models to describe and explore the relationship between employment status, self-reported health and suicidal ideation in Gävleborg County (Studies I and II). Descriptive analysis of means and a multiple regression analysis for adjusted means of HADS, were used in order to estimate the prevalence of anxiety and depression among economically active persons residing in the Gävle Municipality (Study III). Study IV used a qualitative approach to gain a deeper understanding of how involuntarily unemployed persons in Gävlexperceive their well-being. Sixteen unemployed men and women aged 28–62 were interviewed face-to-face. A purposeful sampling strategy was used in order to suit the research question and to increase the variation among informants. The interview texts in Study IV were analysed using thematic analysis.Results: In Study I, the prevalence of poor self-reported health (SRH) was twice as high in the group of people who were not employed (42%) compared to the employed group (21.6%). Individuals outside the labour market had odds of poor health of 2.64 (Cl 2.28–3.05) compared to their employed counterparts. Controlling for other covariates reduced the risk slightly to 2.10 (1.69–2.60), but remained statistically significant. Moreover, other variables such as long-standing illness, age, income and lack of social support were associated with self-reported poor health. In Study II, among those not employed, 11.2% had been in a situation where they had seriously considered taking their life (at some time during the past 12 months). The corresponding figure for those employed was 2.9%. Unadjusted results of the logistic regression analysis revealed that people who were not employed had about a four times higher risk of suicidal ideation, with an OR of 4.21 (CI: 3.14–5.64) compared to their employed counterparts. Controlling for other covariates, reduced the risk from 4.21(CI 3.14–5.64) in model I, to 1.73 (CI 1.16–2.57) in model IV, but remained statistically significant. In addition, other variables were associated with suicidal ideation. In Study III, the prevalence and risk of anxiety and depression were high among people who were out of work. In the multiple regression analysis, compared to employed people, those who were not employed had a risk of anxiety of 7.76 (5.97–9.75) and 4.67 (3.60–5.74) for depression. Study IV revealed six different themes from the interviews: Work was perceived as the basis for belonging; loss of work affected people’s social life and consumption patterns due to changes in their financial situation. Feelings of isolation, loss of self-esteem, and feelings of hopelessness were reported, affecting the respondents’ physical well-being. Longer duration of unemployment increased the respondents’ negative emotions. Activities, structure, and affiliation in other contexts were reported as part of their strategy for coping with poor mental health.Conclusion: This thesis found a statistically significant relationship between being outside the labour market and poor SRH, a high risk of suicidal ideation, anxiety, and depression during the recent economic recession. The relationship between employment status and SRH was partially explained by socioeconomic, demographic and lifestyle variables. In addition, the relationship between employment status and suicidal ideation was, for the most part, explained by demographic, socio-economic and self-reported psychological variables. Atxithe municipal level, the prevalence of anxiety and depression was higher among those who were out of the labour market as compared to those who were employed and the odds of anxiety and depression were higher among people out of the labour market, but this was less prominent for depression than for anxiety. Job loss created feelings of loss of dignity and belonging as a human being. The participants experienced feelings of worry, insecurity, and stress due to their changed financial situation, which in turn led to isolation and loss of self-esteem. Social support and having activities other than work gave structure and meaning to everyday life. The results of this thesis indicate a need for early detection and potential treatment of people out of the labour force and for being aware of the increased risk of poor health symptoms and disorders among unemployed individuals. The findings also indicate a need for primary prevention strategies, implying that policy-makers must pay attention to the health status of those who are out of work, especially during times of combined economic hardship and labour market fluctuations. However, longitudinal studies are warranted to shed further light on the mechanisms through which employment status and conditions impact physical and psychological health outcomes.
