| 1. |
- Levin, Sara, 1974-
(författare)
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The challenges of using structured risk assessment instruments in forensic psychiatric care
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The purpose of psychiatric forensic care is to provide treatment for mentally ill offenders and to prevent future acts of violence and other adverse events. During care, the type of restrictions of freedom, the patient’s continuous need for involuntary treatment and readiness for discharge, are continuously evaluated based on the assessment of risk the patient pose to themselves and others as well as the progress achieved with treatment. The use of structured risk assessment instruments is recommended in clinical guidelines to assess such risks. However, unstructured clinical assessments, considered to be less valid, are often used in clinical practice. There is insufficient research evidence concerning several aspects related to the clinical use of structured risk assessment instruments in terms of guiding the planning and realization of care and risk management interventions. There is also a lack of knowledge about what patients themselves perceive to be mediating factors for their use of violence. Overall aim: The overarching aim of this thesis was to investigate the implementation and use of structured risk assessment instruments to prevent violence and other adverse events in forensic settings and to improve understanding of the factors that influence such events among forensic patients.Methods: Several methods were used for data collection and data were analysed by different types of content analysis. In the first paper, a systematic review of previous research studies on implementation determinants for structured risk assessment instruments in forensic settings was conducted to investigate implementation determinants for such instruments. The second paper evaluates a pilot project of the implementation of a structured risk assessment instrument at a forensic clinic in Östergötland using focus group interviews with staff members who had used the instrument. Their perceptions of the instrument and barriers and facilitators to its implementation and clinical use were investigated. The third paper investigated the actual clinical use of structured risk assessments to guide the planning and realization of care and risk management interventions documented in forensic patients’ records. In the fourth paper, patient perspectives of factors increasing and decreasing the risk for violence were investigated by individual semi-structured interviews with forensic patients.Results: There is a wide variety of determinants for the implementation and clinical use of structured risk assessment instruments, which make such missions complicated. The determinants relate to the characteristics of the implementation object, characteristics of users, the inner setting in which the implementation occurs and the implementation process. Limiting the need to change current routines, and hence the strain on the organization by reducing complexity, and the need for resource allocation seem especially important. Most of the planned risk management interventions in structured risk assessments were realized according to patient records. However, structured risk assessments largely overlap with unstructured risk assessments in terms of planned care and risk management interventions. Noteworthy, most of the interventions realized were not documented as planned. Forensic patients described several risk factors that increased and decreased their use of violence. These factors related to themselves, external influences, social and relational aspects and situational factors. Most patient accounts of mediating factors overlapped with those listed in commonly used risk assessment instruments and previous research. Additional factors identified by patients related to the outer context and interpersonal aspects.Conclusions: There are many barriers and facilitators to the implementation and use of structured risk assessment instruments, implying the need for a multifaceted approach to address determinants at several system levels. Considering the clinical context is important when selecting a structured risk assessment instrument to be implemented, but also the complexity of the instrument, the required change of routines and the provision of continuous resources and interventions to achieve and maintain clinical use. Despite the many barriers, there is evidence of clinical use of both unstructured clinical and structured risk assessments in terms of informing and guiding care and risk management interventions. The large overlap, however, makes it difficult to draw definite conclusion about which type of assessment actually influenced the interventions that were realized. Realized care and risk management interventions are most often not documented as planned. This increases the risk of subjective decisions and provision of interventions, which also make such interventions difficult to evaluate. Forensic patients are actively managing their risk of violence and are capable of identifying and communicating many different mediating factors for their violence risk. They are knowledgeable and important stakeholders and should be involved in their own risk assessments, as well as in research.
