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  • 301.
    Aléx, Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Astrid
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lundman, Berit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Construction of masculinities among men aged 85 and older in the north of Sweden2008In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 17, no 4, p. 451-459Article in journal (Refereed)
    Abstract [en]

    AIM: The aim was to analyse the construction of masculinities among men aged 85 and older. BACKGROUND: All societies have a gender order, constructed from multiple ideas of what is seen as feminine and masculine. As the group of men aged 85 and older is increasing in size and their demand for care will increase, we must recognize the importance of studying these men and various discourses of masculinities. DESIGN: Qualitative explorative. METHODS: Qualitative content analysis was used to analyse thematic narratives. Masculinity theories provided the point of departure for the analysis. RESULTS: The analysis coalesced into three masculinities. 'Being in the male centre', developed from subthemes as: taking pride in one's work and economic situation; being in the centre in relation to others; regarding women as sexual objects; and belonging to a select group. 'Striving to maintain the male facade' developed from subthemes as: emphasizing 'important' connections; having feelings of loss; striving to maintain old norms and rejecting the fact of being old. 'Being related' was formulated from subthemes as: feeling at home with domestic duties; being concerned; accepting one's own aging; and reflecting on life. CONCLUSIONS: Our study indicates the importance of being aware of the existence of multiple masculinities, in contrast to the generally unproblematic and unsubtle particular healthcare approaches which consider men as simply belonging to one masculinity. Relevance to clinical practice. Diverse masculinities probably affect encounters between men and healthcare providers and others who work with an older population and therefore our results are of importance in a caring context.

  • 302. Amaku, M
    et al.
    Azevedo, F
    Burattini, M N
    Coelho, G E
    Coutinho, F A B
    Greenhalgh, D
    Lopez, L F
    Motitsuki, R S
    Wilder-Smith, Annelies
    Massad, E
    Magnitude and frequency variations of vector-borne infection outbreaks using the Ross-Macdonald model: explaining and predicting outbreaks of dengue fever2016In: Epidemiology and Infection, ISSN 0950-2688, E-ISSN 1469-4409, Vol. 144, no 16, p. 3435-3450Article in journal (Refereed)
    Abstract [en]

    The classical Ross-Macdonald model is often utilized to model vector-borne infections; however, this model fails on several fronts. First, using measured (or estimated) parameters, which values are accepted from the literature, the model predicts a much greater number of cases than what is usually observed. Second, the model predicts a single large outbreak that is followed by decades of much smaller outbreaks, which is not consistent with what is observed. Usually towns or cities report a number of recurrences for many years, even when environmental changes cannot explain the disappearance of the infection between the peaks. In this paper, we continue to examine the pitfalls in modelling this class of infections, and explain that, if properly used, the Ross-Macdonald model works and can be used to understand the patterns of epidemics and even, to some extent, be used to make predictions. We model several outbreaks of dengue fever and show that the variable pattern of yearly recurrence (or its absence) can be understood and explained by a simple Ross-Macdonald model modified to take into account human movement across a range of neighbourhoods within a city. In addition, we analyse the effect of seasonal variations in the parameters that determine the number, longevity and biting behaviour of mosquitoes. Based on the size of the first outbreak, we show that it is possible to estimate the proportion of the remaining susceptible individuals and to predict the likelihood and magnitude of the eventual subsequent outbreaks. This approach is described based on actual dengue outbreaks with different recurrence patterns from some Brazilian regions.

  • 303. Amaku, Marcos
    et al.
    Covas, Dimas Tadeu
    Bezerra Coutinho, Francisco Antonio
    Azevedo Neto, Raymundo Soares
    Struchiner, Claudio
    Wilder-Smith, Annelies
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department Public Health and Clinical, Heidelberg Institute of Global Health, University of Heidelberg, Germany; Department of Disease Control, London School of Hygiene and Tropical, Medicine, U.
    Massad, Eduardo
    Modelling the test, trace and quarantine strategy to control the COVID-19 epidemic in the state of Sao Paulo, Brazil2021In: Infectious Disease Modelling, ISSN 2468-0427, Vol. 6, p. 46-55Article in journal (Refereed)
    Abstract [en]

    Testing for detecting the infection by SARS-CoV-2 is the bridge between the lockdown and the opening of society. In this paper we modelled and simulated a test-trace-and-quarantine strategy to control the COVID-19 outbreak in the State of Sao Paulo, Brasil. The State of Sao Paulo failed to adopt an effective social distancing strategy, reaching at most 59% in late March and started to relax the measures in late June, dropping to 41% in 08 August. Therefore, Sao Paulo relies heavily on a massive testing strategy in the attempt to control the epidemic.

    Two alternative strategies combined with economic evaluations were simulated. One strategy included indiscriminately testing the entire population of the State, reaching more than 40 million people at a maximum cost of 2.25 billion USD, that would reduce the total number of cases by the end of 2020 by 90%. The second strategy investigated testing only symptomatic cases and their immediate contacts - this strategy reached a maximum cost of 150 million USD but also reduced the number of cases by 90%. The conclusion is that if the State of Sao Paulo had decided to adopt the simulated strategy on April the 1st, it would have been possible to reduce the total number of cases by 90% at a cost of 2.25 billion US dollars for the indiscriminate strategy but at a much smaller cost of 125 million US dollars for the selective testing of symptomatic cases and their contacts. 

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  • 304. Aman, Malin
    et al.
    Forssblad, Magnus
    Henriksson-Larsén, Karin
    Insurance claims data: a possible solution for a national sports injury surveillance system? An evaluation of data information against ASIDD and consensus statements on sports injury surveillance2014In: BMJ Open, E-ISSN 2044-6055, Vol. 4, no 6, article id e005056Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Before preventive actions can be suggested for sports injuries at the national level, a solid surveillance system is required in order to study their epidemiology, risk factors and mechanisms. There are guidelines for sports injury data collection and classifications in the literature for that purpose. In Sweden, 90% of all athletes (57/70 sports federations) are insured with the same insurance company and data from their database could be a foundation for studies on acute sports injuries at the national level.

    OBJECTIVE: To evaluate the usefulness of sports injury insurance claims data in sports injury surveillance at the national level.

    METHOD: A database with 27 947 injuries was exported to an Excel file. Access to the corresponding text files was also obtained. Data were reviewed on available information, missing information and dropouts. Comparison with ASIDD (Australian Sports Injury Data Dictionary) and existing consensus statements in the literature (football (soccer), rugby union, tennis, cricket and thoroughbred horse racing) was performed in a structured manner.

    RESULT: Comparison with ASIDD showed that 93% of the suggested data items were present in the database to at least some extent. Compliance with the consensus statements was generally high (13/18). Almost all claims (83%) contained text information concerning the injury.

    CONCLUSIONS: Relatively high-quality sports injury data can be obtained from a specific insurance company at the national level in Sweden. The database has the potential to be a solid base for research on acute sports injuries in different sports at the national level.

  • 305.
    Amani, Paul Joseph
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Does health insurance contribute to improving responsiveness of the health system?: the case of elderly in rural Tanzania2022Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas.

    Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. 

    Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and quantile regression models were applied to analyse the association between health insurance and access to healthcare (sub-study 1) and responsiveness (sub-study 2), respectively. For both sub-studies 3 and 4, qualitative content analysis was used to analyse the data.

    Results: Sub-studies 1 and 2 involved a total of 1899 insured and uninsured elderly, while sub-studies 3 and 4 included 8 health providers and 78 elderlies respectively. Sub-study 1 showed that about 45% of the elderly were insured and HI ownership improved access and utilization of healthcare, both outpatient and inpatient services. In sub-study two, however, health insurance was associated with a lower responsiveness of the healthcare system. In general, all six domains: cleanliness, access, confidentiality, autonomy, communication, and prompt attention were rated high, but three were of concern: waiting time; cleanliness; and communication. Sub-study 3 uncovered several challenges coexisting alongside the provision of insurance benefits and thus contributing to a lower responsiveness. These included shortage of human resources and medical supplies, as well as operational issues related to delays in funding reimbursement. In sub-study 4, the elderly revealed that HI did not meet their expectations, it failed to promote equitable access, provided limited-service benefits and restricted use of services within residential areas. 

    Conclusion: While HI seems to increase the access to and use of healthcare services by the elderly in rural Tanzania, a lower responsiveness by the healthcare system among the insured elderly was reported. Long waiting times, limited-service benefits, restricted use of services within schemes, lack of health workforce in both numbers and skills as well as shortage of medical supplies were important explanations for the lower responsiveness. The results of this thesis, while supporting the national aim of expanding HI in rural areas, also exposed several weaknesses that require immediate attention. There is a need to, first, review the insurance policy to improve its implementation, expand the scope of services coverage, and where possible, to introduce cross-subsidization between the publicly owned schemes; additionally, improvements in the healthcare infrastructure, increasing the number of qualified health workforce and the availability of essential medicines and laboratory services, especially at the primary healthcare facilities, should be prioritized and further investments allocated.

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  • 306.
    Amani, Paul Joseph
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Frumence, Gasto
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Kiwara, Angwara Denis
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 1140Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.

    METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data.

    RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.

    CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.

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  • 307.
    Amani, Paul Joseph
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Kiwara, Angwara Denis
    Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study2023In: BMC Public Health, E-ISSN 1471-2458, Vol. 23, no 1, article id 459Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania.

    METHODS: An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data.

    RESULTS: Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement.

    CONCLUSION: While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.

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  • 308.
    Amani, Paul Joseph
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Kiwara, Angwara Denis
    Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    The experience of providing the health insurance benefits to elderly in rural Tanzania: Providers’ perspectivesManuscript (preprint) (Other (popular science, discussion, etc.))
  • 309.
    Amani, Paul Joseph
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    Tungu, Malale
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Kiwara, Angwara Denis
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Responsiveness of health care services towards the elderly in Tanzania: does health insurance make a difference? A cross-sectional study2020In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, no 1, article id 179Article in journal (Refereed)
    Abstract [en]

    Background: Responsiveness has become an important health system performance indicator in evaluating the ability of health care systems to meet patients' expectations. However, its measurement in sub-Saharan Africa remains scarce. This study aimed to assess the responsiveness of the health care services among the insured and non-insured elderly in Tanzania and to explore the association of health insurance (HI) with responsiveness in this population.

    Methods: A community-based cross-sectional study was conducted in 2017 where a pre-tested household survey, administered to the elderly (60 + years) living in Igunga and Nzega districts, was applied. Participants with and without health insurance who attended outpatient and inpatient health care services in the past three and 12 months were selected. Responsiveness was measured based on the short version of the World Health Organization (WHO) multi-country responsiveness survey study, which included the dimensions of quality of basic amenities, choice, confidentiality, autonomy, communication and prompt attention. Quantile regression was used to assess the specific association of the responsiveness index with health insurance adjusted for sociodemographic factors.

    Results: A total of 1453 and 744 elderly, of whom 50.1 and 63% had health insurance, used outpatient and inpatient health services, respectively. All domains were rated relatively highly but the uninsured elderly reported better responsiveness in all domains of outpatient and inpatient care. Waiting time was the dimension that performed worst. Possession of health insurance was negatively associated with responsiveness in outpatient (− 1; 95% CI: − 1.45, − 0.45) and inpatient (− 2; 95% CI: − 2.69, − 1.30) care.

    Conclusion: The uninsured elderly reported better responsiveness than the insured elderly in both outpatient and inpatient care. Special attention should be paid to those dimensions, like waiting time, which ranked poorly. Further research is necessary to reveal the reasons for the lower responsiveness noted among insured elderly. A continuous monitoring of health care system responsiveness is recommended.

