| 1. |
- Gremyr, Andreas
(author)
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Improving health with and for individuals with schizophrenia using a learning health system approach : From idea to daily practice
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Psychotic disorders like schizophrenia have a typical onset in early adulthood with symptoms of hallucinations and disturbances of thought. Despite knowledge on what constitutes effective schizophrenia care, more than 70% of treatment attempts fail in Sweden, sometimes leading to early death. An appraisal of schizophrenia care shows a lack of ways to jointly plan and evaluate care, and an absence of a trustworthy theory-of-change. The Learning Health System (LHS) is a vision that has been translated into theories and models associated with improved outcomes for patients with other chronic conditions. The aim of this thesis is to enhance the understanding of the applicability of the LHS vision in the context of schizophrenia care, from the perspectives of both individuals and the health system in enabling coproduction of better health by addressing two research questions:i) How can improvement of health for individuals with schizophrenia and improvement of system performance be supported by coproduction in an LHS model?ii) Can an LHS-based intervention, i.e. the use of a point of care dashboard, contribute to better health for individuals with schizophrenia?Studying the existing published knowledge of LHS show that the concept has not yet been applied in mental healthcare settings but has potential to increase patient coproduction, continuous improvement and better health. Different forms of coproduction are supported in the most comprehensive LHS models and applications, ranging from dashboards at point of care to platforms that can help facilitate improvement initiatives.A case study, focused on studying the use and usefulness of a point-of-care dashboard at patient visits in outpatient care at the Department of Schizophrenia Spectrum Disorders at Sahlgrenska University Hospital in western Sweden. Use of the dashboard is associated with improved communication and health for patients. Assessment of the dashboard-project’s complexity using the Non-adoption, abandonment, scale-up, spread and sustainability complexity assessment tool (NASSS-CAT) was perceived as helpful in evaluating challenges and provided insight that can guide future development. An LHS model, that builds on both the reviewing of the literature and practical testing, is proposed.Further research is proposed in two areas, exploration of how dashboard initiatives can support coproduction and better health for individuals with complex chronic conditions and further development of LHS models by studying different LHS initiatives regarding system properties, forms of coproduction at play and effects on health outcomes for individuals and populations.
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| 2. |
- Petersson, Christina
(author)
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Using health-related quality of life instruments for children with long-term conditions : On the basis of a national quality registry system
- 2016
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Doctoral thesis (other academic/artistic)abstract
- Introduction: There has been a continuous development of new technologies in healthcare that are derived from national quality registries. However, this innovation needs to be translated into the workflow of healthcare delivery, to enable children with long-term conditions to get the best support possible to manage their health during everyday life. Since children living with long-term conditions experience different interference levels in their lives, healthcare professionals need to assess the impact of care on children’s day-to-day lives, as a complement to biomedical assessments.Aim: The overall aim of this thesis was to explore and describe the use of instruments about health-related quality of life (HRQOL) in outpatient care for children with long-term conditions on the basis of a national quality registry system.Methods: The research was conducted by using comparative, cross-sectional and explorative designs and data collection was performed by using different methods. The questionnaire DISABKIDS Chronic Generic Measure -37 was used as well as semi-structured interviews and video-recordings from consultations. Altogether, 156 children (8–18 years) and nine healthcare professionals participated in the studies. Children with Type 1 Diabetes (T1D) (n 131) answered the questionnaire DISABKIDS and children with rheumatic diseases, kidney diseases and T1D (n 25) were interviewed after their consultation at the outpatient clinic after the web-DISABKIDS had been used. In total, nine healthcare professionals used the HRQOL instrument as an assessment tool during the encounters which was video-recorded (n 21). Quantitative deductive content analysis was used to describe content in different HRQOL instruments. Statistical inference was used to analyse results from DISABKIDS and qualitative content analysis was used to analyse the interviews and video-recordings.Results: The findings showed that based on a biopsychosocial perspective, both generic and disease-specific instruments should be used to gain a comprehensive evaluation of the child’s HRQOL. The DISABKIDS instrument is applicable when describing different aspects of health concerning children with T1D. When DISABKIDS was used in the encounters, children expressed positive experiences about sharing their results with the healthcare professional. It was discovered that different approaches led to different outcomes for the child when the healthcare professionals were using DISABKIDS during the encounter. When an instructing approach is used, the child’s ability to learn more about their health and how to improve their health is limited. When an inviting or engaging approach is used by the professional, the child may become more involved during the conversations.Conclusions: It could be argued that instruments of HRQOL could be used as a complement to biomedical variables, to promote a biopsychosocial perspective on the child’s health. According to the children in this thesis, feedback on their results after answering to web-DISABKIDS is important, which implies that healthcare professionals need to prioritize time for discussions about results from HRQOL instruments in the encounters. If healthcare professionals involve the child in the discussion of the results of the HRQOL, misinterpreted answers could be corrected during the conversation. Concurrently, this claims that healthcare professionals invite and engage the child.