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| 2. |
- Johansson Capusan, Andrea, 1970-
(författare)
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Environmental and Genetic Influences in Attention Deficit Hyperactivity Disorder (ADHD) and its Comorbidities
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Research in past decades has demonstrated the persistence of attention deficit hyperactivity disorder (ADHD) into adulthood, but many questions regarding prevalence, causes, and comorbidities of ADHD in adults remain to be investigated. Previous research focusing on childhood ADHD identified high heritability. Genetic and environmental influences on ADHD symptoms in adults and their association with comorbid conditions are not fully understood.The overall aim of this thesis was to study adult ADHD symptoms in the population and investigate associations with substance use disorders (SUD) and binge eating. In all four papers, we used population-based self-report data from twins aged 20–46 years from the Swedish Twin Registry. We used twin methods to explore the role of genetic and environmental factors underlying ADHD symptoms and their comorbidities.Study I examined the phenotypic association between ADHD and various forms of SUD. ADHD in adults was strongly associated with alcohol abuse and alcohol dependence, illicit drug use and regular nicotine use, with no differences between ADHD subtypes and no apparent substance preference. In Studies II and IV, we used bivariate twin models to examine the role of genetic and environmental factors in the association of adult ADHD symptoms with alcohol dependence (II) and with binge eating (IV). For ADHD symptoms and alcohol dependence, 64% of the overlap was explained by common genetic factors. The remaining variance was accounted for by environmental factors specific for each twin, with no sex differences for the overlap. Similarly, 91% of the association between ADHD symptoms and binge-eating behaviour was explained by common genetic factors. In Study III, using a within-twin pair analysis, we demonstrated that although most of the association between adult ADHD symptoms and self-reported childhood maltreatment (an environmental risk factor for ADHD) was explained by familial (genetic and environmental) confounding, our results were also consistent with a causal interpretation.In conclusion, adult ADHD symptoms are associated with SUD and binge-eating behaviour. We replicated findings from adolescent studies regarding shared genetic risk factors for alcohol dependence and ADHD symptoms in adults. For binge eating, we showed for the first time that shared genetic factors mainly explained the association with ADHD symptoms. Alterations in mesolimbic reward processing as well as the frontal, executive and inhibitory systems have been described for ADHD, alcohol dependence and binge-eating behaviour, possibly suggesting common genetic and neurobiological factors for all three conditions. Results that support a causal hypothesis regarding the association between childhood maltreatment and ADHD symptoms in adults need follow-up in longitudinal clinical samples that can examine neurobiological underpinnings of environmental effects. Clinically, the results of this thesis support that ADHD in adults be considered and addressed in adults with SUD or binge-eating behaviour. Given the common genetic risk factors and the role of the early childhood environment, family interventions should be considered for these populations.
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| 3. |
- 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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| 4. |
- Holmqvist, Marika, 1959-
(författare)
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Addressing Alcohol : Alcohol Prevention in Swedish Primary and Maternity Health Care and Occupational Health Services
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Alcohol consumption in Sweden has reached its highest levels of the past 100 years in the wake of the country’s entry into the European Union in 1995. Increased alcohol prevention efforts in Swedish health care settings have been given high priority by the authorities. The Swedish parliament’s national action plan up to 2010 emphasises that public health must be protected by achieving reductions in alcohol consumption and limiting the negative physical, psychological, and social effects of alcohol.This thesis aims to investigate various aspects related to the current alcoholpreventive activity in 2006 among health care professionals in three important health care settings: primary health care (PHC), occupational health services (OHS), and maternity health care (MHC). The thesis includes four studies based on a total population mail questionnaire survey.Results from the studies show that alcohol issues in both PHC and OHS were addressed less frequently than all other lifestyle issues, i.e. smoking, physical activity, overweight, and stress. Important barriers to alcohol-preventive activity in these settings were perceived lack of time, scepticism regarding the effectiveness of addressing the issue of alcohol, fear of potentially negative patient responses, uncertainty about how to ask, uncertainty about how to give advice regarding alcohol, and uncertainty concerning where to refer the patient.OHS professionals generally considered themselves more skilful than their PHC counterparts in achieving change in patients’ alcohol habits and more knowledgeable about providing advice to patients with risky alcohol consumption. The overall frequency of initiating discussions about alcohol with patients in PHC and OHS was positively associated with self-assessed skills, knowledge, and education for all professional categories.Slightly more than one-third of the MHC midwives used a questionnaire to assess the woman’s alcohol intake before the pregnancy; AUDIT was the most commonly used questionnaire. Their perceived knowledge concerning alcohol and pregnancy matters was generally high, but the midwives considered themselves less proficient at detecting pregnant women with risky alcohol consumption before the pregnancy.MHC midwives had participated in more continuing professional education in handling risky drinking than all other categories investigated. PHC nurses was the category that had the highest proportion of professionals who lacked education in handling risky drinking. Professionals in PHC, OHS, and MHC to a large extent believed that provision of more knowledge about counselling techniques to use when alcohol-related symptoms are evident could facilitate increased alcohol intervention activity.
