| 1. |
- Engstrom, Maria
(författare)
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BarnSäkert : Studies of the Safe Environment for Every Kid model in the Swedish Child Health Services for early identification of psychosocial risk factors in the home environment of young children
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Psychosocial risk factors in the home environment may impair children’s health and development and increase the risk of child maltreatment. The Swedish child health services (CHS), provide health-promoting and primary preventive services for all children 0-6 years of age. However, the national CHS lack evidence-based tools to universally screen for the most common psychosocial risk factors. The Safe Environment for Every Kid (SEEK) model provides a method for identifying children who live in families with economic worries, depressive symptoms, parental stress, intimate partner violence (IPV) and alcohol misuse in order to offer relevant support and assistance to the family. The overarching aim of this thesis was to assess validity, clinical utility and outcomes of the Safe Environment for Every Kid model when applied in the Swedish Child Health Services setting. The SEEK model has been tested in a cluster randomized controlled trial within the CHS in the county of Dalarna. Studies I and II examined CHS nurses’ perception of their routine assessment of psychosocial risk factors in the family environment as well as their self-reported competence and the present organizational conditions in this context. Both studies used the same mixed method design, including surveys and focus group interviews. Study II analyzed the experiences of CHS nurses using the SEEK model in contrast to those using current standard practice. CHS nurses had extensive experience in dealing with the targeted risk factors, but using the SEEK model strengthened their sense of competence in identifying and responding to the needs of families with such problems. Using the SEEK model seems to have narrowed the gap between the nurses’ perception that it is both important and suitable to address psychosocial risk factors within the CHS and their previously limited ability to do so. Study III evaluated the psychometric properties of the Swedish version of the Parent Screening Questionnaire (PSQ-S) using data from surveys answered by parents (n=611). The PSQ-S was compared to standardized instruments for the targeted psychosocial risk factors. The PSQ-S showed a sensitivity of 93%, specificity of 52% and a positive and negative predictive values of 67% and 87%, respectively. Study IV examined the self-reported rates of the targeted risk factors among parents who completed the PSQ-S at age-specific CHS visits during the intervention period. A total of 7483 PSQ-S were analysed. Over half of the PSQ-S had a positive screen for at least one risk factor. The problems were common throughout the child’s first five years of life and were about as common among mothers and fathers. The proportion of PSQ-S with a positive screen decreased significantly from the beginning to the end of the intervention.The results suggest that the SEEK model, as applied in these studies, shows a high degree of validity and clinical utility in the CHS setting. The experience of SEEK nurses showed that the model was helpful in their daily work. There is room for improvement with respect to sensitivity regarding IPV and how the nurses address parents with alcohol misuse. Many parents were willing to disclose the targeted risk factors in the context of the CHS visits and use of the SEEK model likely provided opportunities for assistance that may otherwise have been missed.
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| 2. |
- Arne, Mats, 1954-
(författare)
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Chronic Obstructive Pulmonary Disease : Patients´ Perspectives, Impact of the Disease and Utilization of Spirometry
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to describe subjects with chronic obstructive pulmonary disease (COPD) from different perspectives. Focus was on patients at the time of diagnosis, impact of the disease in comparison to other chronic diseases, factors associated with good health and quality of life (QoL), and diagnostic spirometry in clinical practice. Methods: Qualitative method, grounded theory, was used to analyse patients´ perspectives at the time of diagnosis in a primary care setting (n=10). Public health surveys in the general population were used to compare chronic diseases (n=10,755) and analyse factors associated with health outcomes in COPD (n=1,475). Medical records and spirometry reports, from primary and secondary care, were analysed to assess diagnosis of COPD in clinical practice (n=533). Results: In clinical practice, 70% of patients at the time of diagnosis of COPD lacked spirometry results confirming the diagnosis. Factors related to consequences of smoking, shame and restrictions in physical activity (PA) in particular, were described by patients at the time of diagnosis of COPD. In general subjects with COPD (84%), rheumatoid arthritis (74%) and diabetes mellitus (72%) had an activity level considered too low to maintain good health. In COPD, the most important factor associated with good health and quality of life was a high level of PA. Odds ratios (OR (95%CI)) varied from 1.90 (1.47-2.44) to 7.57 (4.57-12.55) depending on the degree of PA, where subjects with the highest PA level had the best health and QoL. Conclusions: Subjects with COPD need to be diagnosed at an early stage, and health professionals should be aware that feelings of shame could delay patients from seeking care and thus obtaining a diagnosis. The use of spirometry and the diagnostic quality should be emphasised. In patients with COPD greater attention should be directed on increasing the physical activity level, as patients with a low level of physical activity display worse health and quality of life.
