| 1. |
- Skagerström, Janna, 1983-
(författare)
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Alcohol consumption during pregnancy : Prevalence, predictors and prevention
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- It is well established that fetal alcohol exposure can disturb the development of the fetus and cause a range of effects for the affected child. However, research on the effects of exposure to lower levels is inconclusive and the subject is debated. Based on the precautionary principle women in many countries, Sweden included, are advised to maintain total abstinence throughout pregnancy. Regardless, studies have shown that a significant proportion of women consume alcohol around conception and throughout pregnancy. The overall aim of this thesis was to generate knowledge about the prevalence, predictors and prevention of alcohol consumption among women before and during pregnancy.The aim was addressed in five studies using several datasets and methods. A systematic review of the international literature was undertaken to identify predictors of alcohol consumption during pregnancy (Study I). Questionnaires to midwives were used to investigate the alcohol-preventive work in antenatal care in Sweden (Study II). Questionnaires were also used to gather data on alcohol consumption before and during pregnancy from pregnant women across Sweden and from women who had given birth to a child in one area of Sweden (Study III and IV). Focus group interviews were used to assess non-pregnant women’s voices on alcohol consumption and pregnancy in Sweden (Study V).The results from the studies showed that alcohol consumption was common among women of childbearing age in Sweden (Study III-V) and that there were social expectations for women to drink (Study V). During pregnancy, the expectation was the opposite, as pregnant women were expected to abstain from all alcohol consumption (Study V), which is in line with the total abstinence recommendation from antenatal care. The national “Risk Drinking” project led to revised alcohol-preventive routines in Swedish antenatal care, including screening of all pregnant women for hazardous alcohol use in the year preceding pregnancy, an important predictor of drinking during pregnancy (Study II). A great majority of pregnant women and new mothers reported abstinence from alcohol after pregnancy recognition (Study III and IV), yet the level of reported alcohol consumption during pregnancy appeared to be affected by formulation of the question (Study IV). Factors associated with more drinking during pregnancy in Sweden were: living in a major city, older maternal age, tobacco use, low social support, stronger pre-pregnancy drinking habits and stronger social drinking motives (Study III). In the international research, pre-pregnancy drinking habits, exposure to abuse or violence, high income or social class and positive screen for dependence were the factors most consistently reported to be associated with more drinking during pregnancy (Study I). Women of childbearing age were uncertain about the potential effects of drinking in the period around conception and the social expectations to abstain did not seem to be as strong in this period as after pregnancy recognition (Study V). A majority of women reported having reduced their alcohol consumption only after they became aware that they are pregnant, meaning that they could have been dinking for several weeks in early pregnancy (Study III).
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| 2. |
- Andersen, Pia, 1958-
(författare)
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Physical activity on prescription with access to counsellor support implemented in routine care : Healthcare and patient perspectives
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The Swedish PAP (physical activity on prescription) programme FaR®, introduced in 2001, has been adopted by all Swedish regions, which are responsible for provision of healthcare in Sweden. Several studies have shown positive outcomes of the Swedish PAP on patients’ physical activity and other health-related outcomes. There are no guidelines for best practises of the Swedish PAP, which has led to the development of different organizational structures for its delivery. This thesis project was developed with the ambition of providing knowledge for further development of PAP in clinical practise.Aim: The overall aim was to investigate and generate improved understanding of a structure for physical activity on prescription with access to physical activity counsellors, implemented in routine healthcare.Methods: To address the overall aim, four real-world studies with different design and analysis methods were carried out. The study population consisted of patients 18 years or older prescribed PAP in primary and secondary care in Region Kronoberg’s healthcare organization. Study I investigated characteristics of healthcare delivery of PAP over a four-year period, including all patients prescribed PAP in these years. Study II explored factors that influenced patient’s long-term engagement in physical activity after prescription. Study III investigated differences in physical activity and health-related quality of life (HRQoL) at one-year follow-up between patients who used versus