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| 3. |
- Stevenson, Katherine
(author)
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Doing better, together : The intersection between quality improvement and interprofessional collaborative practice in health professions education
- 2024
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Doctoral thesis (other academic/artistic)abstract
- This thesis investigated the intersection of quality improvement (QI) and interprofessional collaborative practice (ICP) in the context of health professions education. The overall aim of the thesis was to explore the potential synergies between QI education and ICP education and to develop a framework that supports a system’s approach to QI and ICP integration for health professional learners’ education.Using a convergent parallel mixed methods approach, where the results of all the individual studies are synthesized in interpretation, the thesis is made up of one quantitative intervention study and three qualitative case studies. The intervention study analysed changes to self-reflection about interprofessional teams before and after participating in a QI activity. The qualitative studies used a mix of one-on-one interviews, stimulated recall interviews, document analysis, and a focus group.The first study found significant increases in reflection scores in a majority of the 16 items measured, indicating that a quality improvement-focused learning activity in an ICP setting can support development of ICP related knowledge, attitudes, and beliefs. The second and third study reported on faculty perspectives about what should be taught in an integrated QI-ICP curriculum, in the form of competency domains, and how it should be taught in terms of curriculum design. The fourth study offered key insights into how program transformation in higher education can be better enabled in practice, using the integration of a QI-ICP curriculum as the case, while also suggesting refinements to a complex adaptive systems-based change management framework.The findings of the four studies were synthesized through the lens of micro-meso-macro system perspectives and points of convergence and divergence were noted in order to develop a more complete picture of QI-ICP integration in health professions education. The results include a framework of design principles to support faculty to integrate QI and ICP education, whether working on curricular innovations in their own classroom, working on an interconnected program of learning, or attempting curricular transformation at the scale of the macrosystem.
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| 4. |
- Ekelund, Maria, 1970-
(author)
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Psoriasis and Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis (JIA) : A Longitudinal Study of the Nordic JIA Cohort
- 2020
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Licentiate thesis (other academic/artistic)abstract
- Juvenile idiopathic arthritis, JIA, is used as an umbrella term covering a heterogeneous group of chronic arthritis forms in children, many of which have important differences compared to adult arthritis, while others possibly represent similar diseases among children and adults. Classification aims to give a better understanding of the pathogenesis, patterns, disease trajectories and treatment responses. For the juvenile psoriatic arthritis, JPsA, the classification criteria are currently being debated. The distribution of affected joints in JIA differs greatly and it is unknown why some joints appear to be more affected than others. The temporomandibular joint (TMJ) can be affected early in the course of the disease and often the symptoms are mild and without obvious swelling.This thesis has its origin in the Nordic Study Group of Paediatric Rheumatology and the population-based prospective study of 510 children with newly diagnosed JIA included between 1997 and 1999. Totally 440 children were included in the eight-year follow-up, and in the TMJ study 265 patients were examined and underwent cone-beam computed tomography, CBCT, 17 years after onset.After eight years a considerable proportion of the children with definite psoriasis were classified as undifferentiated JIA based on the exclusion criteria in the ILAR classification. Our data also presents the heterogenicity of JPsA and the development over time of clinical variables supporting a psoriatic diathesis, as well as the overlap between JPsA and enthesitis-related arthritis in a group of patients. We found that extensive symptoms and dysfunctions of the TMJ are seen in JIA 17 years after disease onset, even in patients registered with inactive disease or remission. Individuals with substantial condylar damage on CBCT were found in all JIA categories. The deeper understanding of a chronic disease over time is crucial for research initiatives to improve care as well as for clinical decisions and planning of the health care.Our findings suggest a need for a more appropriate classification of JPsA and also that aspects of TMJ involvement should be included in the general health assessment in JIA.
