Umeå University's logo

Background: Randomized controlled trials have shown that metformin treatment during pregnancy slows down gestational weight gain (GWG) and reduces the risk of preterm birth in women with polycystic ovary syndrome (PCOS), but these trials have not investigated why metformin treatment produces these effects. Studies of metformin's mechanisms of action have mostly been in-vitro studies of cell lines or animal models, or clinical studies of non-pregnant human populations, and it is unknown whether the results of these studies are applicable to human pregnancy. Neonatal outcomes following metformin treatment have been extensively evaluated against insulin treatment for gestational diabetes mellitus (GDM). However, previous assessments have generally combined results from participants treated with metformin alone and results from those who also required supplemental insulin, which makes it difficult to assess effects of metformin per se, and evaluations against diet and lifestyle treatment are lacking.

Aim: The objectives of this thesis were to explore the potential mechanisms by which metformin treatment during pregnancy slows down GWG, affects fetal growth, and reduces the risk of preterm birth in women with PCOS, and to assess the risk of neonatal hypoglycemia following metformin-treated, insulin-treated, and diet-and-lifestyle-treated GDM.

Method: In Studies I-III, we investigated appetite-regulating hormones and immunological factors in serum and placental tissue obtained from women with PCOS treated with either metformin or placebo. In addition, a group of healthy women with normal pregnancies were included as a reference group. In Study IV, we evaluated associations between metformin treatment and neonatal hypoglycemia, and other neonatal outcomes associated with fetal hyperinsulinemia. We used a register-based approach, and a population-based cohort that consisted of more than 16 000 women with GDM, and their singleton offspring. Metformin as a single adjunctive treatment was assessed separately from metformin combined with insulin treatment.

Results: Women with excessive GWG were more leptin resistant throughout pregnancy, and displayed a lower physiological serum allopregnanolone increase in late pregnancy than women who maintained a healthy GWG (Paper I). Metformin treatment improved leptin sensitivity and counteracted excessive GWG in women with PCOS (Paper I). This treatment effect was uncorrelated with placental leptin and leptin-receptor mRNA expression in women with PCOS (Paper II). Placental leptin mRNA expression correlated positively with the birthweight/placental weight ratio in placebo-treated women with PCOS (Paper II). PCOS status was associated with enhanced decidual immune-cell mobilization, particularly greater abundance of CD4⁺ T cells, and with altered placental IL-18 and IL-5 cytokine mRNA expression (Paper III). Metformin treatment altered the immunological landscape at the maternal-fetal interface in women with PCOS. This was shown by greater abundance of decidual CD56⁺ cells, downregulation of placental IL-4 and IL-18 mRNA expression, fewer placental pro-inflammatory intra-class cytokine mRNA correlations, and different cytokine mRNA expression profiles compared with placebo (Paper III). Offspring exposed in utero to only metformin as a pharmacological treatment for GDM appeared to be at similar risk of neonatal hypoglycemia to infants exposed to diet and lifestyle treatment alone, and at lower risk compared to offspring exposed to insulin, regardless of whether the insulin was administered as monotherapy or in combination with metformin (Paper IV).

Conclusions and implications: Metformin treatment effectively reduces the risk of excessive GWG and appears to counteract physiological leptin resistance during pregnancy in women with PCOS. However, a positive correlation between placental leptin mRNA expression and the placental-efficiency measure ‘birthweight/placental weight ratio’, was erased by metformin treatment. The clinical implication of this finding is unclear, and future research should aim for deeper insight into this mechanism for clarification. Metformin treatment induced complex immunomodulatory effects at the maternal-fetal interface in women with PCOS, but further research is required to determine if these findings can explain why metformin reduces the risk of preterm birth in PCOS. The similar risk of neonatal hypoglycemia to diet and lifestyle treatment is reassuring for all metformin-treated women with GDM that achieve glycemic targets without requiring supplemental insulin. In summary, this thesis contributes to increasing knowledge of how metformin treatment during pregnancy affects metabolic adaptations of importance for maternal weight gain and fetal growth in women with PCOS. Further, it provides some insights into how PCOS status and metformin treatment affect the immunological landscape at the maternal fetal interface; expands previous knowledge of how metformin treatment for GDM associates with neonatal hypoglycemia; and demonstrates the importance of differentiating between metformin with and without supplemental insulin when assessing treatment-associated risk of adverse outcomes.

Aim: From a health psychological perspective, the great need of effective cardiovascular disease (CVD) prevention and the potential of pictorial presentation of subclinical atherosclerosis as part of risk communication implies two important lines of inquiry which constitute the overall aims of this thesis: 1) To explore and assess psychological intervention response in terms of cognitive and emotional reactions to health risk communication about subclinical atherosclerosis, 2) To assess associations between psychological intervention response and lifestyle modification.

