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1.
  • Björling, Gunilla, Docent (författare)
  • Long-Term Tracheostomy : Outcome, Cannula care, and Material Wear
  • 2007
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • Do people with long-term tracheostomy need hospital care? Which cleaning method is most appropriate for decontamination of inner cannulae? Are tracheostomy tubes changed for rational reasons? There is clearly a lack of evidence based research in this field and the clinical guidelines available are often based on local practice. A tracheostomy is a created opening in trachea to facilitate breathing. It is a direct entry to the deeper airways, e.g. for micro-organisms causing a potential risk for lung infections. Indications for long-term tracheostomy can be, e.g. upper airway obstruction, malformations, or chronic hypoventilation, when ventilation via nasal mask is not possible. The research of the present thesis was conducted at the National Respiratory Centre (NRC) at Danderyd Hospital in Stockholm, Sweden. This unit opened in 1982, with the expressed goal of supporting outpatients with long-term tracheostomy. The overall aims of the thesis were to evaluate the outcome of patients with long-term tracheostomy and to conduct evidence based studies concerning their care.A comparison was made for the number of days in hospital care during the 2-year periods before and after the tracheostomy was established. The life expectancy of the general population and the observed life span of a cohort of tracheostomized patients from the start of NRC in 1982 were also compared. Interestingly enough, the need for hospital care was unchanged despite of the tracheostomy. The patients’ observed life spans were remarkably high and for many patients not lower than the life expectancy of Swedish people in general.To find a practical and safe decontamination method for inner cannulae we compared two different cleaning methods; detergent followed by chlorhexidine-alcohol, or detergent alone. Samples for bacterial culture were taken before and after cleaning and the numbers of bacteria colonies were counted. The effectiveness of both cleaning methods was greater than expected and the results showed a nearly total elimination of organisms. Thus, the methods investigated were equivalent in achieving decontamination.The duration of use in our unit for polymeric tracheostomy tubes, i.e. silicone (Si), polyvinyl chloride (PVC), and polyurethane (PU) was determined and compared. We found, that Si tubes were used for longer periods (three months) than tubes made of PU or PVC (both two months).Whether or not surface changes could be observed on the tracheostomy tubes after 30 days’, three and six months’ exposure in the trachea were investigated in collaboration with the Royal Institute of Technology and Sophiahemmet University College in Stockholm, Sweden. The analyzing methods were Scanning Electron Microscopy, Attenuated Total Reflectance Fourier Transform Infrared Spectroscopy, and Differential Scanning Calorimetry. All tubes, except one, showed changes in the surface after 30 days’ exposure. The surface changes had progressed significantly after three and six months' exposure, compared to the changes detected after 30 days. The SF-36 questionnaire and a study specific questionnaire were used to describe the patients’ health-related quality of life and experiences of long-term tracheostomy. The results show that all patients were satisfied with their tracheostomy and demonstrated a numerically mean mental health status score above that of the general population.In summary, long-term tracheostomy does not increase the need for hospital care nor does it reduce a patient’s life span. Cleaning the tracheostomy inner cannula with detergent and water is sufficient to achieve decontamination. Si tracheostomy tubes are used longer compared to those made of PVC or PU. The polymeric material investigated suffered evident surface changes after 30 days’ use. Clinical use of polymeric tracheostomy tubes beyond three months cannot be recommended, as we found extensive surface changes and degradation of the polymeric chains. All patients were, in general content, with their tracheostomy. The findings from the present thesis contribute to making the care of long-term tracheostomized patients’ evidence based.
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2.