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| 3. |
- Ivarsson, Malena, 1962-
(författare)
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Psycho-physiological reactions to violent video gaming : Experimental studies of heart rate variability, cortisol, sleep and emotional reactions in teenage boys
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Playing violent video games may provoke aggression. Psycho-physiological methods may provide knowledge about the underlying psychological processes. Most previous studies have been performed in laboratory settings at daytime with adults. Thus the aim of this thesis was to investigate psycho-physiological (autonomic and HPA related reactions), sleep-related and emotional responses in teenage boys to playing a violent and a non-violent video game at home before going to sleep. In Study I the autonomic responses differed between the violent and the non-violent game during playing and more distinctly during sleep. In Study II the HPA axis was not affected by video gaming at all. In Study III, the effect of habits of playing violent games was assessed (≤ 1h/day and ≥ 3h/day). High versus low experience of violent gaming were related to different autonomic, sleep-related and emotional processes at exposure to a violent and a non-violent game, during playing and during sleep. The present thesis demonstrated that violent and non-violent games induce different autonomic responses during playing and – more distinctly – during sleep. Frequent gaming seems to influence physiological, sleep-related and emotional reactions, possibly as an expression of desensitization processes.
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| 4. |
- Larsson, Malin, 1979-
(författare)
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Indoor Environmental Factors and Chronic Diseases in Swedish Pre-School Children : Risk factors and methodological issues investigated in a longitudinal study on airway diseases and autism spectrum disorder
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Asthma and allergies have increased considerably during the past 40-50 years. Along with this increase, a heightened awareness regarding different neuro-developmental disorders such as autism spectrum disorder has occurred and it has been proposed that such disorders are also on the increase. It has been suggested that environmental factors, especially in the indoor environments, may be associated with the increase in these disorder, especially among children, who spend more than 90% of their time indoors. The aim of this thesis has been to investigate certain environmental factors in homes and their impact on children’s health, in terms of asthma, rhinitis, eczema as well as autism spectrum disorders, and to identify certain methodological difficulties in epidemiological investigations. We found that the mean incidence rate per year for doctor diagnosed asthma was in the range of 0.6-2.4% and for incidence of rhinitis 1.1-3.7%. The incidence rate of eczema ever was 2.7%. These results showed that when using a cohort established after birth the estimated incidence rates are strongly dependent of how the baseline population’s health and how the studied health outcome at follow up is defined. Our results showed that the associations between parental reported moisture problems in the home and asthma in children that were revealed in cross-sectional analyses decreased or disappeared when longitudinal data were used on the same data set. Our results therefore indicate that associations between parental reported moisture problems and asthma from cross-sectional questionnaire studies should be interpreted with caution due to the risk for reporting bias. Our results show that children who were living in homes with PVC-flooring in the bedroom in early childhood were more likely to develop asthma during the following 5-year period when compared with children living in homes without such flooring material. A similar association could be seen for children with autism spectrum disorder, where PVC-flooring in early childhood was associated with more reports of autism spectrum disorder five years later. These results indicate that building materials including suspected endocrine disrupting chemicals such as phthalates might be of importance for the development of these chronic diseases. Further studies are needed to explore the early life exposure and the mechanisms and contribution of phthalates for the development of chronic diseases.
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| 5. |
- Persson, Stefan, 1963-
(författare)
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Adolescents' role in democratic "parenting"
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In research on family democracy there has been a tradition to focus on parents as leaders setting up the family climate. This dissertation challenged this perspective. Keeping with present day’s emphasis on bidirectionality between parents and children democratic family functioning was seen as jointly created by parents and youths. Results showed that youths behaviors and characteristics have to be taken into account if the democratic working of the family is to be fully understood. When controlling for parents’ behaviors, adolescents’ behaviors added significantly to the prediction of a democratic family climate (Study I). Within families, youths democracy compromising behaviors were found to not only have consequences for the individual child. Instead, it was found that changes in younger siblings’ perceptions of family democracy changed as a consequence of an older sibling’s earlier democracy compromising behavior (Study II). Finally, parental openness to communication, youth openness to communication, and parental bad treatment all were found to be separate components of family democracy. Also, these components of family democracy were found to be prospectively linked to adolescents’ perceptions of the democratic climate in their own families. Further, these three components could be used to identify stable family configurations which differed with respect to adolescents’ perceptions of having influence in family matters and their internal-and external adjustment as well as other aspects of the parent-child relationship (Study III). Moreover, changes over-time within families in parental openness to communication, youth openness to communication, and parental bad treatment were associated with changes in youths’ perceptions of having influence in family matters and other features of parent-child relations (Study III). On the whole, these findings lend strong support to seeing children as active agents in the democratic workings of the family and they support a family systems approach to the issue of democratic family functioning. Clearly, young people are human agents with the capacity to interpret and react to their own reality. They are certainly both the harvest and the seeds of democratic family functioning.