Methods: The pragmatic population-based randomized controlled trial VIPVIZA investigates the impact of pictorial information about subclinical atherosclerosis, added to traditional risk factor-based communication. The intervention includes a personalized, colour-coded and age-related risk communication strategy and a motivational conversation, and has been shown to reduce cardiovascular disease risk. Study 1 assessed cognitive and emotional reactions to the intervention, and how reactions were associated to lifestyle modification, measured with a lifestyle index based on physical activity, diet, smoking and alcohol consumption. To gain deeper understanding of why the intervention is effective, Study 2 qualitatively explored reactions evoked by the intervention as well as attitudes to any implemented lifestyle changes among VIPVIZA participants in the intervention group with improved health status. Study 3 assessed risk perception and efficacy beliefs in the intervention group and the control group after one and three years. Furthermore, this study assessed whether risk perception increased with message severity. Study 4 assessed the impact of the VIPVIZA intervention on participants' risk perception accuracy, and also whether risk perception accuracy after one and three years was associated with sustained lifestyle change.

Results: The result letter was easy to understand and the intervention increased understanding of personal CVD risk, the possibility to influence the risk, and how to influence the risk. High level of cognitive response in combination with high level of emotional arousal was found to be most beneficial for lifestyle modification. Informants perceived risk messages to be clear, accurate, reliable and emotionally engaging. Study 1 and Study 2 suggest that an interplay between cognitive and emotional reactions is crucial from early reactions to risk messages, through the decision-making process of behavioural change to maintenance of a healthy lifestyle. The intervention group perceived their cardiovascular disease risk as higher after one year, compared to the control group, with the effect persisting after three years. Within the intervention group, differences in CVD risk perception were found among participants receiving different color-coded risk messages on atherosclerosis status. The intervention had an impact on accuracy of risk perception. Accuracy of risk perception was associated with long-term behaviour change. Underestimating risk was associated with a decrease in health behaviours.

Conclusions: As captured by the idiom "A picture says more than a thousand words", the results indicate that pictorial communication of atherosclerosis is easy to understand, enhances comprehension of risk, and evoke a powerful response. In other words: the communication is effective. Furthermore, in line with the idiom "Seeing is believing", which suggests that seeing something first-hand makes it more credible or believable, the results suggest that pictorial communicating on atherosclerosis status increase understanding of CVD risk since being perceived as accurate, reliable and convincing. In other words: pictorial communication is trustworthy and convincing. Future CVD interventions should acknowledge the role of accuracy of risk perception for behaviour change and focus on strengthening efficacy beliefs.

Background: Globally, studies have indicated a significantly higher prevalence of mental health disorders and suicidal behaviours among young prisoners compared to adult prisoners and the general population. In Cambodia, the experience of historical trauma and contemporary challenges exacerbate mental health concerns among young people, yet there is a lack of adequate mental health resources and research within the prison system. To address these issues, there is a critical necessity for comprehensive assessments of mental health needs, interventions tailored to local contexts, and reforms in the prison healthcare system, all of which are essential for improving the well-being and quality of life of young prisoners in Cambodia and beyond.

Aims: This thesis aimed to address the mental health, well-being, and healthcare needs of young Cambodian prisoners by exploring their mental health situation, efficacy of life skills interventions, coping mechanisms, and health system strengthening strategies, all informed by insider perspectives to enhance their well-being.

Methods: The thesis was conducted in four selected prisons. Both quantitative and qualitative approaches were used to fulfil its aims. The quantitative component was used to assess the current mental health of youngprisoners and to evaluate the impact of the Life Skills Education (LSE) intervention. The qualitative elements aimed to explore the perspectives of both young prisoners and prison staff regarding their current mental health status and coping mechanisms and the strategies applied to enhance the prison health system.

Results: The quantitative findings revealed high levels of mental health problems but low suicidal behaviours among the participants. Factors such as younger age, lower education, and a history of drug use were associated with higher level of mental health problems. While the LSE intervention led to an improvement in mental health, the differences with the controlgroup were not statistically significant. Qualitative insights highlighted the challenges faced by young prisoners, including loneliness, lack of family support, and unmet basic needs, impacting their mental wellbeing.Some employed coping strategies, but overall there was a reliance on self-help and family support due to the limited availability of healthcare services acknowledged by prison staff. Staff emphasized the need for reforms, including mental health awareness activities, staff training, governance improvements, and external support to enhance prison healthcare services.

Conclusion: This thesis revealed a high level of mental health problems among young prisoners in Cambodia, underscoring the critical need for contextualized mental health interventions. While the impacts of the LSE programme were limited, it lays the groundwork for future improvements. Perspectives from both young prisoners and staff emphasized the importance of self-help strategies and staff training. Moving forward, policymakers should prioritize mental health services and reforms to better support young prisoners' well-being in Cambodian prisons.

