| 1. |
- Andersson, Jenny
(författare)
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Genusgörande och läkarblivande : attityder, föreställningar och förväntningar bland läkarstudenter i Sverige
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The inclusion of a gender perspective in medicine has shown that gender is an essential factor in health and disease, in medical encounters and also in medical students’ educational environment. The aim of this study was to explore attitudes, preconceptions and norms regarding gender within medical education and processes of gender bias. First, we explored medical students gendered beliefs about patients. Second, we examined the medical students ideas about their future careers. Third, we compared awareness on gender issues among medical students in Sweden and the Netherlands.Method and materialThe analyses were based on data from two different sources: one experimental study based on authentic patient narratives about being diagnosed with cancer and one extensive questionaire exploring different aspects of gender issues in medical education. Both studies had a design which enabled both qualitative and quantitative research and mixed methods was used.Study I (Paper I and II): Eighty-one anonymous letters from patients were read by 130 students of medicine and psychology. For each letter the students were asked to state the patient’s sex and explain their choice. In paper I the students’ success rates were analysed statistically and the explanations to four letters were used to illustrate the students’ reasoning. Paper II examined the 87 medical students’ explanations closer to examine gender beliefs about patients.Study II (Paper III and IV): The questionaire started with an open question where medical students were asked to describe their ideal future, it also included a validated scale designed to estimate gender awareness. Paper III examined 507 swedish medical students descriptions about their ideal future and compared answers from male and female students in the beginning and at the end of medical school. Paper IV compared gender awareness among 1096 Swedish and Dutch medical students in first term.Findings with reflectionsPaper I showed that the patient’s sex was correctly identified in 62% of the cases. There were no difference between the results of male and female students. However, large differences between letters were observed, i.e. there were some letters were almost all students correctly identified the patient´s sex, others were almost all students were incorrect and most letters were found somewhere in the middle. Another significant finding was that the same expressions were interpreted differently depending on which initial guess the medical student had made regarding the sex of the patient.Paper II identified 21 categories of justifications within the students’ explanations, twelve of which were significantly associated with an assumption of either a male or female patient. Only three categories led to more correct identifications of the patients’ sex and two were more often associated with incorrect assignments. The results illustrate how beliefs about gender difference, even though they might be recognizable on a group level, are not applicable on individuals. Furthermore, the results show that medical students enter the education with beliefs about male and female patients, which could have consequenses and cause bias in their future work as doctors.Paper III found that almost all students, both male and female, were work-oriented. However, the female students even more so than their male counterparts. This result is particularly interesting in regards to the debate about the “feminization of medicine” in which the increasing number of female students has been adressed as a problem. When reflecting on their own lifes and their future its obvious that medical students nowadays, male and female, expect more to life than work, especially those who are on the doorstep to their professional life.Paper IV found that the national and cultural setting was the most crucial impact factor in relation to the medical students preconceptions and awareness about gender. The Swedish students expressed less stereotypic thinking about patients and doctors, while the Dutch students were more sensitive to gender difference. In both countries, the students’ sex mattered for gender stereotyping, with male students agreeing more to stereotypes.ConclusionsA gender perspective is important in medical education. Our studies show that such initiatives needs to take cultural aspects, gender attitudes and students’ gender into account. Moreover, reflections on assumptions about men and women, patients as well as doctors, need to be included in medical curricula and the impact of implicit gender beliefs needs to be included in discussions on gender bias in health care. Also, the next generation of doctors want more to life than work. Future Swedish doctors, both female and male, intend to balance work not only with a family but also with leisure. This attitudinal change towards their future work as doctors will provide the health care system with a challenge to establish more adaptive and flexible work conditions.
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| 2. |
- Ackesjö, Helena, 1973-
(författare)
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Barns övergångar till och från förskoleklass : Gränser, identiteter och (dis-)kontinuiteter
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this study is to gain knowledge of how the transitions to and from preschool class are described and understood by children. Previous research has indicated that transitions between different school forms can be seen as both problematic and threatening. Transitions should be facilitated and "smooth", something that indicates that continuity is important. Of interest for this study is to gain knowledge of children's perspective of continuities: which continuities and discontinuities children express intransitions.Transitions are theoretically considered as social processes that are constructed, shared and reconstructed together with others. In these processes, children mark and construct borders through speech and action. Their border markings (for example, expression of differences and/or similarities between different communities and between different school forms) also become part of a child's identity constructions.The thesis is based upon the research described in three articles. The empirical data underlying these studies was constructed in a longitudinal ethnographic inspired field work where children have been observed in two transitions between three different school forms: preschool, preschool class and compulsory school.Results suggest that from children’s perspectives the transitions between different school forms contain challenges, opportunities, limitations, changes and preservation. However, the transitions also involve expressions concerning security, risk-taking and include visual markings between the different school forms.One of the conclusions that can be drawn from this work is that it isn’t enough to turn to policy level, such as curricula or even teachers’ aims or aspirations to facilitate these transitions. The child’s perspectives need to be taken into account. Through children's narratives, we have gained knowledge about the opportunities transitions can offer, but also how transitions can be considered as threats or be difficult to interpret for children. This study has also increased our understanding of the importance of continuity as well as discontinuity to mark borders between different school forms.