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| 5. |
- 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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| 6. |
- 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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| 7. |
- Trinks, Anna, 1981-
(författare)
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Alcohol prevention in emergency care : Drinking patterns among patients and the impact of a computerized intervention in a Swedish Emergency department
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to generate knowledge about alcohol consumption among patients in a Swedish ED, the reach and effectiveness of a computerized brief intervention delivered in the ED, and factors that are associated with reduced alcohol consumption 6 months after the ED visit.The results from the studies show that alcohol consumption was higher among patients who were injured than patients who were not injured. Injury patients had a higher weekly consumption, drank more frequently and drank higher typical quantities than non-injury patients. Patients who were categorized as acute drinkers had higher weekly alcohol consumption and were more frequently engaged in heavy episodic drinking (HED) than non-acute drinkers.Among the patients who took part in the computerized test, more than 15% stated that they were at the preparation stage or actively motivated to change their alcohol consumption. Of the patients who were categorized as acute drinkers, 34% were at the action or preparation stage.Among patients who were categorized as risky drinkers, 48% became non-risky drinkers at follow-up. The relative change in average weekly consumption among risky drinkers was 30% and the relative change in HED occasions per month was 37% from baseline to follow-up.Motivated to reduce alcohol consumption at baseline, influenced by just visiting the ED, considering the alcohol-related feedback information and impact from a health care provider are independent predictors for reduced alcohol consumption.
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| 8. |
- 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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| 9. |
- Thomas, Kristin, 1978-
(författare)
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Implementation of coordinated healthy lifestyle promotion in primary care : Process and outcomes
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Implementation of healthy lifestyle promotion in routine primary has been suboptimal. There is emerging evidence that coordinating care can improve the efficiency and quality of care. However, more research is needed on the implementation of coordinated care in healthy lifestyle promotion, the role of patients in implementation and the long-term outcomes of implementation efforts.Overall aim: To investigate the implementation of coordinated healthy lifestyle promotion in primary care in terms of process and outcomes, from the perspectives of both staff and patients.Methods: In 2008, Östergötland county council commissioned primary care centres to implement a coordinated care initiative, lifestyle teams, to improve healthy lifestyle promotion routines. A lifestyle team protocol stipulated centres to: (1) create multi-professional teams, (2) appoint team managers, (3) hold team meetings, and (4) create in-house referral routines for at-risk patients. Paper I investigated the implementation process of three lifestyle teams during a two year period using a mixed method, convergent parallel design. A proposed theory of implementation process was used to analyse data from manager interviews, documents and questionnaires. Paper II explored patients’ role in implementation using grounded theory. Interview data from patients with varied experience of promotion was used. Paper III investigated implementation outcomes using a quasi-experimental, cross-sectional design that compared three intervention centres (lifestyle teams) with three control centres (no teams). Data were collected by staff and patient questionnaires and manager interviews at 3 and 5 years after commissioning. The RE-AIM framework was modified and used to define outcome variables: Reach of patients, Effectiveness (attitudes and competency among staff), Adoption among staff, Implementation fidelity to the lifestyle team protocol, and Maintenance of the results at 5-year follow-up.Results: Paper I: The implementation process was complex including multiple innovation components and groups of adopters. The conditions for implementation, e.g. resources varied between staff and team members which challenged the embedding of the teams and new routines. The lifestyle teams were continuously redefined by team members to accommodate contextual factors, features of the protocol and patients. The lifestyle team protocol presented an infrastructure for practice at the centres. Paper II: A grounded theory about being healthy with three interconnected subcategories emerged from data: (1) conditions, (2) managing, and (3) interactions regarding being healthy. Being healthy represented a process of approaching a health ideal which occurred simultaneously with, and could contradict, a process of maximizing well-being. A typology of four patient types (resigned, receivers, co-workers, and leaders) illustrated how processes before, during and after healthy lifestyle promotion were interconnected. Paper III: Reach: significantly more patients at control centres received promotion compared to intervention centres at 3-year (48% and 41% respectively) and 5-year followups (44% and 36% respectively). Effectiveness: At 3-year follow-up, after controlling for clustering by centres, intervention staff were significantly more positive concerning perceived need for lifestyle teams; that healthy lifestyle promotion was prioritized at their centre and that there was adequate competency at individual and centre level regarding lifestyle promotion. At 5-year follow-up, significant differences remained regarding prioritization of lifestyle promotion at centre level. The majority of both intervention and control staff were positive towards lifestyle promotion. Adoption: No significant differences were found between control and intervention centres at 3 years (59% and 47% respectively) or at 5 years (45% and 36% respectively). Implementation fidelity: all components of the lifestyle team protocol had been implemented at all the intervention centres and at none of the control centres.Conclusions: The implementation process was challenged by a complex interaction between groups of staff, innovation components and contextual factors. Although coordinated care are used for other conditions in primary care, the findings suggest that it is difficult to adopt similar routines for healthy lifestyle promotion. Findings suggest that the lifestyle team protocol did not fully consider social components of coordinated care or the varied conditions for change exhibited by adopters. Patients can be seen as coproducing implementation of healthy lifestyle promotion.
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