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| 9. |
- Partanen, Petri, 1969-
(författare)
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Assessment and Remediation for Children with Special Educational Needs : The role of Working Memory, Complex Executive Function and Metacognitive Strategy Training
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to explore the role of different assessment tools and training regimens in assessment and remediation for children with special educational needs in school. A central purpose of assessment explored was that it should inform remediation, teaching and instruction. The concepts of working memory, complex executive function and metacognitive strategy training for children with special educational needs were specifically explored in relation to this purpose of assessment. Complex executive function refers to planning and metacognitive ability, that many children with special educational needs struggle with, and which they are expected to handle in learning during school day. Of particular interest in the thesis was the contrast between working memory and complex executive function and how these concepts inform assessment and remediation practices. In this context, special attention was given to mathematical learning difficulties.The thesis was based on four studies (I‑IV). Study I explored the prevalence of different assessment tools, and dilemmas and challenges as perceived by assessment professionals, teachers and parents, in the work with children with special educational needs in Europe. In Study II, a metacognitive strategy training framework was developed as a training regimen, guided by research on complex executive function, and applied on working memory training. Effects of working memory training were compared between the two training regimens, with and without metacognitive strategy training, and also the overall effect of working memory training on cognitive functioning and the school related skills of reading, writing and arithmetic. In Study III, different types of measures of working memory and their predictive capacities in relation to mathematics achievement in national curriculum assessments were explored, as well as the effects of working memory training on mathematics achievement. In Study IV the role of working memory and complex executive function in identifying risk for mathematical learning difficulties in children with special educational needs was explored.The results from Study I suggested that assessment and remediation practices can contribute to a deficiency‑oriented outlook on children with special educational needs. In contrast parents and teachers in Sweden also reported that assessment could help them to better understand the needs of the child. Results from studies II-IV showed that only the use of a metacognitive strategy training regimen targeting complex executive function resulted in improvements following working memory training. The results also indicated that working memory training strongly predicted mathematical performance in national curriculum assessments of mathematics in school, and that a more complex change measure of working memory was a better predictor than simple working memory measures in this regard. Finally, the results also showed that complex executive function, defined as planning ability, was a better predictor than simple working memory in the assessment of risk for mathematical learning difficulties.The results from the studies were discussed in relation to the purpose of assessment to inform remediation, teaching and instruction for children with special educational needs. It was concluded that, in addition to working memory, as complex executive function – planning and metacognitive ability - seems to be an important cognitive function related to learning, this should be addressed both in the assessment of children with special educational needs as well as in the remediation when designing training regimens and interventions for children with special educational needs in general, and children at risk for mathematic learning difficulties in particular. It was also highlighted that in remediation, the role of the teacher as a mediator of metacognition and complex executive function seems vital.
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- Rondung, Elisabet, 1980-
(författare)
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Psychological perspectives on fear of birth : heterogeneity, mechanisms and treatment
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Although it is medically safe to give birth in most western countries, the vast majority of pregnant women experience some kind of anxiety, fear or worry in relation to their pregnancy or the upcoming childbirth. Most pregnant women find ways of coping with these issues but, for many, fear of birth is a significant source of distress during pregnancy, with negative consequences both when giving birth and in the postpartum period.Previous research on fear of birth has for the most part had a medical perspective, investigating risk factors and consequences of this form of fear or anxiety, along with studies evaluating different forms of interventions. The general aim of this thesis was to approach fear of birth from a psychological perspective, by exploring the role of psychological factors in this form of fear, worry or anxiety.Four studies are included in the thesis. The first study is a randomized controlled trial, in which we compared a guided Internet-delivered self-help program, based on cognitive behavior therapy (guided ICBT), with standard care (midwife led fear of birth specific counseling), for the treatment of fear of birth. Despite poor adherence to the guided ICBT, the results showed a similar reduction in fear levels during pregnancy in both groups, with lower levels of fear of birth in the guided ICBT group one year after birth. The second study is a narrative literature review. This study adopted a psychological perspective on the existing literature describing fear of birth, with a special focus on the specificity of this form of fear or anxiety, the pathways of fear acquisition, and the physiological, cognitive and behavioral aspects of fear of birth. Using systematic procedures for the literature search, inclusion and exclusion, 89 original research papers were included and summarized in the study. The aim of the third study was to explore possible heterogeneity among pregnant women reporting high levels of fear of birth. Comparisons between primiparous and multiparous women revealed that these groups were very similar in their levels of fear of birth as well as in the psychological variables investigated. Using a series of hierarchical and non-hierarchical cluster analyses, five possible subgroups based on psychological characteristics were identified, pointing to psychological heterogeneity among women fearing birth. In the fourth study, our aim was to take a first step in trying to identify psychological mechanisms relevant to the understanding of fear of birth. In this study, pain catastrophizing and intolerance of uncertainty were clear predictors of fear of birth, while parity was not.Taken together, the results of the four studies included in this thesis indicate that fear of birth is a concept in need of further investigation, and that psychological perspectives could offer an important contribution to our understanding of this form of fear or anxiety. Women fearing birth seem to be a heterogeneous group, and psychological characteristics (e.g. pain catastrophizing, or catastrophizing in general, and intolerance of uncertainty) might be of greater importance than parity in both describing this diversity and understanding the development and maintenance of fear of birth. Treating fear of birth using guided ICBT can be challenging, and before introducing this form of treatment as an alternative, further refinement and evaluation of the methods are needed.
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