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| 5. |
- Engstrom, Maria
(author)
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BarnSäkert : Studies of the Safe Environment for Every Kid model in the Swedish Child Health Services for early identification of psychosocial risk factors in the home environment of young children
- 2023
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Doctoral thesis (other academic/artistic)abstract
- Psychosocial risk factors in the home environment may impair children’s health and development and increase the risk of child maltreatment. The Swedish child health services (CHS), provide health-promoting and primary preventive services for all children 0-6 years of age. However, the national CHS lack evidence-based tools to universally screen for the most common psychosocial risk factors. The Safe Environment for Every Kid (SEEK) model provides a method for identifying children who live in families with economic worries, depressive symptoms, parental stress, intimate partner violence (IPV) and alcohol misuse in order to offer relevant support and assistance to the family. The overarching aim of this thesis was to assess validity, clinical utility and outcomes of the Safe Environment for Every Kid model when applied in the Swedish Child Health Services setting. The SEEK model has been tested in a cluster randomized controlled trial within the CHS in the county of Dalarna. Studies I and II examined CHS nurses’ perception of their routine assessment of psychosocial risk factors in the family environment as well as their self-reported competence and the present organizational conditions in this context. Both studies used the same mixed method design, including surveys and focus group interviews. Study II analyzed the experiences of CHS nurses using the SEEK model in contrast to those using current standard practice. CHS nurses had extensive experience in dealing with the targeted risk factors, but using the SEEK model strengthened their sense of competence in identifying and responding to the needs of families with such problems. Using the SEEK model seems to have narrowed the gap between the nurses’ perception that it is both important and suitable to address psychosocial risk factors within the CHS and their previously limited ability to do so. Study III evaluated the psychometric properties of the Swedish version of the Parent Screening Questionnaire (PSQ-S) using data from surveys answered by parents (n=611). The PSQ-S was compared to standardized instruments for the targeted psychosocial risk factors. The PSQ-S showed a sensitivity of 93%, specificity of 52% and a positive and negative predictive values of 67% and 87%, respectively. Study IV examined the self-reported rates of the targeted risk factors among parents who completed the PSQ-S at age-specific CHS visits during the intervention period. A total of 7483 PSQ-S were analysed. Over half of the PSQ-S had a positive screen for at least one risk factor. The problems were common throughout the child’s first five years of life and were about as common among mothers and fathers. The proportion of PSQ-S with a positive screen decreased significantly from the beginning to the end of the intervention.The results suggest that the SEEK model, as applied in these studies, shows a high degree of validity and clinical utility in the CHS setting. The experience of SEEK nurses showed that the model was helpful in their daily work. There is room for improvement with respect to sensitivity regarding IPV and how the nurses address parents with alcohol misuse. Many parents were willing to disclose the targeted risk factors in the context of the CHS visits and use of the SEEK model likely provided opportunities for assistance that may otherwise have been missed.
