Browsing Doctoral Theses /HS by Issue Date

Daily activities among persons with developmental disabilities. Asses...
Dychawy-Rosner, Irena : Studentlitteratur (2003)	DOCTORAL THESIS

The recontextualisation of social pedagogy : a study of three curricu...
Hallstedt, Pelle; Högström, Mats : Malmö högskola, Lärarutbildningen Malmö Studies in Educational Sciences;21 (2005)	DOCTORAL THESIS

English abstract:

The purpose of this thesis is to describe, analyse, and compare the recontextualisation of social pedagogy in three different curricula; in Nijmegen (NL), Lillehammer (N), and Sligo (IRL). The curricula represent different academic orientations and are located in different social-political contexts. The recontextualisation of social pedagogy, the concept derived from the works of Basil Bernstein, indicates the transformation of social pedagogical actions into an educational context. The material consists of texts: syllabuses, study guides, timetables, assignments, practice placements lists, interviews: teachers, administrators, students, and observations: lectures, placement supervision. The outcome of the recontextualisation is firstly analysed with the use of concepts from Bernstein’s code theory: classification and framing, integrated and collection code, and pedagogic discourse. Secondly the analysis of the recontextualisation is compared to a provisional definition based on the contemporary discourse of social pedagogy. The Nijmegen curriculum is characterised by an integrated code with weak classification between subjects. The framing between lecturers and students as well as between theory and practice is strong. The curriculum emphasises the fostering of strong students with artistic skills as a fundemantal resource. Clients are in some sections presented as commensurable and in other as fundamentally different from the social educational worker. The Lillehammer curriculum is characterised by a collection code that turns into an integrated code in later sections of the programme. The degree of academicalisation is high and it has a strong emphasis on scientifically derived methods in social educational work. The classification between college and work field is weak, framing between lecturers is weak but strong between lecturers and students. The two strands stress different client conceptions; child welfare workers and clients are presented as being on the same level, whereas the asymmetry between welfare nurses and clients evident. The Sligo curriculum has an academic orientation. The programme is built on a collection code; strong classification between subjects. The framing is strong between lecturers, lecturers and students, as well as between the college and the work field. A caring relationship between worker and client is a central goal. As a consequence the relationship between worker and client is presented as rather asymmetric. Ethics and therapy-based reflections on the relationship are central. The fundamentals of the respective national social-political context can be detected in all the three curricula. There is an apparent congruency between curriculum and social-political context.

Hallstedt_Hoegstroem_manus.pdf (946.0Kb)

Searching for the meaning of support in Nursing. A study on support i...
Stoltz, Peter : Malmö University, Faculty of Health and Society Malmö University Health and Society Dissertations;2 (2006)	DOCTORAL THESIS

English abstract:	Family carers perform a large amount of the help and assistance that are provided for Swedish frail aged persons who live with one or more chronical illnesses. Consequently, in addition to balancing the Swedish national welfare expenditures, family carers also contribute to the care for older persons in many ways. Parallel to the above, an increased interest for family carers situation can be discerned from research as well as from political decisions. Within these interests, the word support is recurrently used both nationally and internationally. However support for family carers may prove to be a more complex endeavour than it appears. Although there are research in support for family carers, the concept of support remains complex and difficult to conceptualize. It is not unreasonable to assume that the word support can shift meaning across areas where it is used. In nursing, support is highlighted in situations where family carers care for a frail aged person at home. Support is likely to continue to be of importance in these situations as there are no indications of at-home family caring decreasing. To date, there have been little research into understanding the concept of support in nursing. Therefore, support should be further researched in order to be assigned a fruitful and useful meaning. From the general ongoing debate in Sweden on family carers it is easy to conclude that support is “something” that family carers should have or be given. However, it is not as easy to discern who should support family carers, or what the support should entail. As the focus on care for frail aged persons continuously moves towards peoples own homes, it is plausible that nurses will continue to play an important role between informal and formal care provision. Nurses can be expected to be one important group of healthcare professionals that are expected to provide support for family carers even in the future. Proceeding from the above description, this thesis was undertaken with the overall aim to describe, illuminate and understand meanings of support within the nursing context of family care for frail aged persons, as disclosed by family carers, registered nurses and scientific literature. In order to be able to understand meanings of support, it was decided to proceed with the empirical studies in this thesis using a palliative care context. This decision was based on the assumption that the palliative care context would be appropriate for describing meanings of support. Through the four papers underpinning this thesis, the concept of support and its meaning have been studied from differing viewpoints assisted by differing research methodologies. Family carers have narrated on the meaning of support and registered nurses have narrated on the meaning of being supportive. Moreover, the scientific literature was thoroughly searched, synthesized and conceptually analyzed in order to describe, explain and understand the concept of support. The findings from this thesis showed that support in nursing entails two essential dimensions. They were labelled the “tangible dimension” and the “intangible dimension”. The tangible dimension overarchingly represent different services, goods, equipment, information and/or education that, on a general level, can be provided for family carers. The intangible dimension overarchingly is about the quality of the relationship between the family carer and the support provider person. The intangible dimension can be further understood through relationship qualities such as trust, confidence and/or friendship. It moves at a more individual and adaptive level than the general tangible dimension. However, it portantly appears that these two dimensions do not stand in opposition to each other as a dichotonomy. Instead, these two dimensions appear to be co-dependents and essentials for support to gain meaning in nursing.
Swedish abstract:	Anhörigas insatser utgör en stor del av den hjälp och assistans som ges till Sveriges hemmaboende äldre personer som lever med en eller flera kroniska sjukdomar. Anhöriga bidrar också till den nationella välfärden genom att balansera hälso- och sjukvårdens kostnader. Det kan skönjas ett ökande intresse inom forskning så väl som i politiska beslut för anhöriga som vårdare. Stöd till anhöriga som vårdar tycks vara ett mycket aktuellt begrepp inom flera intresseområden, både i Sverige och internationellt. Men stöd till dessa anhöriga kan bli ett mer komplext uppdrag än vad det initialt ger sken av. Trots att det finns forskning om stöd för anhöriga, kan begreppet ändå anses komplicerat och vara svårt att föreställa sig innebörden av. Ordet stöd är gammalt och har fornsvenskt ursprung. Den engelska motsvarigheten support är inte heller nytt. Vad som är anmärkningsvärt och intressant är istället i vilket sammanhang ordet används. Idag används det bland annat inom IT branschen, militären, juridiken, konsten, arkitekturen, medicinen och omvårdnaden. Inom omvårdnad och omvårdnadsforskning blir begreppet stöd särskilt aktuellt i de situationer då en anhörig vårdar en äldre närstående i hemmet. Antalet sådana situationer förväntas inte minska i framtiden och begreppet stöd kommer därför att fortsätta vara aktuellt. För att ge stöd, förbättra stödet och lära nya sjuksköterskor stödja, måste begreppet förtydligas, eftersom det idag finns väldigt lite forskning om begreppet inom omvårdnad. Från den allmänna debatten i Sverige angående anhörigstöd kan slutsatsen dras att stödet bör finnas. Det är emellertid inte lika självklart vem det är som ska stödja eller vilket innehåll stödet bör ha. Allteftersom fokus för vården av äldre flyttas mot vård i hemmet är det rimligt att anta att sjuksköterskor även i fortsättning kommer att spela en betydelsefull roll i kontakten mellan anhöriga och professionella vårdare. I gruppen professionella vårdare förväntas sjuksköterskor ha en betydelsefull roll som anhörigstödjare. Eftersom det finns så lite forskning om innebörden av att vara stödjande, beskrivs genom en av delstudierna innebörden av att vara stödjande så som det berättas av sjuksköterskor. För att kunna förstå innebörden av fenomenet stöd, har de empiriska studierna i avhandlingen genomförts inom den palliativa hemsjukvården, eftersom fenomenet stöd förväntades kunna tydliggöras och beskrivas där. Genom de delstudier som ingår i denna avhandling beskrivs begreppet stöd för äldres anhöriga med hjälp av olika forskningsmetoder. Anhöriga har berättat om sina upplevelser och erfarenheter av stöd och sjuksköterskor har berättat om innebörden av att vara stödjande. Dessutom har den vetenskapliga litteraturen också använts för att beskriva, förklara och förstå begreppet stöd. Det övergripande syftet med avhandlingen är alltså att inom omvårdnad, så som det visar sig med hjälp av anhöriga, sjuksköterskor och den vetenskapliga litteraturen beskriva, belysa och förstå innebörder av stöd för anhöriga som vårdar en äldre närstående hemma. I den första delstudien identifierades former för och vetenskapliga bevis om stöd till anhöriga som vårdar en äldre närstående hemma. Detta genomfördes som en systematisk litteraturstudie. Metoden baserar sig på en känd modell om sju steg för att identifiera, klassificera och kritiskt värdera bästa tillgängliga vetenskapliga bevis inom området. I studien inkluderades 24 artiklar som visade att anhöriga som vårdaren äldre närstående i hemmet räds social isolering samt önskar att träffas i gruppnätverk med jämlikar antingen av sociala skäl eller utbildningsskäl. Anhöriga efterfrågar i hög grad avlastning/växelvård. Trots en omfattande mängd litteratur inom området är det oklart om anhörigas situation förbättras genom dessa insatser. Den vetenskapliga kunskapen om hur insatserna bäst tillhandahålls/ges är otillräcklig. För att kunna belysa innebörden av stöd, så som det berättas av de anhöriga själva genomfördes den andra delstudien. Denna delstudie inleddes med förhoppningen om att bättre kunna förstå anhörigas upplevelser och erfarenheter av stöd utifrån deras situationer. Metoden som användes var en fenomenologisk hermeneutisk metod, baserad på Paul Ricoeurs filosofi. Inledningsvis genomfördes tjugo narrativa intervjuer med anhöriga som vårdar en äldre närstående hemma inom den palliativa hemsjukvården. Dessa intervjuer utgör grunden till en text som analyseras och tolkas på ett strukturerat och återkommande sätt. En del av resultatet utgörs av två övergripande teman som kunde formuleras efter det att intervjuerna hade analyserats. Med temana avses att beskriva innebörden av anhörigas upplevelser och erfarenheter av stöd. Temana som formulerades var: ”Att uppleva en känsla av samhörighet med andra i vårdandet” och ”Att känna samhörighet inom sig själv i vårdandet.” Den samlade innebörden av stöd förstods i denna studie som ”Att känna samhörighet.” För att fördjupa förståelsen av detta och tolka helheten reflekterades denna innebörd genom exempel i litteratur om begreppen vänskap, inre styrka och hanterbarhet. Det senare knyter an till teorin om känsla av sammanhang. För att kunna gå vidare med att belysa begreppet stöd genomfördes delstudie tre. Denna avsåg att belysa innebörden av att vara stödjande så som det berättas av sjuksköterskor. Exemplet hämtades även denna gång från den palliativ hemsjukvården. Den metod som användes var densamma som tidigare beskrevs för delstudie två. Totalt tjugo sjuksköterskor från tre olika sjukhus i södra Sverige deltog genom sina berättelser om att vara stödjande gentemot anhöriga. Flera subteman och teman formulerades från det rika och omfattande intervjumaterielet till två huvudteman: ”Att forma en relation” och ”Att hålla vårdandet hemma”. I den tolkade helheten diskuterades även denna gång innebörden av att vara stödjande i förhållande till exempel ur litteraturen.I den fjärde och vslutande delstudien avsågs att inom omvårdnad induktivt utveckla en definition av begreppet stöd med avgränsning till området anhöriga som vårdar en äldre närstående hemma. För att framgångsrikt uppnå syftet med delstudien användes den så kallade evolutionära metoden för begreppsanalys. Denna innebär ett systematiskt genomsökande av vetenskaplig litteratur och uppslagsverk med avsikten att identifiera samstämmighet om det aktuella begreppets innebörd. Delstudien genomfördes genom att i första hand analysera den litteratur som kan sägas institutionalisera begreppet. Med sådan litteratur avses huvudsakligen vetenskaplig litteratur varför denna utgör en stor del av data i delstudie fyra. Flera olika elektroniska uppslagsverk samt databaser innehållande forskningslitteratur genomsöktes. Efteråt gjordes ett urval av litteratur och urvalet analyserades. Det var möjligt att formulera följande definition; “Delvis innebär stöd tillhandahållandet av generell handgriplig hjälp, så som information, utbildning, ekonomiskt bistånd, hjälpmedel och extern service. Det skapar förutsättningar för att underlätta anhörigas kompetens eller kapacitet att vårda. Dessutom innebär stöd nödvändiga kvaliteter som individuell anpassning, föränderlighet, långsiktighet, utrymme för att ge uttryck för känslor såväl som en idé om ett ömsesidigt och jämnbördigt utbyte mellan de involverade personerna.”