The aim of this study is to develop a pedagogical approach to the teaching of literature in relation to value-based work, specifically regarding questions of sexuality and gender. The starting point for this approach is the pedagogue Gert Biesta’s vision of democracy as something that needs to be exercised within education, rather than a set of values that should simply be transmitted to the students. He also stresses the teacher’s role to actively interrupt the students’ predispositions for the education to be unpredictable, risky, and truly democratic. I combine this approach to teaching with queer theoretical, especially queer temporal, perspectives on sexuality, gender, and literature for ways to disrupt various interpretations of fiction. I also use Rita Felskis theories on literary engagement to interrupt and disrupt previous readings. In the analysis this approach is used to analyze readings of six books – three novels and three picture books: Moominpappa at Sea (1965) by Tove Jansson, Mamman och havet (2012) by Sara Stridsberg and Anna-Clara Tidholm, Darling River (2010) by Sara Stridsberg, Else-Marie and Her Seven Little Daddies (1990) by Pija Lindenbaum, Popular Music from Vittula (2000) by Mikael Niemi, and Kivi & Monsterhund (2012) by Jesper Lundqvist and Bettina Johansson. I study various previous readings of the texts, such as reviews, research, student essays and comments on online forums. This gives an idea of how the text have been read before, and how they are likely to engage the intended readers of this dissertation – interpretations which I disrupt using queer theoretical perspectives. The final chapter problematizes and further develops the thesis’ theoretical framework and discusses its implication for the teaching of literature, as well as for educational philosophy in general, regarding democracy, politics, and ethics.

Federated Learning (FL) is a distributed machine learning paradigm that enables the training of models across numerous clients or organizations without requiring the transfer of local data. This method addresses concerns about data privacy and ownership by keeping raw data on the client itself and only sharing model updates with a central server. Despite its benefits, federated learning faces unique challenges, such as data heterogeneity, computation and communication overheads, and the need for personalized models. Thereby results in reduced model performance, lower efficiency, and longer training times.

This thesis investigates these issues from theoretical, empirical, and practical application perspectives with four-fold contributions, such as federated feature selection, adaptive client selection, model personalization, and socio-cognitive applications. Firstly, we addressed the data heterogeneity problems for federated feature selection in horizontal FL by developing algorithms based on mutual information and multi-objective optimization. Secondly, we tackled system heterogeneity issues that involved variations in computation, storage, and communication capabilities among clients. We proposed a solution that ranks clients with multi-objective optimization for efficient, fair, and adaptive participation in model training. Thirdly, we addressed the issue of client drift caused by data heterogeneity in hierarchical federated learning with a personalized federated learning approach. Lastly, we focused on two key applications that benefit from the FL framework but suffer from data heterogeneity issues. The first application attempts to predict the level of autobiographic memory recall of events associated with the lifelog image by developing clustered personalized FL algorithms, which help in selecting effective lifelog image cues for cognitive interventions for the clients. The second application is the development of a personal image privacy advisor for each client. Along with data heterogeneity, the privacy advisor faces data scarcity issues. We developed a daisy chain-enabled clustered personalized FL algorithm, which predicts whether an image should be shared, kept private, or recommended for sharing by a third party.

Our findings reveal that the proposed methods significantly outperformed the current state-of-the-art FL  algorithms. Our methods deliver superior performance, earlier convergence, and training efficiency.

Modern design has played a role in creating the current world, including injustices and the climate crisis. And the design discipline still contributes to the reproduction of what bell hooks calls white supremacist imperialist capitalist (hetero)patriarchy that distributes privilege and oppression. At best, design supports us; at worst, it hinders or even harms us. Our experience depends on our gender and sexuality, whether we are able-bodied or not, our skin colour, our class, and many more aspects. There is an urgency to transform mainstream design, so that it can become able to not only stay with past and present trouble, but also to contribute to developing more just futures.

Spaces that can facilitate and support such work are needed. Presently, design museums come closest to serving this kind of role. They are mainly public spaces that hold much power and infrastructural resources. They not only represent design to design students, designers, and the wider public. Design museums also have the potential to support discussions on complex issues without the pressure to immediately come up with solutions. However, they are not yet capable of contributing to redesigning design, since they often tend to preserve the problematic status quo rather than enable change. Therefore, these established design museums must be transformed to become able to realise their potential to serve the required role. This thesis investigates potential and limitations of currently existing design museums, envisions alternative spaces, and develops feminist design strategies for initiating transformational processes in design museums towards more just futures.

The approach taken includes looking to the example of community archives as well as combining concepts and methods from feminist research, design research and onto-cartography in ways that leverage their synergies to enable a sense-making of design museums’ involvement with systems of oppression, as well as a development of alternative visions and strategies for intervening and transforming. Community archives make accessible alternative histories, and therefore enable alternative ways of dealing with the present and of envisioning alternative, more just futures. They not only hold deep understandings of oppressive systems and how they are reproduced in daily life and the material world, but also continuously develop creative ways of resisting and, most importantly, initiating transformational processes.

Through this framing, the more specific research question developed is: Which feminist design strategies could support initiating transformational processes in design museums aiming towards more just futures? This research question was addressed through a feminist design methodology that combines feminist and design research. Specific methods used include inventories, museum visits, workshops, consulting secondary literature, illustrations, and visual analysis.