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| 6. |
- Thörne, Karin, 1957-
(author)
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Läkare, lärande och interaktion i hälso-och sjukvårdspraktiker
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Bakgrund: Komplexiteten i hälso- och sjukvården blir kontinuerligt större, liksom möjligheterna till diagnostik och behandling. Samtidigt pressas hälso- och sjukvården av förändringar i demografier och sjukdomspanoraman, olika uttryck för globalisering och tillämpning av nya teknologier. Ett omfattande antal olika professioner förväntas genomföra och utveckla det dagliga arbetet med ännu mer involvering av patienter. Vi behöver mer kunskap om hur lärande sker och hur det underlättas och utvecklas i dagligt hälso- och sjukvårdsarbete för att kunna möta förändringar och utmaningar. Syfte: Avhandlingens övergripande syfte är att fördjupa kunskap och förståelse om pedagogiska processer och lärande i hälso- och sjukvårdspraktiker, med särskilt fokus på läkare. Metoder: Intervjustudier och fältstudie med interaktiv forskningsansats gav data med både bredd och djup från autentiskt hälso- och sjukvårdsarbete. I pågående hälso- och sjukvårdsarbete studerades läkare, vårdgivare i andra professioner, patienter, redskap som användes och praktikens rumsliga utformning. Data analyserades genom både kulturella och sociomateriella praktikteoretiska linser, vilket möjliggjorde att flera dimensioner av lärande och interaktion i hälso- och sjukvårdspraktiker kunde spåras. Fynd: I arbetet med patienter agerade läkare och andra professioner pedagogiskt med eller utan intentioner, i pedagogiska processer som bestod av att avläsa-färdrikta-lärstödja. Den pedagogiska dimensionen av arbetet var inte synliggjord eller diskuterad i relation till patientarbetet. Dynamiskt inbäddat i arbetet lärde och stöttade läkare också yngre läkares och andra vårdgivares lärande. Läkarnas mobilitet i olika vårdsammanhang, såväl som ansvarsfördelning och delande av olika perspektiv, hade betydelse för vilket lärande som uppstod. Genom att betrakta specifika vårdsammanhang som hälso- och sjukvårdspraktiker under utövning, framträdde vid studiet av en rondmodell både samskapande lärande ronder och operativa ronder med begränsat lärande. Det framträdde genom sättet som deltagande personer, rumsliga och materiella förhållande samspelade på, som ömsesidigt utbyte respektive separata individuella arbetsprocesser. Samspelet mellan hälso- och sjukvårdspraktikers arrangemang (praktikarkitekturer) och genomförande snarare begränsade än underlättade underläkares lärandepraktiker. Underläkarnas arbete hade inte kontinuitet, koherens eller progression för att bredden av kunnande i medicinsk praktiskt arbete skulle kunna utvecklas bra. Implikationer: Att förstå och synliggöra lärande i hälso- och sjukvårdens dagliga arbete genom att gemensamt prata om pedagogiska dimensioner i det arbete som pågår, kan utveckla lärande och lärstödjande ageranden. Samskapande lärande hälso- och sjukvårdspraktiker där alla deltagande gruppers behov och uppdrag medräknas, har implikationer på underläkares kompetensutveckling, studenters lärande, patienters involvering i sin vård och interprofessionellt och interdisciplinärt samarbete. Det ger också ledare möjlighet att knyta arbete med förbättringar av vårdens kvalitetet och säkerhet till dagligt vårdarbete.
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| 7. |
- Wallby, Thomas, 1956-
(author)
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Lika för alla? : Social position och etnicitet som determinanter för amning, föräldrars rökvanor och kontakter med BVC
- 2012
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Doctoral thesis (other academic/artistic)abstract
- Child Health Services (CHS) in Sweden are offered free of charge to all Swedish parents with children 0-5 years of age. The regular service schedule includes home visits, health examinations, vaccinations and participation in parenting groups. The CHS should pay extra attention to disadvantaged families. The aim of this thesis was to investigate to what extent the CHS reaches groups of families with special needs, e.g. immigrant families, low income families, young and single mothers, with universal or selective measures, as well as to investigate the variation of two determinants of child health, second hand smoke and breastfeeding, in these groups of families. The thesis also aimed at investigating validity of data in the county CHS quality database (Basta). The thesis is based on data from Basta together with several national registers. The CHS equally reached all families with infants with the universal program except for participation in parenting group. Foreign born, young, single and low-income mothers had lower participation rates. Smoking rates were lower in foreign-born than in Swedish-born mothers and higher for foreign-born than in Swedish-born fathers. Smoking was more common among single and low income parents and young mothers. Young and single mothers had lower breastfeeding rates at 6 months. At 12 months the breastfeeding rates were higher among foreign-born mothers. The validity test of data in the Basta database showed sensitivity values for immunizations, breastfeeding and smoking at 90-100 % and for any home visit, participation in parenting group at any time, a minimum number of 6 visits at the Child Health Centre (CHC) and a minimum number of 11 visits at the CHC at 88 - 96 %. The sensitivity value for the exact match of number of CHC visits (+/- 3 visits) was 88 %. Conclusions: The universal programme was equally distributed in different immigrant and socio-demographic populations. However, the results did not indicate equality according to the assumption that some families need more input than others in order to achieve equity of outcome. Individual data routinely collected from CHS records to a quality database provides data of good quality that can be used for both quality surveillance and research.