Stoltz_AVH_MUEP.pdf (405.1Kb)

Detection of Myocardial Ischemia using Real-Time Myocardial Contrast ...
Gudmundsson, Petri Malmö University Health and Society Dissertations;3 (2006)	DOCTORAL THESIS

English abstract:	Echocardiography is an ideal clinical method for obtaining information about morphology and function of the heart. Echocardiography is more accessible, mobile and inexpensive compared to other imaging techniques and has become the perhaps most used diagnostic method in cardiology during recent years. To assess myocardial ischemia, different types of stress echocardiography have been available, where mainly wall motion analysis at rest and stress has been used to evaluate the presence and extent of ischemia. During the last few years, second generation contrast agents have become clinically available. This has improved image quality in echocardiography, which, combined with new ultrasound technical developments, has made it possible to obtain echocardiographic images of myocardial perfusion. When this myocardial contrast echocardiography technique is carried out in real-time, as in the studies of this thesis, it is labelled real-time perfusion (RTP). RTP in combination of adenosine stress (RTP-ASE) has the potential to become a valuable clinical tool to evaluate myocardial ischemia. If proven as accurate as other clinically and scientifically accepted methods, such as 99mTc-sestamibi single-photon emission computed tomography (SPECT), RTP-ASE might become an alternative method. Compared to SPECT, it is more accessible, mobile, inexpensive, and without radiation, compared to dobutamine-atropine stress echocardiography (DSE) it is more tolerable and swifter, and it is more accurate than exercise ECG. In all studies of this thesis, we performed RTP-ASE in patients with known or suspected stable coronary artery disease (CAD), admitted to adenosine SPECT evaluation. Adenosine was infused to provoke relative regional hypo-perfusion in ischemic myocardial territories. Using a SONOS 5500 echocardiography machine, patients underwent RTP imaging during Sonovue infusion, before and throughout the adenosine stress, also used for SPECT. RTP images were stored for later, blinded, off-line analysis. In studies III and IV, the commercially available software Qontrast was used to generate parametric images of myocardial perfusion and quantitative values of perfusion replenishment from RTP-ASE image loops. Method of reference for the ischemia evaluation in the thesis was the presence or absence of reversible ischemia at SPECT. The left ventricular myocardium was divided into three territories corresponding to the distribution territories of the three main coronary arteries; left anterior descending (LAD), left circumflex (LCx) and right coronary artery (RCA). In studies I and II, we investigated the feasibility of RTP-ASE for the detection of ischemia using visual interpretation of RTP-ASE loops acquired at rest and stress. Study III was carried out to examine the value of quantitatively generated parametric perfusion images from RTP-ASE loops, in detecting myocardial ischemia. In study IV, the usefulness of quantitative detection of myocardial ischemia from RTP-ASE loops was assessed. Data comparing quantitative measurements of perfusion replenishment from RTP-ASE images at rest and stress were used as markers of ischemia. The results from the studies in this thesis suggest that visual evaluation of ischemia from RTP-ASE images, using angio-mode as well as high resolution grey scale mode, is accurate and feasible. It is therefore a clinically useful method in patients with known or suspected stable CAD. Quantification of ischemia or parametric imaging for ischemia evaluation using Qontrast, are not yet suitable for clinical use, as judged by the findings of this thesis. However, since further technical development can be expected, quantitative assessment of myocardial perfusion may well be a clinically useful method in the near future.
Swedish abstract:	Diagnostisering av syrebrist i hjärtmuskeln med hjälp av kontrastförstärkt ultraljudsundersökning av hjärtmuskelns genomblödning. Ultraljudsundersökning av hjärtat (ekokardiografi) används mycket inom hjärtsjukvården idag, oftast för att utreda hjärtats och hjärtklaffarnas anatomi och funktion. Ekokardiografi är en ofarlig och ganska enkel undersökning och apparaturen som används är förhållandevis billig och mobil om man jämför med andra bildgivande undersökningar av hjärtat, såsom röntgen, isotopundersökning eller magnetresonans tomografi. Syrebrist (ischemi) i hjärtmuskeln uppkommer genom att inte tillräckligt med syreförande blod når ett eller flera områden av hjärtmuskeln, vanligen pga. förträngningar i hjärtats kranskärl. Ischemi orsakar ofta, men inte alltid bröstsmärtor, vilket kallas "kärlkramp" i hjärtat. Utvärdering av ischemi i hjärtmuskeln rekommenderas för optimal behandling av patienter med misstänkt sjukdom i hjärtats kranskärl. Denna utvärdering kan göras med hjälp av olika typer av belastningstest. Metoder som finns att tillgå är arbets-EKG, isotopundersökning (99mTc-sestamibi single-photon emission computed tomography - SPECT) och stress-ekokardiografi. Liksom arbets-EKG utförs både SPECT och stress-ekokardiografi med olika typer av belastning. Belastning vid SPECT sker vanligen genom ergometercykling, men kan också utföras genom provokation med läkemedel (dobutamin, adenosin) som ger en belastning på hjärtmuskeln liknande den vid fysisk ansträngning. Vid stress-ekokardiografi görs belastningen vanligast med dobutamin (dobutamin-atropin stress-ekokardiografi - DSE) men kan också göras med ergometercykling eller adenosin. SPECT påvisar ischemi i hjärtmuskeln genom att jämföra genomblödningen (perfusionen) i hjärtmuskeln vid maximal belastning och vila. Minskad genomblödning under belastning är tecken på ischemi. Genomblödningen i hjärtmuskeln uppskattas vid SPECT genom att en radioaktiv isotop injiceras i patientens blod. Isotopen fördelas i hjärtmuskeln på samma sätt som blodet och strålarna från isotopen kan detekteras av en speciell detektor (gammakamera). Från områden utan eller med nedsatt genomblödning detekteras ingen eller nedsatt strålning och i dessa områden föreligger således ischemi. Vid DSE jämför man vanligen hjärtmuskelns förmåga att dra ihop sig (kontraktionsförmåga) i arbete och vila. Om kontraktionen minskar i någon del av hjärtmuskeln under belastning så talar det för ischemi i detta område. Både SPECT och DSE är väldokumenterade och bättre men dyrare än arbets-EKG. Att belasta hjärtat med dobutamin är ofta påtagligt obehagligt för patienten, medan belastning med adenosin ofta uppfattas som mindre obehaglig. Själva belastningen är dessutom oftast kortare än vid både ergometercykling och dobutamin-belastning. Till skillnad från sedvanlig stress-ekokardiografi räcker det dock inte att bedöma hjärtmuskelns kontraktion vid adenosin-belastning, utan det krävs även att genomblödningen bedöms. Genomblödningen i hjärtmuskeln har inte tidigare varit möjlig att värdera vid adenosin-stress-ekokardiografi (ASE). Det blev dock möjligt för några år sedan, då en typ av ny ultraljuds-kontrastmedel introducerades inom ekokardiografi. Kontrastmedlet för ultraljud som användes inom ramen för denna avhandling var Sonovue. En kombination av ny ultraljudsteknik (realtids perfusion - RTP) och kontrastmedel har gjort det möjligt att samtidigt bedöma genomblödningen i hjärtmuskeln och dess kontraktionsförmåga. Därigenom skulle RTP i kombination med ASE (RTP-ASE) kunna användas för att tillförlitligt detektera ischemi i hjärtmuskeln. Om RTP-ASE visar sig kunna detektera ischemi lika bra som en redan erkänd undersökning, exempelvis SPECT, kan RTP-ASE bli en bra alternativ undersökning. Jämfört med SPECT är RTP-ASE mer tillgänglig och utan radioaktiv strålning, jämfört med DSE är den snabbare och mindre obehaglig, och den är mera noggrann än arbets-EKG.

PETRI+Kappa+till+MUEP.pdf (3.630Mb)

LIVING WITH CHILDHOOD DIABETES – Family experiences and Long-Term eff...
Wennick, Anne : Lund University, Faculty of Medicine Doctoral Dissertation Series (2007)	DOCTORAL THESIS

English abstract:

The overall aim of this thesis was to investigate families’ experiences when a child is diagnosed as having type 1 diabetes, and at one and three years after diagnosis. Since childhood health and the circumstances around it in the family have been shown to have a lasting impact on adult health and circumstances, an additional aim was to examine the long-term effect of childhood diabetes on education level attained and self-assessed health. The work described in this thesis was carried out using a combination of qualitative and quantitative methods. In study 1, a longitudinal qualitative study design was used with interviews for data collection, and in study 2 a cross-sectional quantitative study design was used with register data based on structured interviews for data collection. The sample of the first study (papers I–III) was made through a consecutive series of families with children diagnosed with type 1 diabetes in 2003, who were interviewed individually in 2003 (n=12), 2004 (n=11), and then again in 2006 (n=11). Data collected in 2003 and 2004 was analysed using a hermeneutic phenomenological approach, whereas data from 2006 was analysed using latent content analysis. The sample from the second study (paper IV) was made through a set of pooled cross-sectional population survey data, supplemented with register data. It comprised 106 individuals diagnosed with diabetes before age 19 and 20,564 individuals not diagnosed before age 19, aged 19–38, who were interviewed for the Swedish Biennial Survey of Living Conditions (Undersökningar om Levnadsförhållanden, ULF). The data were analysed using two multiple regressions: one for educational level attained and one for self-assessed health, using a human-capital model as a theoretical framework. Findings in study 1 demonstrate that after the affected child had been diagnosed with type 1 diabetes, the family entered an ongoing learning process where they learnt about the inevitable and the extent. The learning process was a recurrent phenomenon whenever the families were exposed to new situations and contexts. One year after diagnosis the family described that they were living an ordinary yet different life, and the family experienced acceptance, health, independence and confidence during periods of well-balanced blood glucose levels. The integration of the illness into the family’s everyday life was, however, obstructed during episodes of unbalanced blood glucose levels, which affected the whole family negatively. Three years after diagnosis all family members had acquired a sound basis for managing the diabetes regimen. They had learnt more about diabetes, which was a natural element of the families’ everyday life, although still affecting the family members differently in their daily life. Furthermore, in study 2, controlling for a set of independent variables, childhood diabetes was found to be associated with lower levels of attained education and self-assessed health in comparison with the general population. More educated individuals reported better health, though. Hence, further research is needed to decide which method of treatment is most beneficial for the individual family when a child is striken with type 1 diabetes. The importance of showing receptivity to each family member’s needs and experiences was further suggested when the families were interviewed three years after the diagnosis, as it revealed that the illness affected the daily life of family members to a different degree. It is also important early in life to strengthen the possibility of having and reaching an agreeable level of attained education for children diagnosed with diabetes, as this may lead to increased health for the child later in life.

