| 1. |
- Broqvist, Mari, 1958-
(författare)
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Asking the public : Citizens´ views on priority setting and resource allocation in democratically governed healthcare
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Resource allocation in publicly funded healthcare systems is inevitably linked with priority setting between different patient groups and between different service areas, so-called meso level priorities. Behind every priority-setting decision (investments, reallocating or rationing), are values affecting both the content of the decisions and how the decisions are made. The importance for priority-setting to reflect social values, has been emphasised for the legitimacy of the healthcare systems and the decision makers. Also important, if supposed to provide enough guidance in practice, is that content values, expressed in ethical principles and criteria, are further operationalised. Few studies exist where Swedish citizens have been asked about priority setting and rationing at meso level, and findings from other countries cannot automatically be transferred to the Swedish context.The overall aim of this thesis is to extend and deepen the knowledge of the Swedish citizens´ views on acceptance of rationing in healthcare, on appropriate decision makers for rationing, and on the severity criterion for priority setting. Two qualitative and one mixmethod study were conducted, where citizens were interviewed. Citizens´ views on severity were also compared, both with a Severity Framework, derived from parliamentary-decided ethical principles and used for resource allocation, and with health professionals´ and politicians´ ranking of different aspects of severity in a quantitative, survey study.Study I shows that citizen participants perceived that acceptance of rationing at meso level is built on the awareness of priority-setting dilemmas between patient groups. No such spontaneous awareness was found. Depending on reactions of self-interest or solidarity, acceptance was also perceived to be built on acceptable principles for rationing and/or access to alternatives to public care. Study II shows that awareness of the meso level forms the basis for awareness of different risks of unfairness, linked with potential decision makers (even health professionals). Collaborative arrangements were promoted in order to control for such risks, especially the risk of self-interest. Politicians, in contrast to previous studies, were favoured as final decision makers for rationing healthcare. In study III, citizen participants identified the same severity aspects as health professionals and experts had done in the Severity Framework. They contributed with some possible refinements, but also promoted aspects not in line with established ethical criteria for priority setting in Sweden. Study IV shows that citizen respondents differ to a larger proportion compared to politicians´ ranking of severity aspects, than with that of health professionals´. The greatest number of significant differences was found between politicians and health professionals.This thesis has several implications. Politicians ought to strive for greater public awareness of the priority-setting dilemma at the meso level in healthcare, both according to the process and the content values behind the decisions. Social values not in accordance to the parliamentary decision indicate a need to facilitate an ongoing dialogue, reason-giving activities and promotion of content values of solidarity. To capture social values on priority setting and rationing, ambitious public deliberation is not the only way. Methodologically stringent research, with a variety of study designs, could contribute in many important ways.
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| 2. |
- Leach, Lindsay
(författare)
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Modeling Bainite Formation in Steels
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This study examines the fundamental aspects of bainite formation in a guided effort to lay a foundation for development of a model capable of predicting bainite formation. In the first part of this study, the tenets of an existing model for growth, developed by Zener and later modified by Hillert are examined. A number of interacting and adjustable parameters are identified namely, diffusivity, driving force, radius of the ferrite plate tip, interfacial carbon content, and thermodynamic barriers. Amongst which, there are a number of assumptions which are no longer justifiable because of the availability of software and databases from which more accurate calculations can be obtained. The approximation of the driving force is one such example. Another is the carbon content in ferrite, which was assumed negligible. The capillarity effect of the curved ferrite interface had initially been assigned by Zener as having a fixed, optimal value at the maximum growth rate. Although this principle was kept it led to quite different results when the earlier approximations were removed. It is shown that the shape of the C-curves is largely dependent on the diffusivity.The second focus of this thesis is aimed towards developing a model for the start temperatures of bainite, WBs and is achieved twofold. The first procedure was to develop an empirical model. Experimental information on which it is based refers to the start conditions for both bainite and Widmanstätten ferrite. A systematic approach is adapted by which Fe-C is the basis and the effect of alloying elements are evaluated separately from ternary alloys. Regression analysis of data on five ternary systems with Mn, Ni, Si, Cr and Mo gives separate coefficients. A linear empirical equation for the WBs is defined from their sum which was possible because their effects were independent. Carbon had by far the largest effect and Ni the smallest. The equation has good agreement with data but further improvement can be achieved with more reliable experimental data. The second procedure is directed towards a thermodynamic description of the start condition. The critical driving forces corresponding to the critical conditions depicted in the empirical equation are calculated. The results are presented with a dependence on temperature and the same could be translated to a carbon dependence. The critical driving force increases substantially with decreasing temperature and increasing carbon content and the effect of alloying elements is varied.In the final section, the growth model is further developed. A more generalized expression for the barrier is formulated and together with the capillarity effect, consists of the energy requirement to move the growth interface. This is balanced with the available driving force and is solved with an optimization procedure. The predicted C-curves are compared with experimental results and reasonably good agreement is found.
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| 3. |
- Matar, Amal
(författare)
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Considering a Baby? Responsible Screening for the Future : Ethical and social implications for implementation and use of preconception expanded carrier screening in Sweden
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Preconception expanded carrier screening is a novel technology that involves the offer of a screening test for many recessive diseases (via an expanded screening panel) to prospective parents, with no priori risk. Test positive couples have a number of reproductive choices; prenatal diagnosis and aborting affected fetus, IVF and preimplantation genetic diagnosis, sperm or ovum donation or simply accept the risk. The test had been piloted in studies and can potentially be implemented in Europe. Therefore, it seemed pertinent to evaluate stakeholders’ perspectives on ethical and social implications of implementing and using preconception ECS in Sweden.Two main stakeholders were examined; healthcare professionals and health policymaking experts, via a mix of qualitative methods for data collection and data analysis. In Study I, we employed in-depth interviews to collect data and content analysis to analyze it. In Studies III and IV, expert interviews were used to gather data while thematic analysis was utilized to interpret it. Furthermore, in Study II, an ethical concept namely; reproductive autonomy, was critically discussed within a setting that expects a couple to make a conjoint reproductive decision about preconception ECS, while each partner still upholds his or her individual autonomy.The main findings of the empirical studies (Studies I, III and IV) echo to a great extent the prevailing ethical and social debates associated with the novel technology. Respondents expressed concerns with reproductive autonomy, medicalization, prioritization of health resources, discrimination and long term societal changes. Furthermore, respondents emphasized the importance to observe Swedish values, such as human dignity, equality and solidarity, when assessing a preconception ECS program. In addition, they described practicalities of implementation and political considerations that are pertinent to the Swedish context. Finally, some respondents recognized the advantages of reduced suffering and decrease in fetal anomalies and abortion as a consequence of preconception ECS.Study II, proposed a notion of couple autonomy, where certain demands if met, a couple’s reproductive decision can be accepted by healthcare staff as autonomous.The findings, in this thesis, steer towards non implementation of preconception ECS in its current status within the publicly-funded healthcare system in Sweden. This is because healthcare providers and experts were of the opinion that it would not solve a medical need, threaten Swedish values and use up resources extensively.
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