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  • Public defence: 2018-04-26 13:00 Hörsal F, Humanisthuset, Umeå
    Bergström, Eva-Lena
    Umeå University, Faculty of Arts, Department of culture and media studies.
    Nationalmuseum i offentlighetens ljus: framväxten av tillfälliga utställningar 1866-19662018Doctoral thesis, monograph (Other academic)
    Abstract [en]

    The purpose of this study is to investigate the emergence of temporary exhibitions at the Nationalmuseum of Sweden 1866–1966. My aim is to discuss and place the exhibitions in the complex ongoing tension between the role of the museum as a scientific and an educative public institution, and in relation to the permanent collection. This I have called the museum dilemma. The dissertation is divided in three main chapters put in a chronological order 1866–1913, 1914–1939 and 1940–1966.

       I have found that during the 1866–1913 period many minor temporary exhibitions were arranged. It seems to have been a practice of coincidences rather than strategic art historical considerations. There were not many exhibitions focusing on art historical narratives. This situation reflects that the main reasons for arranging temporary exhibitions were to complement the museum collection or to present interesting art objects normally hidden from the public view.

    When the term “temporary exhibition” was established in the late 19th century a tension between the exhibitions and the permanent collection was established. The temporary exhibitions were associated with variety and flexibility while the permanent collection indicated a static art historical narrative.

    The 1914–1939 period was very socially inclined. There are many examples of exhibitions that openly supported national values and the ongoing democracy development and the exhibition practice developed in dialog with the museum´s collection. The concept “bringing art alive” was frequently used. The museum collections were talked about as dead material, the museum was called a morgue.

       During the Second World War, the collections were evacuated from the museum building and an innovative period began. A focus on art history dominates the more elaborated exhibition practice during 1939–1966 period, so called “epoch exhibitions”. They invited to innovative actions, technologies as reconstructions of historical exhibitions, mixed materials and rehanging during the exhibition period. Principles as flexibility and variation were prominent. Another common denominator was the scientific focus and the idea that the exhibition is both an experience and a source of knowledge.

       Even though half a century has passed I argue that the results I have found can be related to the museum practice of today. The tendency today is that temporary exhibitions functions as role models for museums, when re-organizing the permanent collections. The effect of this development is that the categories temporary exhibitions and permanent collection melt together. In that sense, I would also suggest that the term temporary exhibition should be replaced. Special exhibition seems to be a more appropriate term for the museums of today.

  • Public defence: 2018-04-27 09:00 Hörsalen Snäckan, Östersund
    de Flon, Pierre
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Treatment with the monoclonal antibody rituximab in Multiple Sclerosis: a study based on an academic clinical trial2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Multiple sclerosis (MS) is a chronic, inflammatory disease, affecting the central nervous system. A growing number of disease modifying treatment alternatives entails a need for an individualised risk-benefit- convenience analysis in the counselling of patients and methods to monitor the treatment effect, including markers for subclinical inflammation. Today, MRI and the biomarker neurofilament light chain (NFL) in cerebrospinal fluid (CSF- NFL) are commonly used. The development of new techniques for analysing NFL in very low concentrations in serum or plasma provides a promising opportunity for a less invasive method. Rituximab is a chimeric monoclonal antibody with B- cell depleting properties vastly used in rheumatological disease and certain haematological malignancies. Phase II studies have shown a beneficial effect on inflammation also in MS, the detailed mechanisms of action yet to be explained.

    Aims: The aims of this thesis were to evaluate rituximab as a treatment alternative in relapsing remitting MS (RRMS) by describing the clinical effect and patient related outcome measures after a switch of therapy from first-line injectables to rituximab and to explore possible immunological mechanisms of B cell depletion as well as to evaluate the use of neurofilament in plasma (p-NFL) as an end-point in a clinical trial setting.

