| 1. |
- Kassymova, Gulnara, 1972-
(författare)
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The impact of postoperative telephone follow-up contacts on recovery after benign hysterectomy : with emphasis on health-related quality of life, postoperative symptoms, and health economics
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundThe course of a postoperative recovery is important for both patient and healthcare services. Efforts to expedite and improve recovery in a safe and cost-effective manner are therefore highly desirable from the perspective of both parties. Telephone follow-up (TFU) has been suggested as a way to improve postoperative recovery and reduce the burden of the healthcare service. This thesis intends to investigate these issues. The overall purpose of the thesis was twofold: to evaluate the effects of nurse-led TFU contacts on the recovery after benign hysterectomy, and to make a health economic analysis of TFU. The specific aims of the thesis were a) to evaluate whether TFU, particularly when combined with structured-oriented coaching, facilitated postoperative recovery in terms of health-related quality of life (HRQoL), the duration of sick leave, and the occurrence of unplanned telephone contacts (uTCs) and unplanned visits (uVs) in the postoperative period, b) to determine if the TFUs affected postoperative symptoms and the consumption of analgesics, c) to analyze whether symptoms of anxiety and depression, and low stress-coping capacity had an impact on the effect of TFU on recovery and the occurrence of uTCs and uVs, and d) to provide a health economic evaluation of the TFU from the healthcare and societal perspectives. By addressing these aims, the intention of the thesis was to contribute with important knowledge to the existing sparse body of science concerning clinical outcomes after nurse-led TFUs and their impact on recovery outcomes after benign hysterectomy. Material and methodsA four-armed, semi-blinded, randomized controlled trial was conducted at the departments of obstetrics and gynecology in five public hospitals in the southeast health region of Sweden from October 2011 to May 2017. The study comprised 487 women between 18 and 60 years old who underwent abdominal or vaginal hysterectomy for benign gynecological conditions. The treatments to be investigated were different nurse-led TFU models and consisted of four groups: Group A had no planned follow-up contact with the healthcare service after discharge (control group); Group B had one planned, structured TFU session with the research nurse (RN) on the day after discharge; Group C had a planned, structured TFU session with the RN on the day after discharge and then once weekly for six weeks; and Group D had a planned, structured, oriented coaching TFU session with the RN on the day after discharge and then once weekly for six weeks. The specific content of the TFUs in Groups B and C, as well as the oriented coaching TFU model in Group D, were outlined in the study. Demographic and clinical data relevant to the study were collected prospectively. Sick leave duration, analgesic consumption, uTC, and uV were recorded from discharge until the six-week follow-up visit with the RN. HRQoL was measured by means of the EuroQoL-5 Dimension with three levels and the Short Form Health Survey with 36 items. Psychological distress was evaluated using the Hospital Anxiety and Depression Scale and the Stress-Coping Inventory. Postoperative symptoms were assessed using the Swedish Postoperative Symptoms Questionnaire. The health economics were evaluated using a cost minimization analysis. The estimation of hospital costs was based on the principles of the Cost Per Patient (CPP) method and the prices from the CPP list for 2022 from the University Hospital in Linköping were applied. ResultsRegardless of the TFU model, women achieved baseline levels of HRQoL four weeks after surgery and no difference was seen between the intervention groups in the trajectory of recovery of HRQoL. The duration of sick leave was similar across all intervention groups, ranging from 26.8 to 28.1 days. There were no significant differences in the trajectory of the intensity of postoperative symptoms or analgesic consumption between the intervention groups. Approximately 46% of the women had uTC and 45% had uV. The oriented coaching TFU was associated with a 33% lower occurrence of uTC compared with other TFU models. Women who had uTC reported higher levels of pain intensity and sum scores of postoperative symptoms, especially when the uTC was followed by a uV. Symptoms of depression, anxiety, and low stress coping capacity did not affect the effects of the TFU models on recovery trajectories, although there were strong associations between symptoms of anxiety, depression and low stress-coping capacity and all recovery measures. In addition, uTCs were more frequent among women with anxiety. The total costs per patient more than doubled in the groups with repeated TFUs compared with the group with no TFU. The coaching TFU group had lower costs for informal care. ConclusionsNurse-led TFU after benign hysterectomy in the form used in the present study did not expedite or improve the postoperative recovery concerning HRQoL, sick leave duration postoperative symptoms, or analgesic consumption. However, nurse-led TFU with structured coaching reduced the occurrence of uTC to healthcare providers, but not uVs. Symptoms of anxiety increased the occurrence of uTC and pain seemed to be a significant cause of both uTCs and uVs, The effect of the TFU on the recovery did not seem to be affected by the psychological state of proneness to anxiety, depression, or low stress-coping capacity. Nurse-led TFUs were cost-driving for the healthcare systems and can be seen as an inefficient use of healthcare resources.