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  • 310. Amaral, André F S
    et al.
    Newson, Roger B
    Abramson, Michael J
    Antó, Josep M
    Bono, Roberto
    Corsico, Angelo G
    de Marco, Roberto
    Demoly, Pascal
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gislason, Thorarinn
    Heinrich, Joachim
    Huerta, Ismael
    Janson, Christer
    Jõgi, Rain
    Kim, Jeong-Lim
    Maldonado, José
    Martinez-Moratalla Rovira, Jesús
    Neukirch, Catherine
    Nowak, Dennis
    Pin, Isabelle
    Probst-Hensch, Nicole
    Raherison-Semjen, Chantal
    Svanes, Cecilie
    Urrutia Landa, Isabel
    van Ree, Ronald
    Versteeg, Serge A
    Weyler, Joost
    Zock, Jan-Paul
    Burney, Peter G J
    Jarvis, Deborah L
    Changes in IgE sensitization and total IgE levels over 20 years of follow-up2016In: Journal of Allergy and Clinical Immunology, ISSN 0091-6749, E-ISSN 1097-6825, Vol. 137, no 6, p. 1788-1795Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Cross-sectional studies have reported a lower prevalence of sensitization in older adults, but few longitudinal studies have examined whether this is an aging or a year-of-birth cohort effect.

    OBJECTIVE: We sought to assess changes in sensitization and total IgE levels in a cohort of European adults as they aged over a 20-year period.

    METHODS: Levels of serum specific IgE to common aeroallergens (house dust mite, cat, and grass) and total IgE levels were measured in 3206 adults from 25 centers in the European Community Respiratory Health Survey on 3 occasions over 20 years. Changes in sensitization and total IgE levels were analyzed by using regression analysis corrected for potential differences in laboratory equipment and by using inverse sampling probability weights to account for nonresponse.

    RESULTS: Over the 20-year follow-up, the prevalence of sensitization to at least 1 of the 3 allergens decreased from 29.4% to 24.8% (-4.6%; 95% CI, -7.0% to -2.1%). The prevalence of sensitization to house dust mite (-4.3%; 95% CI, -6.0% to -2.6%) and cat (-2.1%; 95% CI, -3.6% to -0.7%) decreased more than sensitization to grass (-0.6%; 95% CI, -2.5% to 1.3%). Age-specific prevalence of sensitization to house dust mite and cat did not differ between year-of-birth cohorts, but sensitization to grass was most prevalent in the most recent ones. Overall, total IgE levels decreased significantly (geometric mean ratio, 0.63; 95% CI, 0.58-0.68) at all ages in all year-of-birth cohorts.

    CONCLUSION: Aging was associated with lower levels of sensitization, especially to house dust mite and cat, after the age of 20 years.

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  • 311. Ameh, Soter
    et al.
    D'Ambruoso, Lucia
    Gomez-Olive, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Klipstein-Grobusch, Kerstin
    Paradox of HIV stigma in an integrated chronic disease care in rural South Africa: Viewpoints of service users and providers2020In: PLOS ONE, E-ISSN 1932-6203, Vol. 15, no 7, article id e0236270Article in journal (Refereed)
    Abstract [en]

    Background

    An integrated chronic disease management (ICDM) model was introduced by the National Department of Health in South Africa to tackle the dual burden of HIV/AIDS and non-communicable diseases. One of the aims of the ICDM model is to reduce HIV-related stigma. This paper describes the viewpoints of service users and providers on HIV stigma in an ICDM model in rural South Africa.

    Materials and methods

    A content analysis of HIV stigmatisation in seven primary health care (PHC) facilities and their catchment communities was conducted in 2013 in the rural Agincourt sub-district, South Africa. Eight Focus Group Discussions were used to obtain data from 61 purposively selected participants who were 18 years and above. Seven In-Depth Interviews were conducted with the nurses-in-charge of the facilities. The transcripts were inductively analysed using MAXQDA 2018 qualitative software.

    Results

    The emerging themes were HIV stigma, HIV testing and reproductive health-related concerns. Both service providers and users perceived implementation of the ICDM model may have led to reduced HIV stigma in the facilities. On the other hand, service users and providers thought HIV stigma increased in the communities because community members thought that home-based carers visited the homes of People living with HIV. Service users thought that routine HIV testing, intended for pregnant women, was linked with unwanted pregnancies among adolescents who wanted to use contraceptives but refused to take an HIV test as a precondition for receiving contraceptives.

    Conclusions

    Although the ICDM model was perceived to have contributed to reducing HIV stigma in the health facilities, it was linked with stigma in the communities. This has implications for practice in the community component of the ICDM model in the study setting and elsewhere in South Africa.

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  • 312. Ameh, Soter
    et al.
    Gomez-Olive, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), Accra, Ghana.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), Accra, Ghana.
    Klipstein-Grobusch, Kerstin
    Relationships between structure, process and outcome to assess quality of integrated chronic disease management in a rural South African setting: applying a structural equation model2017In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 17, article id 229Article in journal (Refereed)
    Abstract [en]

    Background: South Africa faces a complex dual burden of chronic communicable and non-communicable diseases (NCDs). In response, the Integrated Chronic Disease Management (ICDM) model was initiated in primary health care (PHC) facilities in 2011 to leverage the HIV/ART programme to scale-up services for NCDs, achieve optimal patient health outcomes and improve the quality of medical care. However, little is known about the quality of care in the ICDM model. The objectives of this study were to: i) assess patients’ and operational managers’ satisfaction with the dimensions of ICDM services; and ii) evaluate the quality of care in the ICDM model using Avedis Donabedian’s theory of relationships between structure (resources), process (clinical activities) and outcome (desired result of healthcare) constructs as a measure of quality of care.

    Methods: A cross-sectional study was conducted in 2013 in seven PHC facilities in the Bushbuckridge municipality of Mpumalanga Province, north-east South Africa - an area underpinned by a robust Health and Demographic Surveillance System (HDSS). The patient satisfaction questionnaire (PSQ-18), with measures reflecting structure/process/outcome (SPO) constructs, was adapted and administered to 435 chronic disease patients and the operational managers of all seven PHC facilities. The adapted questionnaire contained 17 dimensions of care, including eight dimensions identified as priority areas in the ICDM model - critical drugs, equipment, referral, defaulter tracing, prepacking of medicines, clinic appointments, waiting time, and coherence. A structural equation model was fit to operationalise Donabedian’s theory, using unidirectional, mediation, and reciprocal pathways.

    Results: The mediation pathway showed that the relationships between structure, process and outcome represented quality systems in the ICDM model. Structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Of the 17 dimensions of care in the ICDM model, three structure (equipment, critical drugs, accessibility), three process (professionalism, friendliness and attendance to patients) and three outcome (competence, confidence and coherence) dimensions reflected their intended constructs.

    Conclusion: Of the priority dimensions, referrals, defaulter tracing, prepacking of medicines, appointments, and patient waiting time did not reflect their intended constructs. Donabedian’s theoretical framework can be used to provide evidence of quality systems in the ICDM model.

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  • 313.
    Ameh, Soter
    et al.
    Department of Community Medicine, Faculty of Medicine, College of Medical Sciences, University of Calabar, Calabar, Nigeria.
    Gómez-Olivé, Francesc X.
    Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), Accra, Ghana.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), Accra, Ghana.
    Klipstein-Grobusch, Kerstin
    Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Multilevel predictors of controlled CD4 count and blood pressure in an integrated chronic disease management model in rural South Africa: a panel study2020In: BMJ Open, E-ISSN 2044-6055, Vol. 10, no 11, article id e037580Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: In 2011, The National Department of Health introduced the Integrated Chronic Disease Management (ICDM) model as a pilot programme in selected primary healthcare facilities in South Africa. The objective of this study was to determine individual-level and facility-level predictors of controlled CD4 count and blood pressure (BP) in patients receiving treatment for HIV and hypertension, respectively.

    DESIGN: A panel study.

    SETTING AND PARTICIPANTS: This study was conducted in the Bushbuckridge Municipality, South Africa from 2011 to 2013. Facility records of patients aged ≥18 years were retrieved from the integrated chronic disease management (ICDM) pilot (n=435) and comparison facilities (n=443) using a three-step probability sampling process. CD4 count and BP control are defined as CD4 count >350 cells/mm3 and BP <140/90 mm Hg. A multilevel Least Absolute Shrinkage and Selection Operator binary logistic regression analysis was done at a 5% significance level using STATA V.16.

    PRIMARY OUTCOME MEASURES: CD4 (cells/mm3) count and BP (mm Hg).

    RESULTS: Compared with the comparison facilities, patients receiving treatment in the pilot facilities had increased odds of controlling their CD4 count (OR=5.84, 95% CI 3.21-8.22) and BP (OR=1.22, 95% CI 1.04-2.14). Patients aged 50-59 (OR=6.12, 95% CI 2.14-7.21) and ≥60 (OR=7.59, 95% CI 4.75-11.82) years had increased odds of controlling their CD4 counts compared with those aged 18-29 years. Likewise, patients aged 40-49 (OR=5.73, 95% CI 1.98-8.43), 50-59 (OR=7.28, 95% CI 4.33-9.27) and ≥60 (OR=9.31, 95% CI 5.12-13.68) years had increased odds of controlling their BP. In contrast, men had decreased odds of controlling their CD4 count (OR=0.12, 95% CI 0.10-0.46) and BP (OR=0.21, 95% CI 0.19-0.47) than women.

    CONCLUSION: The ICDM model had a small but significant effect on BP control, hence, the need to more effectively leverage the HIV programme for optimal BP control in the setting.

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  • 314. Ameh, Soter
    et al.
    Klipstein-Grobusch, Kerstin
    D'ambruoso, Lucia
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana.
    Gomez-Olive, Francesc Xavier
    Quality of integrated chronic disease care in rural South Africa: user and provider perspectives2017In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 32, no 2, p. 257-266Article in journal (Refereed)
    Abstract [en]

    The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients >= 18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian's structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low-and middle-income countries.

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  • 315. Ameh, Soter
    et al.
    Klipstein-Grobusch, Kerstin
    Musenge, Eustasius
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Sch Publ Hlth, Fac Hlth Sci, Med Res Council,Wits Univ Rural Publ Hlth, Johannesburg, South Africa ; Int Network Demog Evaluat Populat & Their Hlth De, Accra, Ghana ; Univ Witwatersrand, Sch Publ Hlth, Fac Hlth Sci, Hlth Transit Res Unit Agincourt, Johannesburg, South Africa.
    Tollman, Stephen
    Gomez-Olive, Francesc Xavier
    Effectiveness of an Integrated Approach to HIV and Hypertension Care in Rural South Africa: Controlled Interrupted Time-Series Analysis2017In: Journal of Acquired Immune Deficiency Syndromes, ISSN 1525-4135, E-ISSN 1944-7884, Vol. 75, no 4, p. 472-479Article in journal (Refereed)
    Abstract [en]

    Background: South Africa faces a dual burden of HIV/AIDS and noncommunicable diseases. In 2011, a pilot integrated chronic disease management (ICDM) model was introduced by the National Health Department into selected primary health care (PHC) facilities. The objective of this study was to assess the effectiveness of the ICDM model in controlling patients' CD4 counts (>350 cells/mm(3)) and blood pressure [BP (<140/90 mm Hg)] in PHC facilities in the Bushbuckridge municipality, South Africa. Methods: A controlled interrupted time-series study was conducted using the data from patients' clinical records collected multiple times before and after the ICDM model was initiated in PHC facilities in Bushbuckridge. Patients >18 years were recruited by proportionate sampling from the pilot (n = 435) and comparing (n = 443) PHC facilities from 2011 to 2013. Health outcomes for patients were retrieved from facility records for 30 months. We performed controlled segmented regression to model the monthly averages of individuals' propensity scores using autoregressive moving average model at 5% significance level. Results: The pilot facilities had 6% greater likelihood of controlling patients' CD4 counts than the comparison facilities (coefficient = 0.057; 95% confidence interval: 0.056 to 0.058; P < 0.001). Compared with the comparison facilities, the pilot facilities had 1.0% greater likelihood of controlling patients' BP (coefficient = 0.010; 95% confidence interval: 0.003 to 0.016; P = 0.002). Conclusions: Application of the model had a small effect in controlling patients' CD4 counts and BP, but showed no overall clinical benefit for the patients; hence, the need to more extensively leverage the HIV program for hypertension treatment.