    Methods: The thesis is based on the open-label phase II multicentre clinical trial Switch-To-RItuXimab in MS (STRIX-MS; EudraCT 2010-023021-38), in which 75 patients completed a therapy switch from first-line injectables to rituximab, and, to some part, the extended follow-up study, STRIX-MS extension (EudraCT 2013-002378-26). The disease modifying effect was evaluated by regular clinical evaluations, MRI and analyses of CSF-NFL. The clinical outcome was evaluated by the EDSS and SDMT scales. The questionnaires MSIS-29, FSMC and TSQM were used for the evaluation of patient related outcome measures. Immunological mechanisms of the B cell depletion were explored by the analysis of a broad panel of cyto- and chemokines in CSF by an electrochemiluminiscens method before and after therapy switch, and in comparison to healthy controls. The concentration of p-NFL was measured by an in-house NF-light assay on the Simoa platform with a Homebrew kit and explored for the use as a clinical trial end-point.

    Results: During the follow-up, signs of inflammatory activity decreased. Both the mean number of Gd enhancing lesions (0.03 vs 0.36, p=0.029) and the number of new or enlarged T2 lesions were reduced (0.01 vs 0.28, p=0.01). The mean concentration of CSF-NFL was reduced during the first year (491 vs 387, p=0.01). The corresponding reduction in plasma did not reach the level of statistical significance. The rating of overall treatment satisfaction improved significantly (6.3 vs 4.8, scale range 1-7, p<0.001). In the explorative immunological study, the immunological profile was altered after therapy switch with the most prominent reduction observed in the concentrations of IP-10 and IL-12/23p40.

    Conclusions: The results indicate a disease modifying effect of rituximab in line with other studies and provide support for a superior treatment satisfaction with rituximab as compared with injectable therapies. However, the lack of control group hampers the possibility to draw definite conclusions on the therapy effect. The immunological effects of B cell depletion need to be further explored.

  • Public defence: 2018-04-27 10:00 Norra beteendevetarhuset, HS1031, Umeå
    Åström, Elisabeth
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Being in balance or stuck in time: exploring facets of time processing in relation to mental health2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Time is central in human functioning and crucial for adaptive behavior. The aim of the current thesis was to investigate aspects of people’s subjective experience of time and their relationship with mental health, specifically anxiety and subjective well-being. Two time concepts were of key interest in the thesis: time estimation, which refers to the ability to estimate time durations; and time perspective, which refers to people’s habitual way of relating to the past, the present, and the future.

     The thesis comprehends four studies. In the first three studies, time perspective and time estimation were investigated in persons with varying degrees of anxiety, ranging from mild symptoms to anxiety disorders. The results of these studies showed that in particular negative past time perspective and negative future time perspective were associated with anxiety. These time perspectives were further strongly associated with the tendency to ruminate and worry. Time estimation did not largely deviate between persons with anxiety and healthy controls, although there was some evidence that subcomponents of anxiety might be differentially related to time estimation. More specifically, state anxiety was moderately related to retrospective time estimation, such that higher levels of state anxiety was associated with judging time intervals in retrospect as longer.

     In the final study of the thesis, balanced time perspective (BTP) was examined in relation to subjective well-being and age. BTP can be described as an optimal way of relating to the past, the present and the future and has been suggested to facilitate mental health and well-being. However, there are several ways to measure BTP, and there are also indications that what constitutes a BTP is not completely age-invariant or equally associated with well-being across age. The fourth study of the thesis thus aimed at examining three methods of measuring BTP, and each methods distinct association with subjective well-being and age were examined. The study was conducted in a population-based sample of older adults (age range 60 – 90 years of old). Results of this study indicated subjective well-being is strongly related to BTP, particularly methods of measuring BTP that incorporates negative future time perspective. However, the strong (and inverse) relationship between negative future time perspective and subjective well-being diminished with increasing age. Instead, and among the oldest participants in the sample (80+ years), fatalistic views of the present had more bearing on subjective well-being.