patients who did not use counsellor support after prescription. Study IV investigated factors associated with patients increase in physical activity at one-year follow-up. Data sources for the studies were electronic medical records (Studies I, II, III and IV), individual interviews (Study II) and a baseline and a follow-up questionnaire (Studies III and IV). Different statistical analyses were performed in Studies I, III and IV. Study II used qualitative content analysis based on an approach including both inductive and deductive analysis. The final study samples of PAP recipients were N = 4,879 (Study I), n = 13 (Study II), n = 400 (Study = III) and n = 355 (Study IV).Results: Study I: 4,879 PAP recipients were identified, one-third had used the offer of counsellor support. PAP recipients had a high frequency of diagnosis and healthcare consumption prior to PAP. Counsellor users had higher frequency of multiple diagnoses and healthcare visits than non-counsellor users. The main prescriber of PAP was physicians and the main prescribing setting was primary care. Study II: PAP recipients’ long-term engagement with physical activity was influenced by the determinants of capability, opportunity, and motivation. Receiving a prescription of physical activity, and professional counselling and follow up from a physical activity counsellor, and adaption of PAP to the individual’s capacity were important for patients change of physical activity. Study III: Counsellor users had better outcomes in both physical activity and HRQoL than non-users of this support. Study IV: Nearly half of the PAP recipients had increased physical activity one year after prescription. Increased physical activity was positively associated with lower baseline activity, counsellor use, and positive perception of given support after PAP.Conclusions: Patients who were prescribed PAP had a high frequency of diagnoses and high healthcare consumption in the year prior to the prescription. Due to the positive findings regarding patient outcomes on physical activity, and patient experiences of counsellor support, it could be suggested that individualized counselling and follow up by a physical activity counsellor is of importance for patients’ engagement in physical activity, especially for patients with lower baseline activity. Since increased activity was also seen among nonusers of counsellor support, a general recommendation for physical activity counsellor support for all PAP recipients could not be suggested.
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| 3. |
- Bernhardsson, Susanne, 1958-
(författare)
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Advancing evidence-based practice in primary care physiotherapy : Guideline implementation, clinical practice, and patient preferences
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Research on physiotherapy treatment interventions has increased dramatically in the past 25 years and it is a challenge to transfer research findings into clinical practice, so that patients benefit from effective treatment. Development of clinical practice guidelines is a potentially useful strategy to implement research evidence into practice. However, the impact of guideline implementation in Swedish primary care physiotherapy is unknown. To achieve evidence-based practice (EBP), research evidence should be integrated with clinical expertise and patient preferences, but knowledge is limited about these factors in Swedish primary care physiotherapy.The overall aim of this thesis was to increase understanding of factors of importance for the implementation of EBP in Swedish primary care physiotherapy. Specific aims were: to translate and adapt a questionnaire for the measurement of EBP and guidelines; to investigate physiotherapists’ attitudes, knowledge and behaviour related to EBP and guidelines; to examine clinical practice patterns; to evaluate the effects of a tailored guideline implementation strategy; and to explore patients’ preferences for physiotherapy.The thesis comprises four studies (A-D), reported in five papers. In Study A, a questionnaire for the measurement of EBP and guidelines was translated, cross-culturally adapted, and tested for validity (n=10) and reliability (n=42). Study B was a cross-sectional study in which this questionnaire was used to survey primary care physiotherapists in the county council Region Västra Götaland (n=271). In Study C, a strategy for the implementation of guidelines was developed and evaluated, using the same questionnaire (n=271 at baseline, n=256 at follow-up), in a prospective controlled trial. The strategy was based on an implementation model, was tailored to address the determinants of guideline use identified in Study B, and comprised several components including an educational seminar. Study D was an exploratory qualitative study of patients with musculoskeletal disorders (n=20), using qualitative content analysis.The validity and reliability of the questionnaire was found to be satisfactory. Most physiotherapists have a positive regard for EBP and guidelines, although these attitudes are not fully reflected in the reported use of guidelines. The most important determinants of guideline use were considering guidelines important to facilitate practice and knowing how to