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  • Public defence: 2019-10-18 09:00 Stora Hörsalen, 5B, Umeå
    Holmlund, Sophia
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Health professionals’ experiences and views related to obstetric ultrasound in Rwanda and Vietnam2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]


    Obstetric ultrasound has become an indispensable part of maternity care in high-income countries, where it is universally used for screening, diagnostic and surveillance purposes. In low-income countries, insufficient numbers of trained health professionals’ is commonly a barrier to obstetric ultrasound use. Globally, health professionals’ encounter complex clinical situations in which rapid technical improvements in fetal surveillance and pregnancy interventions are components that influence clinical decisions, thereby implicating maternal and fetal health outcomes.


    The overall aim of this thesis was to explore health professionals’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects, in two low-to-middle-income countries with different characteristics, cultures, religions and health care systems.


    Study I (Rwanda) and Study III (Vietnam) are based on focus group discussions in which data were analysed using content analysis. Study I included six focus group discussions with 23 midwives recruited from six different hospitals in the area of Kigali and in the Southern province. Study III included four focus group discussions with 25 midwives working at three different hospitals in the Hanoi area. Study II (Rwanda) and Study IV (Vietnam) are cross-sectional studies using descriptive statistics, Pearson’s chi-square test and logistic regression analyses. A questionnaire, including items based on the results from previous qualitative studies, was used as the data collection tool. For Study II, health professionals (midwives, nurses, obstetricians, other physicians; N=907) working at 108 health facilities representing all provinces of Rwanda were recruited. Study IV constituted a regional sample of 824 health professionals (midwives, obstetricians/gynecologists) working at 29 health facilities in urban, semi-urban and rural parts of Hanoi, Vietnam.

    Main findings

    Obstetric ultrasound was regarded as a highly valued tool for pregnancy management in Rwanda as well as in Vietnam (Papers I–IV). In Rwanda, access to ultrasound was described as poor, especially for women living in rural areas (Paper I). In contrast, access to obstetric ultrasound was described as being very high in all health facilities in urban, semi-urban and rural areas of Hanoi (Paper III & Paper IV). In Rwanda, if a pregnancy was considered normal, obstetric ultrasound was not routinely performed (Paper I), while pregnant women in Vietnam were reported as undergoing several further ultrasound examinations in addition to the three examinations recommended by the Ministry of Health (Paper III). Midwives in Rwanda expressed a need to be trained in ultrasound, particularly those working at health centres in rural areas where ultrasound was rarely available (Paper I). A majority of health professionals (91%) also agreed that maternity care in Rwanda would improve if midwives were qualified to perform basic ultrasound examinations (Paper II). Sub-optimal pregnancy management due to a lack of or insufficient ultrasound training was reported by health professionals in both Rwanda (65%; Paper II) and Vietnam (37%; Paper IV). The use of obstetric ultrasound without medical indication was described as a troubling phenomenon, especially in Vietnam, where participants also reported that pregnant women sometimes replaced antenatal care surveillancewith ultrasound examinations (Paper III).


    Obstetric ultrasound plays a significant role in pregnancy management in Rwanda, although access varies significantly. The findings indicate that physicians in Rwanda are in need of additional formal ultrasound training in order to increase the quality of ultrasound surveillance and to improve maternal and fetal health outcomes. To increase ultrasound access for all pregnant women in Rwanda, midwives could potentially be trained to perform basic ultrasound examinations. In the Hanoi area of Vietnam, ultrasound is a well-integrated tool in pregnancy management and access was high. However, overuse and commercialisation of obstetric ultrasound examinations were described as common and need to be addressed to achieve adequate allocation of resources. The rapid development of technology in maternity care needs to be accompanied by medical guidelines stating the appropriate indications for ultrasound surveillance.