Communication in Palliative Home Care, Grief and Bereavement - A moth...
Holmberg, Lena : Malmö University, Faculty of Health and Society Malmö University Health and Society Doctoral Dissertation;2007:1 (2007)	DOCTORAL THESIS

English abstract:

In this study a mother’s experiences of communication between her adult son dying in leiomyosarcoma and herself (the author), between his family and a palliative home care team and communication in the support of the mother in her parental grief and bereavement are described and analyzed. The mother’s experiences are captured in personal accounts, writings, during the year of her son’s illness with cancer and his palliative home care and during three years of grief and bereavement after her loss. The data analysis is carried out in four steps by the mother as a researcher: 1) Identification of events of experiences of communication and significant concepts in the writings 2) Construction of four narratives, illustrating the concepts and including excerpts from the writings 3) Interpretation, contextualization and validation of the narratives 4) Contextualization in broader contexts. The son’s hope and disavowal and the mother’s fear and despair emerged as important concepts in understanding the communication between them during his palliative home care. Recognition, acknowledgment and respect from the palliative home care team supported the mother. A network of supportive arrangements was made available to the son and his family. The team recognized the son’s and the family members’ emotional needs as well as the family members’ needs to do anything they could for their husband, father, brother and son. Trust was a key concept in the communication between the son and his family on one hand and the palliative home care team on the other. Trust seems to be a base for the empowerment of the family members. Main factors besides the team’s medical professionalism influencing trust were flexibility, accessibility and continuity. Information, control, friendship and shared experiences were important factors in supporting the mother in her first year of bereavement. The findings point to the necessity of customizing bereavement support, specifically for high risk mourners. In the short term perspective the mother found support in her pre school aged granddaughter, who had lost her father. These contacts provided breaks in the grief, actualized positive memories, established and sustained rituals. In the long term perspective confirmed family bonds helped the mother in her reconciliation process. Empathy, based on the welfare system, providing flexible structures in which the mother was recognized and acknowledged, felt trust, was looked upon as an individual, was empowered and finally was reached by support after her loss, was of substantial importance to her. Empathy based on compassion, shared experiences, shared loss and strengthened family bonds supported her. Empathy to self allowed her to make use of the support she received and was part of her reconciliation process.

Lena Holmberg MUEP.pdf (1.417Mb)

Swedish Maternal Health Care in a Multiethnic Society - Including the...
Ny, Pernilla : Malmö University, Faculty of Health and Society Malmö University Health and Society Doctoral Dissertation;2007:1 (2007)	DOCTORAL THESIS

English abstract:

Preventive work in maternal and child health care has a long history in Sweden. Today, Sweden has achieved the lowest maternal and child mortality rates globally based on a maternal health care system regulated by national recommendations; offered to every woman, free of chare, on a continuity basis, by registered midwives at municipal clinics within the community with the purpose of being assessable for all women. Despite the availability of antenatal care, immigrant women living in Sweden often have a different pattern of utilising care and in some cases immigrant women have been shown to be at risk for a negative delivery outcome. The overall aim of this thesis was to investigate differences due to country of birth and utilisation of antenatal care and the experiences of antenatal care, from the perspectives of the both the parents to be. Epidemiological design and explorative qualitative research has been used for the purpose of finding patterns of the utilisation of maternal health care as well as experiences from foreign born men and women concerning maternal health care in general, and maternal health care in the city of Malmö Sweden in particular. Qualitative research has been used to add depth and thereby attain a greater understanding in a social context. In the study population, according to the definitions set in Studies I, IV, the main finding was that 28.3-48.7% of the women had unplanned visits to a midwife and/or to a physician at the delivery ward. Women born in Sweden and in Eastern and Southern Europe had a linear relationship with few planned visits to the midwife at the municipal clinic and more unplanned visits to a midwife at the delivery ward. The women in Study II were positive to the individualised and professional care given at the MHC by empathic and professional midwives. They were positive to the increased involvement of their partner in the area of reproduction and family life since migrating to Sweden. According to the women, this may lead to an increased understanding by the fathers of the woman’s situation during pregnancy, birth and caring for the children as well as it could increase the fathers own emotional as well as practical involvement in their children. The foreign born men, in Study III, were positive towards antenatal care and to be able to take part as support to women at MHC, and during the delivery process. They experienced problems with their situation of being fathers, partners and, as men living in Sweden, due often to their being un-employed and the changed situation that their migration had brought about. The health care system manager need to be aware of the fact that there are groups of women, in a low risk population, who tend to make contact with the maternal care system in a more of less unplanned fashion. By not utilising the planned care offered these women miss an opportunity to meet a midwife who is specialised in preventive care during pregnancy with the focus of treating pregnancy a normal health life event, while at the same time, ensuring the detection of eventual risk factors. A conversation with a midwife in a calm environment is beneficial to the pregnant woman. The immigrant groups need our special attention aimed at making the maternal health care system easily accessible for them, as well as making the maternity staff aware of their own attitudes towards preventive work involving pregnancy in a multiethnic setting. The organisation of care must also, in itself; offer such possibilities for both the staff and the women.

Kappa.pdf (1.049Mb)

Self-care behaviour and daily life experiences in patients with chron...
Holst, Marie (2008)	DOCTORAL THESIS