integrate patient preferences with guidelines. The tailored, multi-component guideline implementation significantly affected awareness of, knowledge of, and access to guidelines. Use of guidelines was significantly affected among those who attended an implementation seminar. Clinical practice for common musculoskeletal conditions included interventions supported by evidence of various strengths as well as interventions with insufficient research evidence. The most frequently reported interventions were advice and exercise therapy. The interviewed patients expressed trust and confidence in the professionalism of physiotherapists and in the therapists’ ability to choose appropriate treatment, rendering treatment preferences subordinate. This trust seemed to foster active engagement in their physiotherapy.In conclusion: The adapted questionnaire can be used to reliably measure EBP in physiotherapy. The positive attitudes found do not necessarily translate to guideline use, due to several perceived barriers. The tailored guideline implementation strategy used can be effective to reduce barriers and contribute to increased use of guidelines. The clinical practice patterns identified suggest that physiotherapists rely both on research evidence and their clinical expertise when choosing treatment methods. Patients’ trust in their physiotherapist’s competence and preference for active engagement in their therapy need to be embraced by the clinician and, together with the therapist’s clinical expertise, integrated with guideline use in the clinical decision making. Further research is needed on how the EBP components and different knowledge sources can be integrated in physiotherapy practice, as well as on implementation effects on patient outcomes.
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| 4. |
- Carlfjord, Siw, 1959-
(författare)
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The Challenge of Changing Practice : Applying Theory in the Implementation of an Innovation in Swedish Primary Health Care
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The translation of new knowledge, such as research findings, new tools or methods into health care practice has gained increased interest in recent years. Important factors that determine implementation outcome have been identified, and models and checklists to be followed in planning as well as in carrying out an implementation process have been produced. However, there are still knowledge gaps regarding what approach should be used in which setting and for which problems. Primary health care (PHC) in Sweden is an area where there is a paucity of research regarding implementation of new methods into practice. The aim of the thesis was to apply theory in the study of the implementation of an innovation in Swedish PHC, and identify factors that influenced outcome.Methods: The study was performed using a quasi-experimental design, and included six PHC units, two from each one of three county councils in the southeast part of Sweden. A computer-based lifestyle intervention tool (CLT) developed to facilitate addressing lifestyle issues, was introduced at the units. Two different strategies were used for the introduction, both aiming to facilitate the process: a theory-based explicit strategy and an implicit strategy requiring a minimum of effort. Data collection was performed at baseline, and after six, nine and 24 months. Questionnaires were distributed to staff and managers, and data was also collected from the CLT database and county council registers. Implementation outcome was defined as the proportion of eligible patients being referred to the CLT, and was also measured in terms of Reach, Effectiveness, Adoption, Implementation and Maintenance according to the RE-AIM framework. Interviews were performed in order to explore experiences of the implementation process as perceived by staff and managers.Results: A positive organizational climate seemed to promote implementation. Organizational changes or staff shortages coinciding with the implementation process had a negative influence on outcome. The explicit implementation strategy seemed to be more effective than the implicit strategy in the short term, but the differences levelled out over time. The adopters’ perceptions of the implementation seemed to be influenced by the existing professional sub-cultures. Successful implementation was associated with positive expectations, perceptions of the innovation being compatible with existing routines and perceptions of relative advantage.Conclusions: The general conclusion is that when theory was applied in the implementation of a lifestyle intervention tool in Swedish PHC, factors related to the adopters and to the innovation seemed to be more important over time than the strategy used. Staff expectations, perceptions of the innovation’s relative advantage and potential compatibility with existing routines were found to be positively associated with implementation outcome, and other major organizational changes concurrent with implementation seemed to affect the outcome in a negative way. Values, beliefs and behaviour associated with the existing sub-cultures in PHC appeared to influence how the implementation of an innovation was perceived by managers and the different professionals.