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| 3. |
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| 4. |
- Andersson, Helene
(författare)
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MRSA and other resistant bacteria : prevalence, patient and staff experiences, wounds and infection control
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Antibiotic resistance has become a major and serious global problem in healthcare. Limited treatment options for infections caused by these organisms can lead to increased morbidity and mortality. Sweden has a low prevalence of antibiotic resistance compared to most other countries but this presents an increasing problem for society and healthcare even in Sweden. The overall aim of this thesis was to illuminate potential problems related to antibiotic resistance from different perspectives: assessing the prevalence of resistant bacteria methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) or other resistant bacteria, and associated wound types, patient and health staff experiences when confronted with resistant bacteria infection, and the occurrence of such infections in the nursing home environment. In the first study a total of 2172 patients admitted to hospital or as out-patient visit at a University hospital during one day were examined with the purpose to identify all wounds, wound types and wound characteristics, and to identify bacteria in all wounds, particularly MRSA, VRE and multi-resistant Gramnegative rods. Four hundred and eight (19%) patients had a total of 668 wounds. Of these, 248 wounds, from 216 patients were cultured. Two unknown MRSA-patients were identified. No patient with VRE was found and there was a low prevalence of other multi-resistant bacteria. In the second study fifteen patients with MRSA infected wounds were interviewed. The aim was to ascertain and describe patients’ knowledge, perceptions and experiences of being MRSA-positive. The interviews were analyzed according to qualitative content analysis. From the analysis three categories and one overall theme were identified. Results showed that information about the MRSA diagnosis often caused a shock-like reaction. The patients’ perception of being MRSA-positive was that it was stigmatizing like the plague or leprosy; they felt dirty and a severe threat to their environment. Fears of infecting someone else and being rejected were commonly expressed. Knowledge and empathy from staff involved in their care was crucial to optimise patients’ experiences. Staff’s needs of education to meet patients’ demands for information, and to prevent spread of antibiotic contamination was essential. In the third study eight nurses and seven assistant nurses from different hospital wards and nursing homes were interviewed regarding their experiences of caring for MRSA-positive patients. Qualitative content analysis was carried out when analysing the data and three themes were identified during the process. Stress and too high workload were factors which were described to cause concerns in the caring situation. A major concern was that nurses felt at risk of becoming infected themselves and then transmitting the infection to other patients and to family members. Knowledge and ignorance about MRSA affected the nurses’ caring; ignorance made them afraid and insecure while knowledge and understanding shaped confidence in their role as caregivers. In the fourth study 560 residents in a total of 67 wards, in nine nursing homes were investigated for prevalence of MRSA, VRE and extended-spectrum β-lactamase (ESBL) - producing Enterobacteriaceae and if carriage of resistant bacteria was related to antibiotic treatment, other risk factors and/or staff´s adherence to guidelines for infection control. In all 296 staff members were interviewed and observed. No resident was positive for MRSA or VRE. Fifteen residents were found to be ESBL-positive. Usage of antibiotics was higher in wards where ESBL-positive residents were detected and there was an indication that there was transmission of ESBL between residents. Staff´s adherence to infection control guidelines sometimes revealed shortcomings but no significant difference regarding adherence to the guidelines could be found. In conclusion: Prevalence of MRSA appears low in both hospitalized patients, out-patients and nursing home residents. Adherence to infection control guidelines among healthcare staff, however, needs further improvement. MRSA colonized patients experienced psychological pressure and stigmatization. Knowledge and empathy from staff involved in their care is crucial to optimise patients’ experiences. Staff education to meet patients' demands for information and the prevention of contamination is essential
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| 6. |
- Danielsson, Ulla EB, 1947-
(författare)
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Träffad av blixten eller långsam kvävning : genuskodade uttryck för depression i en primärvårdskontext