English abstract:	Chronic heart failure (CHF) is a progressive, complex, clinical syndrome resulting from structural and/or functional cardiac disorders that impair systolic and/or diastolic ventricular function. The dominating clinical symptoms are shortness of breath, fatigue, exercise intolerance and peripheral oedema. This considerably affects physical, psychological and social functions of the individual, often making normal daily life activity difficult. The treatment for CHF is both pharmacological and nonpharmacological. Patient education, support and counselling are important parts of the non-pharmacological treatment and aims among other things to improve self-care behaviour and adherence to the treatment. Thirst is, in clinical practise, a common reason for complaint in patients with CHF. One factor that can cause or aggravate thirst is the recommendation to be restrictive with fluid intake. In international guidelines for CHF treatment, a fluid restriction of 1,5-2L/day is often recommended. However, neither is this recommendation based on scientific evidence, nor has it been investigated if and how such a recommendation affects the patients’ physical and mental health. The overall aim of this thesis was to describe and evaluate self-care behaviour and to describe daily life experiences in patients with CHF, with special reference to fluid intake. The aims of Study I were to: (1) describe self-care with special regard to daily selfweighing and salt and fluid restriction in patients with heart failure in primary health care, during one year of monthly telephone follow-up after a single session education, (2) to describe gender differences in regard to self-care and (3) to investigate if selfcare was associated with health-related quality of life. The study was a subgroup analysis of the interventional group from a larger randomised trial. No changes were found in self-care behaviour throughout the study period. The intervention had no effect on quality of life and no associations were found between quality of life and selfcare behaviour. There were no statistically significant differences between the genders. Study II was a randomised, cross-over trial with the aim to compare the effects of a restrictive to those of a liberal fluid prescription, on quality of life, physical capacity, thirst and hospital admissions, in patients who had improved from NYHA class (III- )IV CHF to a stable condition, without clinical signs of significant fluid overload. There were no significant differences in end-of-intervention between the two fluid prescriptions in quality of life, physical capacity or hospital admission. In sense of thirst and difficulties to adhere to the fluid prescription there were significant between- intervention differences in end-of-intervention in favour of the liberal prescription. Study III was a secondary analysis of the data from study II with the aim to describe the self-reported fluid intake and its effects on body weight, signs and symptoms of CHF, quality of life, physical capacity and thirst in patients with stabilised CHF. The efficacy variables were analysed in relation to the median fluid intake of 19ml/kg bodyweight/day. Patients with an above median fluid intake experienced significantly less thirst and difficulties to adhere to the fluid prescription. Study IV was an interview study with the aim to describe how persons with CHF experience and manage daily life. The interviews were analysed with manifest and latent content analysis. The experience of living with CHF is illuminated by the themes Hindering and Facilitating Forces. The distribution between these themes was equal which can be interpreted as despite the difficulties patients with CHF have, they are capable to create a good life for themselves. The results of this thesis confirm the results from other studies regarding self-care behaviour and the experiences of living with CHF. It is the first study showing that it seems beneficial and safe to recommend a liberal fluid prescription, based on body weight, in stabilised patients with CHF. A liberal fluid intake has favourable effects on thirst and difficulties to adhere to the fluid prescription without any detectable effects on quality of life, physical capacity or morbidity. A larger self-reported fluid intake was not associated with any measurable negative effects on signs and symptoms of CHF, diuretic use, or physical capacity. Thus, a more liberal fluid intake may be advisable in patients with CHF who have been stabilised from an initial unstable clinical state.
Swedish abstract:	Under min tid som kliniskt verksam sjuksköterska mötte jag många patienter som besvärades av törst och som hade svårt att följa den vätskerekommendation på 1,5L/dygn som gavs. Detta är upprinnelsen till denna avhandling vars syfte är att beskriva och utvärdera egenvårdsbeteendet samt att beskriva hur det dagliga livet upplevs av patienter med kronisk hjärtsvikt, med speciellt intresse riktat mot vätskeintaget. Kronisk hjärtsvikt är ett komplicerat kliniskt tillstånd som påverkar den drabbade individen på många sätt. Det finns ingen allmänt accepterad och heltäckande definition av kronisk hjärtsvikt. En vanligt förekommande beskrivning är att de tecken/ symtom som kännetecknar hjärtsvikt indikerar att hjärtat av någon anledning inte kan förse kroppens vävnader och organ med den mängd syre och näring som behövs. Gemensamt för alla definitioner av kronisk hjärtsvikt är att den orsakas av en bakomliggande hjärtsjukdom. De vanligaste orsakerna till kronisk hjärtsvikt i Europa är högt blodtryck och hjärtkärlssjukdom, ofta i form av genomgången hjärtinfarkt. Andra orsaker kan vara rytmrubbningar i hjärtat, klaffsjukdom eller hjärtmuskelsjukdom. Cirka två till tre procent av befolkningen i Sverige (200 000-250 000 individer) har kronisk hjärtsvikt och det uppskattas att andelen personer som har en asymtomatisk eller latent hjärtsvikt är lika stor. Det stora flertalet av dessa personer är äldre; cirka 10 procent av befolkningen över 80 år har kronisk hjärtsvikt. Förekomsten av kronisk hjärtsvikt har ökat under de senaste decennierna och anledningen anses vara att medellivslängden har ökat och behandlingen av akut hjärtinfarkt har förbättrats avsevärt, med förbättrad överlevnad som följd, men också till priset av att fler människor lever med nedsatt hjärtfunktion. Kostnaderna för vård och omsorg av personer med hjärtsvikt är höga, cirka två procent av den totala hälso- och sjukvårdsbudgeten går till denna patientgrupp och majoriteten av kostnaderna är för slutenvård. Prognosen för patienter med kronisk hjärtsvikt är beroende av svårighetsgraden. Vid mild hjärtsvikt beräknas den årliga dödligheten till fem procent och vid uttalad hjärtsvikt uppskattas den årliga dödligheten till 40-50 procent. Detta innebär att prognosen vid uttalad kronisk hjärtsvikt i genomsnitt är sämre än vid våra vanligaste cancersjukdomar. Kronisk hjärtsvikt påverkar patienten både fysiskt och psykiskt. De dominerande fysiska symtomen och tecknen är trötthet, andfåddhet samt vätskeansamling i kroppen. Försämrad kognitiv förmåga, depression och sömnstörningar är också vanligt. På grund av de begränsningar som patienter med kronisk hjärtsvikt upplever är deras hälsorelaterade livskvalitet låg. I de intervjustudier som finns är det tydligt att den nedsatta fysiska kapaciteten påverkar patienten med kronisk hjärtsvikt mycket. Detta innebär att patienten inte kan göra det han/hon vill samt att beroendet av närstående eller andra vårdgivare ökar. Diagnosen ställs på de typiska symtom eller fynd som förekommer vid kronisk hjärtsvikt samt objektiva tecken på rubbad hjärtfunktion, företrädesvis med ultraljudsundersökning av hjärtat (ekokardiografi). Behandlingen av kronisk hjärtsvikt ska inriktas på såväl symtomlindring som den bakomliggande orsaken. Hjärtsviktsbehandling