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| 5. |
- Leijon, Matti, 1970-
(författare)
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Activating People : Physical activity in the general population and referral schemes among primary health care patients in a Swedish county
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In this thesis the need for physical activity interventions is investigated in a general adult population, the characteristics of physical activity referral (PAR) scheme recipients and referral practitioners, and the effectiveness of PAR in a routine primary health-care (PHC) setting in the county of Östergötland, Sweden. The thesis consists of four papers: three papers are based on a quantitative, uncontrolled prospective PAR study and one paper is based on a population survey in the county of Östergötland, Sweden.In 2006, only one in four of the adult population, aged 18–84 years, in Östergötland was considered sufficiently active to meet the Swedish national public health recommendations, stated as “30 minutes of moderate physical activity a day”. More than one-third (37%) reported that they hade no intentions to change their physical activity levels, while 36% had thought about change, and 27% were determined to change. Although the individuals felt a large responsibility for their own physical activity, they also believed that this responsibility is partly shared by health-care providers. Among those who wanted to increase their physical activity level, almost one in seven of the total population and one in four among those reporting poor general health, with a BMI over 30 and those who were inactive reported that they wanted support to bring about this change. More than half of them wanted this support from their health-care provider.During 2004 and 2005, a total of 6300 patients received PARs as part of the Östergötland PAR scheme. Two-thirds of the patients were female and half of the patients were 45–64 years old. The PAR scheme reached a relatively high proportion of physically inactive people. PARrelated statistics, including the numbers of referrals made at individual PHC centres and by different professional categories, showed large differences in prescribing activities, both by patient categories, and by prescribing professionals, indicating great potential for further improvements of this scheme in the future.Half of the patients (51%) who received PARs were recommended home-based activities, such as walking. Patient follow-up showed that an increase in self-reported physical activity level was achieved by 52% of the patients at the 12-month follow-up. The proportion of inactive patients decreased from 33% at baseline to 20% at 12 months. The proportion of patients who were physically active on a regular basis increased from 22% at baseline to 32% at 12 months. Neither patient age, diagnosis/PAR reason nor the profession of the prescriber were associated with differences in effectiveness. Low activity levels at baseline and homebased activities were significantly associated with increased physical activity at 12 months. Half of the patients (50%) achieved adherence to PARs at the 12-month follow-up, with adherence assessed by simply asking the patients about their adherence to prescribed activity. Patients’ activity levels at baseline (being at least somewhat physically active) and being issued home-based activities were significantly associated with higher adherence at 12 months.
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| 6. |
- Lindhe Söderlund, Lena, 1954-
(författare)
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Challenges of learning and practicing motivational interviewing
- 2009
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The past three decades have seen a growth in health promotion research and practice, stimulated by the epidemiologic transition of the leading causes of death from infectious to chronic diseases. An estimated 50% of mortality from the 10 leading causes of death is due to behaviour, which suggests individuals can make important contributions to their own health by adopting some health-related behaviours and avoiding others. Motivational interviewing (MI) has emerged as a brief counselling approach for behavioural modification that builds on a patient empowerment perspective by supporting self-esteem and self-efficacy. MI has become increasingly popular in a variety of health care settings as well as non-health care settings.Aims: The overall aim of this thesis is to contribute to improved understanding of the different factors that impact on the learning and practice of MI. The aim of study I was to identify barriers and facilitators to use MI with overweight and obese children in child welfare and school health services. The aim of study II was to identify barriers, facilitators and modifiers to use MI with pharmacy clients in community pharmacies.Methods: Participants in study I were five child welfare centre nurses from the county council and six municipally-employed school health service nurses, all from Östergötland, Sweden. Participants in study II were 15 community pharmacy pharmacists in Östergötland Sweden. Data for both studies were obtained through focus group interviews with the participants, using interview guides containing open-ended questions related to the aims of the studies. Study II also included five individual interviews. Interview data were interpreted from a phenomenological perspective.Results: In study I, important barriers were nurses’ lack of recognition that overweight and obesity among children constitutes a health problem, problem ambivalence among nurses who felt that children’s weight might be a problem although there was no immediate motivation to do anything, and parents who the nurses believed were unmotivated to deal with their children’s weight problem. Facilitators included nurses’ recognition of the advantages of MI, parents who were cooperative and aware of the health problem, and working with obese children rather than those who were overweight. In study II, pharmacists who had previously participated in education that included elements similar to MI felt this facilitated their use of MI. The opportunity to decide on appropriate clients and/or healthrelated behaviours for counselling was also an important facilitator. The pharmacists believed the physical environment of the pharmacies was favourable for MI use, but they experienced time limitations when there were many clients on the premises. They also experienced many difficulties associated with the practical application of MI, including initiating and concluding client conversations.Conclusions: Learning and practicing MI effectively is difficult for many practitioners as it requires a new way of thinking and acting. Practitioners’ use of MI is not effective unless there is recognition that there is an important health-related problem to be solved. Practitioners feel more confident using MI with clients who have health-compromising behaviours and/or risks in which the practitioners feel they have expertise. Possessing considerable MI counselling skills does not compensate for insufficient knowledge about a targeted health-related behaviour and/or risk. Feedback from clients plays an important role for the quality and quantity of practitioners’ MI use.