  • Public defence: 2018-04-27 10:15 Hörsal F, Umeå
    Karlsson, Tomas
    Umeå University, Faculty of Arts, Department of historical, philosophical and religious studies. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Låtsaskrigen: föreställningar om krig, maskulinitet och historia i krigsspel under 200 år2018Doctoral thesis, monograph (Other academic)
    Abstract [en]

    This thesis investigates how different wargames relate to notions of war, masculinity and history. It poses the question how the concept of authenticity is used in relation to wargames portrayal of war, masculinity and history. The outline of the thesis is chronological, spanning roughly from the 19th century to the present. It follows the development and use of wargames, predominately, but not exclusively in a Swedish setting.

    In the analysis a number of different sources are used, including wargaming rulebooks, computer wargames, wargaming magazines for hobbyists, research reports and works of military theory.

    In the military setting, wargames could be used to show how war functioned and to some degree what participating in war was like and how a future war would be fought. In that regard, the analysis show that one aspect of authenticity can be linked to the military utility of wargames as these were used as training tools and instructional devices within the military establishment. From a historical cultural viewpoint however, notions of authenticity in historical wargames can be linked to the construction and presentation of historical narratives and characters, predominantly masculine warrior heroes.

    The thesis shows that authenticity in wargames can be understood relating both to a military theoretical regime of knowledge as well as a form of history culture propagating notions of idealized masculinity. As wars are oftentimes portrayed as progressive historical events populated by masculine stereotypical heroes, great commanders are viewed as agents of history, and individual soldiers as eye-witnesses and participators in great events in history. In recreational wargames gamers are invited to play these roles. In military wargames, historical events and decisions made by historical characters can be discussed and analyzed. As such wargames in both the military and recreational setting are part and parcel of an idealized masculine military-themed history culture.

    To a notable degree, changes in media-technology influenced the notion and presentation of authenticity in wargames and the portrayal of war, masculinity and history in wargames varied as the way wars were being fought changed. Changes in media technology used to portray war also influenced the way these themes were presented in wargames. However, in both the military and recreational setting, notions of the masculine warrior hero in the shape of the great commander or in the shape of the technologically proficient, brave and reliable individual soldier was a recurring theme for 200 years.

  • Public defence: 2018-04-27 13:00 Sal D, Målpunkt T, våning 9, Umeå
    Johansson, Linda
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Rheumatology.
    Insights into the processes preceding the onset of rheumatoid arthritis2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Rheumatoid arthritis (RA) is a chronic inflammatory disease, characterized by the production of anti-citrullinated protein antibodies (ACPA) in the majority of all patients and a persistent inflammation in the synovial tissue leading to joint destruction. The aetiology of RA remains to a large extent unknown but is believed to be a complex interplay between genetic, environmental and stochastic factors. Recently, several infectious agents have been shown to have the capacity to induce citrullination of both endogenous and exogenous antigens e.g., Epstein-Barr virus (EBV) and Porphyromonas gingivalis (P.gingivalis). Disease progression in patients with RA is suggested to be a longstanding process that begins several years before symptom onset of RA. This hypothesis is supported by studies showing increased antibody levels against ACPA and disease related cytokines/chemokines several years before symptom onset of RA. The presence of ACPA is highly specific for RA and is already used as an indicator of progression and prognosis of the disease. This thesis is aimed to further investigate the origin and role of ACPA and the processes preceding the development of RA. New insights into these processes are of importance in order to be able to prevent the disease onset, achieve better diagnostic methods and treatments in the future.

    All of the individuals included in these papers, had attended to the Department of Rheumatology at Umeå University to receive their diagnosis of RA. The register of the patients were thereafter co-analysed with the register of the Medical Biobank of Northern Sweden. Plasma/sera samples were analysed for antibodies and receptor activator of nuclear factor kappa-B ligand (RANKL) using different ELISA techniques from individuals before symptom onset (pre-symptomatic individuals) and at disease onset (patients). Cytokines/chemokines were analysed using Meso Scale Discovery methods. Levels of marginal jawbone loss were measured using dental radiographs from premolar/molar regions. The Larsen score at disease onset was used to grade radiographs of hands and feet.