  • Cadstedt, Jenny (författare)
  • Influence and Invisibility : Tenants in Housing Provision in Mwanza City, Tanzania
  • 2006
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • A high proportion of urban residents in Tanzanian cities are tenants who rent rooms in privately owned houses in unplanned settlements. However, in housing policy and in urban planning rental tenure gets very little attention. This study focuses on the reasons for and consequences of this discrepancy between policy and practice. Perspectives and actions of different actors involved in the housing provision process in Mwanza City, Tanzania, have been central to the research. The examined actors are residents in various housing tenure forms as well as government officials and representatives at different levels, from the neighbourhood level to UN-Habitat. The main methods have been interviews and discussions with actors as well as studies of policy documents, laws and plans. Among government actors, private rental tenure is largely seen as an issue between landlords and tenants. Tanzanian housing policy focuses more on land for housing than on shelter. This means that house-owners who control land have a more important role in urban planning and policies than tenants have. In Tanzania in general and in Mwanza in particular, housing policy focuses on residents’ involvement in upgrading unplanned areas by organising in Community Based Organisations. This means that owners who live for a longer period in an area benefit more from settlement improvements than tenants. Tenants are relatively mobile and do not take for granted that they will stay in the same house for long. This raises the question of tenants’ possibilities to influence as well as their rights as citizens as compared to that of owners. The question of citizens’ rights for dwellers in informal settlements has received increased attention during the last years in international housing policy discussions. There is an evident need to intensify and diversify this discussion.
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3.
  • Christidis, Maria, 1982- (författare)
  • Integrated teaching for expanded vocational knowing : Studies in the Swedish upper secondary Health and social care program
  • 2020
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • Integrated teaching is emphasized in Swedish upper secondary vocational education and training, for managing sociocultural and historical changes related to: a) increased demands on future competent health care workers, b) educational reforms, c) altered conditions for vocational teachers’ work, and d) vocational contextualization of teaching and learning content. However, national curricula from 1970, 1994, and 2011 recommend integrated teaching as a solution without any specific concretization of what integration could or should contribute with. Thus, the aim of this thesis was to explore the realization of integrated teaching and the vocational knowing made available by integration for students at the Swedish upper secondary Health and social care program, and partly for nursing students in higher education and training. The research questions attended to how integrated teaching is realized, and what vocational knowing is made available by integration.Theoretical point of departure was Cultural historical activity theory (CHAT), complemented with New literacy studies (NLS). The methodological framework included ethnographically inspired case studies, interviews, specifically semi-structured interviews and life-history interviews, and a systematic review. Research material was collected in 2012 and 2018. Analysis was performed with selected concepts from CHAT, and in one study also with concepts from NLS. In one study, i.e. the systematic review, GRADE CERQual was used for an assessment of confidence in the review findings.Study results showed that integrated teaching, regardless of composition and format, made available a vocational, a general, and an expanded vocational knowing. Also, vocational contextualization of school subjects was shown to be significant as an additional teaching and learning content and as mediational means between school and workplace.In conclusion, integrated teaching was shown to respond to the sociocultural and historical developments by making available for students an expanded vocational knowing. Also, vocational contextualization was shown to make possible for students learning knowing relevant for their future profession.
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4.
  • Edfeldt, Katarina, 1979- (författare)
  • Small Intestinal Neuroendocrine Tumours : Genetic and Epigenetic Studies and Novel Serum Biomarkers
  • 2014
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • Small intestinal neuroendocrine tumours (SI-NETs) are rare, hormone producing and proliferate slowly. Patients usually display metastases at time of diagnosis, the tumours are difficult to cure, and the disease course is unpredictable.The gene expression pattern was investigated in paper I, with emphasis on aggressive disease and tumour progression. Expression microarrays were performed on 42 tumours. Unsupervised hierarchal clustering revealed three clusters that were correlated to clinical features, and expression changes from primary tumour to metastasis. Eight novel genes, ACTG2, GREM2, REG3A, TUSC2, RUNX1, TGFBR2, TPH1 and CDH6 may be of importance for tumour progression.In paper II, expression of ACTG2 was detected in a fraction of SI-NETs, but not in normal enterochromaffin cells. Inhibition of histone methyltransferase and transfection of miR-145 induced expression and no effect was seen after DNA methylation or selective EZH2 inhibition in vitro. miR-145 expression was reduced in metastases compared to primary tumours. Overexpression of ACTG2 inhibited cell growth, and inducing ACTG2 may have therapeutic effects.TCEB3C (Elongin A3) is located on chromosome 18 and is imprinted in some tissues. In paper III a reduced protein expression was detected. The gene was epigenetically repressed by both DNA and histone methylation in a tumour tissue specific context. The expression was also induced in primary cell cultures after DNA demethylation and pyrosequencing revealed promoter region hypermethylation. Overexpression of TCEB3C inhibited cell growth by 50%, suggesting TCEB3C to be a tumour suppressor gene.In paper IV, 69 biomarkers were analysed in blood serum using multiplex proximity ligation assay. Nineteen markers displayed different levels between patients and controls. In an extended cohort, ELISA analysis showed elevated serum levels of Mindin, DcR3 and TFF3 in patients and protein expression in tumour cells. High levels of DcR3 and TFF3 were associated with poor survival, and DcR3 may be a marker for liver metastases. Mindin, DcR3, and TFF3 are potential novel diagnostic biomarkers for SI-NETs.