The research project resulted in an investigation of established design museums, the formulation of characteristics of alternative design museums which are envisioned as metabolic design museums, and the development of feminist design strategies for initiating transformational processes in design museums. Based on the results, this thesis contributes to design research ways in which the role of design and its established institutions in reproducing white supremacist capitalist patriarchy can be understood and analysed. Furthermore, it makes a methodological contribution to both feminist research and design research by combining these two fields, in parts with the help of onto-cartography, to leverage their synergies. Finally, this thesis – as well as the research process that led to it – contribute to activism in the field of design by scaffolding ways in which design could be transformed so that it becomes more able to unfold its potential to contribute towards the development of more just futures.

Background: In the field of otorhinolaryngology, the paranasal sinuses and the middle and inner ear present a clinical challenge. Radiological methods offer a stable foundation for diagnostics and preoperative decisions in this context. While many studies have explored the prevalence of maxillary sinusitis of dental origin (MSDO), the use of MSDO detected on cone beam computed tomography (CBCT) scans, rather than conventional computed tomography (CT), is a relatively new approach to detect MSDO. CBCT, with its higher ability to assess bony details, is becoming a valuable tool in detecting MSDO. Photon-counting Computed Tomography (PCCT), a cutting-edge diagnostic imaging method, enables radiological examinations with high spatial resolution at a low radiation dose compared with conventional CT. However, the question of how much the dose can be reduced while maintaining still diagnostic value in radiological examinations remains unanswered.

Aims: This thesis aimed to further develop the use of radiology in the ear, nose and throat (ENT) medical field, which could impact how we interpret radiological findings to obtain useful clinical information. The objectives for this thesis were as follows: 1) to investigate the proportion of MSDO among patients with suspected sinusitis referred for radiological examination; 2) to compare the symptomatology of MSDO with sinusitis due to upper respiratory tract infection (URTI); 3) to develop a modular anthropomorphic phantom that could be used to evaluate the performance of radiological techniques in detecting pathology in the temporal bone (TB) region; and 4) to investigate whether the diagnostic quality of TB imaging is maintained even at significantly lower radiation doses using PCCT compared to conventional energy integrated computed tomography (EICT).

Material and methods: Paper I was a retrospective study in which our research team reviewed 303 CBCT sinus examinations and analysed the data to determine the prevalence of MSDO among patients with suspected sinusitis who had been referred for radiological examination.A retrospective study was conducted in Paper II, in which the medical records from 61 patients with maxillary sinusitis confirmed via CBCT were thoroughly reviewed. Two independent observers reviewed all cases; when the observers disagreed, the examinations were re-reviewed to reach a consensus, ensuring the reliability of the findings. For comparison, the patients were divided into MSDO and URTI sinusitis groups. Information including self-reported symptoms, clinical findings, and time between first medical contact to correct diagnosis were collected and compared between the groups, providing a comprehensive understanding of the differences between the two conditions.

In Paper III, a modular anthropomorphic phantom was constructed. '

To evaluate anatomical structures and image quality, the phantom was used in paper IV to scan 10 human TB specimens using PCCT and conventional CT systems.

Results: In paper I, we found that the prevalence of unilateral MSDO was 40 %. Maxillary sinus mucosal swelling adjacent to periapical destruction was found in 91 % of the studied patients.

In paper II, we found that the MSDO patients reported a foul odour and foul taste more often, and the time from their first symptom to the correct diagnosis was significantly longer. The URTI sinusitis patients reported toothache, bilateral facial pain, and symptoms associated with a cold more often than the MSDO patients. The accuracy of CBCT for detecting MSDO was 97%.

In paper III, we found that the radiological attenuation of the polyurethane (PUR) plastic and alginate plastic used for the phantom was similar to those of the soft tissues of a living human. The mean Hounsfield unit (HU) values of the CT slices representing tissue at the TB and brain level were comparable in the phantom and patient groups.

In paper IV, we found that reviewers preferred PCCT scans for the majority of structures being evaluated and for overall image quality. This was true even at a radiation dose below 15 % of that in the clinical EICT protocol.

Conclusion: The close relationship between dental infections and unilateral sinusitis should not be overlooked. MSDO differs from URTI sinusitis regarding symptoms and clinical findings, and should be suspected in patients with unilateral symptoms presenting little pain and experiencing a foul odour and/or foul taste. CBCT is a reliable method of detecting MSDO. The modular phantom developed in the third study can be used to evaluate examination methods in a set-up corresponding to a living human without exposing patients to radiation. Finally, PCCT was found to be superior to EICT in terms of image quality. 

Earthworms are among the most crucial species for global food production and soil fertility. However, in soils and ecosystems that have evolved without worms, their introduction can lead to significant ecological change. Due to the eradication of soil fauna during the last glacial cycle, and slow recolonization, high-latitude soils generally lack large earthworms. But this situation is about to change as several species of earthworms are spread to northern habitats through human-mediated dispersal.

In this thesis, I investigate the impacts on plant communities and carbon cycling that results from the dispersal of earthworms—primarily Lumbricus and Aporrectodea spp.—in the Fennoscandian Arctic. To achieve this, I combined data from a four-year mesocosm study with observations from earthworm-invaded soils in the Fennoscandian mountain range. My findings indicate that earthworm presence can make tundra ecosystems more graminoid-rich, and cause preferential grazing by rodents, likely due to the higher nitrogen content in plants growing in more fertile soil.