omfattar både farmakologisk och icke-farmakologisk behandling. Målet för den farmakologiska behandlingen är att förbättra hjärtats funktion och att minska den stresshormonella aktiveringen som föreligger vid kronisk hjärtsvikt, men också att lindra symtom och därigenom öka livskvalitet och arbetskapacitet, samt att förbättra överlevnad. I riktlinjer från både Europa och USA rekommenderas, beroende av hjärtsviktens svårighetsgrad, en kombination av ACE-hämmare eller angiotensin receptor blockerare, beta-blockerare, diuretika och aldosteronhämmare. Den icke-farmakologiska behandlingen är till stor del inriktad på att motivera till livsstilsförändringar och modifikation av riskfaktorer. I detta är patientutbildning en viktig del. Utbildningen bör innehålla information om orsaker till hjärtsvikt, vad hjärtsvikt innebär och varför symtom uppträder, samt den farmakologiska behandlingens verkan och biverkningar. Det är viktigt att motivera till monitorering av symtom såsom andfåddhet, trötthet och ödemutveckling med t.ex. dagliga viktkontroller för att patienten tidigt ska kunna upptäcka en försämring av hjärtsvikten. Andra områden som omfattas är rekommendationer om salt- och vätskerestriktion, fysisk träning, anpassning av energiintaget (främst näringstillskott vid malnutrition), måttlig alkoholkonsumtion samt infektionsprofylax i form av influensa och pneumokock vaccination. Ämnen som också bör beröras är sömnsvårigheter och sexuell aktivitet. I Sverige bedrivs mycket av denna utbildning på sjuksköterskebaserade hjärtsviktsmottagningar. Sjuksköterskorna som driver hjärtsviktsmottagningar arbetar ofta självständigt och har ofta delegeringar för att titrera och justera läkemedel såsom diuretika, ACE-hämmare och beta-blockerare. Arbetet bedrivs med stöd av kardiologer med särskilt intresse för patienter med hjärtsvikt och på vissa sjukhus är också sjukgymnaster, dietister, kuratorer, arbetsterapeuter och farmaceuter involverade. Hjärtsviktsmottagningarna har visat sig leda till en effektivare läkemedelsanvändning, högre hälsorelaterad livskvalitet och förbättrad egenvårdsförmåga. Dessutom har man kunnat visa att hjärtsviktsmottagningar leder till förbättrad överlevnad samt kostnadseffektivitet, beroende på ett minskat behov av inläggning på sjukhus. Förutom de vanliga symtomen är törst något som patienter med kronisk hjärtsvikt ofta uttrycker som besvär. Orsaken till detta kan vara flera; den vätskedrivande behandlingen är en, den stresshormonella aktiveringen en annan och den vätskerestriktion som patienterna är rekommenderade kan vara den tredje. I gällande riktlinjer rekommenderas en vätskerestriktion på 1,5-2 l vätska per dygn men denna rekommendation bygger inte på någon vetenskaplig kunskap. Förutom törst är muntorrhet ett problem som i sin tur kan leda till förändrat smaksinne, försämrad munhälsa och i värsta fall svårigheter att tala. Torr hud och klåda är också symtom som kan kopplas samman med en strikt vätskerestriktion. Kroppens behov av vätska anges i litteraturen vara mellan 25 och 35 ml/kg kroppsvikt/dygn. Räknat på 30 ml/kg kroppsvikt/dygn skulle 1,5 l täcka behovet för en person som väger 50 kg och för en person som väger 80 skulle gällande riktlinjer innebära ett dagligt underskott på nästan 1 liter. När den farmakologiska behandlingen för kronisk hjärtsvikt inte var så utvecklad som den är idag var vätskerestriktion en naturlig och motiverad åtgärd, men med dagens effektiva farmakologiska behandling bör behovet av denna vätskerestriktion omprövas eftersom den medför obehag för patienterna. Syftet med denna avhandling var att beskriva och utvärdera egenvårdsbeteendet samt att beskriva hur det dagliga livet upplevs av patienter med kronisk hjärtsvikt, med speciellt intresse riktat mot vätskeintaget. Syftet med delstudie I var att beskriva egenvårdsbeteendet hos patienter med kronisk hjärtsvikt inom primärvården under ett år efter en patientutbildning. Studien var en analys gjord på interventionsgruppen i en större randomiserad studie. Interventionen bestod av ett utbildningstillfälle i hemmet genomförd av en sjuksköterska från primärvården. Uppföljningen skedde sedan via telefon varje månad under ett år, förutom månad tre och tolv då uppföljningen skedde i hemmet. Sextio patienter utvärderades och resultaten visade ingen förändring i egenvårdsbeteende, avseende viktkontroller, salt- och vätskerestriktion under uppföljningstiden. Inget samband sågs mellan hälsorelaterad livskvalitet och egenvårdsbeteende. Det fanns inga könsskillnader i egenvårdsbeteende eller i sambandet mellan hälsorelaterad livskvalitet och egenvårdbeteende. Resultaten indikerar att det inte räcker med ett utbildningstillfälle för att förbättra egenvårdsbeteendet och den hälsorelaterade livskvaliteten. Delstudie II var en randomiserad cross-over studie, vilket innebär att alla patienter deltar i båda de interventioner som studien omfattar. Varje patient blir därmed sin egen kontroll. Under intervention 1 fick patienterna inte dricka mer än 1,5L/dag och under intervention 2 baserades rekommendationen om det maximala vätskeintaget på kroppsvikten; 30ml vätska per kg kroppsvikt/dygn. Sjuttiofyra patienter randomiserades och syftet var att utvärdera effekterna av vätskeintaget på hälsorelaterad livskvalitet, fysisk kapacitet, törst och sjukhusinläggning hos patienter med stabil kronisk hjärtsvikt. Resultatet visade ingen skillnad mellan interventionerna avseende hälsorelaterad livskvalitet, fysisk kapacitet eller inläggning på sjukhus. Upplevd törst och svårigheter att hålla vätskerekommendationen var dock signifikant mindre i gruppen som hade en individuellt anpassad vätskerekommendation. Resultatet antyder att en mindre strikt vätskerekommendation är både säker och fördelaktig för patienter med stabil kronisk hjärtsvikt, vilket aldrig tidigare visats. Delstudie III bestod i en sekundäranalys av data från delstudie II. Syftet var att beskriva patienternas uppgivna vätskeintag samt dess effekter på kroppsvikt, symtom, diuretikaanvändande, hälsorelaterad livskvalitet och fysisk kapacitet. Data från 63 patienter ingick i analysen. Gruppindelningen baserades på medianen (19ml/kg kroppsvikt/ dygn) av intagen vätska för hela studieperioden. Medelvärdet av intagen vätska i ”under median gruppen” var 16 ml/kg kroppsvikt/dygn, medan det var 24 ml/kg kroppsvikt/dygn i ”över median gruppen”. Inga skillnader mellan grupperna sågs förutom en signifikant mindre upplevelse av törst och svårigheter att hålla vätskerestriktionen i ”över median gruppen”. Resultatet antyder, som i delstudie II, att en mindre strikt vätskerekommendation inte har några negativa effekter på hälsan hos patienter med stabil kronisk hjärtsvikt, medan patientens törst kan minskas. Delstudie IV var en intervjustudie som analyserades med manifest och latent innehållsanalys. Femton personer intervjuades och syftet var att beskriva hur personer med kronisk hjärtsvikt upplever och hanterar sitt dagliga liv. Resultatet beskrivs i två huvudteman Hindrande och Främjande krafter, där hindrande krafter belyser fysiska och psykiska svårigheterna i det dagliga livet medan främjande krafter beskriver hur personer med kronisk hjärtsvikt accepterar, anpassar sig och hanterar sitt dagliga liv. Sammanfattningsvis visar denna avhandling att hjärtsvikt påverkar den hälsorelaterade livskvaliteten och det dagliga livet både fysiskt och psykiskt (Studie I, IV). Följsamheten till den egenvård som rekommenderas är relativt god men ska den förbättras ytterligare krävs mer än ett utbildningstillfälle (Studie I). Den törst som många patienter med hjärtsvikt upplever som besvärande (Studie II-IV) kan utan märkbara negativa effekter minskas genom att rekommendera en mindre strikt vätskerekommendation (Studie II, III). Därmed kan en begränsning i livet tas bort och det dagliga livet bli lite lättare att leva för patienter med hjärtsvikt (Studie IV).