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5.
  • Ekstrand, Per (författare)
  • "Tarzan och Jane" : Hur män som sjuksköterskor formar sin identitet
  • 2005
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • The study focuses on locally situated interactions between men and women and among men. The main focus is on how men in nursing practice constitute their identities. The aim of the disserta-tion is to understand the meaning of gender, particularly the constitution of masculinities, in the formation of identity for men in nursing.Theoretical points of departure were post-structuralist and masculinity theories. Within the theoretical framework, processes of gender should be seen as activities that are relational and integrated in ongoing organisational life, in this case, in the nursing context.My methodological approach was qualitative, based on ethnography. Techniques used for data collection were following observations and interviews. I followed seven men in their daily work in two hospital environments, one emergency department and a department in elder care (sheltered housing).The gender order was maintained by rewards to medical and technical knowledge and skills. The phenomenon of”gender dizziness” was manifested through interaction and became visible through the men’s practice. Different positions of masculinities co-operated and the physicality of the body was important in performing masculinities. Hegemonic positions of masculinities are maintained and other positions are subordinated. Homosociality creates influence and power in social relations, and it was obvious that the informants in these organisations found ways to keep together, in spite of their different positions in the organisation.Some of the informants cross over the border and perform ideals that are not traditional for men in nursing. In the nursing environment these men’s identities show a caring attitude. The stereotype, connected to heteronormative ways of thinking, plays an important role for men in constructing their identities in the nursing context. A central conclusion in this study is that sexuality order put strong pressure on identity formation and the construction of masculinities for men in nursing.
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6.
  • Gabrielsson, Hanna, 1977- (författare)
  • Adults with Spina bifida : voices from everyday life and exploration of living conditions
  • 2020
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • The overall aim of this thesis was to generate knowledge about living with Spina bifida, by mapping the condition and together with the adults with Spina bifida explore their living conditions and experiences in everyday life. Methods Study I was a quantitative study with a cross-sectional design. In Study II, individual experiences of daily life were explored by deep interviews using a reflective lifeworld approach. Study III had a participatory approach including five members of a photovoice group who met for eight sessions. Photographs taken by the members served as a starting point for the dialogue about what was of interest in their daily life. A narrative analysis was conducted by the researchers, incorporating the analysis the group did together. Study IV focused on alignment with the methodology in which photovoice is grounded. By returning to the ideological cornerstones of photovoice, the empirical experiences from Study III and examples from the literature were elaborated through processes within photovoice. The findings show that those adults with Spina bifida who were >46 years old had less complex medical conditions and better physical and cognitive functions, and had attained a higher level of education. The main theme in Study II was presented as “The contradictory path towards wellbeing in daily life.” In Study III, the members’ experiences in everyday life showed that many solutions offered by society were “An adaptation for us, but it works for no one.” The findings are further presented under three themes: “Accessibility – a never-ending project,” “Tensions of a normative view” and “Power to influence.” By focusing on action and narrative in Study IV, it is shown that dialogue, action, and interaction are important aspects of using photovoice. In conclusion, not all adult persons receive the support they need in everyday life, something future generations of adult persons with Spina bifida may have a higher need for. The stories and experiences of adults with Spina bifida in this thesis paint a history of not being asked, concerning their own situation. This shows that there is insufficient integration of the persons’ experiences in society’s efforts to plan for, and support, these individuals. The photovoice method was feasible for this group, providing opportunity for being part of dialogue, action, and interaction.
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7.