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| 6. |
- Simmons, Johanna, 1980-
(författare)
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Toward an integrated approach in research on interpersonal violence : Conceptual and methodological challenges
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: There is a growing understanding that different kinds of interpersonal violence are interrelated. Many victims report experiences of cumulative violence, i.e., being subjected to more than one kind of violent behaviour (sexual, physical, emotional) and/or violence from more than one kind of perpetrator (family members, partners, acquaintances/strangers). To gain a more comprehensive understanding of what violence entails for victims, how victims can be helped and how violence can be prevented, there is a need to learn more about the co-occurrence of violence. Also, despite strong associations repeatedly being found between exposure to violence and the reporting of different kinds of ill-health, only a minority of victims have told health care professionals about their victimization. Less is known about the process of disclosing victimization to health care professionals for men than for women.Main aims: 1) Investigate the prevalence and co-occurrence of self-reported lifetime experiences of different kinds of interpersonal violence among male and female clinical and random population samples in Sweden (Study I-II). 2) Investigate whether cumulative violence is more strongly associated with self-reported symptoms off psychological ill-health than with any kind of victimization alone (Study III). 3) Develop a theoretical model concerning male victims’ process of disclosing experiences of victimization to health care professionals in Sweden (Study IV). Method: The self-reported prevalence of interpersonal violence as well as self-reported symptoms of psychological ill-health were estimated by means of secondary analyses of data collected with the NorVold Abuse Questionnaire (NorAQ). Both sexes were represented in clinical (women n=2439 men n=1767) and random population samples (women n=1168 men n=2924). Descriptive statistics as well as binary logistic regression and ordinal regression analyses were used (Study I-III). In study IV, constructivist grounded theory was used, and 12 men were interviewed concerning their experience of disclosing victimization to health care professionals.Results: A large proportion of victims (women: 47-48%, men: 29-31%) reported experiences of more than one kind of violent behaviour. Many also reported being subjected to violence by more than one kind of perpetrator (women: 33-37%, men: 22-23%). Reporting cumulative violence had a stronger association with symptoms of psychological ill-health than reporting only one kind of victimization. In study IV, the interviewed men’s own perceptions and considerations beforehand (e.g., perceived need for help and feelings of shame), as well as the dynamics during the actual health care encounter (e.g., patient-provider relationship and time constraints), were essential for understanding the process of disclosure. Also, the men’s own conformity to hegemonic constructions of masculinity and professionals’ adherence to gender norms had a strong negative influence on the men’s process of disclosure.Discussion: Experiences of cumulative violence were common. Prevalence rates of experiences of different kinds of interpersonal violence were compared to previous studies on interpersonal violence in Sweden. Large discrepancies were found between all studies, which is a symptom of methodological and conceptual difficulties within the research field. Violence is a gendered phenomenon. Differences were seen in the kind of violence men and women reported. In addition to this, the results in study IV indicate that gender affects how violence is perceived and how victims are treated by health care professionals. Conclusion: Integrated approaches in research on interpersonal violence, as well as in clinical work, are needed. If the co-occurrence of violence is ignored, it may hamper our understanding of the experiences and consequences of interpersonal violence for victims. More research is needed into what produces the differences found in prevalence rates between studies to improve the methodology.
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| 7. |
- Svensson, Birgitta, 1974-
(författare)
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Barn som riskerar att fara illa i sin hemmiljö : Utmaningar i ett förebyggande perspektiv
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BaksidestextBarnmisshandel är ett omfattande folkhälsoproblem med långsiktiga negativa konsekvenser för den enskilda individen och för samhället i stort. Förebyggande insatser kan vara livsavgörande för de utsatta barnen. Denna avhandlings övergripande syfte var att öka kunskapen om barn som riskerar att fara illa i sin hemmiljö samt att identifiera utmaningar i ett förebyggande perspektiv. Två områden har studerats:(1) Våld mot barn med långvarig sjukdom/funktionsnedsättning(2) Förskolan som upptäckande och stödjande arenaGemensamt för inriktningarna är att barn med långvarig sjukdom/funktionsnedsättning och barn i förskoleåldern utgör särskilt sårbara grupper, som löper ökad risk att fara illa i sin hemmiljö. De har också unik kontakt med professionella med möjlighet att upptäcka och agera vid oro.Avhandlingen bygger på fyra delstudier; en nationell kartläggning riktad till skolelever, en intervjustudie med föräldrar samt två förskolestudier. Resultaten från studierna diskuteras utifrån identifierade utmaningar i ett förebyggande perspektiv. Utmaningarna inkluderar emotionella hinder samt behov av ett mer nyanserat och proaktivt förhållningssätt för att kunna utveckla tidiga insatser till barn och föräldrar.