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| 2. |
- Nilsson, Marie, 1966-
(författare)
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Salutogenetic resources in the everyday lives of teachers : promoting workplace learning and well-being
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to explore salutogenic resources in the everyday lives of teachers, and toinvestigate how an intervention of collegial reflection influences their work-related learning and their being.The thesis includes two parts, a needs assessment and an intervention, performed between 2009 and2016. Both qualitative and quantitative approaches have been used in the process of the thesis. Methods used for data generation have been multistage focus groups interviews, individual interviews, questionnaire, open mail questions, and digital recordings of the reflection meetings. Four different methods have been used For the analyses: content analysis, hermeneutic analysis, multiple linear regression, and thematic analysis.The findings indicate that the caring relationships with pupils, but also colleagues, were important for the teachers’ finding meaning in their work. The caring relationships and the sense of meaningfulness were important resources for the teachers well-being.Collegial reflection was a health promoting resource in that it contributed with social support from colleagues, a sense of belonging, a consensus regarding shool issues, and recovery. This recovery occurred while the teachers were having their collegial reflection, indicating that they still felt recovered even though they were reflecting on work-related issues.The thesis also indicates that teachers’ experiences of time pressure at work was the variable with the strongest associaton to their experience of work-life balance. The integration of work and private lives is an important part of being a teacher. Certain aspects of work was considered as positive and salutogenic when integrated with their private lives, such as the creative aspect of teaching. However, other aspects, such as ruminating over abused pupils, were affecting their well-being in a detrimental way when integrated in their private lives.In a time when much focus is put on teachers’ increasing workload, documentation and psychosocial risks, it is important to pay more attention to the salutogenic and the enhancing aspects of teacher's work. By doing that, teachers’ well-being may be enhanced, as well as supporting teacher retention.
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| 3. |
- Nilsson, Per A., 1957-
(författare)
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Studying abroad : exploring mobility, expectations and experiences among mobile students
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis deals with the experiences and outcomes of temporarily studying abroad, via follow-up studies, aiming to explore international student mobility with a focus on the individual’s perspective. The specific research questions, dealing with the individual students’ expectations and experiences, are addressed in three papers. The fourth paper is a framing of these studies, using results from a global study.The first research question connects to the attractiveness of international study experiences: Q1. What are the individual’s expectations for studying abroad, among inbound and outbound students, and what are the students’ reported experiences compared with these expectations? The second research question connects to the mobility culture of youth: Q2. Does students’ reported life satisfaction change in any way after studying abroad?A main finding for outbound students was an appreciation of courses offered at the destination higher education institution that were not available at Umeå University. The students also had a desire to change their environment and have new experiences. Conversely, the desire to work abroad in the future was lower after returning home. A major finding for inbound students was that they assigned higher value to personal development than academic development. The experience made the students positive in regard to working abroad. Inbound students reported significantly higher satisfaction at follow-up six months later for the domains somatic health and activities of daily living. For both in- and outbound students, experiencing a new culture was more important than pure academic experiences.When the experience was compared with the expectation, in most cases the outcomes were positively related for both in- and outbound students. The motives for international study were primarily related to personal achievements, indicating a fulfilment of one’s potential and curiosity about a sojourn abroad.Finally, the results from the Umeå studies were compared with a global survey. The Umeå studies shows that the respondents viewed studying abroad as an important experience and as a merit later in life. The global survey results indicate that the transition from education to the world of work is of increasing importance to students, and that it matters more for non-European students. The global study showed that employability, teaching ability, expert lectures, and course organization are important to international students.