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| 8. |
- Carlsson, Noomi
(author)
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A Zero-vision for Children’s Tobacco Smoke Exposure : Tobacco prevention in Child Health Care
- 2012
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Doctoral thesis (other academic/artistic)abstract
- Adverse health effects in children caused by environmental tobacco smoke (ETS) are well known. Children are primarily exposed by their parents’ smoking in their homes. A comprehensive evidence base shows that parental smoking during pregnancy and ETS exposure in early childhood are associated with an increased risk for a range of adverse health problems. Child Health Care nurses, who meet nearly all families in Sweden with children aged 0-6 years, have thus an important role in tobacco preventive work in order to support parents in their ambitions to protect their children from ETS exposure.The overall aim of this thesis was to develop, test and evaluate a new model for tobacco preventive work in Child Health Care (CHC) with special focus on areas with a high prevalence of parental smoking. In a first step CHC nurses’ and parents’ views on tobacco preventive work were analysed in two studies based on questionnaires.The intervention was performed during the second step, based on the results from nurses’ and parents’ experience of the tobacco preventive work in CHC, and with methods from Quality Improvement. An “intervention bundle” was developed which included evidence based methods for prevention of ETS exposure, and four learning sessions for the nurses. The instrument “Smoking in Children’s Environment Test” (SiCET) included in the bundle was evaluated with focus group interviews with the CHC nurses who participated in the intervention. Two urine samples were analysed to measure cotinine levels in children which provide an estimate for ETS exposure. Parents’ answers from the SiCET questionnaire, measurements of cotinine, and data from the nurses’ log-books were used in the evaluation of the effects of the intervention. In areas with a high prevalence of parental smoking 22 nurses recruited 86 families of whom 72 took part for the entire one-year period of the intervention.The results showed that parents wanted to have information on the harmful effects tobacco smoke have on their children and how they can protect their children from ETS exposure. The nurses saw tobacco preventive work as important but they experienced difficulties to reach certain groups such as fathers, foreign-born parents, and those who are socio-economically disadvantaged. The SiCET instrument provided a basis for dialogue with parents. The main results from the intervention showed that ten parents (11%) quit smoking, thirty-two families (44%) decreased their cigarette consumption in the home, and fewer children were exposed to tobacco smoke. Consequently, more children showed levels of urinary cotinine less than 6 ng/ml (base-line n=43, follow up n=54; p=0.05). The total number of outdoor smokers did not change. Seven of the nurses (30%) had successful results in their areas with a decrease of smokers in families with a child of 8 months, from 20% in 2009 to 12% in 2011. The corresponding figures for the whole county as well as the country did not decrease during the same period.The sustainability of the intervention has to be followed and thus measures should be followed prospectively over time. The SiCET instrument was found useful and might be applicable in other arenas where children’s ETS exposure is discussed. The development of an instant cotinine test using dipsticks would make it possible to give parents immediate feedback on the effectiveness of taken protective actions. This could work as a pedagogic resource in the dialogue with parents.