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| 8. |
- Backe, Stefan, 1963-
(författare)
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Safety promotion and injury surveillance with special focus on young people´s club sports : Challenges and possibilities
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Physical activity in youth has many benefits, but parallel to these benefits, sport related injuries pose considerable risks. It is important to public health to address sport related injuries, particularly those affecting young people, who comprise the majority of participants in organised sport in Sweden. The first study in this research showed that inspections of local sport environments, where injuries often occur, did not occur uniformly. Two additional studies pointed out the need for better surveillance of injuries, and described the use of ambulance attendance reports as a possible improvement to current surveillance systems, with a possibility to improve safety for youth and other sport participants. Two other studies identify risk factors that were specific to football and climbing sports, which can be used to guide targeted safety interventions for the young participants of these sports. The studies, taken as a whole, provide new information about the factors associated with sport related injuries, particularly for young people, and point out the need for better sport injury surveillance, improved inspection strategies for fields maintained by organised sport clubs in local communities, and the need to address risk factors specific to different sport activities.
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| 9. |
- Engström, Lars-Gunnar, 1965-
(författare)
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Sickness Absence in Sweden : Its relation to Work, Health and Social Insurance Factors
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The high levels of sickness absence and disability pensioning experienced during the 1990's and 2000's have become both socially as well as financially burdensome for society. Sickness absence implies a costly loss of production for society and large groups of individuals are risking to become marginalised on the labour market. Sickness absence is both a public health and an economic problem. Thus from both a human approach as well as from an economic perspective it is urgent to increase knowledge about what influences individual behaviour when it comes to sickness absence and return to work. Objectives: The overall aim of the thesis is to elucidate the decisive factors for explaining sickness absence. Three different aspects of sickness absence were considered, i.e. factors leading to sickness absence, factors preventing sickness absence and factors leading back to work ability and work when being sickness absent. This is done using a frame of reference involving broadly defined areas of work, health and social insurance related factors. Material and methods: Study I analyzes the outcome of unemployed sick-listed individuals. A total of 280 individuals from the county of Värmland were followed through register data between the years 2000 to 2001. Linear and logistic regression models were used to analyze the occurrence of short and long term economic incentives. Study II has a longitudinal design and explores determinants of return to work. Sick-listed individuals with a stress-related psychiatric diagnosis from the county of Värmland were analyzed over a period of three years (2000-2003) using logistic regression. The data comprised 911 individuals. Study III is a cross-sectional study using questionnaire data from the county of Värmland from year 2004. A total of 3123 persons either working or being self employed were analyzed on determinants of work presence through logistic regression. Study IV had a cross-sectional design and used questionnaire data from five counties in central Sweden. The data, from 2004, comprised 10536 individuals being employed, i.e. not self-employed, and with self reported physical and mental medical conditions. Logistic regression was mainly used in the analysis and the focus was on risk factors for long term sickness absence. Study V comprises cross-sectional data retrieved at three separate occasions between 1991 and 1994. It includes 8839 individuals from five counties in western Sweden with sickness absence spells over 60 days. The data was analysed through bi-variate probit regression with a focus on effects of vocational rehabilitation on return to work. Results: The results from study I were interpreted as that both short and long term economic incentives matter for the outcome of sickness absence through the interaction of different insurance systems. The principal findings from study II was that age, gender and factors implying less favourable health characteristics and thereby lower work capacity, reduce probabilities of returning to work after long term sickness absence. Considering study III determinants of work presence were found to vary between sexes and whether the determinants were counteracting long or short term sickness absence. Factors interpreted as job control counteracted short term absence. Sense of coherence was found to be an important determinant of work presence for women. In study IV long term sickness absence was found to be related to the level of ill-health. Moreover it was concluded that work environment factors as job strain, job satisfaction, physical work environment were important factors for explaining sickness absence in a population with impaired health. The results from study V indicated that vocational rehabilitation is a potentially effective instrument for improving the individual's work ability and chances of return to work. That no signs of prioritizing selection of rehabilitation participants to those likely to return to work with or without rehabilitation measures, i.e. "managerial creaming", were found was also considered as important results. Conclusions: This thesis shows that we need different models and approaches to improve knowledge about the various aspects of sickness absence as entry into absence, return to work or into disability retirement. It also has the implications that sickness absence behaviour can be influenced. Largely depending on what long term path is chosen for welfare policy at the political level it should be acknowledged that other means, improving working conditions and promoting rehabilitation rather than reducing benefit levels and narrowing the eligibility criteria for the insurance benefits are at hand.