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| 4. |
- Sandberg, Ylva, 1968-
(författare)
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Bilingual subject-specific literacies? Teachers’ and learners’ views and experiences of two school languages in biology, civics, history and mathematics : Case studies from the Swedish upper secondary school
- 2018
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This licentiate thesis investigates teachers’ and students’ cognitions of bilingual subject-specific literacies. The thesis builds on three different studies, referred to as case studies, conducted in Content and Language Integrated Learning (CLIL) study programmes in the Swedish upper secondary school. Participants’ views and experiences of two languages of schooling, English and Swedish, were elicited in interviews, and analysed thematically. To gain understanding of the three studies in combination, a further analytical framework was developed and tested. In this analysis, participants’ descriptions, explanations and reflections on teaching and learning curriculum content bilingually emerged as three-dimensional discourses.In the first study, new and experienced teachers’ challenges and strategies were in focus. The biology and civics teachers, who were new teachers, and new to CLIL, found teaching through the second language of schooling, English, time-consuming and demanding. They expressed concern about limited communication and learning in the classroom. The mathematics teachers, who had long teaching experience, and of teaching in the CLIL programme, had developed strategies to meet perceived challenges, for example, they had designed parts of lessons in a monolingual mode, and parts of lessons in a bilingual mode.The second study explored intermediate CLIL teachers’ rationales for language choice in teaching. The biology and history teachers found that access to English, as afforded through the CLIL framework, coincided well with the new syllabi for their school subjects. For instance, the history teachers could use web-based study materials in English in class, and found teaching and learning more authentic than in the mainstream, Swedish-speaking, study programmes. The biology teachers mentioned that access to English terminology facilitated the teaching and learning of complex subject-specific content areas. It functioned as a potential source to enhance students’ understanding.The third study documented students ́cognitionsof CLIL. The views of upper secondary students studying curriculum content through English were overall positive. However, results showed that their experiences of CLIL varied with school subject. Whereas studying mathematics through English was reported to be conducive to learning and understanding, learning civics through English only, or trying to listen to lectures in civics, where teachers would change languages seemingly without a rationale, were perceived as less conducive to learning.
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| 5. |
- Wijk, Lena, 1971-
(författare)
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Enhanced Recovery After Hysterectomy
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: To study recovery after hysterectomy under Enhanced Recovery After Surgery (ERAS) care, and in relation to different operation techniques.Materials and Methods: An observational study was conducted comparing 85 patients undergoing hysterectomy with ERAS care to 120 patients immediately before establishing ERAS. In a prospective cohort study of 121 consecutive patients undergoing hysterectomy, the outcome was compared for patients with malignant versus benign indications. The main outcome measure was length of stay (LOS). A randomised controlled trial (RCT) of 20 women scheduled for hysterectomy compared robot-assisted laparoscopic with abdominal hysterectomy in terms of the development of insulin resistance, inflammatory reactions, and clinical recovery, and examined the relation to hormonal status. All studies were conducted in 2011--2015, at the Department of Obstetrics and Gynaecology, Örebro University Hospital, Sweden.Results: Implementation of a structured ERAS protocol significantly reduced LOS compared to non-ERAS care. The effect was similar between patients with malignant and benign indications for surgery. No difference in complications was found. There was no difference in development of insulin resistance between robotic and abdominal technique, but clinical outcomes and inflammatory responses significantly favoured robot-assisted hysterectomy. Female sex hormone status was associated with the development of insulin resistance.Conclusions: Recovery after hysterectomy can be influenced. ERAS care seems to be effective and safe. Clinical outcome can also be influenced by operational technique. Hysterectomy triggers a stress reaction in both the metabolic and the inflammatory system. It remains unclear why the reduced inflammatory reaction and favourable clinical outcome in robotic surgery were not mirrored by less insulin resistance. This could not be explained by female sex hormone status.