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Depression is a common mental health problem in primary health care. One third of the Swedish population is expected to experience depression at some point in their lives. The understanding of depression has expanded, both from a lay and primary health care perspective. The number of persons considering themselves as depressed, receiving the diagnosis, and getting treatment for it has increased steadily over the last decades. Unchanged, however, is that depression is diagnosed twice as often in women as in men, while twice as many men as women commit suicide. These gender differences appear in adolescence. In earlier research biomedical, psychological, and social-cultural explanations of gender differences have been discussed. Patient’s own perspectives have more seldom stood in focus, and men’s narratives in particular are still scarce. In this thesis, gender, i.e. how to be a woman or a man, is considered as a construct, formed and negotiated in social interaction. The aim of the study is to explore the gendered face of depression from a patient perspective: How is depression expressed and explained by patients in primary health care, by women and men, adults and adolescents? How are depressed women and men portrayed in the media? How do patient and media accounts of depression compare with the perspective offered in medical research articles? Method and material The analyses are based on data from three different sources: patient narratives, newspaper portrayals and scientific medical articles. – 37 in-depth interviews were undertaken with primary health care patients diagnosed with depression. Informants were chosen to include both men and women, grown-ups (Studies I + II) and young adults (Study V) of varying occupational and social class backgrounds. Data were analyzed according to grounded theory. – 26 articles portraying lay informants with depression (Study III) were drawn from three major Swedish daily newspapers by a search of database Mediearkivet 2002. The articles were analyzed by qualitative content analysis. –82 scientific articles concerning depression in relation to gender were identified in a PubMed search 2002. The understanding of depression in these articles was explored and compared with findings in the grown-up patient narratives and in the media portrayals by means of discourse analysis (Study IV). Findings Study I captured women’s and men’s formulations of their experiences of depression. To be marked with demands constituted a central experience for both women and men, but the outward manifestations differed in relation to gender as well as to class. Home and work had different priority. Men talked more about physical distress (often chest pain) than about emotions. Women readily verbalized emotional distress – shame and guilt – while physical symptoms were vague and secondary (often about the stomach). Men dealt with insecurity by aggrandizing their previous competence, women by self-effacement. Study II disclosed gendered trajectories into depression. Four symbolic illness narratives were identified: struck by lightning, nagging darkness, blackout and slowly suffocating. Most of the men considered their bodies suddenly “struck” by external circumstances beyond their control. The stories of women in the study were more diverse, reflecting all four illness narratives. However, the women had a tendency to blame their own personality and to describe depression as insidious and originating from the inside. The women expressed feelings of guilt and shame but also conveyed a personal responsibility and concern with relationships. Study III identified four themes in media portrayals of depression: displaying a successful facade, experiencing a cracking facade, losing and regaining control and explaining the illness. The mediated image of depression both upheld and challenged traditional gender stereotypes. The women’s stories were more detailed, relational, emotionally oriented and embodied. The portrayal of men was less emotional and expressive, and described a more dramatic onset of depression. Study IV revealed gaps in how depression in relation to gender is understood by the patients, the media, and the medical research establishment. There were differences in recognition, in understanding of the reasons, and in contextualization of depression. Although women and men described different symptoms and reasons for falling ill, in scientific articles these gendered differences were conceptualized mainly in terms of hormones and other biological markers. Study V elucidated the impact of gender on adolescent depression. The young women and men were all striving to be normal, influenced by demanding media images, confronted by identity trouble, and overwhelmed by feelings. They had dreams of an ordinary family and described normative expectations. Getting a safety net of friends and other adults was a way out. Both the young women and men were eager to communicate their distress when given the opportunity. This seemed especially important to some of the young men, who in talking about their emotional problems transgressed gender norms. Conclusions Patient perspectives enrich the understanding of gendered expressions of depression by making visible transgressions of and breaks with stereotype gender norms. Gender awareness is an important key in clinical consultation. To recognize gendered narratives of illness might have a salutary potential, making depression more visible among men, and relieving self-blame among women. By re-evaluating restrictive gender patterns, the clinician might encourage development of healthier practices of how to be a man or a woman, a development especially important for adolescents. An integrated model for understanding biological, gender and cultural aspects of depression has yet to be developed. As general practitioners we have a unique possibility to see and to study the whole individual in her social and cultural context.