Holst MUEP.pdf (479.7Kb)

The Impact of Advanced Home Care on Health-related Quality of Life. R...
Ahlner Elmqvist, Marianne : Malmö University Hospital, Lund University Lund University, Faculty of Medicine doctoral dissertation series;85 (2008)	DOCTORAL THESIS

English abstract:

Aim of study - The aim of the present work was to compare patients with advanced cancer receiving specialized palliative home care with those receiving conventional care with regard to time spent at home and place of death (Paper I), factors associated with the patients’ choice of palliative care (Paper II), and to describe the health-related quality of life (HRQL) and the occurrence and changes in symptoms over the last three months of the patients’ lives (Paper III). In addition, sociodemographic and clinical differences between participants and dropouts were explored in order to establish whether the missing data could be regarded as missing at random (Paper IV). Background - A hospital-based advanced home care programme was initiated in Malmö, Sweden in December1995, in order to enable patients to remain at home for a longer period and to choose to die at home. The allocation to advanced home care (AHC) or conventional care (CC) was performed according to the patients’ preferences. This intervention offered an opportunity to investigate the effect of AHC and to describe the HRQL of patients with a progressive, life-threatening disease. Methods - A prospective longitudinal comparative study was performed including 297 patients consecutively recruited over 2½ years. The two groups of patients (AHC and CC) were compared and the main outcome variables were place of death, time spent in institution or at home, and the patients’ HRQL. The latter was assessed monthly by using self-reported questionnaires, including the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), the Impact of Event Scale (IES), five questions about social support (MA) and two items concerning general well-being (NT). At the same time, in Trondheim, Norway, a similar palliative care intervention programme was started. The design of the study was slightly different, but patients were evaluated using the same sociodemographic and clinical variables, and questionnaire data were collected in the same way as in the Swedish study. Results - The AHC patients spent more time outside the hospital and more patients died at home compared with patients in the CC group (Paper I). However, there was a difference between patients in the two interventions. Compared with the CC patients, patients who chose the AHC programme had lived longer with their cancer diagnosis, had a shorter survival period after study enrolment, and had poorer performance status. In addition, although all patients had reduced HRQL at inclusion, the AHC patients reported poorer functioning and more symptoms than the CC patients (Paper II). Results from the HRQL questionnaires returned during the last three months of the patients’ lives were analysed in order to describe the symptom burden of dying patients. Due to considerable attrition over the study period, data from the Norwegian study were included in order to increase the study sample to 116 patients. Generally, a marked, but gradual deterioration was seen during the patients’ last three months of life. A more rapid increase in problems was observed between two and one month before death regarding Physical, Cognitive and Social function, as well as Fatigue. The mean scores for Pain, Nausea/Vomiting, Sleeping problems, Diarrhoea and Financial impact were stable over time (Paper III). Analyses of the characteristics of patients who dropped out of the study after filling in the first questionnaire after inclusion confirmed that they had a less favourable prognosis, with regard to both clinical variables and HRQL data. This pattern was not found when analysing data from patients dropping out of the study during the last two months before death (Paper IV). Conclusions -The results obtained in this work add knowledge about patients’ preferences regarding care at the end of life, and changes in their HRQL during the last few months of life. The palliative intervention with AHC proved successful, and enabled more patients to stay at home for a longer period, and to die at home. Dying at home is strongly associated with the patients’ preference to do so. Due to the design of the study, the impact of such preferences cannot be separated from the impact of the AHC. The results indicate that patients are reluctant to accept home care until necessary due to the severity of functioning impairments and symptom burden. It is important to be aware of the high level of symptoms in the patients’ last three months of life. Symptom assessment using standardised questionnaires may enhance the focus on symptom management. Results from HRQL studies must be interpreted with care due to non-random attrition. This is less evident close to death.