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| 6. |
- Allbrand, Marianne, 1958-
(författare)
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Gene expression of inflammatory markers and growth factors in placenta in relation to maternal obesity and foetal and postnatal growth
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Maternal obesity is a growing health problem, that contributes to obstetrical complications in pregnancy, as well as neonatal morbidity and mortality. The placenta serves for gas and nutrient exchange between the mother and the foetus, and obesity may influence and modify placental growth and function. The aims of this thesis were to investigate associations between maternal obesity without associated morbidity and gene expression of inflammatory markers and growth factors in the placenta, as well as offspring birth weight and postnatal growth. Study I and III were designed as matched case-control studies including 32 obese women with an early pregnancy body mass index (BMI) ≥ 35.0 kg/m2, study II was an experimental study examining twelve placentas of normal weight women, and study IV was a cohort study including 109 obese women with a BMI ≥ 34.5 kg/m2. In studies I-IV analyses of gene expression were performed and in study III additionally cord blood concentrations were determined. No difference was found in the occurrence of placental gene expression of inflammatory markers or growth factors between obese and normal weight women, nor did the sampling site in placentas of normal weight women influence gene expression of these markers, except for leptin gene (LEP) and insulin receptor gene (INSR) expression. Ghrelin gene (GHRL) and LEP expression, as well as cord blood ghrelin and adiponectin levels, was not altered in maternal obesity, and a negatively U-shaped relationship between LEP expression and infant birth weight (BW) z-scores was observed in the placentas of obese women.In conclusion, no statistically significant difference in gene expressions of inflammatory markers and growth factors in the placenta between severely obese and normal weight women was found. These results are in contrast with earlier studies and could be due to the fact that we examined mainly healthy obese women. The correlations we found between gene expression of leptin in the placenta and the birth weight of the infants warrants further studies.
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| 7. |
- Andersson, Håkan A., 1948-
(författare)
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Svenska småföretags användning av reserveringar för resultatutjämning och intern finansiering
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Small firms often have inadequate access to the capital necessary for sucessful management. The Swedish Government introduced in the mid-1990s allowance rules that facilitate retention of profit for sole proprietorships and partnership firms. The tax credits arising from the allowances give certain benefits as a source of financing compared to traditional forms of credits. Among the more essential benefits are that the payment for some parts of the tax credit can be put on hold almost indefinitely, or alternatively never be paid. The firms are free to use these means, and the responsibility of future payment of the postponed tax debt stays with the individual firms. The comprehensive purpose of the dissertation may be stated as to increase the understanding of small Swedish firms, especially sole proprietorships, utilizing possibilities for allowances for income smoothing and internal financing. At the beginning the dissertation describes case studies, comprising a smaller selection of microfirms. With a starting-point from the accounted and reported income-tax returns, alternative calculations are made where additional positive tax and finance effects appear possible to obtain. One purpose of these studies is to increase the insight regarding the possibilities of income smoothing and internal financing that arise from utilizing these allowances. These studies also illuminate, to what extent and in what way they are being used in reality. Another objective of these studies is to give a more substantive insight into the technics behind the different allowances, appropriation to positive or negative interest rate allocation appropriation or dissolving of tax allocation reserve appropriation or dissolving of “expansion fund” Theories regarding the creation of resources, through building of capital, and theories on financial planning and strategy are studied. The purpose is to find support for the choice of theoretical grounded underlying independent variables that can be used in cross-sectional studies to explain the use of the possibilities of appropriations. Theories of finance that are of greatest interest, in the operationalisation of these variables, are theories that discuss the choices of different financing alternatives for small firms. The “pecking order theory”, describes