  • 316.
    Amgarth-Duff, Ingrid
    et al.
    University of Technology Sydney, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Sydney, NSW, Australia; Telethon Kids Institute, Perth, Western Australia.
    Hosie, Annemarie
    University of Technology Sydney, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Sydney, NSW, Australia; The University of Notre Dame Australia, School of Nursing & Midwifery, Darlinghurst, NSW, Australia; St Vincent’s Health Network Sydney, The Cunningham Centre for Palliative Care, Darlinghurst, NSW, Australia.
    Caplan, Gideon A.
    Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia; Department of Geriatric Medicine, Prince of Wales Hospital, Randwick, NSW, Australia.
    Adamis, Dimitrios
    Sligo Mental Health Services, Clarion Road, Sligo, Ireland.
    Watne, Leiv Otto
    Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo, Norway; Oslo University Hospital, Oslo, Norway.
    Cunningham, Colm
    Trinity Biomedical Sciences Institute; Trinity College Institute of Neuroscience, Trinity College, Dublin.
    Oh, Esther S.
    John Hopkins University School of Medicine, Baltimore, MD, USA.
    Wang, Sophia
    Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA.
    Lindroth, Heidi
    Mayo Clinic, Department of Nursing, Division of Nursing Research, Rochester, MN, USA; Indiana University, School of Medicine, Center for Health Innovation and Implementation Science, USA; Center for Aging Research, Regenstrief Institute, USA.
    Sanders, Robert D.
    University of Sydney, Camperdown, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Girard, Timothy D.
    University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
    Steiner, Luzius A.
    Department of Anesthesiology, University Hospital Basel and Department of Clinical Research, University of Basel, Basel, Switzerland.
    Vasunilashorn, Sarinnapha M.
    Beth Israel Deaconess Medical Centre, Boston, Massacheusetts, USA; Harvard Medical School, Boston, Massacheusetts, USA; Harvard T.H Chan, School of Public Health, Boston, Massacheusetts, USA.
    Agar, Meera
    University of Technology Sydney, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Sydney, NSW, Australia; South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia; Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia.
    Reporting essentials for DElirium bioMarker studies (REDEEMS): explanation and elaboration2022In: Delirium Communications, ISSN 2959-104XArticle in journal (Refereed)
    Abstract [en]

    Despite many studies of potential delirium biomarkers, delirium pathophysiology remains unclear. Evidence shows that the quality of reporting delirium biomarker studies is sub-optimal. Better reporting of delirium biomarker studies is needed to understand delirium pathophysiology better. To improve robustness, transparency and uniformity of delirium biomarker study reports, the REDEEMS (Reporting Essentials for DElirium bioMarker Studies) guideline was developed by an international group of delirium researchers through a three-stage process, including a systematic review, a three-round Delphi study, and a follow-up consensus meeting. This process resulted in a 9-item guideline to inform delirium fluid biomarker studies. To enhance implementation of the REDEEMS guideline, this Explanation and Elaboration paper provides a detailed explanation of each item. We anticipate that the REDEEMS guideline will help to accelerate our understanding of delirium pathophysiology by improving the reporting of delirium biomarker research and, consequently the capacity to synthesise results across studies.

  • 317.
    Aminoff, Carina
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lind, Nadja
    Umeå University, Faculty of Medicine, Department of Nursing.
    Distriktssköterskors upplevelse av sitt arbete efter kommunalisering av hemsjukvården: en intervjustudie2014Independent thesis Advanced level (degree of Master (One Year)), 10 credits / 15 HE creditsStudent thesis
    Abstract [sv]

    Syftet med denna studie var att beskriva hur distriktssköterskor på hälsocentral uppleversitt arbete sedan hemsjukvården överförts till kommunen. Åtta distriktssköterskor på fyraolika hälsocentraler intervjuades, texten analyserades med kvalitativ innehållsanalys. Iresultatet framkommer tre kategorier med vardera två underkategorier; en dimension somförsvann som beskriver förlust av frihet och förlust av helhet, distriktssköterskan som bromellan organisationerna som beskriver distriktssköterskan som mellanhand och dennesoro för patientsäkerheten samt distriktssköterskans mottagning i fokus som beskrivermindre splittring, mer tid, ökad trivsel och att variationen i arbetet har fortsatt medinriktning mot specialisering och prevention. Sammanfattningen är att distriktssköterskorupplevde en förlust över att inte vara verksam i hemsjukvård, men som positivtövervägdes av möjligheten att fokusera på hälsocentralens mottagning, men trotskommunaliseringen upplevde distriktssköterskorna att de behövde utföra vissahemsjukvårdsuppdrag åt kommunens sjuksköterskor på bekostnad av hälsocentralens tid.

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  • 318.
    Aminoff, Hedvig
    et al.
    Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden.
    Meijer, Sebastiaan
    Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden.
    Arnelo, Urban
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Groth, Kristina
    Innovation Center, Karolinska University Hospital, Stockholm, Sweden.
    Modeling the implementation context of a telemedicine service: Work domain analysis in a surgical setting2021In: JMIR Formative Research, E-ISSN 2561-326X, Vol. 5, no 6, article id e26505Article in journal (Refereed)
    Abstract [en]

    Background: A telemedicine service enabling remote surgical consultation had shown promising results. When the service was to be scaled up, it was unclear how contextual variations among different clinical sites could affect the clinical outcomes and implementation of the service. It is generally recognized that contextual factors and work system complexities affect the implementation and outcomes of telemedicine. However, it is methodologically challenging to account for context in complex health care settings. We conducted a work domain analysis (WDA), an engineering method for modeling and analyzing complex work environments, to investigate and represent contextual influences when a telemedicine service was to be scaled up to multiple hospitals.

    Objective: We wanted to systematically characterize the implementation contexts at the clinics participating in the scale-up process. Conducting a WDA would allow us to identify, in a systematic manner, the functional constraints that shape clinical work at the implementation sites and set the sites apart. The findings could then be valuable for informed implementation and assessment of the telemedicine service.

    Methods: We conducted observations and semistructured interviews with a variety of stakeholders. Thematic analysis was guided by concepts derived from the WDA framework. We identified objects, functions, priorities, and values that shape clinical procedures. An iterative “discovery and modeling” approach allowed us to first focus on one clinic and then readjust the scope as our understanding of the work systems deepened.

    Results: We characterized three sets of constraints (ie, facets) in the domain: the treatment facet, administrative facet (providing resources for procedures), and development facet (training, quality improvement, and research). The constraints included medical equipment affecting treatment options; administrative processes affecting access to staff and facilities; values and priorities affecting assessments during endoscopic retrograde cholangiopancreatography; and resources for conducting the procedure.

    Conclusions: The surgical work system is embedded in multiple sets of constraints that can be modeled as facets of the system. We found variations between the implementation sites that might interact negatively with the telemedicine service. However, there may be enough motivation and resources to overcome these initial disruptions given that values and priorities are shared across the sites. Contrasting the development facets at different sites highlighted the differences in resources for training and research. In some cases, this could indicate a risk that organizational demands for efficiency and effectiveness might be prioritized over the long-term outcomes provided by the telemedicine service, or a reduced willingness or ability to accept a service that is not yet fully developed or adapted. WDA proved effective in representing and analyzing these complex clinical contexts in the face of technological change. The models serve as examples of how to analyze and represent a complex sociotechnical context during telemedicine design, implementation, and assessment.

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  • 319. Amirian, E. Susan
    et al.
    Ostrom, Quinn T.
    Armstrong, Georgina N.
    Lai, Rose K.
    Gu, Xiangjun
    Jacobs, Daniel I.
    Jalali, Ali
    Claus, Elizabeth B.
    Barnholtz-Sloan, Jill S.
    Il'yasova, Dora
    Schildkraut, Joellen M.
    Ali-Osman, Francis
    Sadetzki, Siegal
    Jenkins, Robert B.
    Lachance, Daniel H.
    Olson, Sara H.
    Bernstein, Jonine L.
    Merrell, Ryan T.
    Wrensch, Margaret R.
    Johansen, Christoffer
    Houlston, Richard S.
    Scheurer, Michael E.
    Shete, Sanjay
    Amos, Christopher I.
    Melin, Beatrice S.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Bondy, Melissa L.
    Aspirin, NSAIDs, and Glioma Risk: Original Data from the Glioma International Case-Control Study and a Meta-analysis2019In: Cancer Epidemiology, Biomarkers and Prevention, ISSN 1055-9965, E-ISSN 1538-7755, Vol. 28, no 3, p. 555-562Article in journal (Refereed)
    Abstract [en]

    Background: There have been few studies of sufficient size to address the relationship between glioma risk and the use of aspirin or NSAIDs, and results have been conflicting. The purpose of this study was to examine the associations between glioma and aspirin/NSAID use, and to aggregate these findings with prior published studies using meta-analysis.

    Methods: The Glioma International Case-Control Study (GICC) consists of 4,533 glioma cases and 4,171 controls recruited from 2010 to 2013. Interviews were conducted using a standardized questionnaire to obtain information on aspirin/NSAID use. We examined history of regular use for ≥6 months and duration-response. Restricted maximum likelihood meta-regression models were used to aggregate site-specific estimates, and to combine GICC estimates with previously published studies.

    Results: A history of daily aspirin use for ≥6 months was associated with a 38% lower glioma risk, compared with not having a history of daily use [adjusted meta-OR = 0.62; 95% confidence interval (CI), 0.54–0.70]. There was a significant duration-response trend (P = 1.67 × 10−17), with lower ORs for increasing duration of aspirin use. Duration-response trends were not observed for NSAID use. In the meta-analysis aggregating GICC data with five previous studies, there was a marginally significant association between use of aspirin and glioma (mOR = 0.84; 95% CI, 0.70–1.02), but no association for NSAID use.

    Conclusions: Our study suggests that aspirin may be associated with a reduced risk of glioma.

    Impact: These results imply that aspirin use may be associated with decreased glioma risk. Further research examining the association between aspirin use and glioma risk is warranted.

  • 320.
    Amnesäter, Dahlia
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy.
    Olovsson, Kristina
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy.
    Transitionsprocessen: Upplevelser av att flytta hemifrån för unga vuxna med rörelsehinder2012Independent thesis Basic level (degree of Bachelor), 10 credits / 15 HE creditsStudent thesis
    Abstract [sv]

    Att flytta hemifrån innebär både möjligheter och ansvar för sig själv och sitt boende. För unga vuxna med funktionsnedsättning kan detta bli en stor utmaning som, enligt olika studier, kräver stöd från olika håll. Övergången till vuxenlivet utmanar även individens förmåga att klara sig själv. Självständighet kan ses utifrån olika aspekter och påverkas av olika omständigheter. Kvalitativa intervjuer med fem unga vuxna genomfördes och analyserades med kvalitativ innehållsanalys. Syftet var att belysa upplevelser av transitionen till vuxenlivet för unga vuxna med rörelsehinder. Resultatet visar att intervjupersonernas transition till vuxenlivet innebar en omvälvande process, men att de ändå upplevde sig självständiga trots krånglig byråkrati och en mycket tidskrävande process. Upplevelsen av självständighet kan även kopplas till omgivningens attityder. Resultatet och tidigare forskning stämmer överrens i många avseenden, men visar samtidigt på avsaknad av svensk forskning inom området.