Interactions of Mucins with Biopolymers and Drug Delivery Particles
Svensson, Olof : Malmö University (2008)	DOCTORAL THESIS

English abstract:

The main components in the mucous gels apart from water are mucins, which are proteins with high molecular weights and an abundance of negatively charged oligosaccharide side chains. The aim of the investigations was to characterize interactions between mucins and other proteins that are present in the mucous gel, and also between mucins and components used in pharmaceutical formulations. More specifically, the main objectives were (I) to investigate the possibility to assemble multilayer films with mucins and oppositely charged polymers or proteins on solid substrates; (II) to evaluate mucoadhesive proper-ties of drug delivery particles by examination of their interactions with mucins. The construction of multilayer films was performed on silica and hydrophobized silica surfaces by alternate adsorption, and the adsorbed amount and thickness of the films were measured in situ by time resolved ellipsometry. It was demonstrated that films could be assembled using mucins in combination with both chitosan and lactoperoxidase. The build-up was characterized by adsorption and redissolution processes, and the extent of redissolution could be explained by taking the charge densities and concentrations of the components into account. It was also demonstrated that the nature of the substrate can be crucial for the possibilities to assemble multilayer films, and from the results it may be concluded that a high amount of mucin in the first step is important for successful layer-by-layer assembly. Furthermore, it was demonstrated that lactoperoxidase is catalytically active when adsorbed to mucin layers, and it may thereby exert its antimicrobial action. The evaluation of mucoadhesive properties of drug delivery particles was performed with lipid nanoparticles stabilized by a poly(ethylene oxide) based polymer and with particles modified by chitosan. Both types of model particles (unmodified and chitosan modified) were investigated by measuring their adsorption to mucin-coated silica surfaces by ellipsometry. It was shown that the binding of unmodified particles to mucin-coated silica surfaces was weak and pH-dependent. Based on the pH and electrolyte dependence of the adsorption, it was proposed that the interaction is mediated by hydrogen bonding between protonated carboxyl groups in the mucin molecule and oxygen atoms in poly(ethylene oxide). Chitosan modified particles, on the other hand, showed a substantial and strong binding to mucin-coated surfaces, which can probably be attributed to interactions between amino groups in chitosan and negatively charged groups in the mucin layer. The findings from the present investigations are in agreement with previous reports on the interaction of mucins with poly(ethylene oxide) and chitosan. It can therefore be concluded that the methodology applied is useful for evaluating mucoadhesive properties of nanoparticles.

Olof Svensson Kappan.pdf (2.785Mb)

In search of evidence-based practices. Exploring factors influencing ...
Bahtsevani, Christel : Malmö University Malmö University, Faculty of Health and Society Doctoral Dissertation;4 (2008)	DOCTORAL THESIS

English abstract:

Within the evidence-based movement means are developed to support the practitioner in becoming a research consumer with knowledge and skills to create an evidence-based practice (EBP). But little is actually known about whether, and how, this evidence-based accumulation of knowledge is used by practitioners and in what way any actual use leads to improved outcomes. Clinical practice guidelines (CPGs) are described to provide means to keep up with scientific development and may serve as an interface between science and practice. Implementation of evidence and guidelines in daily care are very complex and knowledge about the best way to implement evidence to facilitate best practices is still limited. The overall aim of this thesis was to explore factors that influence an evidence-based clinical practice, and more specifically, to investigate outcomes of an evidence-based practice, the dissemination and awareness of evidence-based literature, and to describe factors of importance when implementing CPGs. A systematic review was conducted to identify outcomes, and different experimental designs have been used for the purpose of describing awareness and dissemination of evidence-based literature as well as experience of the implementation of CPGs. Furthermore, a test-retest was conducted to test the reliability of items constructed from factors drawn from The Promoting Action on Research Implementation in Health Services (PARIHS) framework. The findings of the systematic review showed that it is difficult to prove effects of an EBP and the studies that managed this had implemented evidence-based CPGs. Although improvements in outcomes were reported for patients, personnel and the organisation, the synthesis showed a weak scientific foundation for the overall result since the studies included were heterogeneous in their designs. In a questionnaire study, in the area of psychiatric nursing with a pre-post design in relation to published evidence-based nursing reports, some differences were detected over time. But still 39.5 % of the sample reported no access to evidence-based literature one year after the publication of the two evidence-based nursing reports, and few of the respondents who had access to evidence-based literature reported any use of it. In the test-retest items of factors such as clinical experience, patients experience, leadership, context, culture, evaluation and facilitation was included. The findings of the test-retest showed that the reliability varied from good to fair agreement regarding the Kappa values, with a predominance of moderate agreement. The interview study, with an interpretive qualitative design, revealed several factors that appeared to be of importance for the implementation CPGs. The factors seemed to form a base consisting of circumstances, conditions and requirements. These have a relation to components that constitute a process, thus illustrating that implementing CPGs are continuous processes of creating reliable and tenable routines which involve all staffs member and are expected to lead to better and safer care of patients and increase knowledge and confidence among the staff. In conclusion, it is complicated, but not impossible, to demonstrate the outcomes of an EBP. To implement evidence-based CPGs is one way to make an evidence-based care visible. But more research is needed to strengthen the scientific foundation and to establish whether the tendency towards improved outcomes reported can be further supported. To implement CPGs is described as processes of bringing about a certain level of best practice that benefits patients as well as the staff. There are several factors influencing the process in relation to both positive and negative aspects and depending on which aspects will rise in the foreground the processes are visible or concealed, move forward or stagnate, promote or impede a successful implementation.

MUEP Bathsevani.pdf (3.457Mb)

Designing online support for families living with depression
Stjernswärd, Sigrid : Malmö University, Faculty of Health and Society Malmö University Health and Society Doctoral Dissertation;6 (2009)	DOCTORAL THESIS

English abstract:

Families living with mental illness experience an added burden and may experience such psychological distress that they require therapeutic intervention. The Internet is used as a daily tool by a growing share of the population worldwide, including for health related matters. Its potential as a health care tool, including advantages and drawbacks, should be explored. The overall aim of the present thesis was to explore the relatives’ experiences of living close to a person with depression and the Internet’s potential to address their needs. Explorative qualitative research has been used to map the e-health field in relation to depression, to explore what the Internet offers the families living with depression, as well as the relatives’ experiences of living with a person with depression. An iterative design process was used in the development of a digitally based tool aimed at supporting the relatives in their daily life with depression. Users’ experiences of the tool were explored using qualitative explorative research. A vast array of different organizations and initiatives are represented within the e-health field. However, initiatives that are targeted and tailor-made for families living with depression are scarce. Research in the e-health field with focus on depression illuminates health seekers’ and online community users’ profiles, effects of online cognitive behavioral therapy (CBT), and a number of strengths (i.e. accessibility) and weaknesses (i.e. reliability) related to the Internet as a health care tool. Living close to a person with depression can strongly affect the private, social and professional areas of the relatives’ daily life. A growing feeling of not living one’s own life may arise, due to the difficulties of balancing relationships, a process of adaptation and re-evaluation of life circumstances, and a struggle to act as advocate and voice for the person with depression within the health care system and society. Relatives often come in contact with health professionals on 12 behalf of their ill kin and need information and support; needs that are rarely addressed by the health care system. A digitally based tool aimed at supporting the relatives in their daily life with depression was developed using an iterative design process. The tool’s development was carried out in close cooperation with users with the help of focus groups and prototypes. Motivations and obstacles to using online self-help tools were illuminated. Privacy stood out as an important factor when developing online tools. The study resulted in a website, www.sommarregn.se, entailing an online diary (private and encrypted), including scales, and a forum (members only access), including an e-mail function. Users’ experiences of the website over a 10 weeks test period were illuminated. The diary and forum appeared to fill a number of valuable functions, although a further development of the tool may enhance its usability, which was good. The tool promoted communication with the self and others. The Internet as a technology offered a number of advantages, such as convenience of use and perceived anonymity, and disadvantages, such as qualitative issues. The relatives’ needs ought to be addressed in order to support them in a daily life with depression. Empowered relatives are in a better position to help their ill kin and support may prevent ill health in the relatives themselves, and subsequently additional costs to society. Health care professionals meet patients that are also online health seekers. Professionals must be aware of the advantages and drawbacks of e-health when meeting patients. In an economically pressured society, alternative support options have to be explored in order to address the needs of target groups at risk.