My research has revealed that earthworms play a significant role in stimulating tundra plant biomass growth, particularly belowground. I attribute this increase in plant biomass to the extended growing season facilitated by earthworm activity and more plant available nitrogen. This growth enhancement was consistent across different vegetation types but only led to an increase in net ecosystem carbon (C) uptake in dwarf shrub-dominated tundra. In contrast, in meadow tundra, earthworms had no net effect on the ecosystem C pool, due to an increased mineralization of soil organic carbon (SOC), which counterbalanced the enhanced plant carbon sequestration.

Furthermore, using species distribution modelling, I confirmed that earthworm dispersal in the Fennoscandian Mountains is likely driven by human vectors. I estimate that approximately 7% of this region currently consists of habitats that are both climatically suitable and prone to human-mediated earthworm dispersal.

Efficient municipal solid waste (MSW) management promotes resource conservation, climate-change mitigation, public health, and environmental protection. A key aspect of environmental protection within MSW management is ensuring that potential pollutants are not released into the environment. One group of environmental pollutants of global concern is per- and polyfluoroalkyl substances (PFAS). Also known as “forever chemicals”, these are used in a wide variety of consumer products and industrial processes, and are known for their persistence. The fate of PFAS in waste-management processes, such as Waste-to-Energy (WtE), is largely unknown. This thesis aimed to investigate the fate of PFAS in a WtE plant.

Comprehensive sampling was performed to provide a synoptic overview of the occurrence and distribution of PFAS in residual streams, and to investigate the potential emission of PFAS from the WtE process to the environment.

Short-chain (C ≤ 7) perfluorocarboxylic acids were the dominant class of PFAS across all matrices analysed. PFAS was found in leachate from the temporary MSW stockpile located at the WtE plant, as well as in most incineration residues (e.g., bottom ash, condensate, and flue gas) during the incineration of MSW. Co-incineration of sewage sludge from a wastewater treatment plant and MSW (with the former added at 5–8 wt.% of the latter) led to an increase in the concentration of PFAS in all matrices, with the exception of filter ash and stack flue gas.

In general, the wet flue-gas treatment was able to capture some PFAS and transfer them to the in-house process-water treatment; however, further optimisation is required to increase the ability of this treatment to capture the shortest PFAS investigated (perfluorobutanoic acid).

Overall, these findings highlight that some PFAS are not fully degraded during WtE conversion, and that PFAS could enter the environment via both leaching from unburnt MSW and incineration residues.

Background: During magnetic resonance imaging (MRI), the interaction between the alternating currents of the gradient coil and the static magnetic field (SMF) generates vibrational forces, perceived as loud acoustic noise. The sound pressure levels (SPLs) are high enough to cause hearing damage, necessitating hearing protection for anyone in the scanner room. To address this, technological advancements have introduced acoustic noise reduction (ANR) software that can alter the gradient currents, resulting in lower vibrational forces and quieter scans. However, such alterations might decrease image quality and prolong scan times. Therefore, it is crucial to evaluate different ANR software to understand their specific utilities and limitations. Additionally, it remains unclear whether, when, and how such software is being utilized clinically, and how MR personnel manage acoustic noise overall. Furthermore, exposure to the SMF within the scanner vicinity can induce transient adverse health effects, such as vertigo, dizziness, nausea, headaches, drowsiness, and metallic taste. However, the evidence is inconclusive regarding the regularity of symptoms, and control groups are needed to account for environmental confounders. Insights into the management of acoustic noise, gradient field applications, and SMF exposure may assist in making MRI both safer and quieter, thereby improving the MR work environment, patient comfort, and the overall clinical experience.

Aim: The overall aim of this thesis was to present a radiography perspective on acoustic noise management, gradient field applications and SMF exposure in MR.

Methods: This thesis encompasses four studies. In Study I, we explored health complaints subjectively associated with SMF and acoustic noise exposure, including symptom prevalence and attribution over the last year. Data were extracted from a nationally distributed cross-sectional survey answered by MR radiographers and CT radiographers (the latter used as controls; CT, computed tomography) across Sweden. In total, data from 529 participants were included and analyzed both descriptively and analytically using logistic regression. In Study II, we conducted 15 individual semi-structured interviews with MR radiographers across Sweden, to explore how they manage acoustic noise in clinical MR settings. The interviews were analyzed thematically. Studies III and IV were both experimental studies that compared ANR software to conventional (non-ANR) imaging. Study III evaluated T2-weighted turbo spin echo (T2W TSE) during lumbar MRI at 1.5 Tesla (T) using two different ANR software – Whisper Mode (WM) and Quiet Suite (QS). In Study IV, we evaluated T2W fast spin echo (FSE) and three-dimensional T1-weighted turbo field echo (3D T1W TFE) during brain MRI at 7 T using the ANR software SofTone. In both Studies III and IV, peak SPLs, perceived noise levels, image quality, and inter-observer agreements between radiologists were compared. In Study III we also measured switched gradient field exposure and gradient currents. Study III included 40 patients, and Study IV 28 healthy volunteers. Data were analyzed using repeated measures analysis of variance (ANOVA), Friedman’s ANOVA, and Wilcoxon’s signed-rank test in Study III. In Study IV, we used paired t-test and Wilcoxon’s signed-rank test. Inter-observer agreement between radiologists’ assessments of image quality was reported in percentage agreement for both studies, with Krippendorff’s alpha also calculated in Study IV.