  • 321.
    Amroussia, Nada
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    "Is the doctor God to punish me?!!": Childbirth experiences and self-perceptions of single mothers in Tunisia2016Independent thesis Advanced level (degree of Master (Two Years)), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    Introduction: Worldwide, single mothers are considered a vulnerable group in the society. This vulnerability draws on multiple factors and it is reflected in different aspects of women's social, economic and health status depending on the context. In Tunisia, single mothers suffer from social stigmatization and socio-economic marginalization. There are few studies that have explored the social aspects of single motherhood in Tunisia, but, to the authors’ knowledge, the experiences of single mothers with the maternal health services facilities have not been explored yet. The general aim of this study is to explore the childbirth experiences of single mothers at the public health facilities in Tunisia.

    Methods: The thesis follows a qualitative design. In collaboration with non-governmental organizations in Tunisia, 11 single mothers were interviewed in regard to their experiences with maternal health care services and their perceptions of the attitudes of the health workers towards them. The interviews also addressed the barriers faced by these women in accessing adequate maternal health care services, and their self-perceptions as single mothers. The data was analyzed using an inductive thematic approach to generate codes. The development of themes was guided by a theoretical framework that connects the gender relational theory and the intersectional approach.

    Results: Three themes emerged during the data analysis. The first theme "Health systems disciplines single mothers" describes the relation between the single mothers and the maternal health care providers. The majority of the participants were subjected to discriminatory practices, neglect and even violence inflicted by the maternal health care providers. Few of the participants described positive childbirth experiences that are considered as signs of resistance. The second theme "If a woman makes a mistakes once. She has to pay for the rest of her life" reflects the self-perceptions of the participants as single mothers. The participants' self-perceptions are multifaceted: they are overwhelmed mothers living with a persistent feeling of guilt, and they are also challenging and determined mothers. The last theme "The trilogy of vulnerability" includes: the social stigmatization and the socio-economic marginalization experienced by the participants as single mothers, and the situation of the health system described as crumbling by the participants.

    Conclusion: The study highlights that childbirth experiences of single mothers are shaped by intersectional factors that go beyond the health system. Gender plays a major role in constructing these experiences while intersecting with other social structures. The participants had experienced disrespectful and discriminatory practices and even violence when they sought maternal health care services at the public health facilities in Tunisia. Those experiences reflect how the health system translate in its practices the discrimination and stigma culturally associated with single motherhood in this setting. Social discrimination and stigma did not only affect how single mother were treated during the childbirth, but also how they perceived themselves. Thus, ensuring women's right to dignified, respectful health care during childbirth requires tackling the underlying causes of women's marginalization and discrimination in many settings where women face the contingency of multiple social inequities.

  • 322.
    Amroussia, Nada
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Reproductive health policy in Tunisia (1994-2014): Impact on women's right to reproductive health and gender empowerment2015Independent thesis Advanced level (degree of Master (Two Years)), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    Introduction: Tunisia was regarded as a pioneer in adopting a successful population policy in North Africa and the Middle East region. The Tunisian official family planning program started in 1966 with an objective of controlling population growth. After the International Conference on Population and Development (ICPD) in Cairo in 1994, there was a shift in the Tunisian population policy as the concept of reproductive health was introduced for the first time in national health programs and strategies.

    Methods: The thesis is a policy analysis of the reproductive health policy in Tunisia from a human rights based approach using the Health Rights of Women Assessment Instrument (HeRWAI). The analysis focuses on the impact of this policy on women’s right to reproductive health and gender empowerment.

    Results: The results revealed that Tunisia has started adopting laws promoting for reproductive rights since 1960s, in the form of the right to contraceptive use and the right to abortion. However, slow progress has been made since the ICPD conference in 1994. Furthermore,   significant limitations were found in the implementation of reproductive health policy in relation to women’s right to reproductive health: regional inequities in women’s access to reproductive health care services, discriminatory practices affecting single women and HIV patients, low quality of maternal care services and delay in the integration of the gender-based violence component into the reproductive health care services. The thesis also found that there was a lack of meaningful engagement in action to achieve gender equality in Tunisia. 

  • 323.
    Amroussia, Nada
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Alison
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Reproductive health policy in Tunisia: women's right to reproductive health and gender empowerment2016In: Health and Human Rights: An International Journal, ISSN 1079-0969, E-ISSN 2150-4113, Vol. 18, no 2, p. 183-194Article in journal (Refereed)
    Abstract [en]

    Although Tunisia is regarded as a pioneer in the Middle East and North Africa in terms of women's status and rights, including sexual and reproductive health and rights, evidence points to a number of persisting challenges. This article uses the Health Rights of Women Assessment Instrument (HeRWAI) to analyze Tunisia's reproductive health policy between 1994 and 2014. It explores the extent to which reproductive rights have been incorporated into the country's reproductive health policy, the gaps in the implementation of this policy, and the influence of this policy on gender empowerment. Our results reveal that progress has been slow in terms of incorporating reproductive rights into the national reproductive health policy. Furthermore, the implementation of this policy has fallen short, as demonstrated by regional inequities in the accessibility and availability of reproductive health services, the low quality of maternal health care services, and discriminatory practices. Finally, the government's lack of meaningful engagement in advancing gender empowerment stands in the way as the main challenge to gender equality in Tunisia.

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  • 324.
    Amroussia, Nada
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Explaining mental health inequalities in Northern Sweden: a decomposition analysis2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1305814Article in journal (Refereed)
    Abstract [en]

    Background: There has been a substantial increase of income inequalities in Sweden over the last 20 years, which also could be reflected in health inequalities, including mental health inequalities. Despite the growing body of literature focusing on health inequalities in Sweden, income-related inequalities in mental health have received little attention. Particularly scarce are research from Northern Sweden and examinations of the social determinants of health inequalities.

    Objectives: The present study seeks to provide evidence regarding inequalities in mental health in Northern Sweden. The specific aims were to (1) quantify the income-related inequality in mental health in Northern Sweden, and (2) determine the contribution of social determinants to the inequality.

    Methods: The study population comprised 25,646 participants of the 2014 Health on Equal Terms survey in the four northernmost counties of Sweden, aged 16 to 84 years old. Income-related inequalities in mental health were quantified by the concentration index and further decomposed by applying Wagstaff-type decomposition analysis.

    Results: The overall concentration index of mental health in Northern Sweden was −0.15 (95% CI: −0.17 to −0.13), indicating income inequalities in mental health disfavoring the less affluent population. The decomposition analysis results revealed that socio-economic conditions, including employment status (31%), income (22.6%), and cash margin (14%), made the largest contribution to the pro-rich inequalities in mental health. The second-largest contribution came from demographic factors, mainly age (11.3%) and gender (6%). Psychosocial factors were of smaller importance, with perceived discrimination (8%) and emotional support (3.4%) making moderate contributions to the health inequalities. 

    Conclusions: The present study demonstrates substantial income-related mental health inequalities in Northern Sweden, and provides insights into their underpinnings. These findings suggest that addressing the root causes is essential for promoting mental health equity in this region.

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  • 325.
    Amroussia, Nada
    et al.
    Division of Social and Behavioral Health, University of Nevada, Reno, USA..
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Pearson, Jennifer L.
    Division of Social and Behavioral Health/Health Administration and Policy, University of Nevada, Reno, USA..
    Do inequalities add up?: Intersectional inequalities in smoking by sexual orientation and education among U.S. adults2020In: Preventive Medicine Reports, E-ISSN 2211-3355, Vol. 17, article id 101032Article in journal (Refereed)
    Abstract [en]

    Introduction: Inequalities in smoking by socio-economic status (SES) are well-known. A growing body of literature has demonstrated additional inequalities in smoking by sexual orientation. This study used an intersectional lens to examine smoking at the intersection of sexual orientation and education.

    Methods: Data come from 28,362 adult participants in Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. We used educational level (less than high school education (HS); HS or more) and sexual orientation (heterosexual; sexual minority) to form four intersectional positions.

    We estimated prevalence differences in smoking corresponding to joint, referent, and excess intersectional inequalities using weighted linear binomial regression models. Results were stratified by gender and adjusted for ethnicity and age.

    Results: The adjusted joint inequality represented 7.6% points (p.p.) (95% CI: 2.5, 12.8) difference in smoking between the doubly advantaged (heterosexual with HS or more) and doubly disadvantaged (sexual minority with less than HS) positions. Joint inequality was decomposed into referent SES inequality (12.5 p.p. (95% CI: 10.5, 14.4)); referent sexual orientation inequality (9.7 p.p. (95% CI: 6.8, 12.6)); and a substantial negative excess intersectional inequality (−14.6 p.p. (95% CI: −20.8, −8.3)), attributed to an unexpectedly low prevalence of smoking among doubly disadvantaged persons. Similar overall patterns were found in the stratified analyses.

    Conclusions: We found that “doubly-disadvantaged” group of low-educated sexual minority adults did not have the greatest burden of smoking; whereas, low-educated heterosexual adults had the highest smoking prevalence. Our findings support tailoring cessation interventions to disadvantaged groups’ different needs.

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  • 326.
    Amroussia, Nada
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Alison
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Vives-Cases, Carmen
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    "Is the doctor God to punish me?!": An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia2017In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 14, article id 32Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Disrespectful and abusive treatment during childbirth is a violation of women's right to dignified, respectful healthcare throughout pregnancy and childbirth. Although reports point out that marginalized groups in society such as single mothers are particularly vulnerable to abusive and disrespectful care, there is a lack of in-depth research exploring single mothers' encounters at the maternal healthcare facilities, especially in Tunisia. In Tunisia, single mothers are particularly vulnerable due to their social stigmatization and socio-economic marginalization. This study examines the self-perceptions and childbirth experiences of single mothers at the public healthcare facilities in Tunisia.

    METHODS: This study follows a qualitative design. Eleven single mothers were interviewed in regard to their experiences with maternal healthcare services and their perceptions of the attitudes of the health workers towards them. The interviews also addressed the barriers faced by the participants in accessing adequate maternal healthcare services, and their self-perceptions as single mothers. The data were analyzed using an inductive thematic approach guided by the feminist intersectional approach. Emergent codes were grouped into three final themes.

    RESULTS: Three themes emerged during the data analysis: 1) Experiencing disrespect and abuse, 2) Perceptions of regret and shame attributed to being a single mother, and 3) The triad of vulnerability: stigma, social challenges, and health system challenges. The study highlights that the childbirth experiences of single mothers are shaped by intersectional factors that go beyond the health system. Gender plays a major role in constructing these experiences while intersecting with other social structures. The participants had experienced disrespectful and discriminatory practices and even violence when they sought maternal healthcare services at the public healthcare facilities in Tunisia. Those experiences reflect not only the poor quality of maternal health services but also how health system practices translate the stigma culturally associated with single motherhood in this setting. Social stigma did not only affect how single mothers were treated during the childbirth, but also how they perceived themselves and how they perceived their care.

    CONCLUSION: Ensuring women's right to dignified, respectful healthcare during childbirth requires tackling the underlying causes of social inequalities leading to women's marginalization and discrimination.

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  • 327. Amroussia, Nada
    et al.
    Pearson, Jennifer L.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    What drives us apart?: Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults2019In: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 18, article id 109Article in journal (Refereed)
    Abstract [en]

    Background: Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented; however, there is a lack of research examining the social processes driving these complex inequalities. Using an intersectional framework, the current study examines key processes contributing to inequalities in smoking between four intersectional groups by education and sexual orientation.

    Methods: The sample (28,362 adults) was obtained from Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Four intersectional positions were created by education (high- and low-education) and sexual orientation (heterosexual or lesbian, gay, bisexual, or queer/questioning (LGBQ). The joint inequality, the referent socio-economic inequality, and the referent sexual orientation inequality in smoking were decomposed by demographic, material, tobacco marketing-related, and psychosocial factors using non-linear Oaxaca decomposition.

    Results: Material conditions made the largest contribution to the joint inequality (9.8 percentage points (p.p.), 140.9%), referent socio-economic inequality (10.01 p.p., 128.4%), and referent sexual orientation inequality (4.91 p.p., 59.8%), driven by annual household income. Psychosocial factors made the second largest contributions to the joint inequality (2.12 p.p., 30.3%), referent socio-economic inequality (2.23 p.p., 28.9%), and referent sexual orientation inequality (1.68 p.p., 20.5%). Referent sexual orientation inequality was also explained by marital status (20.3%) and targeted tobacco marketing (11.3%).