  • Georgsson Öhman, Susanne (författare)
  • Women's Experiences of Fetal Screening for Down's Syndrome by Means of an Early Ultrasound Examination
  • 2005
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • The general aim of this thesis was to explore women's reactions to and experiences of fetal screening for Down's syndrome PS) by means of an ultrasound examination, including measurement of fetal nuchal translucency (NT). The effect of this screening on maternal worry about the baby's health was investigated, as well as reactions to a false positive test and interpretation of information about riskAlso, an instrument measuring worry during pregnancy, the Cambridge Worry Scale, was translated into Swedish and tested on a sample of pregnant women.A sub-sample of 2026 women was drawn from a larger randomised controlled trial including 39,572 women, which investigated medical outcomes of the new fetal screening policy. Of these women, 1030 were randomly allocated to the intervention group, and 996 to routine care. No statistically significant differences were found between the two groups regarding major worry about something being wrong with the baby, general anxiety and depressive symptoms m midpregnancy and two months postpartum.Twenty-four women who had received information about an increased risk according to NT were interviewed during pregnancy and after birth. Twenty of these women had false positive tests, and for 16 the risk was higher than expected considering their age. These women expressed major worry, and many said they chose to reject their pregnancy, to take "time out", while waiting for the results of fetal karyotyping. Two months after the birth, most of these women seemed to have overcome the stressful situation.In the intervention group of the above trial 796 women had a risk score for DS recorded in a clinical database. Of these women 620 said they had received information about the risk score, and 64 percent stated the figure almost correctly. The actual risk was associated with women's perception of the risk. Worry about the baby's health and depressive symptoms did not differ statistically between women who were at high risk (1:250 or higher) and at low risk. However, women who perceived that the risk was high were more worried about the baby's health and also seemed to have more depressive symptoms in mid-pregnancy compared with those who perceived the risk to be low. No differences were observed at two months after birth.The translated version of the Cambridge Worry Scale was tested on 200 Swedish pregnant women in Stockholm. The three main sources of worry were about the baby's health, giving birth and miscarriage. The internal- consistency reliability was 0.81 (Cronbach's alpha). Three items were added to the original scale to capture women's worry about the maternity services.In conclusion, the intervention with an early ultrasound examination including risk assessment for DS by measuring the NT did not affect maternal worry about the baby's health, general anxiety or depressive symptoms 'm mid-pregnancy or two months after birth. However, a false positive test could cause strong reactions of anxiety and rejection of the pregnancy for some weeks. Many had problems to recall and interpret a given risk score. An actual high risk score was not associated with major worry about the baby's health or depressive symptoms, whereas a woman's perception of being at high risk had such an association. The Swedish version of the Cambridge Worry Scale was considered to be useful and well suited for its purpose.
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8.
  • Gottvall, Maria, 1980- (författare)
  • Introduction of School-Based HPV Vaccination in Sweden : Knowledge and Attitudes among Youth, Parents, and Staff
  • 2014
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • The overall aim of this thesis is to provide a better understanding of knowledge, attitudes, consent, and decision-making regarding Human papillomavirus (HPV) vaccination, seen from the perspectives of concerned parties – high school students, school nurses, and parents.Two quantitative studies were performed: one descriptive cross-sectional study and one quasi-experimental intervention study. Qualitative studies using focus group interviews and individual interviews were also performed.High school students’ knowledge about HPV and HPV prevention was low but their attitudes toward HPV vaccination were positive. An educational intervention significantly increased the students’ knowledge regarding HPV and HPV prevention. Their already positive attitudes toward condom use and HPV vaccination remained unchanged. The students wanted to receive more information about HPV from school nurses. The school nurses were also positive to HPV vaccination but identified many challenges concerning e.g. priorities, obtaining informed consent, culture, and gender. They saw an ethical dilemma in conflicting values such as the child’s right to self-determination, the parents’ right to make autonomous choices on behalf of their children, and the nurse’s obligation to promote health. They were also unsure of how, what, and to whom information about HPV should be given. Parents, who had consented to vaccination of their young daughters, reasoned as follows: A vaccine recommended by the authorities is likely to be safe and effective, and the parents were willing to do what they could to decrease the risk of a serious disease for their daughter. Fear of unknown adverse events was overweighed by the benefits of vaccination. Parents also saw the school nurse as an important source of HPV information.Conclusions: Positive attitudes toward HPV vaccination despite limited knowledge about HPV, are overarching themes in this thesis. School nurses have a crucial role to inform about HPV prevention. It is important that the concerned parties are adequately informed about HPV and its preventive methods, so that they can make an informed decision about vaccination. A short school-based intervention can increase knowledge about HPV among students. From a public health perspective, high vaccination coverage is important as it can lead to a reduced number of HPV-related disease cases. 