    In Paper I antibodies against Epstein-Barr virus nuclear antigen (EBNA) 1 and 2 (VCP1 and VCP2) and histone 4 (H4) derived citrullinated peptides (HCP1 and HCP2) were found to predate symptom onset of RA. In Paper II, antibodies against anti-P.gingivalis (anti-CPP3 and -RgpB IgG) were significantly increased in pre-symptomatic individuals and were detectable several years before symptom onset of RA. In Paper III the concentration of RANKL was shown to be increased several years before symptom onset of RA, especially in ACPA/rheumatoid factor (RF)/anti-carbamylated (CarP) antibody positive individuals. Positivity for RANKL was found to appear later in time than both positivity for ACPA, RF and anti-CarP antibodies. The highest Larsen score at disease onset was yielded when combining positivity for RANKL and anti-CarPivantibodies. In Paper IV periodontitis, defined as marginal jawbone loss was significantly higher in pre-symptomatic individuals who never smoked, compared with matched controls. RANKL positive individuals particularly those that were also ACPA positive, had a significantly greater extent of jawbone loss in comparison to those individuals who were RANKL negative.

    Antibodies against citrullinated exogenous and endogenous peptides were found to be associated with the symptom onset of RA. No hierarchy among the citrullinated epitopes could be identified. RANKL levels were particular increased in ACPA-positive individuals, and RANKL positivity appeared later in time than the general ACPA response. Periodontitis, defined as marginal jawbone loss was significantly higher in pre-symptomatic individuals, who never smoked.

  • Public defence: 2018-05-04 09:00 Vårdvetarhusets, aula, Umeå
    Backman, Annica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Leadership: person-centred care and the work situation of staff in Swedish nursing homes2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Swedish nursing home managers, who constitute the empirical focus of this thesis, hold overall operational responsibility for the nursing homes, which includes the care of residents, direct care staff and work environment. Aged care organisations are also expected to provide person-centred care. Working towards a person-centred approach poses new demands and leads to challenges for leaders, and there is currently limited knowledge of what characterises leadership that promotes a person-centred approach. In addition, an ongoing demographic shift in the aged care workforce entails further challenges, as the proportion of professional workers is decreasing. Leading a healthy work environment is therefore important for ensuring and protecting staff health. Based on this, it is important to explore nursing home managers’ leadership in relation to person-centred care and the work situation of staff.

    Aim: The overall aim was to explore leadership in relation to person-centred care and the work situation of staff in Swedish nursing homes.

    Methods: This thesis is based on data from two data collections. First, it includes cross-sectional baseline data from a national inventory of health and care in Swedish nursing homes (SWENIS) collected in 2013-2014. The SWENIS dataset consists of a sample of staff n=3605 from 169 nursing homes in 35 municipalities, and nursing home managers n=191. The second data collection consists of 11 semi-structured interviews with 12 nursing home managers in highly person-centred nursing homes that already participated in SWENIS. Data were explored via descriptive statistics, simple and multiple regression analyses, and qualitative content analysis.

    Results: Leadership was positively associated with person-centred care and psychosocial climate. Highly rated leadership behaviors’ among nursing homes managers was characterized by experimenting with new ideas, controlling work closely, relying on his/her subordinates, coaching and giving direct feedback, and handling conflicts constructively. Leading person-centred care can be outlined by four leadership processes: embodying person-centred being and doing; promoting a person-centred atmosphere; maximizing person-centred team potential and optimising person-centred support structures. Leadership was also positively associated with social support and negatively associated with job strain. Further, the variation in leadership was to a very small extent explained by the nursing home managers’ educational qualification, operational form of the nursing home and the number of employees in a unit.

