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- Barman, Linda, 1972-
(author)
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Striving for Autonomy : Health sciences teachers’ enactment of policy
- 2015
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Doctoral thesis (other academic/artistic)abstract
- Abstract This thesis explores how teachers within the health sciences enact education policy. The questions address how teachers’ choices related to the design of courses and curricula are made in the light of reforms that emphasise standardisation and transparency. Employing a hermeneutical framework teachers’ enactment were regarded as a meaning-making process shown through reason and action. In line with the interpretative approach, the two research projects were performed with qualitative methods. The first research project (study I and II) concerned how teachers’ understood and carried out changes in course design related to the implementation of outcome-based education and the European Bologna Process. For that purpose, course material and interview data was analysed. The second research project (study III and IV), was conducted to deepen the understanding of findings from the first project. A group of teachers who conducted major changes related to previous reform was chosen and studied with a narrative approach when they engaged in the development of teaching and learning. In particular, the teachers’ development of assessment criteria of students’ clinical competencies was studied over one year. A body of literature report on how teachers conceptualise teaching and learning. Based on those studies there has been an emphasis on supporting teachers’ shift in views regarding teaching and learning. Related to recent reforms in higher education, it is however suggested that teachers are less free to decide upon educational matters, and hence individual teachers’ deepened understanding are not enough for development of practice to occur. The findings in this thesis suggest that wide interpretations of education policy in combination with pedagogical knowledge may benefit educational development in practice. Teachers were found to approach outcome-based education when introduced as policy in four different ways, with outcome blind, technocratic, pragmatic or ideological approach. These approaches were related to student-centred learning to more or less extent, and to greater or lesser autonomy in the decision-making related to course design. The studies showed how teachers’ experience a tension between bureaucratic demands and what is emphasised through teaching and learning theory. For some teachers this meant that theoretical constructs were applied in instrumental ways and that pedagogy equated the bureaucratic and rational standards involved in quality control. The findings suggest however, that learning and development can be promoted through education policy but that teachers’ local practices should be supported.
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- Grundberg, Åke
(author)
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Mental health promotion among community-dwelling seniors with multimorbidity : perspectives of seniors, district nurses and home care assistants
- 2015
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Doctoral thesis (other academic/artistic)abstract
- The prevalence of mental illness is increasing among the older population in Sweden. One of the most vulnerable groups for mental health problems is older persons with multimorbidity, i.e. seniors with multiple chronic conditions. Many of them remain in their own homes with a comprehensive and complex need of support and healthcare, mainly provided by home care assistants (HCAs) and district nurses (DNs). However, the detection of mental health problems for adequate treatment or to promote mental health among community-dwelling seniors with multimorbidity, calls for skills and competences in this area.This thesis aimed to gain a deeper understanding of how mental health may be promoted among community-dwelling seniors with multiple chronic conditions. Four studies have been included in this thesis (I-IV). All studies had a qualitative descriptive design with either a phenomenographic approach or latent and manifest qualitative content analysis technique. The aim of study I was to describe the variations in how community-dwelling seniors with multimorbidity perceived the concept of mental health and what may influence it. The findings showed the participants conceptualised mental health as having both positive and negative facets. The participants further conceived that social contact, physical activity and optimism may improve mental health, while social isolation, ageing, and chronic pain may worsen it. Study II aimed to describe the experience of health-promoting dialogues from the perspective of community-dwelling seniors with multimorbidity, and what these seniors believed to be important for achieving a dialogue that may promote their mental health. The main finding was the necessity of being seen as a unique individual by an accessible and competent person. Further, the participants missed having friends and relatives to talk to and they especially lacked healthcare or social service providers for health-promoting dialogues that may promote mental health. The aim of study III was to describe DNs’ perspectives on detecting mental health problems and promoting mental health among community-dwelling seniors