    Conclusion: The study highlights the pervasive role of material conditions in inequalities in cigarette smoking across multiple dimensions of advantage and disadvantage. This points to the importance of addressing material disadvantage to reduce combined socioeconomic and sexual orientation inequalities in cigarette smoking.

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  • 328.
    An, Qingfan
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Kelley, Marjorie
    College of Nursing, The Ohio State University, Columbus, OH, United States.
    Hanners, Audra
    College of Nursing, The Ohio State University, Columbus, OH, United States.
    Yen, Po-Yin
    Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, MO, United States.
    Sustainable development for mobile health applications using the human-centered design process2023In: JMIR Formative Research, E-ISSN 2561-326X, Vol. 7, article id e45694Article in journal (Refereed)
    Abstract [en]

    Well-documented scientific evidence indicates that mobile health (mHealth) apps can improve the quality of life, relieve symptoms, and restore health for patients. In addition to improving patients' health outcomes, mHealth apps reduce health care use and the cost burdens associated with disease management. Currently, patients and health care providers have a wide variety of choices among commercially available mHealth apps. However, due to the high resource costs and low user adoption of mHealth apps, the cost-benefit relationship remains controversial. When compared to traditional expert-driven approaches, applying human-centered design (HCD) may result in more useable, acceptable, and effective mHealth apps. In this paper, we summarize current HCD practices in mHealth development studies and make recommendations to improve the sustainability of mHealth. These recommendations include consideration of factors regarding culture norms, iterative evaluations on HCD practice, use of novelty in mHealth app, and consideration of privacy and reliability across the entire HCD process. Additionally, we suggest a sociotechnical lens toward HCD practices to promote the sustainability of mHealth apps. Future research should consider standardizing the HCD practice to help mHealth researchers and developers avoid barriers associated with inadequate HCD practices.

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  • 329.
    An, Qingfan
    et al.
    School of Design, Royal College of Art, London, UK.
    Kelley, Marjorie M.
    Yen, Po-Yin
    Stakeholder Mapping on the Development of Digital Health Interventions for Self-Management Among Patients with Chronic Obstructive Pulmonary Disease in China2022In: Medinfo 2021: One World, One Health – Global Partnership for Digital Innovation / [ed] Paula Otero; Philip Scott; Susan Z. Martin; Elaine Huesing, IOS Press, 2022, p. 1106-1107Conference paper (Refereed)
    Abstract [en]

    Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung disease consisting of chronic bronchitis and emphysema. Digital Health Interventions (DHIs) can improve COPD patients' self-management. However, the market penetration of DHIs is lower than expected. Using stakeholder mapping, healthcare providers identified opportunities for design and development of sustainable DHIs. Two different stakeholder maps were identified. These maps demonstrated the importance of utilizing structured mapping techniques to understand roles of different stakeholders, and addressing regulatory and practice needs to ultimately support patient self-management.

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  • 330.
    An, Qingfan
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Sandlund, Marlene
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Agnello, Danielle
    Glasgow Caledonian University, Glasgow, United Kingdom.
    Mccaffrey, Lauren
    Glasgow Caledonian University, Glasgow, United Kingdom.
    Chastin, Sebastien
    Glasgow Caledonian University, Glasgow, United Kingdom.
    Helleday, Ragnberth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wadell, Karin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    A scoping review of co-creation practice in the development of non-pharmacological interventions for people with chronic obstructive pulmonary disease2023In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 62, no Suppl. 67, article id PA2416Article in journal (Refereed)
    Abstract [en]

    Background: Incorporating co-creation process in the development of interventions may improve the outcome. However, there is a lack of synthesis of co-creation practices in the development of Non-Pharmacological Interventions (NPIs) for Chronic Obstructive Pulmonary Disease (COPD).

    Objective: This scoping review aimed to examine the co-creation practice used when developing NPIs for people with COPD.

    Methods: The methodology proposed by Arksey and O’Malley for scoping reviews was followed, and it was reported according to the PRISMA-ScR framework. The search included PubMed, Scopus, CINAHL, and Web of Science. Studies reporting on the process and/or analysis of applying co-creation practice in developing NPIs for people with COPD were included.

    Results: 13 articles complied with the inclusion criteria. The composition of co-creators was diverse and reported in most of the included studies. Facilitating factors described in the co-creation practices included administrative preparations, diversity of stakeholders, cultural considerations, employment of creative methods, creation of an appreciative environment, and digital assistance. Few creative methods were mentioned or explained in the studies. Challenges around the physical limitations of patients, the absence of key stakeholder opinions, a prolonged process, recruitment, and digital illiteracy of co-creators were listed. Most of the studies did not report implementation considerations as a discussion point in their co-creation workshops.

    Conclusion: This review provides suggestions for evidence-based co-creation in COPD care which may improve the quality of care delivered by NPIs.

  • 331.
    An, Qingfan
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Sandlund, Marlene
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Agnello, Danielle
    School of Health and Life Sciences, Glasgow Caledonian University, UK.
    McCaffrey, Lauren
    School of Health and Life Sciences, Glasgow Caledonian University, UK.
    Chastin, Sebastien
    School of Health and Life Sciences, Glasgow Caledonian University, UK; Department of Movement and Sports Sciences, Ghent University, 9000, Ghent, Belgium.
    Helleday, Ragnberth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wadell, Karin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    A scoping review of co-creation practice in the development of non-pharmacological interventions for people with chronic obstructive pulmonary disease: a health CASCADE study2023In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 211, article id 107193Article, review/survey (Refereed)
    Abstract [en]

    Background: Incorporating co-creation processes may improve the quality of outcome interventions. However, there is a lack of synthesis of co-creation practices in the development of Non-Pharmacological Interventions (NPIs) for people with Chronic Obstructive Pulmonary Disease (COPD), that could inform future co-creation practice and research for rigorously improving the quality of care.

    Objective: This scoping review aimed to examine the co-creation practice used when developing NPIs for people with COPD.

    Methods: This review followed Arksey and O'Malley scoping review framework and was reported according to the PRISMA-ScR framework. The search included PubMed, Scopus, CINAHL, and Web of Science Core Collection. Studies reporting on the process and/or analysis of applying co-creation practice in developing NPIs for people with COPD were included.

    Results: 13 articles complied with the inclusion criteria. Limited creative methods were reported in the studies. Facilitators described in the co-creation practices included administrative preparations, diversity of stakeholders, cultural considerations, employment of creative methods, creation of an appreciative environment, and digital assistance. Challenges around the physical limitations of patients, the absence of key stakeholder opinions, a prolonged process, recruitment, and digital illiteracy of co-creators were listed. Most of the studies did not report including implementation considerations as a discussion point in their co-creation workshops.

    Conclusion: Evidence-based co-creation in COPD care is critical for guiding future practice and improving the quality of care delivered by NPIs. This review provides evidence for improving systematic and reproducible co-creation. Future research should focus on systematically planning, conducting, evaluating, and reporting co-creation practices in COPD care.

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  • 332.
    Anad, Tina
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy.
    Ungdomars upplevelser kring arbetslöshet2014Independent thesis Basic level (degree of Bachelor), 10 credits / 15 HE creditsStudent thesis
    Abstract [sv]

    Abstrakt

    Arbetslösheten drabbar Sverige i stor omfattning och påverkar inte enbart samhället utan även individerna. Arbetsmarknaden är idag instabil och på grund av detta ökar arbetslösheten bland ungdomar årligen. Forskning visar att arbetslösheten påverkar individen både psykiskt och fysiskt. Syftet med föreliggande undersökning var att belysa ungdomars upplevelser av sin situation som arbetslös med fokus på vilka faktorer de upplever blir mest påverkade. Studien har en kvalitativ ansats och fem arbetslösa ungdomar mellan 18 – 26 år som varit arbetslösa mer än 3 månader intervjuades. Insamlad data analyserades genom kvalitativ innehållsanalys och grupperades till fem huvudkategorier, som utgör resultatdelarna. Resultatet visade att ungdomarna saknar struktur i vardagen och att upprätthålla meningsfulla aktiviteter är svårt främst på grund av deras bristande självförtroende och dåliga ekonomi. De upplevde frustration och stress över att inte få en anställning och deras sociala liv påverkas negativt. Fortsatt forskning behövs för att få mer underlag om ungdomars upplevelser och tankar kring arbetslösheten.

     

    Sökord: arbetslöshet, arbete, unga vuxna, hälsa, rutiner, ekonomi, självförtroende.

  • 333. Analitis, Antonis
    et al.
    De' Donato, Francesca
    Scortichini, Matteo
    Lanki, Timo
    Basagana, Xavier
    Ballester, Ferran
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Paldy, Anna
    Pascal, Mathilde
    Gasparrini, Antonio
    Michelozzi, Paola
    Katsouyanni, Klea
    Synergistic Effects of Ambient Temperature and Air Pollution on Health in Europe: Results from the PHASE Project2018In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 15, no 9, p. 1-11, article id E1856Article in journal (Refereed)
    Abstract [en]

    We studied the potential synergy between air pollution and meteorology and their impact on mortality in nine European cities with data from 2004 to 2010. We used daily series of Apparent Temperature (AT), measurements of particulate matter (PM10), ozone (O₃), and nitrogen dioxide (NO₂) and total non-accidental, cardiovascular, and respiratory deaths. We applied Poisson regression for city-specific analysis and random effects meta-analysis to combine city-specific results, separately for the warm and cold seasons. In the warm season, the percentage increase in all deaths from natural causes per °C increase in AT tended to be greater during high ozone days, although this was only significant for all ages when all causes were considered. On low ozone days, the increase in the total daily number of deaths was 1.84% (95% CI 0.87, 2.82), whilst it was 2.20% (95% CI 1.28, 3.13) in the high ozone days per 1 °C increase in AT. Interaction with PM10 was significant for cardiovascular (CVD) causes of death for all ages (2.24% on low PM10 days (95% CI 1.01, 3.47) whilst it is 2.63% (95% CI 1.57, 3.71) on high PM10 days) and for ages 75+. In days with heat waves, no consistent pattern of interaction was observed. For the cold period, no evidence for synergy was found. In conclusion, some evidence of interactive effects between hot temperature and the levels of ozone and PM10 was found, but no consistent synergy could be identified during the cold season.

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  • 334. Anandavadivelan, Poorna
    et al.
    Wiklander, Maria
    Eriksson, Lars E.
    Wettergren, Lena
    Lampic, Claudia
    Department of Women’s and Children’s Health, Karolinska Institutet, Solna, Sweden; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Cultural adaptation and psychometric evaluation of the Swedish version of the Reproductive Concerns After Cancer (RCAC) scale2020In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 18, no 1, article id 273Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Reproductive concerns are common among young cancer survivors and include worries related to different aspects of fertility and parenthood. The Reproductive Concerns After Cancer (RCAC) scale is an 18-item scale with six dimensions, developed to capture a variety of such concerns. The aim of the present study was to describe the cultural adaptation of the RCAC scale into Swedish and evaluate its psychometric properties among young women who have undergone treatment for cancer.

    METHODS: The RCAC was forward translated from English into Swedish and assessed for cultural adaptation based on a two-panel approach followed by cognitive interviews with the target group. For the psychometric evaluation, a Swedish cohort of 181 female young adult breast cancer survivors completed a survey including the RCAC scale approximately 1.5 years post-diagnosis. Psychometric properties were examined by analyses of construct validity (confirmatory factor analysis and convergent validity), data quality (score distribution, floor and ceiling effects), reliability and known-groups validity.