Results: In Study I, no significant differences in symptom prevalence were seen between the radiographers who work in MR and those in CT. However, working at ≥3 T doubled the risk of SMF-associated symptoms as compared to working at ≤1.5 T. Stress was a significant confounder of symptoms. Work-related acoustic noise was rated as more troublesome by CT than MR radiographers. Study II yielded three main themes on how MR radiographers manage acoustic noise: (I) Navigating Occupational Noise: Risk Management and Adaptation; (II) Protecting the Patient and Serving the Exam, and (III) Establishing a Safe Healthcare Environment with Organizational Support. Compared to conventional imaging, software-based ANR reduced the peak SPLs by 72% and 84% with WM and QS, respectively (Study III), and by 89% (T2W FSE) and 92% (3D T1W TFE) using SofTone (Study IV). In both Studies III and IV, all ANR sequences were perceived as being significantly quieter than their conventional counterparts. Furthermore, all sequences remained diagnostic, although qualitative assessment scores differed slightly for 3D T1W TFE. Switched gradient field exposure was reduced by 48% and 66% using WM and QS, respectively. 

Conclusion: No significant differences in symptom prevalence were seen between MR and CT radiographers. However, working at 3 T increased the risk of SMF symptoms, and stress increased adverse health effects. Although noise was considered to be more troublesome by CT radiographers, this does not suggest that acoustic noise is not problematic in MR environments. MR radiographers demonstrate a willingness to adapt and employ measures to mitigate acoustic noise, thereby enhancing safety and comfort for both patients and personnel, all while striving to deliver diagnostic exams. However, they require appropriate tools and support to do so, suggesting that organizations need to adopt more proactive, holistic approaches to safety initiatives. This thesis also evaluated software-based ANR for its functionality in clinical practice, and found that T2W TSE/FSE and 3D T1W TFE can maintain acceptable subjective image quality while considerably decreasing peak SPLs. This reduction in sound intensity provides both a safer, quieter, and (presumably) more comfortable scan environment.

Background

Psoriatic disease, encompassing skin psoriasis and psoriatic arthritis, is a common condition affecting 2-3% of the Western population associated with reduced quality of life and increased healthcare costs. To improve patients’ lives and the stewardship of societal resources, a nuanced understanding of the associations between patient characteristics and health outcomes are needed for optimal clinical and societal decision making. While randomised clinical trials play a central role in evidence-based medicine, they have limitations relating to patient selection, follow-up duration, and idealised clinical conditions. In recent years, the role of real-world evidence in health research has grown, including in dermatology, due in part to its ability to describe and compare patients in routine clinical care. This thesis contains four analyses using Swedish real-world data describing associations between patient characteristics and outcomes in psoriatic disease.

Methods

Data from several administrative population registers in Sweden and the clinical registry PsoReg were collected for those with psoriatic disease in routine clinical care and linked at the patient level. The data include diagnoses, pharmacy dispensed medications, mortality, socioeconomic information, quality of life, and clinical severity. A matched non-psoriatic control group was also extracted.

The first analysis assessed the association between disease severity (measured by the Psoriasis Area and Severity Index [PASI]) and health-related quality of life (measured the EuroQol 5-dimension instrument [EQ-5D]) in 2,674 patients with longitudinal follow-up in PsoReg, a fixed effects regression model was deployed adjusting for confounding factors including certain types of unobserved confounding. 

Second, the independent associations of skin psoriasis and somatic comorbidity with incident psychiatric illness were described across 93,239 psoriasis patients and 1.4 million controls. Their individual contributions and synergistic interaction were assessed using a time-to-event model. Diagnosis codes were used to construct the composite psychiatric illness outcome consisting of depression, anxiety, and suicidality. Diagnosis codes were also used to create the Elixhauser and Charlson comorbidity indexes to measure somatic comorbidity. 

The third analysis assessed age-related inequities in biologic prescriptions in 1,465 patients enrolled in PsoReg using a time-to-event analysis controlling for decision-making variables including disease severity. The analysis also described the non-parametric relationship between age and incident biologic prescriptions using a kernel regression.

Finally, the fourth analysis describes rates of non-persistence in individuals with psoriatic arthritis treated with adalimumab, ustekinumab, and secukinumab using a time-to-event model. A total of 4,649 drug exposure period across 3,918 patients were assessed. Non-persistence was defined as a treatment switch or discontinuation, the latter defined as a failure to refill an existing prescription within two times the days of drug supplied.

Results

The analysis found a statistically significant, negative association between PASI and the EQ-5D (                    =-0.0186, 95% confidence interval [CI]: -0.0360, -0.0201) which was non-linear (  =0.0003, 95% confidence interval [CI]: 0.0001, 0.0004). Incremental PASI improvements for those with less skin involvement were associated with larger increases in quality of life than in those with more skin involvement. 