with multimorbidity. Findings revealed that the DNs’ focus was on assessment, collaboration and social support as a way of detecting mental health problems and promoting mental health. Study IV described HCAs’ perspectives on detecting mental health problems and promoting mental health among the seniors in focus. The findings revealed that continuity of care and the seniors’ own thoughts and perceptions were regarded as essential for the detection of mental health problems. Further, observation, collaboration, and social support emerged as important means of detecting mental health problems and promoting mental health.Conclusions: The results of this thesis are based on interviews and show that: 1) Seniors with multimorbidity should have an opportunity to describe how multiple chronic conditions may affect their life situation; 2) An optimal level of care can be achieved through continuity, involvement, and by providing a health-promoting dialogue based on the person’s wishes and needs; 3) Even if DNs seemed engaged in primary mental healthcare, there were no expressed goals set in the improvement of mental health, and it seemed that these DNs could not bear the primary responsibility for early detection of mental health problems and early interventions to improve mental health; 4) HCAs had knowledge about risk factors for mental health problems and it appears that they were dependent on care managers’ decision-making in granted support, as well as supervision from DNs in the detection of mental health problems and to promote mental health.In summary, the finding in the present thesis demonstrates that managing mental health problems is still an ongoing challenge for those organisations providing continuity in home care and home healthcare for homebound elderly persons with complex chronic conditions. The finding in the thesis also shows that DNs and HCAs seem to be dependent on each other in this area. Mental health promotion was expressed as an important assignment among DNs and HCAs, even though they describe different prerequisites and factors which could be seen as barriers in the detection of common mental health problems such as depression, anxiety and sleep problems. These personnel further described difficulties in collaboration and transmission of information between care- and healthcare providers from the community and primary care context. Social and physical interventions - as well as social contacts and social support to break social isolation - seemed important according to all the informants, with their different perspectives of how mental health may be promoted.
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- Nilsen, Charlotta
(author)
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Do psychosocial working conditions contribute to healthy and active aging? studies of mortality, late-life health, and leisure
- 2017
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Doctoral thesis (other academic/artistic)abstract
- The growing demographic challenge posed by an aging population makes finding predictors of health in old age increasingly important. This thesis investigated long-term associations between midlife psychosocial working conditions and late-life health and leisure and examined whether sense of coherence in midlife modified the association between psychosocial working conditions and all-cause mortality. The studies were based on individually linked data from the Swedish Cause of Death Register and two Swedish longitudinal surveys, the Level of Living Survey (LNU) and the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD).The results of Study I and Study II suggest that self-reported adverse psychosocial working conditions in late midlife, especially low job control, high strain, or passive jobs, were associated with complex health problems and limitations in physical functioning 20-24 years later. However, women and men seemed to be vulnerable to different self-reported psychosocial working conditions. High job strain (high psychological demands and low control) was more negative for women than men. Passive jobs (low psychological demands and low control) were negative for men but not for women.The results of Study III suggest that a weak sense of coherence magnified the association between occupation-based (measured with a job exposure matrix) high job strain in midlife and mortality in women and men and self-reported passive jobs in midlife and mortality in men.The results of Study IV suggest that occupation-based active jobs (high psychological demands and high control) in midlife were associated with physical, social, and intellectual/cultural activity 23 years later in women and men.In summary, the results underscore the importance of psychosocial working conditions in midlife for health, physical functioning, and leisure activity after retirement²and thus for healthy and active aging. It is therefore important to reduce stress at work but at the same time induce intellectual stimulation and personal growth. Moreover, it is important to find ways to strengthen sense of coherence in midlife to buffer the negative influence of adverse psychosocial working conditions on health. Investing in healthy workplaces and strengthening sense of coherence to improve the health of workers may reduce societal costs during working age. It may also lower the cost of health and social care by improving the health of the older population. Hence, it would be a double-win investment for society.