  • Public defence: 2019-10-18 10:15 S213H, Umeå
    Gümüscü, Ahmet
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Socialtjänsten och familjen: socialarbetares konstruktion av familj och insatser i familjerelaterad komplexitet2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The aim of this dissertation is to describe and analyse how social workers in Swedish social services define “family” and handle complexity when they work with families, and especially “families with complex needs” as the target of their interventions. Whereas families with complex needs can be understood to involve one or more family members having two or more simultaneously occurring needs or problems (e.g. mental health issues, addiction, financial problems, dysfunctionality, child abuse, ageing, disabilities, and family violence), complexity in social work extends beyond that which exists in families. Therefore, to broaden our understanding of these complexities in social work, this research sought answers to the following questions:

    • How do social workers define and set boundaries around the concept of “family” when they target their interventions? How do these definitions differ between different sectors of the social services – elderly care, disability care, addiction, child welfare, and financial assistance? (study I)

    • How do social workers involve families and family members in the casework from intake and through the investigation process within different social service sectors? What happens to the conceptualisation of family through an investigation process? (study II)

    • How do social workers in child welfare services describe and manage complexity in their work generally and when they work with families with complex needs? (study III)

    • How then do social workers in different service sectors conceive of and manage complexities in their everyday work, especially when it comes to families with complex needs? (study IV)

    The empirical material in studies I and IV consists of telephone interviews with 60 social workers working in five different sectors in four municipalities. Study II is based on five focus group interviews with social workers working in five different sectors in one larger municipality. Study III is based on focus groups with vignettes with social workers working in child welfare in three municipalities.

    In the first study findings revealed that different mediating mechanisms were adopted by social workers in what can be understood to be a deconstruction of the family. These mechanisms included legislation (as a control mechanism), household composition (boundary mechanism) and service needs (professional mechanism), which were used in various ways and to differing degrees within each sector. The five unique and sector-specific conceptualisations of families are implicated in how interventions are constructed and work processes targeted at individuals and families.

    In the second study findings showed that clienthood and family are interpreted in different ways. The family was brought into or kept out of service provisions in ways that were connected to social workers’ construction of the family either as expert, client or non-client. How social workers understood the role of the family changed during the casework process. In the third study, findings showed that social workers were challenged in their everyday work where they focused on immediate conditions for children while avoiding problems that were less amenable to being solved. Social workers tried to manage complexities related to families by either sorting prioritizing or oscillating between different child welfare orientations. In the fourth study, findings showed that there were different types of reported complex needs: deeprooted needs and broad-based needs. Complex family needs were transformed into complex cases by social workers, based on considerations of family composition, relationships between clients and social workers, and organizational contexts of practice. The boundaries between these three domains were not distinct, and the interconnectivity and complexities occurring in and between them contributed to the production of much of the “wickedness” that exists in social work practice.

    A main conclusion is that the concept of family is understood and targeted differently in different sectors of social work. In some cases, the use of the family concept can be related to the clients' specific needs. Families who social workers meet often have combinations of needs and problems that result in numerous interventions from the social services. When social workers meet these families, they can feel ambiguity and uncertainty because of the complexity of the needs or other complexities. And, in individualised social services, a narrow focus on the needs of individuals can make it difficult to see the situation of the family as a whole. This research highlights the importance of bringing this web of complexities to the forefront of practice.

  • Public defence: 2019-10-18 13:00 S Hörsal 205, Umeå
    Byström, Joakim
    Umeå University, Faculty of Social Sciences, Department of Geography. Umeå Universitet.
    Tourism Development in Resource Peripheries: conflicting and Unifying Spaces in Northern Sweden2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The northern Swedish inland is a sparsely populated area with a historical dependence upon natural-resource extraction. Therefore, this region has traditionally been defined as a resource periphery for extractive purposes. However, the rise of tourism challenges this narrative by producing a pleasure periphery for touristic purposes. A pleasure periphery in this context is linked to nature-based tourism that sells dreams of pristine nature and/or vast wilderness. This touristic “story” therefore becomes an antithesis to the region's industrial past. The overlapping touristic and extractive spaces, and their seemingly conflicting development narratives, constitute the theoretical approach to tourism development in the scope of this thesis. Further, this thesis adds to theorizing tourism development in northern peripheries, by contesting established development theories against each other in a northern Swedish setting. Multiple methods using both quantitative and qualitative data are used to answer the questions in this thesis.