Skin psoriasis was found to be independently associated with the onset of psychiatric illness (hazard ratio [HR]=1.32, 95% CI: 1.27-1.36) as was somatic comorbidity (HR=2.09, 95%CI: 2.06-2.13). However, the results were compatible with a lack of synergistic effect between skin psoriasis and somatic comorbidity on psychiatric illness (HR=0.93; 95% CI: 0.81-1.04).

Older psoriasis patients appeared less likely to initiate biologic therapies than their younger counterparts after controlling for disease severity and comorbidity (HR=0.97, 95% CI: 0.95-0.99).

Individuals with psoriatic arthritis treated with ustekinumab were found to have lower rates of non-persistence compared to adalimumab (HR=0.56, 95% CI: 0.49-0.64). Secukinumab and adalimumab appeared to have similar rates of non-persistence (HR=1.01, 95% CI: 0.88-1.15), although the results differed in biologic-naïve and biologic-experienced subgroups. The definition of discontinuation was sensitive and had material effects on the results.

Conclusions

Patient characteristics appear to play an important role in a variety of health outcomes in psoriatic disease, demonstrated across four real-world settings. The utilisation of data from routine clinical care enabled the investigation of research questions that are not suitable for clinical trial contexts, providing relevance for patients in everyday clinical practice. The study designs and methodologies applied in this thesis are associated with a variety of strengths and limitations, many of which are closely linked to the observational nature of the data, which have material importance for the interpretation of the results and implications for healthcare and policy. Understanding the associations between patient characteristics and subsequent outcomes is an important element in the delivery of holistic, personalised healthcare.

Background

Universal Health Coverage (UHC) is vital for improving health outcomes through financial protection and responsive health services, as outlined in the Sustainable Development Goals. In 2007, Ecuador initiated significant social and health system reforms aimed at enhancing its citizens’ quality of life. Over a decade, efforts expanded coverage and improved the efficiency and quality of public health services. Reforms included free health services at all care levels, reducing system fragmentation, and significant investments in health facilities, medicines, and medical equipment. While some studies noted improved health coverage; this thesis aims to assess whether Ecuador’s recent health system reform reduced socio-economic inequalities in health care and financial protection and to identify the main facilitators and obstacles to its implementation.

Methods

The study used quantitative and qualitative methods, including three cross-sectional studies with data from the Living Standards Measurement Surveys (2006 and 2014 waves). Descriptive statistics identified key population characteristics, health indicators, and financial protection coverage. Health inequality was measured through socio-economic differences in UHC components. Population coverage was measured by abstention from seeking care during illness, while preventive care and reproductive health services were key health service coverage indicators. Catastrophic Health Expenditure (CHE) was used to gauge financial protection. The second objective was addressed through thematic analysis of interviews with key stakeholders.

Results

The reforms led to increased population and basic health service coverage, with a notable reduction in care abstention. However, persistent socio-economic inequalities remained, particularly among rural, indigenous, and uninsured groups. CHE and health expenditure on medicines decreased, but uninsured households remained vulnerable. Political commitment, innovative coverage mechanisms, and a focus on prevention facilitated reform implementation, while private interests, weak governance, and health care commodification hindered progress.

Conclusions

The reforms improved UHC in Ecuador but did not fully address socio-economic inequalities, particularly among disadvantaged groups. Ongoing political and structural challenges must be tackled to further strengthen Ecuador’s health system.

Background 

Opportunistic salpingectomy at the time of hysterectomy, i.e., removing presumed healthy fallopian tubes when removing the uterus, is suggested to reduce the risk of ovarian cancer. However, the impact of opportunistic salpingectomy on complications and ovarian function is insufficiently studied. Furthermore, the perspectives of women with no increased risk of ovarian cancer facing the choice to undergo opportunistic salpingectomy at hysterectomy have not been previously explored. There is consensus that surgical complications are important to register, both for quality control and research. Nevertheless, internationally there is no agreement on when, how, and even what to register, which reduces the comparability. This thesis aimed to compare complication rates and menopausal symptoms after opportunistic salpingectomy, as well as to explore women’s views on hysterectomy and salpingectomy before surgery. Furthermore, it aimed to validate complication registration after uterine and adnexal surgery in the Swedish National Quality Register of Gynecological Surgery (GynOp).

Methods

A retrospective cohort study with data from GynOp (Paper I), explored the uptake of opportunistic salpingectomy in Sweden 1998-2016. Hysterectomy with bilateral salpingectomy vs hysterectomy only, performed 2013-2016, was compared regarding complications and menopausal symptoms one year after surgery. Paper II is a qualitative study, with focus group discussions including women waiting for hysterectomy in different parts of Sweden. The participants’ experiences and perceptions of health, healthcare, and potential outcomes of hysterectomy with or without salpingectomy were explored. For Paper III, a cross-sectional study based on a survey sent to Swedish gynecologists was conducted. Fictional cases describing various postoperative courses were used to explore interrater reliability in assessing complications according to the methods in GynOp. Finally, a cohort study including surgeries of the uterus and/or adnexa with benign indications 2017-2020 was conducted. Complications registered in GynOp, the National Patient Register, Prescribed Drug Register, and Cause of Death Register were compared (Paper IV).