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- Sjölund, Britt-Marie
(author)
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Physical functioning in old age : temporal trends and geographical variation in Sweden
- 2014
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Doctoral thesis (other academic/artistic)abstract
- ADL disability is an age-related condition that leads to poor quality of life, increased health-related care costs, and increased mortality. The proportion of older adults are increasing worldwide, and it is therefore important both for society and the individual that research provide us with information about the process leading to ADL disability and how to identify persons at risk. The most effective design for following the aging process is found in population-based studies that include all older persons, both those living at home and those in residential care. This thesis uses data from three populationbased studies: the Kungsholmen Project (KP), the Nordanstig Project (NP) and the SNAC-N study. The aims of the thesis was to examine temporal changes in physical functioning in older adults, to identify underlying development of new disability and functional decline, as well as to explore geographical variation in physical functioning between urban and rural elderly habitats. We also wanted to describe the amount of informal and formal care in relation to levels of ADL disability. The ultimate aim was to identify factors suitable for prevention. Study I: We I compared two populations of older adults, 75 years and older (the KP and the NP) from different living areas (urban and rural) and found differences in ADL disability, morbidity and disease patterns. The most common health problem in both areas was cardiovascular diseases (39.9% in the urban area and 45.2% in the rural area). There were great differences, urban vs rural, in the prevalence of stroke (7.4% vs 14.0%), diabetes mellitus (6.3% vs 16.1%), and Parkinson’s disease (1.0% vs 3.7%). Having two or more diseases vs. no disease was more common in the rural area than in the urban area, odds ratio (OR) = 1.9, 95% confidence interval (CI) = 1.4-2.4. Living area differences (urban vs rural) were found in population attributable risk (PAR) for disability due to stroke (5.6 vs 32.2), diabetes mellitus (1.2 vs 6.1), fractures (1.4 vs 10.7), and hearing impairment (8.7 vs 22.0). Study II: Data were gathered from a population-based study of adults 60 years and older, the SNAC-Nordanstig (SNAC-N), and the study explored the association between ADL disability, muscle strength, disease severity and mortality. Upper and lower muscle strength decreased with increasing age, with a tendency for lower performance in women than in men. A significant association was found between ADL disability and having reduced lower muscle strength. Having an increased number of diseases increased the risk of being ADL disabled. Diseases with the greatest impact on ADL disability were musculoskeletal diseases, hypertension and dementia. ADL disability and being unable to perform the gait speed test were factors that increased the risk of death. Inability to perform the chair stand test or weaker grip strength increased the risk of death for men. Study III: Data from two populations, 78 years and older, the NP (1995-1998) and the SNAC-N study (2001-2003), were used to study time trends in the prevalence of ADL disability and survival, comparing two cohorts. The prevalence of ADL disability was stable from 1995-1998 to 2001-2002 for men, while women became more disabled in ADL over the time period, (OR 2.36; CI 1.12-4.94). No significant difference was found in survival time between the cohorts in either ADL-disabled or non-disabled persons. There was a tendency for increased survival for non-disabled persons in the SNAC-N study compared with the NP, although it was not significant; this was particularly true for women. In general, women survived longer than men did regardless of whether they were ADL disabled or not. Study IV: The aims were to examine the incidence of ADL disability, to explore whether being physically active earlier in life is a significant predictor of being disability free at follow-up, and to describe the amount of informal and formal care received in relation to ADL disability. Data were gathered from persons 78 years and older in the SNAC-N study. The incidence rates for men were almost the same in the age group 78-81 compared with the age group 84 years and older, 42.3 vs. 42.5/1000 person-years. For women the incidence rate for ADL disability increased significantly from the age group 78-81 to the age group 84 years and older, 20.8 vs. 118.3/1000 person-years. In the age group 78-81 years, being physically active earlier (aOR 6.2) and during the past 12 months before the baseline examination (aOR 2.9) were both significant preventive factors for ADL disability. The amount of both informal and formal care increased with the number of ADL activities the persons were dependent on and the amount of informal care was greater than the amount of formal care. Conclusions: This thesis shows an increase in ADL disability due to increased age, and that women are more ADL disabled than men, but also shows how diseases affect ADL disability. The diseases that negatively affect ADL are often due to unhealthy lifestyle, e.g. physical inactivity, obesity and smoking, etc. The results show the importance of prevention of the factors that cause ADL disability, preferably already in midlife. The amount of both informal and formal care increased significantly with the number of ADL activities the persons required help with. Regarding prevention of becoming ADL disabled, it is of importance to find ways to postpone the onset of ADL disability so that we can live longer without disability.