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| 7. |
- Fhärm, Eva, 1955-
(författare)
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Treatment of cardiovascular risk factors in type 2 diabetes : time trends and clinical practice
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives Patients with type 2 diabetes are at much greater risk of developing cardiovascular diseases (CVD), including coronary heart disease (CHD), compared to non-diabetics. The lowering of glucose, blood pressure, and plasma lipid levels has been shown to reduce CHD risk, and treatment goals for these risk factors are now part of clinical practice guidelines. However, the incidence and outcome of CHD in diabetic patients does not show the same favourable trend as in the general population. Thus, the overall aim of the thesis was to investigate how the treatment goals for CVD risk factors contained in the national guidelines for diabetes care were reflected in clinical practice, and to explore factors that might influence the remaining high incidence of CHD in the type 2 diabetes population. Research designs and results I. The effectiveness of the introduction of treatment goals for dyslipidaemia was evaluated in a retrospective observational population-based cross-sectional study of 971 diabetic patients participating in the Västerbotten Intervention Programme (VIP) 1995–2004. There was a stronger trend of decrease in cholesterol levels among patients with diabetes compared to the non-diabetic population in 2000–2004. Increased use of lipid-lowering agents influenced the trend in diabetic patients, even though only 25.3% received lipid-lowering treatment after the introduction of the new guidelines. II. The experiences of general practitioners relating to treatment practice for type 2 diabetes with specific focus on the prevention of cardiovascular disease were explored in a focus group study. The overall theme was ‘dilemmas’ in GPs’ treatment practice for patients with type 2 diabetes. Five main dilemma categories were identified. First, GPs were hesitant about labelling a person who feels healthy as ill. Second, as regards communicating a diabetes diagnosis and its consequences, GPs were unsure as to whether patients should be frightened or comforted. Third, GPs experienced uncertainty in their role: should they take responsibility for the care or not? Fourth, GPs expressed concern over a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties when attempting to translate science into reality. III. Screening for microvascular and coronary heart disease according to national guidelines was evaluated in a cross-sectional study of 201 screening-detected patients with type 2 diabetes 1.5±0.7 years after diagnosis. A larger proportion of diabetic patients was screened for nephropathy and retinopathy than for CHD. Twenty-three percent of the patients had minor or major ECG abnormalities, but ECG findings seemed to have little or no impact on CHD prevention using lipid-lowering medication and ASA. A clinical history of CHD correlated with a larger proportion of patients receiving secondary prevention. IV. Time trends relating to the achievement of treatment goals and 10-year CHD risk at three years of diabetes duration were studied in 19,382 patients with type 2 diabetes without CHD, who were reported by primary health care sources in the National Diabetes Register in 2003–2008. National treatment goals for glycaemia, blood pressure, total cholesterol, and LDL cholesterol were achieved in 78.4%, 65.5%, 55.6%, and 61.0%, respectively, of the diabetic patients in 2008 following a trend of improved results in 2003–2008. Absolute 10-year risk of CHD increased between year of diagnosis and follow up in a studied subgroup while modifiable risk decreased. Conclusions The introduction of treatment goals for dyslipidemia in Swedish national guidelines in 1999 were reflected in lowered cholesterol levels in people with type 2 diabetes. Since the introduction of the guidelines, an increasing number of diabetic patients are treated in accordance with guidelines. A remaining microvascular focus on the patients together with the revealed dilemmas within the GP’s consultation with diabetic patients might negatively influence the remaining high incidence of CHD in the type 2 diabetes population. Lipid levels, blood pressure and smoking are targets for further improvements.
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| 8. |
- Halvars-Franzén, Bodil, 1959-
(författare)
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Barn och etik : möten och möjlighetsvillkor i två förskoleklassers vardag
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim is to examine how children create and embody ethics by analyzing their encounters and how possibilities are conditioned by the framework surrounding them. The focus has been on the following problem areas: Conditions that enable children’s ethical encounters with regard to frameworks, rules and order Conditions that enable children’s ethical encounters related to the teachers’ approach Children’s encounters in play from an ethical perspective Children’s encounters with nature from an ethical perspective The theoretical standpoint is ”the ethics of an encounter” from Emmanuel Levinas’ idea of ethics of alterity. In ethics which precedes being itself, the ethical becoming and its relational aspects appear in the encounter with the Other. The tools of analysis are mainly drawn from previous pedagogical/didactical research in ethics which highlights the ethical conditions, such as listening, encounters with diversity and differences, and preschool/school as an ethical space. The study is based on one year of ethnographical field studies relying on participant observations, video observations, focus groups, stimulated recalls and guided tours. The empirical findings show that rules and frameworks which regulate the everyday life of the preschool classes are repeatedly negotiated. The negotiations about “what’s what?”, where both the children and the teachers are involved, take place on a verbal and a bodily level. In the pedagogues’ approach, the listening is a central and complex condition for the ethical space in the preschool classes. In the children’s encounters in play and in their encounters with nature the relational aspect becomes clear. The ethical boundaries and the fixing of those boundaries are discussed in connection with the idea of the ethics of an encounter and the vision of preschool/school as a potential ethical space.