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| 10. |
- Eriksson, Ulla-Britt, 1949-
(författare)
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"Man är ju inte mer än människa" : Långtidssjukskrivning ur ett emotionellt, relationellt och strukturellt perspektiv
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The background to this thesis is the dramatic increase of the long-term sickness absence that took place in Sweden from the late 1990s. There was also a shift in the diagnostic pattern with rising mental diagnoses. The overall purpose was to describe and try to understand the process leading to long-term sickness absence from the perspective of the sickness absentees, in order to get a better knowledge base for preventive and rehabilitative actions. The thesis comprises four studies (I-IV). Research methods have been both qualitative and quantitative. In study I data from individual interviews with 32 persons on long-term sick leave due to burnout was analyzed using a grounded theory approach. In study II the study population comprised of 2064 employed sick-listed persons, a sub sample derived from the 2002 national Swedish survey on health, working conditions, life situation and sick-listing. It was analyzed if persons with burnout had higher probability of having experienced the steps in the burnout staircase compared to other diagnostic groups in accordance with the previously suggested hypothesis of "the burnout staircase". Study III comprised of 2521 employed persons, a sub sample derived from the same national survey as in study II. It was analyzed if psychosocial work environment and conflicts and losses in private life independently or in combination were more strongly associated to sickness absence with mental diagnoses as compared to a healthy population. In study IV individual interviews with 25 professional rehabilitation actors and 14 unemployed sick-listed persons were conducted. Data were analyzed according to grounded theory method. The process that led to sicknes absence can be described as an emotional deprivation process, illustrated as a flight of stairs (the burnout staircase) describing a sequence of steps toward sickness absence (I). In accordance with the tested hypothesis persons with burnout to a noticeable higher extent reported expereince of being in the different steps in the burnout staircase compared to sickness absentees with other diagnoses. The model seemed to be valid also for persons with other mental diagnoses (II). Reorganization and conflicts at work as well as adding adverse private life events were associated with increased risk for sickness absence with mental diagnosis (III). Three significant factors behind the weak co-operation between local social insurance and employment agencies were identified: indistinct regulation of co-operation, shifting political goals over time and conflicting goals between agencies (IV). In this thesis it has been suggested that the course of events preceding sickness absence might be understood as a process of emotional deprivation, where the individual is gradually emptied of the life-giving emotional energy revealed in joy, commitment, and empathy. This life-giving force finds its nourishment in safe and secure social relations with others and in a social structure that promotes this type of social relations. The profound changes in the Swedish labour market during the 1990s influenced not just the psychosocial work climate but also the rehabilitation efforts for unemployed sick-listed persons. When the political goal of reducing the unemployment level came to the forefront the indistinct regulation and the conflicting goals in addition were factors that impaired co-ordinated rehabilitation. In this process also the physicians were involved. A labour market problem was turned into a medical problem.
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| 11. |
- Huus, Karina, 1968-
(författare)
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Weight gain in children : possible relation to the development of diabetes
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The prevalence of overweight and obesity among children has increased the last decades and is now defined as a global epidemic disease by the World Health Organization. Also the incidence of type 1 diabetes has increased and there are some hypothesises that argue there is a connection between overweight/obesity and type 1 diabetes.Aim: The general aim of this thesis was to study factors contributing to the development of overweight and obesity among children and to study possible relations to the development of diabetes.Method: All Babies in Southeast Sweden, ABIS, is a prospective cohort study. The study includes all babies who were born in southeast Sweden between Oct 1st 1997 until Oct1st 1999 and the design was to follow them up to school age in ABIS I and to follow them until 14 years in ABIS II, of the eligible 74 % entered the study. The families have answered questionnaires and biological samples were taken mainly from the children at the different time points: birth, 1 year, 2.5 years, 5 years and 8-9 years. In this thesis studies have been made including the whole cohort, but some studies have also been made involving only a part of the children.Results: The prevalence of overweight and obesity among children in the ABIS study was 12.9% overweight and 2.5 % obese at 5 years of age. One risk factor which appeared to have a great impact on the development of overweight and obesity at 5 years of age was the child’s own BMI at an early age and also the heredity for overweight/ obesity and the heredity for type 2 diabetes. If the father had a university degree, the child was less likely to be obese at 5 years of age. Other factors, such as the parents´ age, if the child had any siblings, and if the child lived with a single parent, did not show any significant correlation to the child’s BMI at 5 years of age.Early nutrition has been studied and no correlation could be found between breastfeeding less than 4 months and the development of overweight/obesity at 5 years of age. The parents answered questions about how frequent the child ate different food at 2.5 years and at 5 years. Intake of sweet lemonade was the only single food which was correlated to a higher BMI in 5 years old children. Porridge seemed to be protective against overweight/ obesity. In one of the studies the physical activity was measured by a step counter. The fewer steps the children were taking, the higher BMI and waist circumference they had. Low physical activity was also associated with a higher C-peptide value and decreased insulin sensitivity. Children who spent more time in front of TV/video had a higher fasting blood glucose value.Conclusions: A strong factor for the development of overweight and obesity among children is the child’s own BMI at an early age and also its heredity for overweight/ obesity and the heredity for type 2 diabetes. Early nutrition did not show any obvious correlations with overweight and obesity at 5 year old children. Low physical activity was associated with higher fasting C-peptide value and decreased insulin sensitivity. Low physical activity may cause β-cell stress which might contribute to an autoimmune process in individuals genetically predisposed to autoimmunity and, thereby, to the increasing incidence of Type 1 diabetes in children.