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- Akselsson, Anna
(author)
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Awareness of fetal movements and pregnancy outcomes
- 2020
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Doctoral thesis (other academic/artistic)abstract
- Fetal movements are one, among others, of the measurable factors indicating wellbeing of the fetus. Decreased fetal movements are associated with intrauterine growth restriction and stillbirth. Women with experience of stillbirth have often noticed decreased and weaker fetal movements preceding the intrauterine death. Further, seeking care for decreased fetal movements is a common reason for unscheduled contact with health care. The aim of this thesis was to investigate whether a method, aimed to increase women’s awareness of the fetal movement pattern, had an effect on pregnancy outcomes. Further, the thesis aimed to study pregnancy outcomes for women seeking care for decreased or altered fetal movements.In Study I, 2683 women completed questionnaires when they presented for decreased fetal movements, after an examination of their unborn baby, that did not result in any interventions aimed at ending the pregnancy. In Studies II–IV, we evaluated Mindfetalness, a method aimed to increase women’s awareness of the fetal movement pattern. Women were given a leaflet of how to practise Mindfetalness in third trimester: lie down on your side when the baby is awake and focus on the strength, character and frequency of the movements for about 15 minutes daily (but do not count each movement). Women’s attitudes to and compliance with Mindfetalness were investigated in Study II, comprising 104 women. In studies III-IV we studied the effect of Mindfetalness on pregnancy outcomes and, through cluster-randomisation, 19 639 women in Stockholm were randomised to Mindfetalness and 20 226 to routine care. Study IV comprised a sub-analysis, where we compared women born in Somalia and Sweden.Women in the Mindfetalness group (Study III) had spontaneous onset of labour to a higher extent (RR 1.02, CI 1.01–1.03), less cesarean sections (RR 0.95, CI 0.91–0.99) and labour inductions (RR 0.96, CI 0.92–1.00), than women in the Routine-care group. More women in the Mindfetalness group contacted healthcare due to decreased fetal movements (RR 1.72, CI 1.57–1.87). A decreased number of babies born small for gestational age (RR 0.95, CI 0.90–1.00) and those transferred to neonatal care (RR 0.93, CI 0.86–1.00) was seen in the Mindfetalness group. No differences were found in Apgar score <7 at 5 minutes. Women born in Somalia had a higher risk of Apgar score <7 at 5 minutes (RR 2.17, CI 1.19–3.61) and of having a baby small for gestational age (RR 2.19, CI 1.85–2.56), than women born in Sweden (Study IV). The majority of the women had a positive attitude towards Mindfetalness and practised the method daily (Study II). Women contacting healthcare due to decreased fetal movements had labour induction to a higher extent than women not seeking care due to decreased fetal movements (Study I).Increased maternal awareness of fetal movements by Mindfetalness in the third trimester is advantageous for mother and baby. Spontaneous start of labour increased and interventions, notably cesarean sections, decreased. Fewer babies were born small for gestational age and in need of neonatal care. Women expressed having positive attitudes to the method and feelings of safety and calm, when they practised Mindfetalness.