    RESULTS: The confirmatory factor analysis yielded an acceptable fit (RMSEA 0.08, SRMR 0.09, CFI 0.92). Convergent validity was demonstrated by a negative correlation of moderate size (- 0.36) between the RCAC total score and the emotional function scale of the EORTC QLQ-C30. Reliability measured with Revelle Ω total was satisfactory (0.73-0.92) for five of the dimensions, and poor for the dimension Becoming pregnant (Revelle Ω total = 0.60); Cronbach's alpha showed a similar pattern. Known-groups validity was indicated by significant RCAC mean score differences (MD), reflecting more concerns among women with a certain (MD 4.56 [95% CI 3.13 to 5.99]) or uncertain (MD 3.41 [95% CI 1.68 to 5.14]) child wish compared to those with no wish for (additional) children.

    CONCLUSION: The translation and cultural adaptation of the Swedish RCAC has resulted in a scale demonstrating construct and known-groups validity, and satisfactory reliability for five of six dimensions. The dimension Becoming pregnant showed non-optimal internal consistency and should undergo further evaluation. The Swedish RCAC is recommended to be used in research settings for measurement of concerns related to fertility and parenthood in young women with cancer.

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  • 335. Ancelle-Park, R.
    et al.
    Armaroli, P.
    Ascunce, N.
    Bisanti, L.
    Bellisario, C.
    Broeders, M.
    Cogo, C.
    de Koning, H.
    Duffy, S. W.
    Frigerio, A.
    Giordano, L.
    Hofvind, S.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lynge, E.
    Massat, N.
    Miccinesi, G.
    Moss, S.
    Naldoni, C.
    Njor, S.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Paap, E.
    Paci, E.
    Patnick, J.
    Ponti, A.
    Puliti, D.
    Segnan, N.
    Von Karsa, L.
    Tornberg, S.
    Zappa, M.
    Zorzi, M.
    Summary of the evidence of breast cancer service screening outcomes in Europe and first estimate of the benefit and harm balance sheet2012In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, p. 5-13Article in journal (Refereed)
    Abstract [en]

    Objectives To construct a European 'balance sheet' of key outcomes of population-based mammographic breast cancer screening, to inform policy-makers, stakeholders and invited women. Methods From the studies reviewed, the primary benefit of screening, breast cancer mortality reduction, was compared with the main harms, over-diagnosis and false-positive screening results (FPRs). Results Pooled estimates of breast cancer mortality reduction among invited women were 25% in incidence-based mortality studies and 31% in case-control studies (38% and 48% among women actually screened). Estimates of over-diagnosis ranged from 1% to 10% of the expected incidence in the absence of screening. The combined estimate of over-diagnosis for screened women, from European studies correctly adjusted for lead time and underlying trend, was 6.5%. For women undergoing 10 biennial screening tests, the estimated cumulative risk of a FPR followed by non-invasive assessment was 17%, and 3% having an invasive assessment. For every 1000 women screened biennially from age 50-51 until age 68-69 and followed up to age 79, an estimated seven to nine lives are saved, four cases are over-diagnosed, 170 women have at least one recall followed by non-invasive assessment with a negative result and 30 women have at least one recall followed by invasive procedures yielding a negative result. Conclusions The chance of saving a woman's life by population-based mammographic screening of appropriate quality is greater than that of over-diagnosis. Service screening in Europe achieves a mortality benefit at least as great as the randomized controlled trials. These outcomes should be communicated to women offered service screening in Europe.

  • 336.
    Anchalia, Manju M
    et al.
    Civil Hospital, Asarwa, Ahmedabad, Gujarat, India .
    D'Ambruoso, Lucia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Immpact, University of Aberdeen, UK.
    Seeking solutions: scaling-up audit as a quality improvement tool for infection control in Gujarat, India2011In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 23, no 4, p. 464-470Article in journal (Refereed)
    Abstract [en]

    QUALITY PROBLEM OR ISSUE: Surgical-site infections (SSIs) give rise to significant demands on the health systems as well as economic and social sequelae for patients. This article describes an audit for infection control developed in a surgical unit of a tertiary care setting in Gujarat state, India that was scaled-up to all state-owned hospitals in the district.

    IMPLEMENTATION: Surveillance and hospital epidemiology were established and practice reforms implemented. Monthly and annual meetings to review implementation were held.

    EVALUATION: After 12 months, an 88% decrease in the infection rate in the surgical unit was demonstrated. Thereafter, the process was replicated across the surgical department and for all cases undergoing surgery. After 12 months, a 67% reduction in the infection rate was detected. The process has since been applied across the state.

    LESSONS LEARNED: A locally owned and team-led process embedded within routine working conditions can challenge widely held perceptions, inform low-cost and no-cost remedial actions, and improve cultures of practice, quality of care and health outcomes. As urban populations grow, methods that are capable of continuously identifying, and responding to, problems and sustaining quality of care in facilities are necessary. SSIs may be largely preventable. With careful implementation, audit has the potential to be a major contributor to their reduction.

  • 337.
    Anckarman, Erika
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Sports medicine.
    Den framgångsrika personliga tränaren: En kvalitativ studie om klienters upplevelse av vilka egenskaper och faktorer som är viktiga för personliga tränare2016Independent thesis Advanced level (degree of Master (One Year)), 20 credits / 30 HE creditsStudent thesis
    Abstract [en]

    Background: During the last years the fitness industry has expanded fast. Today PT is offered at almost every health club. Training with a PT have positive physical effects but it has also shown an influence on behaviour associated with training. A good relation between client and coach is needed for a positive outcome of the training.

    Purpose: The aim of the study was to investigate what the clients that are training or has trained with at personal trainer during the last year consider as important factors and personal qualities related to personal trainers.

    Design and method: A qualitative descriptive design was used. Data collection was done by semi-structured interviews. Data was analysed with qualitative content analysis.

    Results: The analyses resulted in 3 themes, 6 categories and 17 sub categories. The themes and categories were: To appear as competent: Appearance and displayed experience ,Give a feeling of a broad knowledge.

    Coaching style: To be present here and now, To personalize Pedagogical strategies: Tools to reach results, To create a secure feeling,

    Conclusion: Background information of the PT should always be available at the health club or on the website. The client should have the opportunity to choose a PT based on their personal requests. This may result in good preconditions for a strong and effective working alliance. Reserach in this area are limited therefor further studies are needed. 

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  • 338.
    Ander Ljung, Erika
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Occupational Therapy.
    Hjälmsson, Emma
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Occupational Therapy.
    Motivations innebörd och inverkan: En litteraturstudie om psykosociala faktorer inom idrottsrehabilitering2020Independent thesis Basic level (degree of Bachelor), 10 credits / 15 HE creditsStudent thesis
    Abstract [sv]

    Idrott är både en vanlig fritidssysselsättning och en vanlig orsak till skador. Tidigare forskning har främst studerat idrottsrehabilitering ur ett biomekaniskt perspektiv men på senare år har psykosociala aspekter studerats allt mer. Syftet med denna studie var att beskriva hur motivation påverkar och uttrycks vid rehabilitering av idrottsskador, genom en litteraturstudie med den arbetsterapeutiska Model of Human Occupation som teoretisk utgångpunkt. Resultatet baserades på analys av nio kvalitativa artiklar. En av artiklarna hade även en kvantitativ del som exkluderades från denna studie. I resultatet framkom två huvudteman; ’intrapersonella faktorer’ och ’interpersonella faktorer’, med totalt sju underkategorier. I ’intrapersonella faktorer’ framkom att självförtroende, värderingar och intresse var faktorer som hade samband med motivation. Under ’interpersonella faktorer’ framgick det att även omgivningen spelade en betydande roll i relation till motivation och idrottsrehabilitering. Merparten av de faktorer som framkom visade sig kunna styra utfallet av rehabiliteringen i olika riktningar, beroende på den övriga kontexten. Utifrån studiens resultat kan motivation beskrivas som resultatet av många olika faktorer samt att motivation tydligt påverkar rehabilitering av idrottsskador. Däremot kan dessa faktorer påverka både positivt och negativt. Därmed krävs vidare forskning för att kartlägga vad som styr påverkans riktning och vilka interventioner som kan främja ett positivt utfall. 

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  • 339.
    Anderback, Nanny-Maja
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Sports medicine.
    Öling, Kajsa
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Sports medicine.
    Kan fysisk aktivitet under graviditeten reducera graviditetsrelaterade besvär?2017Independent thesis Basic level (degree of Bachelor), 180 HE creditsStudent thesis
    Abstract [en]

    Background: Many women are pregnant for one or more periods of their lives. During this time, studies have shown that women tend to become physically inactive. With a pregnancy, there is also an increased risk of other diseases and disorders such as pregnancy diabetes and obesity. Studies have shown that physical activity can prevent some of these disorders. Traditionally, the general opinion on physical activity during pregnancy has been that it could be dangerous for both the pregnant woman and the fetus. Today, there is a more liberal view of physical activity during pregnancy, but research is still inadequate.Aim: Our purpose with this literature study is to examine the effects of physical activity during pregnancy in pregnancy-related disorders, and look into the current recommendations on physical activity during pregnancy.Results: Our study has seen positive effects of physical activity during pregnancy especially in pregnancy-related disorders such as lumbar pain, pelvic floor dysfunction, fatigue, gestational diabetes and weight gain, as well as some positive trends in preeclampsia, edema and pelvic girdle pain. The research on nausea and rectus diastasis is too inadequate to draw any conclusions about possible effects.Conclusion: More RCT studies on pregnancy-related disorders are needed to reach consensus about what type of physical activity, duration, intensity and frequency during pregnancy that are beneficial for these disorders. From this knowledge we can then work out more specific recommendations.

  • 340.
    Andermo, Susanne
    et al.
    Community Nutrition and Physical Activity, Department of Global Public Health, Karolinska Institutet.
    Hallgren, Mats
    Epidemiology of Psychiatric Conditions, Substance Use and Social Environment, Department of Global Public Health, Karolinska Institutet.
    Nguyen, Thi-Thuy-Dung
    Epidemiology of Psychiatric Conditions, Substance Use and Social Environment, Department of Global Public Health, Karolinska Institutet.
    Jonsson, Sofie
    Unit for Intervention and Implementation Research, Department of Environmental Medicine, Karolinska Institutet.
    Petersen, Solveig
    Department of Living Conditions and Lifestyle, The Public Health Agency of Sweden,.
    Friberg, Marita
    Department of Living Conditions and Lifestyle, The Public Health Agency of Sweden.
    Romqvist, Anja
    Department of Living Conditions and Lifestyle, The Public Health Agency of Sweden.
    Stubbs, Brendon
    Physiotherapy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, UK..
    Elinder, Liselotte Schäfer
    Community Nutrition and Physical Activity, Department of Global Public Health, Karolinska Institutet.
    School-related physical activity interventions and mental health among children: a systematic review and meta-analysis.2020In: Sports medicine - open, ISSN 2199-1170, Vol. 6, no 1, article id 25Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Low levels of physical activity, sedentary behaviour and mental health problems are issues that have received considerable attention in the last decade. The aim of this systematic review and meta-analysis was to investigate effects of interventions targeting school-related physical activity or sedentary behaviour on mental health in children and adolescents and to identify the features of effective interventions.

    METHODS: Scientific articles published between January 2009 and October 2019 fulfilling the following criteria were included: general populations of children and adolescents between age 4 and 19, all types of school-related efforts to promote physical activity or reduce sedentary behaviour. Study selection, data extraction and quality assessment were done by at least two authors independently of each other. Data were analysed with a random effects meta-analysis and by narrative moderator analyses.