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| 7. |
- Lindhe Söderlund, Lena, 1954-
(författare)
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Motivational Interviewing in Theory and Practice
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- An estimated 50% of mortality from the 10 leading causes of death is due to behaviour. Individuals can make important contributions to their own health by adopting health-related behaviours and avoiding others. Motivational interviewing (MI) has emerged as a counselling approach for behavioural change that builds on a patient empowerment perspective by supporting autonomy and self-efficacy.The overall aim of this thesis is to contribute to improved understanding of the different factors that impact on general health care professionals’ learning and practice of MI. Specific aims are; study I was to identify barriers, facilitators and modifiers to use MI with pharmacy clients in community pharmacies; study II was to identify barriers and facilitators to use MI with overweight and obese children in child welfare and school health services; study III was to evaluate the attitudes towards MI and clinical use of MI with children´s weight issues one year after child health care nurses’ participation in MI training; study IV was to systematically review studies that have evaluated the contents and outcomes of MI training for general health care professionals.Participants in study I were 15 community pharmacy pharmacists in Östergötland, Sweden. Participants in study II were five child welfare centre nurses from the county council and six municipally-employed school health service nurses, all from Östergötland, Sweden. Data for both studies were obtained through focus group interviews. Study III, participants were 76 nurses from child health care centres in Östergötland, Sweden. 1-year after MI training they answered a survey. Study IV, the material was 10 empirical studies that have evaluated different aspects of MI training.MI training for general health care providers is generally of short duration and tends to focus on specific topics such as diabetes, smoking, and alcohol. The training seems to contain more training on phase I elements, such as clients’ inner motivation, than on phase II, which involves strengthening clients’ commitment to change. MI is seen as practical and useful in work with lifestyle and health promotion issues, especially with issues that may be perceived as sensitive, such as alcohol and obesity. General health care providers have positive attitudes to MI and view MI as being compatible with their values and norms about how they want to work. Clients’ resistance reactions are difficult to handle in the first stages of learning MI, and may lead to frustration. Strategies to avoid resistance are including in the final stages of learning MI. Learning and clinical use of MI for general health care providers is influenced by interactions with their environment (colleagues, staff and organization). Unlearning of old knowledge can be a problem for general health care providers in the learning and clinical use of MI.