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- Amsberg, Susanne
(author)
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Health Promotion in Diabetes Care : Studies on Adult Type 1 Diabetes Patients
- 2008
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Doctoral thesis (other academic/artistic)abstract
- Introduction: A landmark report has shown that improving glycaemic control among type 1 diabetes patients markedly reduces diabetes-related complications. In clinical practice, however, many patients have problems in adhering to the treatment, and thus remain in poor glycaemic control. Research suggests a more behaviour-oriented approach to diabetes, but there is a lack of evidence on the efficacy of interventions, especially for those adult type 1 diabetes patients who are in poor glycaemic control. Diabetes-related distress has been associated with poor adherence to treatment and poor glycaemic control. There is a need for validated measures in this area, to identify patients who experience diabetes-related distress. Additionally, injection technique is crucial for the management of diabetes, and lipohypertrophy is a common side effect which deserves further attention.Objectives: The overall aim of this thesis was to evaluate a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients, and to gain a deeper knowledge in an area of diabetes self-management.Methods: Quantitative design was used for the studies, and the clinical settings comprised two diabetes care units in Stockholm, Sweden. Study I: The Swedish version of the Problem Areas in Diabetes (Swe-PAID-20) scale was evaluated regarding its psychometric properties by type 1 diabetes patients, as well as by an expert panel of diabetes specialist nurses. Study II: A behavioural medicine intervention based on Cognitive Behaviour Therapy (CBT) was evaluated in a randomised controlled trial among poorly controlled adult type 1 diabetes patients. Study III: Using the same sample as in study II, descriptive statistics were produced, and predictive and comparative analyses performed, in order to find predictors of or associations with improvements in glycaemic control as a response to the intervention. Study IV: In a randomised crossover trial insulin absorption in lipohypertrophic injection sites was investigated in type 1 diabetes patients.Results and conclusions: Study I: A three-factor solution of the scale was found, comprising sub-dimensions of diabetes-related emotional problems, treatment-related problems and support-related problems. Cronbach’s alpha for the total score was 0.94 and varied between 0.61 and 0.94 in the three subscales. The findings also supported the convergent and content validity. The Swe-PAID-20 seems to be a reliable and valid outcome for measuring diabetes-related distress in type 1 diabetes patients. Study II: Significant differences were observed with respect to HbA1c, well-being, diabetes-related distress, frequency of blood glucose testing, fear of hypoglycaemia, perceived stress, and depression, all of which improved more in the intervention group compared with the control group. The CBT based behavioural medicine intervention appears to be a promising approach to diabetes self-management. Study III: The participation rate in the study was 41% and attrition was 24%. Of those patients who actually participated in the intervention, 13% withdrew. From the regression models no predictors or associations were found with regard to improvement in HbA1c. The programme proved to be feasible in terms of design and methods. However, no clear pattern was found regarding predictors of or associations with improved metabolic control. Study IV: Impairment of insulin absorption from lipohypertrophic injection sites was also found with analogue insulins. It is suggested that patients should be advised to refrain from injecting insulin aspart into lipohypertrophic subcutaneous tissue.
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- Anderbro, Therese
(author)
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Behavior change intervention and fear of hypoglycemia in type 1 diabetes
- 2012
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Doctoral thesis (other academic/artistic)abstract
- Introduction: Individuals with type 1 diabetes require lifelong insulin supply as well as behavioral adjustments for good treatment result. Only a minority reach the goal for glycemic control set in order to reduce the risk of severe long-term complications. Interventions based on cognitive behavior therapy (CBT) have been proposed to improve diabetes-management, but evidence for its efficacy in adults with poorly controlled type 1 diabetes is sparse. One common barrier to optimal diabetes-management is fear of hypoglycemia (FOH), especially in those who have experienced severe hypoglycemic episodes. Thus there is a need for a valid and reliable instrument to assess individuals who are affected by FOH. It is also vital to identify factors associated with FOH in order to find targets for interventions to reduce fear.Aim: The overall aims of this thesis were to evaluate a CBT intervention for poorly controlled individuals with type 1 