the firm’s order of priority when choices of finance alternatives are made. The concept of “financial bootstrapping” expands the frame for different forms of financing choices that especially very small firms have at their disposal.The last part of the theoretical frame deals with the phenomenon of “income smoothing,” which can be translated as leveling out profits/losses. A number of financial and non-financial variables are supported by and operationalised from these financial theories e.g., return on sales, capital turnover, quick ratio and debt-to-equity ratio, respectively age, gender and line of business. Cross-sectional studies are implemented for the taxation years of 1996 and 1999, on databases that have been extracted from Statistics Sweden. The group of 87,276 sole proprietorships included in the study were required to complete tax returns and pay taxes for the business activity according to the supporting schedule, N2, information from the sole proprietorships’ income statement and balance sheet in an accounting statement that comes with the income tax return form. The possibilities of allowances are considered as dependent variables. The intention of the cross-sectional studies is to survey and describe the utilization of possible allowances, with the support of the financial and non-financial independent variables. The connection of these variables to the decision of sole proprietorships to appropriate to the tax allocation reserve is also summarized in a logistic regression model. A number of theoretically based propositions are made for the purpose of observing how the variables are connected to the chances that sole proprietorships actually appropriate to this form of allowance. Appropriation to the tax allocation reserve stands out as the most practiced form of allowance. The studies also clarify that utilization varies among different forms of allowances, but that not all firms that have the prerequisites to utilize the possibilities really do so to the full. A further utilization of the different possibilities of allowances is often conceivable. For the sole proprietorships that are not utilizing these possibilities, the allowances should be considered eligible as a contribution to internal financing and to increase access to capital.
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| 8. |
- Jansson, Markus, 1982-
(författare)
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Pelvic Floor Dysfunction and Perineal and Vaginal Tears in Primiparous Women
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Pelvic floor dysfunction (PFD), including urinary incontinence, faecal incontinence (FI), and pelvic organ prolapse, is highly prevalent among parous women. There is evidence that pregnancy, vaginal delivery, and obstetric perineal tears increase the risk of pelvic floor dysfunction, but many of the studies in this field are retrospective. The overall aim of this thesis was to prospectively examine risk factors for perineal and vaginal tears and postpartum PFD in primiparous women.Study I was a validation study of a protocol for documentation of perineal tears, including 187 primiparous women in 2015–2016. The coverage of documentation was higher in the protocol compared to the obstetric record system (ObstetriX). Incidence of second degree perineal tears was 26% according to the protocol and 11% according to ObstetriX.Studies II–IV utilized a cohort of initially nulliparous women (n=1049) prospectively included in early pregnancy in 2014–2017. Women completed questionnaires on PFD in early and late pregnancy and at 8 weeks and 1 year postpartum.Study II (n=644) showed that high foetal weight and vacuum extraction were risk factors for both second degree tears and OASI, suggesting that these tears should be viewed as a continuum rather than different entities. Risk factors for high vaginal tears were large foetal head circumference, vacuum extraction, and heredity of PFD/connective tissue deficiency. Study III (n=670) found that vaginal delivery increased the risk of stress urinary incontinence (SUI) but not urgency urinary incontinence (UUI) 1 year postpartum. No single characteristic of the vaginal delivery was associated with SUI. SUI during pregnancy increased the risk of SUI postpartum, and UUI during pregnancy increased the risk of UUI postpartum.Study IV (n=898) showed that FI increased by late pregnancy, and that this increase persisted 1 year postpartum. Obstructed defecation was associated with increased FI postpartum, suggesting that post-defecatory faecal loss may be an underlying mechanism of FI. Overall conclusion: The extent to which pregnancy, vaginal delivery, and their respective characteristics contributed to the development of PFD differed between the pelvic floor disorders studied. For SUI, both the pregnancy and the vaginal delivery increased the risk, whereas for FI it was the pregnancy itself rather than the vaginal delivery that was demonstrated to increase the risk.