Results

The uptake of bilateral salpingectomy at the time of hysterectomy increased from 1.9% in 2012 to 37.8% in 2016. Comparing hysterectomy with bilateral salpingectomy vs hysterectomy only, salpingectomy was associated with an increased risk of menopausal symptoms one year after surgery (adjusted relative risk (aRR) 1.35, 95% confidence interval (CI) 1.07-1.71)). A slight increase in mean length of hospital stay (0.1 day, 95% CI 0.01-0.17) was seen, as well as an increased risk of minor complications in unadjusted analysis (relative risk (RR) 1.36, 95% CI 1.05-1.77). The latter was, however, not significant after adjusting for potential confounders (aRR 1.29, 95% CI 0.92-1.82) (Paper I). Women waiting for hysterectomy expressed that healthcare personnel held differing perspectives from the women, both regarding the surgery and the health problems being the cause of surgery. They also perceived a dependency on the advice and opinion of the physician for the choice of surgical procedure and possibly having opportunistic salpingectomy (Paper II). Swedish gynecologists demonstrated high interrater reliability in assessing whether a complication had occurred (agreement >80% in 85% of cases (17/20)), and in using the Clavien-Dindo classification, (agreement >90% in 80% of cases (16/20)) in our survey. Cases with lower agreement rates were bordering between minor complications and normal postoperative course (Paper III). From 2017 to 2020, 32,537 surgeries of the uterus and/or adnexa were registered in GynOp (Paper IV). Higher rates of complications from discharge to three months were found in GynOp compared with the Patient Register (13.7% vs 6.9%). The coverage of all complications was 79.1% in GynOp and 46.1% in the Patient Register when linking the two registers. Of the included individuals, 12.7% had a prescription of antibiotics ≤30 days after surgery, indicating a postoperative infection.

Conclusions

This thesis suggests that bilateral salpingectomy at the time of hysterectomy affects ovarian function and might increase the risk of minor complications, concerns which must be properly addressed in the consultation before surgery as well as in future research. Research on surgical interventions require reliable tools for evaluating complications. In finding a higher rate of complications captured in GynOp compared with the health registers, and a high interrater reliability among Swedish gynecologists, the registration of complications in GynOp are validated. However, continued work is required with definitions of what is normal in recovery after any specific surgery, for reliable capture of complications and to provide adequate information before surgery.  Shared decision-making based on high quality scientific evidence of risks and benefits is important in all interventions, especially in prophylactic surgery, e.g., opportunistic salpingectomy.

This thesis explores the work of Swedish municipalities in dialogue and digital communication. It examines digital communication and dialogue through field studies in Örnsköldsvik municipality from 2015 to 2019, and the presence of Swedish municipalities on Facebook from 2009 to 2017. During this period, digital communication and dialogue have been prominent on the agendas of municipalities both in Sweden and internationally. The development of social media, e-services, strategic communication, branding, and citizen dialogues are crucial for understanding the evolution of communication and democracy, both now and in the future. The overall aim of this thesis is to investigate how municipalities communicate with citizens, with a focus on digital media.

The dissertation is grounded in the fields of participatory research, organizational research, strategic communication, and organizational communication. The material includes notes, reports, and documents from observations, policy documents, guidelines, interviews with officials and communicators, and Facebook posts from municipalities’ Facebook pages. The four case studies draw on new institutional theory, communication theory, and deliberative systems theory to varying degrees. These case studies are theoretically linked through a focus on institutions and how they shape and are shaped by understandings of communication and participation.

The thesis captures ideas about communication and participation through eight perspectives, shedding light on what it means to be, work in, and represent a municipality today. Communicators play a central role in conveying meanings about communication by acting as internal consultants, trainers, and critical reviewers of the organization’s communication purposes. They also have a strategic role in formulating guidelines and standards for communication design. The thesis argues that both communication and participation must be understood through a broader media concept to grasp the complex interactions between the municipality and citizens. The municipality speaks, listens, and negotiates with citizens directly and indirectly in various ways, from user data and motion sensors to physical meetings. The thesis also shows that municipalities use communication to steer citizens in different directions, from how they should contact the municipality to how and where they can be involved in designing services and policies. Through large-scale digital text analysis, the phatic nature of communication also emerges. Municipalities seem to communicate to maintain, build, and establish social relationships with citizens on social media. This form of communication not only fulfills a social function but also alludes to local pride and community by highlighting landmarks and other local and “sacral” objects. The results also show that citizen participation from the municipality’s perspective is characterized by ideas about inclusion and strengthening the decision-making process. The more (and different) perspectives that can be considered, the better and more sustainable the decisions will be. However, the perspectives on participation are fraught with problems and challenges, as broad inclusion is time-consuming and makes it difficult to reach consensus.