    Three conclusions can be derived based on the empirical findings. Firstly, established tourism development theories are at risk of being invalid in more peripheral settings. As an example, protected areas constitute a poor development strategy, and are not producing tourism employment as shown in studies from more densely populated regions. Other destination-development theories presupposing urban-like infrastructure, which is absent in peripheries, also become invalid. Secondly, conflicts between tourism and extractive industries do occur at the discursive level where they tend to be described in dualistic terms. However, in terms of labor-market processes, findings show that tourism and resource extraction are actually rather interrelated. Within mining tourism, such a related diversification occurs due to the spatial distribution of mining and tourism skills and the interaction between them. Thirdly, the location of tourism destinations is broadly governed by resource-extractive infrastructure. Therefore, tourism destinations are normally located in places that have previously been made accessible via investments in the resource-extractive sector. Hence, resource extraction projects (unintentionally) produce accessibility to the touristic “wilderness”.

    In summary, resource extraction becomes a precondition for tourism development in northern Sweden, rather than a conflicting land-use competitor. Therefore, planners and decision makers should consider incorporating aspects of tourism in future plans for resource extraction as these industries often spatially overlap, intertwine, and consequently form a development symbiosis in northern resource peripheries.

  • Public defence: 2019-10-25 09:00 9D, 9th Floor, Tandläkarhuset, Umeå
    Tinc, Pamela J.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Raising the (roll)bar: exploring barriers and facilitators to research translation in US public health2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background In public health, implementation science work is crucial to protecting the safety and health of populations. Despite this, such efforts have been extremely limited within the specific public health field of occupational safety and health. The overall aim of this thesis is to examine the concept of research translation, the barriers and facilitators that researchers have faced in translating research to the worker environment, and the process of scaling up an evidence-based agricultural safety program. Additionally, this study will provide an opportunity to adapt the clinically based Consolidated Framework for Implementation Research (CFIR), as well as the Proctor Taxonomy (of implementation outcomes), to occupational safety settings.

    The implementation research conducted within this dissertation is focused on a case study in agricultural safety. With an annual fatality rate seven times higher than the all-worker fatality rate, agriculture is one of the most dangerous occupations to work in. Though nearly all aspects of farming can be considered dangerous, tractor overturns claim the greatest number of lives. Rollover protective systems (ROPS) are 99% effective in preventing death and disability in the event of an overturn when used with seatbelts. The ROPS Rebate Program was developed in 2006 to encourage the installation of retrofit ROPS in New York State and has been shown to be effective in this goal and in the long-term goal of reducing overturn fatalities. After expanding to six additional states, the National Tractor Safety Coalition was formed in order to facilitate the scaling up of the ROPS Rebate Programs. The National ROPS Rebate Program (NRRP) was formally announced in June 2017, though implementation of it is currently ongoing. 

    Methods This dissertation is composed of five sub-studies which applied a mixed methods approach. Sub-study I consisted of a scoping literature review. Manuscripts were identified through six databases to explore how research translation is discussed among the research community. In addition, the review aimed at assessing the T0-T4 model of research translation (first developed by the National Institutes of Health) as it applies to agriculture, forestry, and fishing safety and health and used knowledge gained through the review to make modifications to this model.

    To apply the CFIR and Proctor Taxonomy to agricultural safety settings (sub-study II), a survey was developed to assess the relevance of the constructs included in each framework to the NRRP implementation. The final survey was distributed to members of the National Tractor Safety Coalition. Using the results from this survey, quantitative and qualitative evaluation tools were developed.