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| 8. |
- Ridelberg, Mikaela, 1982-
(författare)
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Towards safer care in Sweden? : Studies of influences on patient safety
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Patient safety has progressed in 15 years from being a relatively insignificant issue to a position high on the agenda for health care providers, managers and policymakers as well as the general public. Sweden has seen increased national, regional and local patient safety efforts since 2011 when a new patient safety law was introduced and a four-year financial incentive plan was launched to encourage county councils to carry out specified measures and meet certain patient safety related criteria. However, little is known about what structures and processes contribute to improved patient safety outcomes and how the context influences the results.The overall aim of this thesis was to generate knowledge for improved understanding and explanation of influences on patient safety in the county councils in Sweden. To address this issue, five studies were conducted: interviews with nurses and infection control practitioners, surveys to patient safety officers and a document analysis of patient safety reports. Patient safety officers are healthcare professionals who hold key positions in their county council’s patient safety work. The findings from the studies were structured through a framework based on Donabedian’s triad (with a contextual element added) and applying a learning perspective, highlight areas that are potentially important to improve the patient safety in Swedish county councils.Study I showed that the conditions for the county councils’ patient safety work could be improved. Conducting root-cause analysis and attaining an organizational culture that encourages reporting and avoids blame were perceived to be of importance for improving patient safety. Study II showed that nurses perceived facilitators and barriers for improved patient safety at several system levels. Study III revealed many different types of obstacles to effective surveillance of health care-associated infections (HAIs), the majority belonging to the early stages of the surveillance process. Many of the obstacles described by the infection control practitioners restricted the use of results in efforts to reduce HAIs. Study IV of the Patient Safety Reports identified 14 different structure elements of patient safety work, 31 process elements and 23 outcome elements. These reports were perceived by patient safety officers to be useful for providing a structure for patient safety work in the county councils, for enhancing the focus on patient safety issues and for learning from the patient safety work that is undertaken. In Study V the patient safety officers rated efforts to reduce the use of antibiotics and improved communication between health care practitioners and patients as most important for attaining current and future levels of patient safety in their county council. The patient safety officers also perceived that the most successful county councils regarding patient safety have good leadership support, a long-term commitment and a functional work organisation for patient safety work.Taken together, the five studies of this thesis demonstrate that patient safety is a multifaceted problem that requires multifaceted solutions. The findings point to an insufficient transition of assembled data and information into action and learning for improved patient safety.
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| 9. |
- Öhrn, Annica, 1960-
(författare)
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Measures of Patient Safety : Studies of Swedish Reporting Systems and Evaluation of an Intervention Aimed at Improved Patient Safety Culture
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Unsafe health care delivery results in millions of patients suffering from injuries or death worldwide. A Swedish study estimated the prevalence of preventable adverse events as high as 8.6% in hospital care, which demonstrates that patient safety is no less a problem in Sweden than elsewhere. Reporting of adverse events has become an integral part of patient safety work. The aim of reporting is to identify patient safety problems and provide background data and information for efforts to improve patient safety. However, adverse events in health care can be captured and measured using different methods and stored in disparate systems that are not fully integrated. This makes it difficult to obtain a complete coherent picture of the frequency and nature of various types of adverse events. Another difficulty is to distinguish between adverse events and accepted complications of medical care.The overall aim of this thesis is to generate knowledge for improved understanding of how patient safety can be measured in terms of reporting adverse events and improved by targeting patient safety culture with an intervention implemented in a Swedish county council. Three research questions have been derived from the aim: (1) To what extent can analysis of patient claims contribute to an understanding of the magnitude of the patient safety problem? (2) To what extent do data captured from different reporting systems in Sweden differ? (3) To what extent can a structured intervention that fosters learning on patient safety issues and encourages leadership commitment improve the patient safety culture in a Swedish county council from a five-year perspective?The research is based on studies of three national reporting systems: Lex Maria to the National Board of Health and Welfare; patient claims to the County Councils´ Mutual Insurance Company; and medical data reported to the National Swedish Spine Register (Swespine). Data have also been assembled as part of an evaluation within the Patient Safety Dialogue intervention.This thesis indicates that different Swedish reporting systems provide disparate views and have many discrepancies regarding data quality and coverage of adverse events. Patient claims seem to be an important source of information that can complement information from incident reporting systems and quality registries in health care to provide an understanding of the magnitude of the patient safety problem.The research also shows that a structured intervention that fosters learning on patient safety issues and encourages leadership commitment can improve the culture of patient safety. However, a longer period of time and focused efforts might be required to achieve improvements across all departments within a Swedish county council.
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