Sigrid Kappa final.pdf (325.2Kb)

Oral health in an outpatient psychiatric population : oral status, li...
Persson, Karin : Faculty of Health and Society, Malmö University (2009)	DOCTORAL THESIS

English abstract:

Oral health has generally improved in Sweden over the past 30 years. Investigations of living conditions have indicated that people with chronic mental health problems requiring psychiatric services diverge from that pattern. Research into oral health-related quality of life in this group might enhance our knowledge of the relationship between oral health, health perceptions, life satisfaction, and oral status, and its impact on quality of life in people with mental health problems. It could contribute to the description and broaden the understanding of the concept quality of life. The overall aims of this thesis were to describe oral health and oral health-related quality of life in persons attending psychiatric outpatient services; and to investigate oral health in relation to its biological aspects and perceived quality of life, including self-related variables and social aspects. Additional aims were to describe how persons with severe mental illness perceive oral health problems and to analyze the support they receive in counteracting dry mouth. The population studied consisted of 113 persons attending outpatient psychiatric services who voluntarily underwent a visual oral examination and a structured interview monitoring different aspects of life. Ten persons took part in a longitudinal investigation of how people with severe mental illness perceive oral health problems and support by means of regular visits aimed to evaluate the increase of such support. The findings showed that people in the total cohort were missing an average of 2.4 teeth. Poor oral hygiene was found in 41% of the group and 44% had objective signs of dry mouth. Seventy percent were assessed to be in need of some kind of dental treatment: 50% were overdue for scaling and polishing, 13% required more extensive dental treatment, and in 7% the need was acute. Routine dental visits were not uncommon: 75% had visited the dentist during the last year. Use of psychopharmceuticals was prevalent: 65% reported taking two or more prescribed 10 drugs. The investigation improved the understanding of psychological aspects associated with oral health among those studied, and showed measurably lower scores on life satisfaction items than is found in the general population. Analyses of the relationships between perceived oral health-related quality of life and biological and psychological factors demonstrated a correlation with numbers of teeth, type of psychiatric diagnosis, and gender. In the study population, number of teeth, life satisfaction, perceived physical health, and gender were found important. In relation to the psychiatric diagnoses, number of teeth was a significant factor in participants diagnosed with mood disorders and within the schizophrenia spectra. In participants diagnosed with anxiety and other psychiatric diagnoses, life satisfaction and reliance on chance were significant. The perception of health explained the variance in males. To females, number of teeth, life satisfaction, dental fear, and reliance on chance were also significant factors. In the study describing experience of oral health and perceived support, the result was illustrated by five categories: feelings and experiences related to poor oral health, experiences of dental care, experience of self-care, strategies for handling poor oral health, and experience of support. Oral health was important to the informants’ ability to relate to their social environment. A compromised dental status caused feelings of shame and stigma. Dental care revealed positive as well as negative experiences associated with the provider’s ability to meet the informant’s special needs. Strategies for dealing with poor oral health were mostly circumventions and were at best given ad-hoc solutions. Receiving support in oral health matters from staff was almost perceived as offensive; oral care reminders were often disregarded in an apparent assertion of the autonomy of informants, even though such behaviour could have negative consequences for their health. In conclusion, the findings showed that dental status, expressed as numbers of missing teeth, was higher for those attending psychiatric outpatient services than in a general population. The need for prophylactic dental treatment was considerable, suggesting that oral health issues need to receive increased attention during the course of psychiatric care in order to treat the whole patient. Experiences of oral health-related quality of life are of importance to the total appreciation of quality of life in an individual. This study might also contribute to the understanding of health problems in an outpatient psychiatric population since the perception of oral health-related quality of life was found to be dependent on the particular psychiatric diagnosis and gender. Questions regarding oral health in people with severe mental illness need to receive increased interest from dental, psychiatric, and social services in order to encourage self-care and enhance the autonomy of individuals.

KP_kappa.pdf (1.272Mb)

In vitro and in vivo studies of salivary films at solid/liquid interf...
Svendsen, Ida Malmö University health and society doctoral dissertations;2 (2009)	DOCTORAL THESIS

English abstract:

A conditioning film, the pellicle, of which many salivary proteins are important constituents, covers the surfaces present in the mouth. The pellicle forms in a selective adsorption process, and it has protective and lubricating functions as well as an influence on the adherence of oral microbes that ultimately leads to the development of dental plaque. Understanding the interactions responsible for the selective pellicle formation would make it possible to strive at creating a pellicle that serves its protective and lubricating functions and also promotes a healthy biofilm for the benefit of the individual. The aim of this research was to characterize the adsorption of salivary proteins to different types of substrates, to evaluate the influence of different protein-surface interactions on the adsorption process, and also to assess substrate dependent differences in film composition. Furthermore, as it is well known that complexes form between different salivary proteins and mucins (large glycoproteins) in bulk saliva, the aim was also to study interactions between mucins and other pellicle constituents at the solid/liquid interface. Additionally, the effects of a surfactant, sodium dodecyl sulphate (SDS), on the protein films were investigated, to evaluate the stability of the films and also the possibilities to completely remove the in vivo formed pellicle. The adsorption experiments were performed in vitro using null ellipsometry, by which parameters such as adsorbed amount per unit area and average layer thickness can be obtained. Hydrophilic and hydrophobized silica were used as model substrates. The adsorption behaviour of the cationic, antimicrobial proteins lactoferrin, lactoperoxidase, lysozyme, and histatin 5 indicated that the adsorption on hydrophilic substrates was mainly driven by electrostatics, while on hydrophobized substrates hydrophobic interactions also influenced the adsorption process. Furthermore, it was shown that 12 sequential alternating adsorption of the anionic salivary mucin MUC5B and lactoperoxidase resulted in the build-up of multilayered structures on the surface. The rate of build-up was influenced by the surface characteristics. Sequential adsorption studies showed that neither MUC5B nor human whole saliva (HWS) was able to exchange substantial amounts of the pre-adsorbed anionic pellicle proteins acidic proline-rich protein 1 (PRP-1) or statherin, respectively. The resistance of the adsorbed mixed protein films to SDS elution depended on surface properties as well as on the number of layers adsorbed and adsorbed components. Pre-adsorbed PRP-1 was to some extent protected from SDS elution by the sequential adsorption of MUC5B to the PRP-1 film. Pellicles formed on natural tooth enamel were collected in vivo and investigated using two-dimensional gel electrophoresis (2-DE). Mechanicallyassisted SDS elution was used to collect the in vivo formed pellicle. The effectiveness of the collection procedure was validated in vitro by means of mechanical removal in combination with HCl treatment. The results indicated that rubbing the tooth surfaces with fibre pellets soaked in 0.5 % (w/v) SDS was sufficient to completely remove the pellicle from human enamel. In addition, 2-DE analysis of pellicles formed in vitro on human enamel and the dental materials titanium and poly (methyl methacrylate) (PMMA) showed differences in composition when compared to each other, revealing that the pellicle is influenced by the substrate properties.

Ida_Svendsen_thesis.pdf (849.4Kb)

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Rättssäkerhet och tvångsvård: en rättssociologisk studie
Staaf, Annika : Lund : Sociologiska institutionen, Univ. Lund studies in sociology of law;22 (2005)	DOCTORAL THESIS