    Sub-study III utilized a repeat measure survey collected at four time points to capture changes in CFIR and Proctor constructs over time. Correlational analyses were conducted to compare each survey item to three outcome measures: state progress toward securing rebate funding for the Program, farmers intakes into the Program, and completed retrofits

    Thirteen individuals participated in qualitative research interviews for sub-study IV; nine of these individuals also participated in follow-up interviews. Interview guides were developed based on the survey results in sub-study III. Grounded Theory Situational Analysis was used to analyze each set of data. 

    Sub-study V was developed as a result of missing data from sub-studies III and IV. To conduct this analysis, media reports published about the ROPS Rebate Programs were collected. Discourse analysis for print media was used to assess the media reports in comparison to the ROPS Rebate Program trajectory in each state and nationally. 

    ResultsSub-study I led to the development of a modified T0-T4 research translation model, which takes into account the real-life challenges in moving proven innovations into widespread practice. The remaining sub-studies in this dissertation focused in the T3 phase of this model (widespread adoption). Sub-study II led to the identification of 21 CFIR and Proctor constructs that National Tractor Safety Coalition members believed would be important to the NRRP implementation. Sub-study III demonstrated that eight CFIR and Proctor constructs were highly correlated (rho ≥ 0.5) with at least one of the outcome measures (progress, intakes, or retrofits). Two primary themes were developed from the qualitative portion of the study (sub-study IV): 1) the implementation strategy evolved inconsistently across stakeholders, and 2) stakeholder engagement is a function of perceived feasibility and "small wins." Finally, sub-study V identified components of successful media strategies for implementation including diversity in actors and messages, timing, and frequency. In total, sub-studies III-V identified 27 CFIR and Proctor constructs that were relevant to the implementation of the NRRP, 10 of which were identified in more than one study. 

    ConclusionsThis dissertation has served to examine, specifically, the implementation of the NRRP, and more generally, the field of implementation science as it applies to occupational safety and health. The methods applied in this study as well as the findings have resulted in: application of implementation frameworks to the field of agricultural safety and health, assessment of the unique challenges associated with initiatives to scale up innovations, assessment of implementation from the perspective of the CFIR and Proctor Taxonomy, and assessment of the use of media advocacy as an implementation strategy. The knowledge gained through this research will be helpful in improving the implementation of the NRRP and in developing implementation science efforts within the specific public health field of occupational safety and health. 

  • Public defence: 2019-11-01 09:00 KBE301, Umeå
    Engvall, Sara
    Umeå University, Faculty of Science and Technology, Department of Science and Mathematics Education.
    Opening the black box of mathematics teachers’ professional growth: a study of the process of teacher learning2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    There is a lot of research done on professional development programs for teachers, especially with a focus on different characteristics of the program and whether it makes teachers change their teaching practice to such an extent that it enhances student achievement. However, there is not much research done on the learning process. As long as we do not open the black box of teacher learning it is difficult to say anything about what characteristics in a professional development program actually are important for teachers to learn, develop and grow as professionals.

    The aim of the thesis is to better understand the process of teacher learning while participating in aprofessional development program. The focus is on different aspects of the process of teacher professional growth, as well as on external factors that have an impact on the process of learning. The participants are secondary school teachers that participated in a professional development program in formative assessment. The data have been collected during and after the professional development program took place. Different types of data have been used in this thesis; teacher interviews, classroom observations and questionnaires, and have been collected over a time period of two and a half years. In two of the included papers the studies focus on four mathematics teachers, and the learning process is explored from two different perspectives: how the professional growth can develop, and how their testing of formative assessment activities relates to their understanding of formative assessment. In one of the papers all secondary school teachers are included and a comparison in expectancy of being able to use high quality formative assessment after the professional development program between the mathematics teachers and the other teachers were conducted. In the fourth paper focus is on all mathematics teachers in the study and their motivation are investigated over a time period of two years.

    The four papers take different perspectives to explore the professional growth for teachers while participating in a professional development program in formative assessment. The results show the complexity of teacher learning and indicate that large-scale implementations risk being inefficient and not reach the intended goals.