    Conclusions: All findings point in the same direction: that leadership, as it is characterized and measured in this thesis, is significantly associated with person-centred care provision as well as with the work situation of staff. This suggests that nursing managers have a central leadership role in developing and supporting person-centred care practices, and also in creating a healthy work environment. The results also highlight five specific leadership behaviours that are most characteristic of highly rated leadership, thereby adding concrete descriptions of behaviours to the literature on existing leadership theories. The findings also include four central processes for leading towards person-centred care in nursing homes. Taken together, it seems important for managers to translate the person-centred philosophy into actions and to promote an atmosphere pervaded by innovation and trust, in which cultural change is enhanced by positive cultural bearers. Utilizing the overall knowledge and competencies among staff and potentiating care teams was also considered important for leading person-centred care, along with optimising supportive structures for supporting and maintaining person-centred care. If aged care organisations are to be committed to person-centred care, an important implication seems to be to organise nursing homes in a way that allows nursing home managers to be close and present in clinical practice and actively lead towards person-centred care. The findings of this thesis contribute to our understanding of leadership in relation to person-centre care and the work situation of staff. These findings can be used in leadership educations and nursing curriculum. Longitudinal studies would be valuable for following leadership, person-centred care and the work situation of staff over time.

  • Public defence: 2018-05-09 09:00 Hörsal D, Unod T9, Umeå
    Westerlund, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The role of implementation science in healthcare improvement efforts: investigating three complex interventions2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    For decades, scholars have found significant gaps between the knowledge available and the knowledge applied in healthcare. Many potential benefits of adequate knowledge based interventions are therefore never achieved. A considerable body of knowledge has evolved on how to promote a better uptake of evidence-based knowledge into routine use. Even so, the actual impact and usefulness of implementation research findings among healthcare practitioners have not been extensively studied.

    Accordingly, the overall aim of this thesis is to contribute to the understanding of how the implementation of complex interventions into healthcare can be improved. This is done by investigating whether some of these efforts do correspond with available scientific knowledge on implementation.

    The thesis is based on three cases contributing to four studies. The cases studied are: the National Perinatal Patient Safety program (NPPS), the Dynamic and Viable Organisation initiative (DVO), and the International Child Development Program (ICDP). All studies focuses on the early stages of implementation.

    A mixed methods approach was adopted, involving both qualitative and quantitative methods. Data collection consisted of interviews, questionnaires, observations, and process diaries. Qualitative content analysis (conventional and directed), descriptive and non-parametric statistics were used. The focus was on implementation strategies used by healthcare actors in relation to factors influencing implementation processes and outcomes. More specifically, healthcare actors perspectives on such factors and whether they were addressed by the strategies used, was investigated. A process evaluation of implementation outcomes was also part of the thesis.

    The healthcare actors in focus were the adopters, i.e. practitioners expected to change their work practices, and implementation facilitators. The latter refer to actors with a more or less explicit responsibility to implement new practices or interventions aimed at improving the quality and effectiveness of the provided health services.

    Variation was found regarding how the implementation strategies used in the three cases corresponded with available scientific knowledge on implementation. In Case NPPS, the implementation facilitators planned, designed, and ensured that the core interventions of the implementation strategy were executed in a rational manner. Several important implementation factors were addressed by the strategy. The process evaluation of effects on readiness for change by the development of a team mental model among adopters showed positive results.

    In Case DVO a strategy was used that evolved over time, partly based on raised questions and feedback from staff and managers involved. The strategy can be described as an intuitive ‘socially accomplished activity’. This strategy involved addressing ‘Implementation Process-related factors’ in order to affect motivation and increase the tension for change among adopters.

    In Case ICDP, the results reflected a shortage of strategies during the early stage of implementation. The main intervention was the stepwise ICDP-education. A more comprehensive implementation strategy covering implementation factors highlighted as important among adopters was not developed. The process evaluation revealed vague directives on what was expected regarding the use and adaptation of ICDP to current practice versus preservation of fidelity to the original ICDP. This situation resulted in a rather large variation in how the changes in work practices were perceived among the health centres involved. No health centre practiced ICDP in its original form.