    RESULTS: The literature search resulted in 10265 unique articles. Thirty-one articles, describing 30 interventions, were finally included. Eleven relevant outcomes were identified: health-related quality of life, well-being, self-esteem and self-worth, resilience, positive effect, positive mental health, anxiety, depression, emotional problems, negative effect and internalising mental health problems. There was a significant beneficial effect of school-related physical activity interventions on resilience (Hedges' g = 0.748, 95% CI = 0.326; 1.170, p = 0.001), positive mental health (Hedges' g = 0.405, 95% CI = 0.208; 0.603, p = < 0.001), well-being (Hedges' g = 0.877, 95% CI = 0.356; 1.398, p = < 0.001) and anxiety (Hedges' g = 0.347, 95% CI = 0.072; 0.623, p = 0.013). Heterogeneity was moderate to high (I2 = 59-98%) between studies for all outcomes except positive effect, where heterogeneity was low (I2 = 2%). The narrative moderator analyses of outcomes based on 10 or more studies showed that age of the children moderated the effect of the intervention on internalising mental health problems. Interventions in younger children showed a significantly negative or no effect on internalising mental health problems while those in older children showed a significant positive or no effect. Moreover, studies with a high implementation reach showed a significant negative or no effect while those with a low level of implementation showed no or a positive effect. No signs of effect moderation were found for self-esteem, well-being or positive mental health. Risk of publication bias was evident for several outcomes, but adjustment did not change the results.

    CONCLUSIONS: School-related physical activity interventions may reduce anxiety, increase resilience, improve well-being and increase positive mental health in children and adolescents. Considering the positive effects of physical activity on health in general, these findings may reinforce school-based initiatives to increase physical activity. However, the studies show considerable heterogeneity. The results should therefore be interpreted with caution. Future studies should report on implementation factors and more clearly describe the activities of the control group and whether the activity is added to or replacing ordinary physical education lessons in order to aid interpretation of results.

    TRIAL REGISTRATION: PROSPERO, CRD42018086757.

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  • 341.
    Andersdotter, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Asplund, Anna
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Hur påverkas armpendling av gånghastigheten?2013Independent thesis Basic level (degree of Bachelor), 10 credits / 15 HE creditsStudent thesis
    Abstract [sv]

    BAKGRUND: Kunskap om armpendling vid gång i olika hastigheter kan innebära en möjlighet att skilja på förändrade gångmönster orsakade av hastighet eller av underliggande patologi. Syftet med denna studie var att beskriva hur Range Of Motion (ROM)-, Gait Variable Score (GVS)- och Arm Posture Score6 (APS6)-värden påverkas vid gång och att jämföra dessa variabler mellan två olika hastigheter, självvald och långsam gång, samt mellan dominant och ickedominant arm.

    METOD: I denna studie, som ingår i en större, deltog 42 personer utan muskuloskelettala problem. Alla 42 gick i självvald hastighet och 28 av dessa gick även i långsam gånghastighet. Deltagarnas gång registrerades av optoelektroniska 3D-kameror. Som utfallsmått användes ROM, GVS och APS6.

    RESULTAT: Resultatet visade en signifikant skillnad för ROM vid alla rörelser förutom vid axelrotation vid jämförelse mellan hastigheterna. Signifikant skillnad sågs i GVS i armbågsflexion/extension i jämförelse mellan hastigheterna. APS6 visade inga signifikanta skillnader.

    SLUTSATS: Vid kvantifiering av armpendling för att jämföra två olika hastigheter kan vi i denna studie konstatera att, förutom vid axelrotation, ROM fick en signifikant ökning vid den självvalda hastigheten. När GVS användes för att jämföra hastigheterna påträffades signifikant skillnad i armbågsflexion/extension. För APS6 sågs ingen signifikant skillnad. För att ytterligare utvärdera avvikelsemåtten behövs fler studier på olika patientgrupper.

    Examensarbete

    15 hp

  • 342.
    Andersdotter Sandström, Anna
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Patienter med utmattningssyndrom, deras upplevelse av fysisk aktivitet på recept i grupp.2019Independent thesis Advanced level (degree of Master (One Year)), 40 credits / 60 HE creditsStudent thesis
    Abstract [sv]

    Sammanfattning:

    Introduktion: Fysisk aktivitet (FA) är effektivt för att förbättra symtom och kognition hos personer med utmattningssyndrom. Trots detta har denna grupp svårigheter att uppnå rekommendationerna gällande fysisk aktivitet. Därför är det intressant att finna metoder som kan stödja en hållbar beteendeförändring och vidmakthållande av rutiner för FA för dessa personer.

     

    Syfte: Syftet med denna studie var att utforska hur personer med utmattningssyndrom upplever FA och fysisk aktivitet på recept som en del av ett gruppbaserat multimodalt rehabiliteringsprogram.

     

    Metod: Totalt deltog 27 informanter i 6 fokusgrupper i studien. Informanterna hade alla genomgått ett multimodalt rehabiliteringsprogram som inkluderade en intervention i form av fysisk aktivitet på recept intervention i grupp. Interventionen baserades på kognitiv beteendeterapi och inkluderade information om FA, hemuppgift och individuell målsättning för FA. Modifierad Grundad Teori användes vid analys av data.

     

    Resultat: Anlysen resulterade i en teoretisk modell med kärnkategorin Internalisera fysisk aktivitet på ett hållbart sätt och tre kategorier Erhålla nya insikter om fysisk aktivitet, Lära genom att göra och Skräddarsy fysisk aktivitet. Att ta del av fysisk aktivitet på recept i grupp gav deltagarna nya insikter om sin FA, detta genom att praktiskt prova FA. Att praktiskt utföra FA på olika sätt och med stöd av andra, internaliserades FA på ett hållbart sätt.

     

    Slutsats: Fysisk aktivitet på recept i grupp kan vara en användbar metod för att internalisera och främja FA på ett hållbart sätt för individer med utmattningssyndrom. Det är dock viktigt att identifiera de personer som är i behov av ett mer skräddarsytt stöd.

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  • 343.
    Andersdotter Sandström, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Fjellman-Wiklund, Anncristine
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Sandlund, Marlene
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Eskilsson, Therese
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Patients with stress-induced exhaustion disorder and their experiences of physical activity prescription in a group context2023In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 16, no 1, article id 2212950Article in journal (Refereed)
    Abstract [en]

    Background: Physical activity is a useful means to improve symptoms and memory performance to some extent in individuals with stress-induced exhaustion disorder. Individuals in this group commonly do not need to reach the recommended levels of physical activity. Developing methods to support physical activity as a lasting behaviour is important.

    Objective: The aim of the study was to explore the processes involved when using physical activity prescription as part of rehabilitation in a group context for individuals with stress-induced exhaustion disorder.

    Method: A total of 27 individuals with stress-induced exhaustion disorder participated in six focus groups. The informants underwent a multimodal intervention including prescription of physical activity. The physical activity prescription had a cognitive behaviour approach and included information about physical activity, home assignments and goal setting. The data was analysed with grounded theory method using constant comparison.

    Results: The analysis of the data was developed into the core category ‘trying to integrate physical activity into daily life in a sustainable way’, and three categories: ‘acceptance of being good enough’, ‘learning physical activity by doing’ and ‘advocation for physical activity in rehabilitation’. The informants identified that during the physical activity prescription sessions they learned what physical activity was, what was ‘good enough’ in terms of dose and intensity of physical activity, and how to listen to the body’s signals. These insights, in combination with performing physical activity during home assignments and reflecting with peers, helped them incorporate physical activity in a new and sustainable way. A need for more customised physical activity with the ability to adjust to individual circumstances was requested.

    Conclusion: Prescription of physical activity in a group context may be a useful method of managing and adjusting physical activity in a sustainable way for individuals with stress-induced exhaustion disorder. However, identifying people who need more tailored support is important.

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  • 344.
    Andersen, C. D.
    et al.
    Department of Clinical Sciences, Lund University, Malmö, Sweden.
    Bennet, L.
    Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindblad, U.
    Department of Primary Health Care, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
    Lindholm, E.
    Department of Clinical Sciences, Lund University, Malmö, Sweden.
    Groop, L.
    Department of Clinical Sciences, Lund University, Malmö, Sweden.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Worse glycaemic control in LADA patients than in those with type 2 diabetes, despite a longer time on insulin therapy2013In: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 56, no 2, p. 252-258Article in journal (Refereed)
    Abstract [en]

    Our aim was to study whether glycaemic control differs between individuals with latent autoimmune diabetes in adults (LADA) and patients with type 2 diabetes, and whether it is influenced by time on insulin therapy. We performed a retrospective study of 372 patients with LADA (205 men and 167 women; median age 54 years, range 35-80 years) from Swedish cohorts from SkAyenne (n = 272) and Vasterbotten (n = 100). Age- and sex-matched patients with type 2 diabetes were included as controls. Data on the use of oral hypoglycaemic agents (OHAs), insulin and insulin-OHA combination therapy was retrieved from the medical records. Poor glycaemic control was defined as HbA(1c) a parts per thousand yen7.0% (a parts per thousand yen53 mmol/mol) at follow-up. The individuals with LADA and with type 2 diabetes were followed for an average of 107 months. LADA patients were leaner than type 2 diabetes patients at diagnosis (BMI 27.7 vs 31.0 kg/m(2); p < 0.001) and follow-up (BMI 27.9 vs 30.2 kg/m(2); p < 0.001). Patients with LADA had been treated with insulin for longer than those with type 2 diabetes (53.3 vs 28.8 months; p < 0.001). There was no significant difference between the patient groups with regard to poor glycaemic control at diagnosis, but more patients with LADA (67.8%) than type 2 diabetes patients (53.0%; p < 0.001) had poor glycaemic control at follow-up. Patients with LADA had worse glycaemic control at follow-up compared with participants with type 2 diabetes (OR = 1.8, 95% CI 1.2, 2.7), adjusted for age at diagnosis, HbA(1c), BMI at diagnosis, follow-up time and duration of insulin treatment. Individuals with LADA have worse glycaemic control than patients with type 2 diabetes despite a longer time on insulin therapy.

  • 345.
    Andersen, Peter M.
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Kuźma-Kozakiewicz, Magdalena
    Department of Neurology, Medical University of Warsaw, Warsaw, Poland; Neurodegenerative Diseases Research Group, Medical University of Warsaw, Warsaw, Poland.
    Keller, Jürgen
    Department of Neurology, University of Ulm, Ulm, Germany.
    Maksymowicz-Śliwińska, Anna
    Department of Neurology, Medical University of Warsaw, Warsaw, Poland.
    Barć, Krzysztof
    Department of Neurology, Medical University of Warsaw, Warsaw, Poland.
    Nieporęcki, Krzysztof
    Department of Neurology, Medical University of Warsaw, Warsaw, Poland.
    Finsel, Julia
    Department of Neurology, University of Ulm, Ulm, Germany.
    Vazquez, Cynthia
    Department of Neurology, University of Ulm, Ulm, Germany.
    Helczyk, Olga
    Department of Neurology, University of Ulm, Ulm, Germany.
    Linse, Katharina
    Department of Neurology, Technische Universität Dresden, and German Center for Neurodegenerative Diseases (DZNE), Dresden, Germany.
    Häggström, Ann-Cristin E.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Stenberg, Erica
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Semb, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Professional Development.
    Ciećwierska, Katarzyna
    Department of Neurology, Medical University of Warsaw, Warsaw, Poland.
    Szejko, Natalia
    Department of Neurology, Medical University of Warsaw, Warsaw, Poland.
    Uttner, Ingo
    Department of Neurology, University of Ulm, Ulm, Germany.
    Herrmann, Andreas
    Department of Neurology, Technische Universität Dresden, and German Center for Neurodegenerative Diseases (DZNE), Dresden, Germany.
    Petri, Susanne
    Department of Neurology, Hannover Medical School, Hannover, Germany.
    Meyer, Thomas
    Department of Neurology, Charité CVK, Berlin, Germany.
    Ludolph, Albert C.
    Department of Neurology, University of Ulm, Ulm, Germany; German Center for Neurodegenerative Diseases (DZNE), Ulm, Germany.
    Lulé, Dorothée
    Department of Neurology, University of Ulm, Ulm, Germany.
    Caregivers’ divergent perspectives on patients’ well-being and attitudes towards hastened death in Germany, Poland and Sweden2022In: Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, ISSN 2167-8421, E-ISSN 2167-9223, Vol. 23, no 3-4, p. 252-262Article in journal (Refereed)
    Abstract [en]

    Background: During the course of amyotrophic lateral sclerosis (ALS), patients and their families are faced with existential decisions concerning life-prolonging and -shortening measures. Correct anticipation of patient’s well-being and preferences is a prerequisite for patient-centered surrogate decision making.