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| 12. |
- Jernbro, Carolina, 1976-
(författare)
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Barnmisshandel ur barns och ungas perspektiv : Omfattning, hälsa, avslöjande och stöd
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Child abuse is a major public health problem which is largely hidden in the society.The main aim of the thesis was to study child maltreatment from children’s and young people’s perspectives focusing on prevalence, health, disclosure and support.The thesis is based on four studies. Quantitative and qualitative data from three national surveys of child maltreatment, including children in different age groups and young adults, have been analysed.The results showed that child maltreatment is prevalent and there is a large degree of overlap between maltreatment types. Neglect and witnessing intimate partner violence were the types that overlapped most with other types of maltreatment. Child maltreatment was strongly associated to psychosomatic symptoms and impaired quality of life. Young people who have been victims of child maltreatment described the psychological consequences, such as painful memories, low self-esteem and depression. The psychological abuse was described as particularly detrimental. Victims of sexual abuse expressed feelings of shame and guilt. About half of the severely abused children did not disclose the abuse, mainly because of lack of trust in adults. Many children felt that they did not receive adequate support when they disclosed the maltreatment, particularly because they experienced a lack of child perspective among professionals. Children and young people experienced positive support from the school health services which they considered to have a particularly important role in the detection and support of maltreated children. The results emphasize an increased awareness among professionals to recognise and respond to child maltreatment.
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| 13. |
- Flacking, Renée, 1964-
(författare)
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Breastfeeding and Becoming a Mother : Influences and Experiences of Mothers of Preterm Infants
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to expand the knowledge and understanding of the processes of breastfeeding and becoming a mother in mothers of preterm infants. For this purpose, in-depth interviews were conducted with 25 mothers, whose very preterm infants had received care in seven neonatal units (NU) in Sweden, 1-12 months after discharge (I-II). In addition, prospective population-based register studies were performed of infants born 1993-2001; among 35 250 term and 2093 preterm infants (III), and a subpopulation of 225 very preterm infants (IV). Data were obtained from the Child Health Service registry of breastfeeding in Uppsala and Örebro, the Medical Birth Registry, and Statistics Sweden. The experiences of mother-infant separation, institutional authority, emotional exhaustion and disregard of breastfeeding as a relational interplay, comprised major hindrances to mothers’ experiences of breastfeeding as reciprocal and of a secure mother-infant relation, during and after the discharge from an NU (I-II). All studied socioeconomic factors, i.e. lower educational level, receiving unemployment benefit or social welfare or having a low equivalent disposable income, were individually adversely associated with breastfeeding up to six months of infants’ postnatal age, but were not found more decisive for weaning in mothers of preterm infants compared to those of term infants (III). Preterm infants were breastfed for a shorter time than term infants (III), but a long breastfeeding duration was evident. In addition, gestational age and neonatal disorders were not associated with breastfeeding duration in very preterm infants (IV).In conclusion, this thesis shows that improvements in the NU environment and the caring paradigm are called for. Furthermore, as socioeconomic status clearly has an impact on breastfeeding duration, increased equity in health care in accordance with the individuals’ needs must be sought, where resources are allocated to ensure fulfilment of needs in more vulnerable mothers and infants.