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| 9. |
- Dannapfel, Petra, 1978-
(author)
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Evidence-Based Practice in Practice : Exploring Conditions for Using Research in Physiotherapy
- 2015
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Doctoral thesis (other academic/artistic)abstract
- Research developments have led to increased opportunities for the use of improved diagnostic and treatment methods in physiotherapy and other areas of health care. The emergence of the evidence-based practice (EBP) movement has led to higher expectations for a more research-informed health care practice that integrates the best available research evidence with clinical experience and patient priorities and values. Physiotherapy research has grown exponentially, contributing to an increased interest in achieving a more evidence-based physiotherapy practice. However, implementation research has identified many individual and contextual barriers to research use. Strategies to achieve a more EBP tend to narrowly target individual practitioners to influence their knowledge, skills and attitudes concerning research use. However, there is an emerging recognition that contextual conditions such as leadership and culture are critical to successfully implementing EBP.Against this background, the overall aim of this thesis was to explore conditions at different levels, from the individual level to the organizational level and beyond, for the use of research and implementation of an evidence-based physiotherapy practice. The thesis consists of four interrelated papers that address various aspects of the aim. Individual and focus group interviews were conducted with physiotherapists and managers within physiotherapy in various county councils in Sweden between 2011 and 2014. Data were analysed using qualitative content analysis, direct content analysis and hermeneutics.It was found that many different types of motivation underlie physiotherapists’ use of research in their clinical practice, from amotivation (i.e. a lack of intention to engage in research use) to intrinsic motivation (research use is perceived as interesting and satisfying in itself). Most physiotherapists tend to view research use in favourable terms. Physiotherapists’ participation in a research project can yield many individual learning experiences that might contribute to a more research-informed physiotherapy practice. However, organizational learning was more limited. Numerous conditions at different levels (individual, workplace and extra-organizational levels) provide support for physiotherapists’ use of research in their clinical practice. However, physiotherapy leaders appear to contribute to a modest degree to establishing a culture that is conducive to implementing EBP in physiotherapy practice. Instead, EBP issues largely seem to depend on committed individual physiotherapists who keep to up to date with research in physiotherapy and inform colleagues about the latest research findings.
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| 10. |
- Fröding, Elin
(author)
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Patient safety and suicide : learning in theory and practice from investigations of suicide as patient harm
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Suicide is a global public health challenge, around 700 000 people die from suicide every year. A large proportion was in contact with healthcare close in time before death, suggesting healthcare to be an important resource in the work with prevention of suicide.The overall aim of this thesis was to increase the knowledge and understanding of suicide as an incident of patient harm, and to find possibilities of changes in the approach to suicide investigations which could contribute to increased learning and improve suicide prevention in healthcare.Four studies were performed: in the first two studies we reviewed investigations of healthcare performed of suicide cases reported to the supervisory authority as patient harm. Study III was a scoping narrative literature review of the problems with the current approaches to investigations of suicide as patient harm and possible changes for improvement. Study IV was an interview study in which I explored the requirements for valuable investigations of suicide from the views of persons with lived experience of suicidality and professionals. All studies were performed in a Swedish context.The majority of suicides reported as incidents of patient harm were reported by a psychiatry healthcare provider. Most suicides occurred shortly after the last contact with healthcare and during outpatient care. Demographically, these cases were representative compared to the suicide cases in the entire population.As incidents of patient harm, suicides differ from most other kinds of reported patient harm in some ways. Only a small proportion occurs in hospitals, most occur in the home of the patient without any witnesses or staff around. Suicide is an act performed by the patient himself/herself and is usually the final outcome of the complex interplay of several different variables with different impacts in different contexts, varying over time and between individuals.It was found that the adaptation of the investigations to the requirements of the supervisory authority contributed to the fact that the learning from the healthcare’s investigations of suicide has levelled off, the same shortcomings and actions were reported over time. The investigations were performed with a strict healthcare provider perspective, with focus on the last contact with the patient, routines, and what went wrong. This resulted in suggested measures for improvement at an organizational micro level without organizational sustainability over time and with a risk to not address organizational system deficiencies.The investigations of suicide as potential patient harm should integrate current knowledge in suicidology and patient safety to enable learning and insights valuable for healthcare improvement. This include a holistic perspective of the patient’s situation, analysis of a longer time period and factors of importance for suicidality, suicide prevention, and patient safety, professionalization of the investigations, analyses across organizational boundaries, and focus on learning. A framework to guide this analysis is suggested in this thesis.The development of knowledge in the science fields of patient safety and suicidology imply the need for a cultural shift in the understanding of suicide as an incident of patient harm. Instead of making a difficult and often to some extent speculative assessment if a suicide had been prevented if other actions had been performed in the contacts with healthcare, and therefore should be investigated and reported as a severe patient harm, or not, the focus in the analyses should be on risk management over time. I propose a framework with factors of importance for a safe healthcare at suicidality to guide this analysis.
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