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- Gremyr, Andreas
(author)
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Improving health with and for individuals with schizophrenia using a learning health system approach : From idea to daily practice
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Psychotic disorders like schizophrenia have a typical onset in early adulthood with symptoms of hallucinations and disturbances of thought. Despite knowledge on what constitutes effective schizophrenia care, more than 70% of treatment attempts fail in Sweden, sometimes leading to early death. An appraisal of schizophrenia care shows a lack of ways to jointly plan and evaluate care, and an absence of a trustworthy theory-of-change. The Learning Health System (LHS) is a vision that has been translated into theories and models associated with improved outcomes for patients with other chronic conditions. The aim of this thesis is to enhance the understanding of the applicability of the LHS vision in the context of schizophrenia care, from the perspectives of both individuals and the health system in enabling coproduction of better health by addressing two research questions:i) How can improvement of health for individuals with schizophrenia and improvement of system performance be supported by coproduction in an LHS model?ii) Can an LHS-based intervention, i.e. the use of a point of care dashboard, contribute to better health for individuals with schizophrenia?Studying the existing published knowledge of LHS show that the concept has not yet been applied in mental healthcare settings but has potential to increase patient coproduction, continuous improvement and better health. Different forms of coproduction are supported in the most comprehensive LHS models and applications, ranging from dashboards at point of care to platforms that can help facilitate improvement initiatives.A case study, focused on studying the use and usefulness of a point-of-care dashboard at patient visits in outpatient care at the Department of Schizophrenia Spectrum Disorders at Sahlgrenska University Hospital in western Sweden. Use of the dashboard is associated with improved communication and health for patients. Assessment of the dashboard-project’s complexity using the Non-adoption, abandonment, scale-up, spread and sustainability complexity assessment tool (NASSS-CAT) was perceived as helpful in evaluating challenges and provided insight that can guide future development. An LHS model, that builds on both the reviewing of the literature and practical testing, is proposed.Further research is proposed in two areas, exploration of how dashboard initiatives can support coproduction and better health for individuals with complex chronic conditions and further development of LHS models by studying different LHS initiatives regarding system properties, forms of coproduction at play and effects on health outcomes for individuals and populations.
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| 2. |
- Ekström, Elin
(author)
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From a place without speech : negotiations of othering among unaccompanied female minors in Sweden
- 2019
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Licentiate thesis (other academic/artistic)abstract
- The study presented in this thesis focuses on unaccompanied female minors and their experiences as newly arrived migrants in Sweden. As a group, unaccompanied female minors have until recently been rather invisible in both academic research and media. However, according to previous research on migration and integration, they risk being constructed as ‘others’ both due to their status as unaccompanied minors, being female and in relation to general perceptions of what it means to be Swedish.This study is based on qualitative interviews with 11 girls, 13 to 18 years old, who arrived in Sweden as unaccompanied minors in the period between 2014 and 2017. The interviews were conducted in two phases, with nine months to one year between the first and second phases. Whereas the focus in the first phase was on getting to know the participants, the second phase provided an opportunity to delve deeper into discussions on recurring themes from the first phase. The interviews were transcribed using a denaturalised approach and thematically analysed through an abductive process.The thesis explores the girls’ narratives of everyday experiences and interprets them through a theoretical framework of othering. Without losing sight of the social structures that situates the girls’ experiences, othering is approached as a reciprocal, three-dimensional relationship, focusing on knowledge, values and conduct towards the other.The findings indicate that the girls participating in this study were often seen through the normative perception of an already othered context, and as a consequence, their own voices and agency were disregarded. They were, metaphorically, put in places without speech. However, by engaging a critical perspective on their everyday interactions, the girls were also able to recognise and resist othering by keeping true to their own experiences. The thesis concludes that by exploring the margins between their comfort zones and new contexts the girls engage in an epistemic merging of different horizons, which can be understood as a slow but insistent process of moving out from the place without speech.
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| 3. |
- Lannering, Christina
(author)
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Experiences and outcomes of systematic preventive work to reduce malnutrition, falls and pressure ulcers in nursing home residents
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Background: Older people living in nursing homes are at a high risk of becoming malnourished, falling and developing pressure ulcers. In Sweden the national quality registry Senior Alert was developed to support prevention in these areas. Prevention according to Senior Alert follows a preventive care process of four steps, including risk assessment, analysis of the causes of risk, to determine and perform appropriate actions, and finally, to evaluate the care given.Aim: The overall aims of this thesis were to investigate how the preventive care process in Senior Alert functions as a tool for preventive work among older persons living in nursing homes, and to investigate the results of risk assessments and actions.Design: The thesis is based on three longitudinal quantitative studies (I, III, and IV) and one qualitative study (II). In Studies I and III, process- and patient results were compared among different groups of nursing home residents, with a follow-up time of 6 months. In Study IV, associations between the assessment instruments and the outcomes of weight loss, falls and pressure ulcers were investigated. The qualitative study (II) was based on focus group interviews with healthcare professionals and was analyzed using content analysis.Results: The residents included in the registry during the later years (2013-2014) had a higher proportion of registered preventive actions in the three areas, and were followed up more frequently regarding weight and new assessments than residents included during the earlier years (2010-2012). Nevertheless, regardless of risk, only 30% were reassessed, and 44% of the residents at risk for malnutrition were followed up for body weight within 6 months. No difference in weight change was found between a group of residents included in Senior Alert and a second group receiving ‘care as usual’. Generally, the mobility variables in the risk assessment instruments had the strongest associations with the tested outcomes of weight loss, fall and pressure ulcers, albeit in different ways. Healthcare professionals described that Senior Alert stimulated better teamwork while at the same time they experienced the increased documentation and time constraints as aggravating circumstances. They also described a lack of reliability of the assessment instruments in that they overrated the risks compared to their own clinical judgement. Healthcare professional’s knowledge about the evaluation part of the process was low.Conclusion: The evaluation and follow-up step of the preventive care process was not sufficiently applied. This was expressed by the participants in the focus groups and was also reflected in registry data by the varying time to follow-up and the poor event registration. As a consequence, the sample to measure outcomes within 6 months became small. Therefore, larger samples are needed to study longitudinal outcomes, if a fixed system-mandatory time point for follow-up is not implemented. A committed leadership is important to improve the preventive work and to stimulate follow-up of results.
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