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| 14. |
- Hasselgren, Mikael, 1964-
(författare)
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Epidemiological Aspects of Asthma in Primary Care : Special Reference to Prevalence, Clinical Detection and Validation
- 2005
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives. To describe the prevalence of asthma in a mid-Swedish region and measure the detection rate of asthma in primary care. To compare clinical outcomes for adolescents with asthma in primary care or in paediatric care and to perform a clinical validation in children with airway, nose and skin symptoms. Material and methods. A questionnaire survey of respiratory symptoms and disease in an adult population and an investigation of the occurrence of clinically detected asthma in primary care. A cross-sectional study comparing management, asthma control and quality of life in adolescents. The last study was a nested case-control study with a clinical validation of reported allergic symptoms in children. Results. The prevalence of asthma in the adult population was 8%. The clinical prevalence of asthma in primary care was 2%. The detection rate was higher in primary health care centres with asthma clinics, as compared to primary care without such clinics. In adolescents with asthma there was no difference in clinical outcomes between primary care and paediatric care. The validation study showed a high correlation between assigned cases and disease. Conclusions. Asthma is a common disease where the majority of cases are managed in primary care. Many cases are, however, not diagnosed and the detection rate becomes a quality care indicator. The study of adolescents confirms that proactive care can be further improved regardless of whether their management is in primary or paediatric care. The nested case-control design is suitable to suggest causational risk factors for asthma and for prediction of allergic disease development.
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| 15. |
- Nolén, Sixten, 1962-
(författare)
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Increased bicycle helmet use in Sweden : needs and possibilities
- 2004
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: From the perspective of what is called "vision zero" in Sweden, fatalities and injuries among bicyclists are unacceptable. Despite that, bicyclists constitutes approximately one third of all road user inpatients in Swedish hospitals, which is about the same proportion seen for drivers and passengers of motor vehicles. There are too many bicycle-related head injuries, but the risk of such traumas could be reduced considerably by the use of helmets. Bicycle helmet wearing can be increased by voluntary means, for instance by long-term community-based helmet promotion programs. However, the best effect has been achieved by combining promotion with a compulsory helmet law for all bicyclists, as has been done in Australia, New Zealand, and North AmericaAim: The general aim of the research underlying this dissertation was to provide further information about the need for increased bicycle helmet use in Sweden, and to determine what measures can lead to more widespread helmet wearing. The four papers included addressed two main questions: (1) What is the need for increased helmet wearing among different categories of bicyclists in Sweden? (2) Is a non-compulsory local bicycle helmet law a realistic alternative to a mandatory helmet law for all bicyclists?Materials and methods: Observational studies of helmet use by bicyclists in Sweden were conducted once a year (average n = 37,031/year) during the period 1988-2002 (paper I). The general trend in observed helmet wearing in different categories of bicyclists was analyzed by linear regression, and the results were used to predict future trends in helmet wearing. Three studies (papers II-IV) were also performed to evaluate a non-compulsory local bicycle helmet "law" in Motala municipality during the study period 1995 to 1998 (papers II-IV). This law was introduced in 1996 and applies specifically to school children (ages 6-12 years), although the intention is to increase helmet use among all bicyclists. Adoption of the law was accompanied by helmet promotion activities. In one of the studies in the evaluation, written material and in-depth interviews (n=8) were analyzed qualitatively to describe the process and structure of development of the Motala helmet law. The other two studies used a quasi-experimental design to assess the impact of the helmet law: one comprised annual observations of helmet wearing among bicyclists in Motala (average n=2,458/year) and control areas (average n=17,818/year); and the other included questionnaire data on attitudes, beliefs, and self-reported behavior of school children in Motala (n=1,277) and control areas (n=2,198). The average response rate was 72.8%.Results and discussion: There was a significant upward trend in helmet use in all categories of bicyclists from 1988 to 2002. Helmet wearing increased from 20% to 35% among children(≤ 10 years) riding bikes in their leisure time, from 5% to 33% among school children, and from 2% to 14% in adults. Total average helmet use rose from 4% to 17%. However, during the last five years of the study period (1998-2002), there was no upward trend in helmet wearing for any of the categories of bicyclists. If the historic trend in helmet use continues, the average wearing rate will be about 30% by the year 2010. The Motala helmet law was dogged by several problems, mainly during the initiation phase, and some of them led to poor rooting of the law in the schools and indistinct roles and responsibilities of the municipal actors. Despite that, the law initially led to a significant increase in helmet wearing among the primary target group (school children), from a pre-law level of 65% to about 76% six months post-law, whereas thereafter the wearing rate gradually decreased and was at the pre-law level 2 ½ years after the law was adopted. Nonetheless, a weak but significant effect on adult bicyclists remained: the pre-law level of about 2% rose to about 8% at the end of the study period. Only about 10% of bicyclists on bike paths in Motala wore helmets 2 ½ years post-law. The questionnaire study showed one significant effect on school children in Motala two years post-law, namely, a stronger intention to ride bicycles if a national compulsory helmet law was introduced. There was, however, no significant long-term influence on children's attitudes or beliefs about helmet wearing, which agrees with the results of the observational study.General conclusions: It is indeed necessary to increase bicycle helmet wearing in Sweden. Both the current average rate of helmet use and the rate predicted for the near future are far from the goal of 80% that was officially proposed by several years ago. Previous research has shown that, to achieve substantial and sustained bicycle helmet use, it is necessary to use helmet promotion in combination with a national helmet law that is compulsory and applies to all bicyclists. The present evaluation of the non-compulsory local helmet law in Motala indicated that this type of initiative is not a powerful alternative to a mandatory national helmet law. Nevertheless, much has been learned from the initiation and implementation of this local action.