diabetes and to explore fear of hypoglycemia in an effort to gain deeper knowledge of possible targets for interventions to reduce FOH.Methods: All four studies applied quantitative designs. Study I was a randomized controlled trial in which a cognitive behavioral intervention was evaluated on poorly controlled adult persons with type 1 diabetes. Study II was a psychometric evaluation of a Swedish version of the Hypoglycemia Fear Survey (HFS) in a survey study in adult persons with type 1 diabetes. Studies III and IV were cross-sectional survey studies employed on adults with type 1 diabetes exploring disease-specific, demographic, (studies III and IV) emotional and psychosocial factors (study IV) related to FOH.Results and conclusions: Study I: The intervention group receiving CBT showed significant improvements in HbA1c, diabetes related distress, well-being, FOH, perceived stress, anxiety and depression as well as frequency in self monitoring of blood glucose. Study II: A three- factor solution was found for the Swedish version of the HFS with the dimensions Worry, Behavior and Aloneness. Cronbach’s alpha for the total scale was 0.85 and varied between 0.63 – 0.89 in the subscales. Convergent validity was also supported with moderate correlation between Swe-HFS and Swe-PAID-20. The Swe-HFS seems to be a reliable and valid instrument to measure FOH in adults with type 1 diabetes. Study III: Seven hundred and sixty- four persons (55%) responded to the questionnaire. The HFS-Worry subscale was significantly associated with frequency of severe hypoglycemia, number of symptoms during mild hypoglycemia, gender, hypoglycemic symptoms during hyperglycemia and hypoglycemic unawareness. The HFS-Aloneness subscale was significantly associated with frequency of severe hypoglycemia, number of symptoms during mild hypoglycemia, gender, frequency of mild hypoglycemia, HbA1c, hypoglycaemic unawareness and visits to the emergency room because of severe hypoglycemia. FOH proved to be more prevalent in females. Frequency of severe hypoglycemia was identified as the most important factor associated with FOH. Study IV: A total of 469 (61%) persons responded to the questionnaire. The HFS was significantly associated with The Anxiety Sensitivity Index, the Anxiety subscale of Hospital Anxiety and Depression Scale and Social Phobia Scale. Together with the disease-specific factors the regression model explained 39% of the variance. Support for a positive association between FOH and anxiety was present and previously identified gender differences were confirmed. Differences between the subgroups on factors associated with FOH were found that may have implications in developing interventions
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| 10. |
- Andersson, Eva A
(author)
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EMG and strength in trunk and hip muscles
- 1997
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Doctoral thesis (other academic/artistic)abstract
- The overall aim of this thesis was to study the myouelectric activity of all major muscles involved in the movements and stabilization of the trunk, pelvis and hips during training exercises, postures, motor tasks, maximal strength performance and locomotion. By use of ultra-sound, EMG electrodes could be guided safely and accurately into muscles situated even close to the spinal column, such as psoas, quadratus lumborum and deep parts of erector spinae. A task specific variation in activation levels were seen between muscle synergies, as well as between individual muscles within a synergy. Selective engagement of the abdominal muscles could be achieved in trunk flexion sit-ups, that is lifting only the upper trunk from the floor. An even higher activation of abdominal muscles was needed for static stabilization of the trunk and pelvis during hip flexion sit-ups, whereas single leg lifts were performed without involvement of the abdominal muscles. A selective activation of either the iliacus or psoas muscle was observed, for example in certain types of training exercises and in walking and running. Applying bending moments to the spine, resulted in a grading of the muscle activation response according to mechanical advantage, that is highest in the quadratus lumborum in lateral loading and in the superficial erector spinae in ventral loading. An exception was the most forward flexed position in standing where the superficial erector spinae "relaxed" but quadratus lumborum remained active. In general, the level of EMG in maximal efforts was maintained at the same high level irrespective of position in the range of motion, despite a marked variation in strength output. This position-dependency, as well as the strength values as such, varied in a specific way in groups of athletes, related to previous background. These data contribute to the understanding of muscle function and motor control of the trunk , pelvis and hips. They are also of relevance when evaluating and designing tests and training programs in rehabilitation and sport contexts as well as for improving biomechanical models of spinal loading.
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