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| 9. |
- Nilsson, Sofia, 1975-
(författare)
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Civil and Military Leadership Processes in Situations of Extreme Environmental Demands
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of the studies included in this thesis has been to develop the knowledge about civil and military leadership processes and the conditions for these in situations characterized by extreme environmental demands. The main part of the thesis is based upon empirical data gathered through semi-structured qualitative interviews with Swedish civil and military leaders. The studies, published in four articles, focused leadership during situations characterized by extreme environmental demands. The fourth article aimed at validating the theoretical model that was developed in study one. The thesis has pursued an integrated view in seeking to understand leadership and environment interactions during the conduct of international humanitarian aid and military peacekeeping operations. Hence it has been a matter of considering the individual leader in relation to the organisational and the external environment in order to study human adaption to meet the challenges and demands of disasters and conflicts. The results show that leadership during international humanitarian aid and military peacekeeping operations is a highly complex and demanding task. Premises for the processes involve a great number of environmental factors. In order to restore system balance within a larger system, there has to be congruence between individual appraisal of the organizational and the external environment to achieve successful task completion. Inconsistency among the environmental factors influencing leadership processes may evoke adaptional struggles characterized by both positive and negative stress responses that may affect performance and task completion. Reappraisal processes are shown to involve continuous assimilation processes of, and accommodation processes to, the environment, illustrating the shifting balances between environmental forces, organizational pressures, and individual initiative. The findings on stress responses are in line with earlier research, demonstrating that stress reactions exhibit great similarities regardless of hierarchical level while also indicating a double-edged pattern concerning the overall development of stress reactions. However, it does seems that hierarchical differences exist with regard to moral stress, while moral stress appears to lack the double-edged pattern since no positive reactions are reported even at moderate levels of stress impact. Taken together, future civil and military leaders need education in complex person-environment interactions in order to get a holistic picture of the underlying mechanisms, thus promoting the development of their adaptive capabilities. It is suggested that this thesis can be regarded as a context-specific contribution to complex system theory by providing insight into the organizational and external environmental factors/demands that influence civil and military leadership.
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| 10. |
- Nordqvist, Petra
(författare)
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Exploring the Wood Adhesive Performance of Wheat Gluten
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The increasing environmental concern has reawakened an interest in materials based on renewable resources as replacement for petroleum-based materials. The main objective of this thesis was to explore plant proteins, more specifically wheat gluten, as a binder in wood adhesives intended for typical solid wood applications such as furniture and flooring. Alkaline and acidic dispersions of wheat gluten were used as wood adhesives to bond together beech wood substrates. Soy protein isolate was used as a reference. The tensile shear strengths of the substrates were measured for comparison of bond strength and resistance to cold water. AFM in colloidal probe mode was used to investigate nanoscale adhesion between cellulose and protein films. Wheat gluten was divided into the two protein classes; glutenins and gliadins, and their adhesive performance was compared with that of wheat gluten. Heat treatment and mild hydrolysis were investigated as means for improving bonding performance of wheat gluten. The treated wheat gluten samples were analysed by SE-HPLC and 13C-NMR to correlate molecular size distribution and structural changes with bonding performance. Soy protein isolate is superior to wheat gluten, especially in regards to water resistance. However, the bond strength of wheat gluten is improved when starved bond lines are avoided. The AFM analysis reveals higher interfacial adhesion between soy protein isolate and cellulose than between wheat gluten and cellulose. These results partly explain some of the differences in bonding performance between the plant proteins. Soy protein isolate contains more polar amino acid residues than wheat gluten and possibly interacts more strongly with cellulose. Furthermore, the bond performances of wheat gluten and glutenin are similar, while that of gliadin is inferior to the others, especially regarding water resistance. The extent of penetration of the dispersions into the wood material has a large impact on the results. The bonding performance of gliadin is similar to the others when over-penetration of the dispersion into the wood material is avoided. Moreover, the bond strength of the wheat gluten samples heated at 90°C was in general improved compared to that of wheat gluten. A small improvement was also obtained for some of the hydrolyzed wheat gluten samples (degree of hydrolysis: 0-0.6 %). The improvements in bonding performance for the heat treated samples are due to polymerization, while the improvements for the hydrolyzed samples are due to denaturation. The 13C-NMR analysis of the treated samples confirms some degree of denaturation.
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