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| 16. |
- Otterman, Gabriel
(författare)
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Health sector and community response to child maltreatment in Sweden and in a European context
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Child maltreatment is a public health problem of global magnitude. This thesis examined different aspects of the multi-sector response to child maltreatment in Sweden and in Europe.Aims To explore how child physical abuse (CPA) is disclosed and how adolescents perceive adult support when they report physical abuse. To examine how police-reported cases of suspected CPA were associated with criminal investigation procedures and prosecutions. To assess how physicians who care for maltreated children across Europe are organised to recognise and respond to child abuse and neglect. To investigate time trends in rates of childhood deaths in Sweden recorded as due to external, ill-defined and unknown causes, from 2000 to 2014.Methods We analysed data from a school-based national survey of adolescents, police records of reported suspected CPA in a metropolitan area, a purposeful survey of European child abuse physicians and individual-level data from the Swedish cause of death register. We used quantitative methods to calculate prevalence, descriptive statistics, odds ratios, logistic regression and trends in mortality rates. Qualitative methods included content analysis and narrative synthesis.Results Only a minority of reported CPA was brought to the attention of professionals and the most prominent barrier to disclosure was lack of trust in adults or authorities. The police-reported cases of suspected CPA were characterised by high severity, but only a small proportion of the 158 alleged child victims were physically examined and only half were forensically interviewed. All 88 responding physicians in 22 European countries described multidisciplinary involvement in the management of suspected child maltreatment, but wide variations in the organisational approaches were revealed. A sustained decline in childhood deaths from external causes during a 15-year period was observed. A sizeable number of infant deaths were recorded each year as ill-defined or with incomplete documentation from clinicians.Conclusions The results presented in this thesis suggest that the multi-sector response in Sweden and in Europe is insufficiently organised, with no clear mandate for the health sector to robustly combat child maltreatment, and that this may undermine the ability of society to adequately protect children.
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| 17. |
- Welin, Staffan, 1966-
(författare)
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Midgut Carcinoid Tumours : New Diagnostic Procedures and Treatment
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Midgut carcinoid tumours are rare with an incidence of 0.5-2.1/100 000. The primary tumour is usually small and grows slowly but has almost always set metastases at diagnosis. When radically operated, most patients will eventually recur in their disease. We evaluated different methods in detecting recurrent disease in 61 malignant midgut carcinoid tumours that had been radically operated. Thirty-eight patients have been diagnosed with a recurrence. In 32/38 of these patients P-Chromogranin A was the first method to indicate a recurrence. We therefore recommend using P-CgA in the work up in these patients.We investigated characteristics, survival and independent factors that could be of bad prognostic value. We found that in our 284 malignant midgut carcinoid tumours, 208/284 (73%) had distant metastases and 30/284 (11%) had carcinoid heart disease. Median survival was 115.5 months and five-year survival was 77%. In a multivariate analysis liver metastases and carcinoid heart disease were poor prognostic factors.We performed a phase II study with octreotide pamoate investigating the clinical effect in 12 malignant midgut carcinoid tumours in a progressive phase. We found that 9/12 (75%) were stabilised for a median duration of 12 months. We think that this is a good effect considering the advanced stage.We investigated the frequency of four different tyrosine kinase receptors, platelet derived growth factor receptor (PDGR) α and β, epidermal growth factor receptor (EGFR) and c-kit, in 36 malignant midgut carcinoid tumours with immunohistochemistry. We found that 13/34 (38%) tumour samples expressed PDGFRα, 29/33 (88%) PDGFRβ, 24/33 (73%) EGFR, whereas none expressed c-kit. This implicates that midgut carcinoid tumours might be susceptible to treatment with tyrosine kinase receptor inhibitors.
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