    A new knowledge-practice gap is discussed based on the findings in this thesis: a gap between the scientific knowledge on implementation and the actual implementation strategies used in practice during improvement efforts initiated by healthcare actors. The findings show that correspondence between scientific knowledge on implementation and what is actually done in order to accomplish change in practice might be more random (or implicit) than systematic. The question of how to transfer scientific knowledge on implementation into user-friendly resources for practitioners is discussed. A tentative model is suggested, which contributes to existing determinant frameworks by focusing on relations among factors. The model may be used in healthcare practice, to guide the design of an implementation strategy (or as a pathway for tailored implementation interventions) and aid the assignment of responsibilities in relation to factors that are known to affect implementation processes and outcomes.

    The question of how to transfer models and frameworks into user-friendly resources needs further attention. It is suggested that action oriented research aiming at further developing and establishing the concept of ‘practical implementation science’ should be conducted. This could be a way of bridging the knowledge-practice gap in healthcare.

  • Public defence: 2018-05-18 10:00 Hörsal B, Samhällsvetarhuset, Umeå
    Zetterberg, Liv
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Tvångsvård i frihet: tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    This thesis aims to analyze compulsory community care (CCC) as a social and normative practice in different contexts in the Swedish welfare system. The research questions are:

    - How can the motives to introduce CCC in Sweden and other Western countries be understood?

    - What happens in and between psychiatric and social service organizations when CCC is implemented?

    - How are the legal rights of patients protected and what forms of social control of patients is discernible in written court decisions regarding CCC?

    - What normative positions regarding autonomy is the CCC legislation based on?

    - How can CCC be understood from steering, historic and power perspectives?

    The four first research questions corresponds to the four research studies included in the thesis and the fifth question relates to the material as a whole.

    The empirical material for the first study mainly consists of documents from the parliamentary process. For the second study, 15 interviews with employees in psychiatric and social services were conducted. For the third study, all written court decisions over a 6 month period (N=541) were investigated. In the fourth study, the analysis is primarily based on the current legislation and its history.

    Community care has already taken over most tasks of the old institutions. With the adoption of CCC, even the coercive measures are now formally found in community settings. CCC was adopted despite lack of evidence supporting its effectiveness. Although the policy process started in the aftermath of high-profile crimes, the government bill was focused on integration and rehabilitation with the stated intention to reduce coercive powers. While CCC entails an actual expansion of coercive powers, those coercive elements are downplayed in the bill. CCC allows for preventative restrictions on non-violent civilly committed patients. The CCC example shows that political steering is not something that automatically restricts discretion over the medical profession. Earlier political steering strategies had failed to reduce the excessive clinical use of use of temporary leave. The introduction of CCC meant that politicians adapted legislation to previously undesired practices.

    In psychiatric and social services, CCC is materialized as a physical object in the coordinated care plan. The interviewees talked about the template form for the coordinated care plan as almost synonymous with CCC. It helped clarify responsibilities and facilitated coordination between the organizations. These changes extended even beyond services for the targeted patients under CCC. The requirement of a coordinated care plan thus served as a political steering strategy for enhancing collaboration.

    In the written court decisions about CCC we found deficiencies in procedural fairness in all four requirements for a fair trial that were investigated: transparency, clarity, consistency and impartiality. For example, more than 99 % of the decisions were made in favor of the claims of treating psychiatrist and a substantial minority of courts routinely delegated decision-making authority to treating psychiatrists. The special provisions often involved surveillance controlling techniques. The control is mostly physical, because of the unique role of medication, but also spatial and temporal. Even though no formal coercive measures are allowed, the special provisions as controlling measures seem to have real impact on patients. CCC may therefore be understood as disciplinary power.

    A legal requisite for coercive care is that the patient oppose care. However, in practice it is assumed that a patient under CCC will accept the coercive elements (i.e. special provisions). The legal requisites for allowing and discharging from CCC are thus met at the same time. Restrictions of patient autonomy in the legislation is often motivated in terms of enhanced autonomy in the future, for example through avoiding relapse. Another rationale for the restriction of autonomy is to safeguard the health and quality of life of patients. There is no research evidence that compulsory community works. Accordingly, it is hard to identify what benefits CCC provide that can trump the autonomy of the patient.