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9.
  • Hallberg, David, 1978- (författare)
  • Lifelong learning : The social impact of digital villages as community resource centres on disadvantaged women
  • 2014
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • The overall aim of this research was to enhance the understanding of what affects the social impact of ICT in lifelong learning on disadvantaged women.In contributing to the field of social informatics, this research employs behavioural theories as strategy and analytic possibilities. This research mainly used the Kenyan digital villages as CRCs as settings but did also look beyond such establishments to provide a more solid picture. The studies were located in Kenya with complementary studies in Bolivia, Cameroon, Sri Lanka, and Sweden. The main strategies and methods used were case study, comparative education approaches, and observations and interviewing techniques.The findings suggest that ICT and CRCs have the potential to support disadvantaged women and their lifelong learning. However, the positive social impacts are limited because the arrangement of them generally does not favour vernacular languages, illiterate users, female owners and users, or non-students. In general, the use of ICT was sometimes perceived as forced, which is both a barrier and a stressor in the use of ICT in lifelong learning. It also emerged from the comparative studies that discussions among the participants in the CRCs largely covered issues in respect to 1) family and reproduction and 2) self-esteem, i.e. what settles the matter of the social impact of ICT in lifelong learning depends on change attitude among men and women. With minimal if not zero self-esteem a change that would make the difference or break a woman’s “legendary status quo” in order for a woman to feel that she can reach her goal or ambitions in lifelong learning would be difficult. Hence the lack of self-esteem is a stressor in itself.This research is valuable for stakeholders delving into issues of development and learning using ICTs, not only in Kenya but in a broader, global perspective.
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10.
  • Holmér Pettersson, Pia (författare)
  • Pain treatment after surgery : With special reference to patient-controlled analgesia, early extubation and the use of paracetamol
  • 2004
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • The introduction of general anaesthesia eliminated pain during surgical operations. After surgery, however, pain and postoperative nausea and vomiting (PONV) have remained a persistent problem for many patients. The need for analgesics varies widely among patients, therefore standardised treatment protocols are often insufficient pain treatment. Our studies dealt with the incidence and severity of pain and PONV after cardiac surgery. Study aims were to use and develop techniques for better evaluation of analgesic needs – visual analogue scale (VAS; 0 to 10) – and to develop a multimodal treatment of pain with opioids administered by the patients themselves – Patient Controlled Analgesia (PCA) – combined with paracetamol. In 48 patients, PCA was compared to conventional Nurse Controlled Analgesia (NCA) on the ward after coronary artery bypass surgery. PCA led to lower VAS-scores, i.e. less pain, with the use of more opioids. In 57 patients, pain after heart surgery was compared for extubation “early” at 3 hours or “late” at 7 hours after surgery. VAS-scores, PONV and the amount of opioids used were similar whether patients were extubated early or late. Rectal and intravenous (i.v.) administration of paracetamol was compared in 28 patients after heart surgery with respect to its bioavailability after repeated doses. Plasma concentrations after the first dose were low with rectal administration. After the fourth dose at 24 hours they reached a plateau. With i.v. administration concentrations were higher both after the first and fourth dose. Oral and i.v. paracetamol was compared in 80 patients after heart surgery and in 35 patients after day surgery (hernia repairs etc). After heart surgery the use of opioids was less in the i.v. group but VAS-scores and PONV were similar. A majority of the patients scored higher than 3 once or more than once on the 10 degree VAS-scale. In the oral group after day surgery, the plasma concentration increased in a dose-dependent manner but the scatter was wide and unpredictable as compared to the i.v. group. Conclusions: PCA is a promising alternative to NCA for adequate pain treatment in the wards after heart surgery and is “by itself” adjusted to the needs of the individual patient. There is no risk that early extubation after cardiac surgery is followed by more postoperative pain. Intravenous paracetamol seems to have an opioid-sparing potential after heart surgery. Our routines must be further developed and more studies are needed to find an optimal regimen, since pain treatment sometimes was insufficient in many patients receiving the combined therapy.
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