    Methods: In Germany (N = 84), Poland (N = 77) and Sweden (N = 73) patient-caregiver dyads were interviewed. Standardized questionnaires on well-being (ADI-12 for depressiveness; ACSA for global quality of life) and wish for hastened death (SAHD) were used in ALS patients. Additionally, caregivers were asked to fill out the same questionnaires by anticipating patients’ perspective (surrogate perspective).

    Results: Caregivers significantly underestimated patients’ well-being in Germany and Poland. For Swedish caregivers, there were just as many who underestimated and overestimated well-being. The same was true for wish for hastened death in all three countries. For Swedish and Polish patients, caregivers’ estimation of well-being was not even associated with patients’ responses and the same was true for estimation of wish for hastened death in all three countries. Older caregivers and those with the most frequent encounter with the patient were the closest in their rating of well-being and wish for hastened death to the patients’ actual state, while caregivers with chronic disease him/herself were more likely to underestimate patient’s well-being.

    Discussion: Despite distinct cultural differences, there was a clear discrepancy between patients’ and caregivers’ perspective on patients’ well-being and preferences towards life in all three countries. This possible bias in caregivers’ judgment needs to be taken into account in surrogate decision making.

  • 346. Andersen Sand, Rikke
    et al.
    McArtney, John
    Rasmussen, Birgit H.
    Berhardson, Britt-Marie
    Hajdarevic, Senada
    Umeå University, Faculty of Medicine, Department of Nursing.
    Malmström, Marlene
    Ziebland, Sue
    Caring as sharing: Negotiating the moral boundaries of receiving care2020In: Critical Public Health, ISSN 0958-1596, E-ISSN 1469-3682, Vol. 30, no 5, p. 537-576Article in journal (Refereed)
    Abstract [en]

    Informal caregiving is increasingly considered a health care delivery-resource within the North European welfare states. While ‘informal’ often refers to non-professional, ‘caregiving’ connotes both affective concern (caring about) and practical action (caring for). This duality of meanings, however, often refers to the one direction in which care is given. Care, we suggest, is relational and also requires that people receiving care are able to or wanting to share their needs. Informal caregiving thus requires sharing. Based on 155 semi-structured, narrative interviews with people with lung or bowel cancer, living in Denmark, Sweden or England, this paper explores how and with whom people ‘share’ when they fall ill. We approach sharing as a heuristic for reflecting on informal-caregiving, and illustrate how being cared for or asking for care are entangled with the management of social risks and notions of selfhood. We conclude that informal caregiving should explicitly be recognised as morally and sympathetically committed practices, which attend to the diversity of local moral worlds of patients, their needs and experiences.

  • 347.
    Andersen, Sofie T.
    et al.
    Department of Studies and Analysis, National Association against Eating Disorders and Self-Harm, Valby, Denmark.
    Linkhorst, Thea
    Forensic Mental Health Research Unit Middelfart, Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Middelfart, Denmark.
    Gildberg, Frederik A.
    Forensic Mental Health Research Unit Middelfart, Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Middelfart, Denmark; Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, Middelfart, Denmark.
    Sjögren, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry. Psychiatric Center Ballerup, Ballerup, Denmark.
    Why do women with eating disorders decline treatment? A qualitative study of barriers to specialized eating disorder treatment2021In: Nutrients, E-ISSN 2072-6643, Vol. 13, no 11, article id 4033Article in journal (Refereed)
    Abstract [en]

    Despite the fact that eating disorders (EDs) are conditions that are potentially life-threat-ening, many people decline treatment. The aim of this study was to investigate why women decline specialized ED treatment, including their viewpoints on treatment services. Eighteen semi-struc-tured qualitative interviews were conducted with women who had declined inpatient or outpatient specialized ED treatment. A thematic analysis revealed five main themes: (1) Disagreement on treatment needs, (2) rigid standard procedures, (3) failure to listen, (4) deprivation of identity, and (5) mistrust and fear. The women had declined ED treatment because they believed that treatment was only focused on nutritional rehabilitation and that it failed to address their self-identified needs. From their perspectives treatment was characterized by rigid standard procedures that could not be adapted to their individual situations and preferences. They felt that the therapists failed to listen to them, and they felt deprived of identity and reduced to an ED instead of a real person. This investigation is one of the first of its kind to provide clues as to how treatment could be moderated to better meet the needs of women who decline specialized ED treatment.

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  • 348.
    Andersen Thulin, Elin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Exploring Maternal Mortality in Tigray, Ethiopia. - The obstacles faced by a region undergoing obstetric transition.2017Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 349. Andersen, Zorana J.
    et al.
    Pedersen, Marie
    Weinmayr, Gudrun
    Stafoggia, Massimo
    Galassi, Claudia
    Jørgensen, Jeanette T.
    Nilsson Sommar, Johan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Olsson, David
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Oftedal, Bente
    Aasvang, Gunn Marit
    Schwarze, Per
    Pyko, Andrei
    Pershagen, Göran
    Korek, Michal
    De Faire, Ulf
    Östenson, Claes-Göran
    Fratiglioni, Laura
    Eriksen, Kirsten T.
    Poulsen, Aslak H.
    Tjønneland, Anne
    Vaclavik Bräuner, Elvira
    Peeters, Petra H.
    Bueno-de-Mesquita, Bas
    Jaensch, Andrea
    Nagel, Gabriele
    Lang, Alois
    Wang, Meng
    Tsai, Ming-Yi
    Grioni, Sara
    Marcon, Alessandro
    Krogh, Vittorio
    Ricceri, Fulvio
    Sacerdote, Carlotta
    Migliore, Enrica
    Vermeulen, Roel
    Sokhi, Ranjeet
    Keuken, Menno
    de Hoogh, Kees
    Beelen, Rob
    Vineis, Paolo
    Cesaroni, Giulia
    Brunekreef, Bert
    Hoek, Gerard
    Raaschou-Nielsen, Ole
    Long-term Exposure to Ambient Air Pollution and Incidence of Brain Tumor: the European Study of Cohorts for Air Pollution Effects (ESCAPE)2018In: Neuro-Oncology, ISSN 1522-8517, E-ISSN 1523-5866, Vol. 20, no 3, p. 420-432Article in journal (Refereed)
    Abstract [en]

    Background: Epidemiological evidence on the association between ambient air pollution and brain tumor risk is sparse and inconsistent.

    Methods: In 12 cohorts from 6 European countries, individual estimates of annual mean air pollution levels at the baseline residence were estimated by standardized land-use regression models developed within the ESCAPE and TRANSPHORM projects: particulate matter (PM) ≤2.5, ≤10, and 2.5–10 μm in diameter (PM2.5, PM10, and PMcoarse), PM2.5 absorbance, nitrogen oxides (NO2 and NOx) and elemental composition of PM. We estimated cohort-specific associations of air pollutant concentrations and traffic intensity with total, malignant, and nonmalignant brain tumor, in separate Cox regression models, adjusting for risk factors, and pooled cohort-specific estimates using random-effects meta-analyses.

    Results: Of 282194 subjects from 12 cohorts, 466 developed malignant brain tumors during 12 years of follow-up. Six of the cohorts also had data on nonmalignant brain tumor, where among 106786 subjects, 366 developed brain tumor: 176 nonmalignant and 190 malignant. We found a positive, statistically nonsignificant association between malignant brain tumor and PM2.5 absorbance (hazard ratio and 95% CI: 1.67; 0.89–3.14 per 10–5/m3), and weak positive or null associations with the other pollutants. Hazard ratio for PM2.5 absorbance (1.01; 0.38–2.71 per 10–5/m3) and all other pollutants were lower for nonmalignant than for malignant brain tumors.

    Conclusion: We found suggestive evidence of an association between long-term exposure to PM2.5 absorbance indicating traffic-related air pollution and malignant brain tumors, and no association with overall or nonmalignant brain tumors.

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  • 350. Andersen, Zorana J.
    et al.
    Stafoggia, Massimo
    Weinmayr, Gudrun
    Pedersen, Marie
    Galassi, Claudia
    Jørgensen, Jeanette T.
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Olsson, David
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Oftedal, Bente
    Aasvang, Gunn Marit
    Aamodt, Geir
    Pyko, Andrei
    Pershagen, Göran
    Korek, Michal
    De Faire, Ulf
    Pedersen, Nancy L.
    Östenson, Claes-Göran
    Fratiglioni, Laura
    Eriksen, Kirsten T.
    Tjønneland, Anne
    Peeters, Petra H.
    Bueno-de-Mesquita, Bas
    Plusquin, Michelle
    Key, Timothy J.
    Jaensch, Andrea
    Nagel, Gabriele
    Lang, Alois
    Wang, Meng
    Tsai, Ming-Yi
    Fournier, Agnes
    Boutron-Ruault, Marie-Christine
    Baglietto, Laura
    Grioni, Sara
    Marcon, Alessandro
    Krogh, Vittorio
    Ricceri, Fulvio
    Sacerdote, Carlotta
    Migliore, Enrica
    Tamayo-Uria, Ibon
    Amiano, Pilar
    Dorronsoro, Miren
    Vermeulen, Roel
    Sokhi, Ranjeet
    Keuken, Menno
    de Hoogh, Kees
    Beelen, Rob
    Vineis, Paolo
    Cesaroni, Giulia
    Brunekreef, Bert
    Hoek, Gerard
    Raaschou-Nielsen, Ole
    Long-term exposure to ambient air pollution and incidence of postmenopausal breast cancer in 15 European cohorts within the ESCAPE project2017In: Journal of Environmental Health Perspectives, ISSN 0091-6765, E-ISSN 1552-9924, Vol. 125, no 10, article id 107005Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Epidemiological evidence on the association between ambient air pollution and breast cancer risk is inconsistent.

    OBJECTIVE: We examined the association between long-term exposure to ambient air pollution and incidence of postmenopausal breast cancer in European women.

    METHODS: In 15 cohorts from nine European countries, individual estimates of air pollution levels at the residence were estimated by standardized land-use regression models developed within the European Study of Cohorts for Air Pollution Effects (ESCAPE) and Transport related Air Pollution and Health impacts – Integrated Methodologies for Assessing Particulate Matter (TRANSPHORM) projects: particulate matter (PM) ≤2.5μm, ≤10μm, and 2.5–10μm in diameter (PM2.5, PM10, and PMcoarse, respectively); PM2.5 absorbance; nitrogen oxides (NO2 and NOx); traffic intensity; and elemental composition of PM. We estimated cohort-specific associations between breast cancer and air pollutants using Cox regression models, adjusting for major lifestyle risk factors, and pooled cohort-specific estimates using random-effects meta-analyses.

    RESULTS: Of 74,750 postmenopausal women included in the study, 3,612 developed breast cancer during 991,353 person-years of follow-up. We found positive and statistically insignificant associations between breast cancer and PM2.5 {hazard ratio (HR)=1.08 [95% confidence interval (CI): 0.77, 1.51] per 5 μg/m(3)}, PM10 [1.07 (95% CI: 0.89, 1.30) per 10 μg/m(3)], PMcoarse[1.20 (95% CI: 0.96, 1.49 per 5 μg/m(3)], and NO(2) [1.02 (95% CI: 0.98, 1.07 per 10 μg/m(3)], and a statistically significant association with NOx [1.04 (95% CI: 1.00, 1.08) per 20 μg/m(3), p=0.04].

    CONCLUSIONS: We found suggestive evidence of an association between ambient air pollution and incidence of postmenopausal breast cancer in European women.

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