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| 9. |
- Nilsson, Kerstin, 1951-
(författare)
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Förändringsstrategier i grundskolan : ett ledarperspektiv
- 1998
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Change Strategies in Primary School - a leader perspective This thesis focuses on change strategies in the Swedish primary school. The schoolleaders have a new situation and role as change agents since the school was brought under local government control with among others the reguirement to be responsible for the local process of development in school. Further studies have the main focus on schoolleaders´ work situation and role, however not on how schoolleaders handle change processes. There are many studies from other organizations that show how important it is that the staff take part in local change processes. In the decentralized school it is of great interest to have an elucidation of different change strategies and how the schoolleaders´ way to act have effects on the participation of the staff. Empirical data have been collected in case studies. This thesis is a separate part of a more comprehensive research project in Swedish schools, called "The School in change". That project focuses on environmental work in the work organization and includes twelve schools. Theese schools were chosen depending on their geografical situation and from the point that both the leader and the staff had a clear wish for active work with their working environment, by starting local development projects. Of these schools, I chose three that I wanted to study in another point of view. The research purposes were to describe and understand how schoolleaders, in this case principals, at the primary school work with change strategies. To reach my aim, I chose to study the change strategies of the principals from an actor´s point of view. Semi-structured interviews were conducted at three times and to complete the picture from the answers, I used the observation method. Some data from a staff investigation in the main project "The School in change" has been used in this study, with a view to making the results clear and better understanding them. The main results from this study are that I am able to identify two different change strategies, related to the schoolleaders´ way of working with local development in the school organization. One of the schoolleaders has a stationary strategy and two schoolleaders have mobile strategies. They are different in the way that the stationary schoolleader and one of the mobile leaders show a clear own change strategy of their own, while one schoolleader has an imitated strategy. The results also show that the leader with her own and stationary strategy, has a growing part of participating staff in ordinary work organization as in local development work. Another result is that in the schools with the mobile leaders the participation decreases. It makes no difference if the leader has her own or an imitated strategy for change and development of the school. Different kinds of theory have been used to interpret the results. Two aspects have been found important to be able to understand how the leaders of the school act with change strategies. These aspects are the work with the local development and the role and situation of leadership in school.
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| 10. |
- Rönnberg, Ann-Kristin, 1967-
(författare)
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Gestational Weight Gain : Implications of an Antenatal Lifestyle Intervention
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Excessive gestational weight gain (GWG) is common in developed countries and is associated with an increased risk of maternal and offspring morbidity. Evidence regarding efficacy and safety of antenatal lifestyle intervention is limited in terms of both systematic reviews and original trials. This thesis is based on the need to further explore this research area. Objectives: To assess and grade current evidence and evaluate short and long-term effects of an antenatal lifestyle intervention on women and their offspring Materials: Controlled trials of intervention publishedbefore August 2009 were systematically searched and reviewed. A randomized controlled trial (RCT) including 445 healthy women aged >18 years with a body mass index (BMI) ≥19 and ≤16 weeks pregnant and their offspring was performed during 2007-2015 in Örebro Region, Sweden. Methods: The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used for review. Our RCT (called the VIGA trial) compared standard care with a composite intervention consisting of education, application of a personalized weight graph, prescription of exercise and more frequent monitoring of weight. Standardized measures of weight and height in offspring waere analysed based on World Health Organization (WHO) Child Growth Standards. Results: Quality of evidence across the studies published pre-August 2009 was concluded to be very low. Our intervention significantly reduced mean GWG (kg) but the proportion of women with excessive GWG, according to recommendations, was not significantly reduced. Short- term postpartum weight retention (PPWR) was significantly lower after the intervention but no significant difference remained 1 year after delivery. Offspring mean BMI z-scores or proportion of obesity did not differ between study groups at either birth or age 5. Conclusions: The antenatal lifestyle intervention reduced mean GWG and short-term PPWR but no long-term effects on maternal weight retention or offspring obesity were seen. Alternative modes and timing of intervention should be considered in future research. Reducing the prevalence of pre-conception obesity must still be considered the primary means to improve maternal and fetal outcome.
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