At the Nutrition and Physical Activity Research Centre for Optimal Health and Functionality through Life (NUPARC), a research gap was uncovered regarding the concept optimal functionality based on the older adult’s own perspective. The overall aim was to explore the concept of optimal functionality among older adults and the possibility of creating and developing an ICT-platform to measure it. Method: An existing cohort from NUPARC was used for recruitment in studies I-III and to some extent study IV. A scoping study design and framework was adopted for the inclusion of the articles in Study I. Study II had a descriptive design. Six focus group discussions were conducted and analysed using qualitative deductive content analysis to extend the qualitative understanding. Study III used a phenomenological approach describing the experience of mental health and its impact on the ability to function as optimally as possible. Six interviews were analysed using Giorgi’s phenomenological approach. Study IV was a feasibility study and included 8 older adults using an ICTplatform for a period of four weeks. Results: Optimal Functionality comprises three major corner stones: Body-related factors, Self-related factors and External factors (I) accompanied by nine aspects, and according to older adults it is a matter of functioning as optimally as possible (II). The three major cornerstones are intricately linked and all but the mental aspects were included in the discussions (II). Life situations affecting mental health, consequences of mental health and strategies for maintaining good mental health were described by older adults as having an impact on mental health and affecting their ability to function as optimally as possible (III). The older adults managed the usage of an ICT-tool well and it was perceived as meaningful (IV). Conclusion: Optimal functionality is holistic, subjective, dynamic and applicable to all older adults. Identification of the factors involved can help the older adults on their path to health. An ICT-platform can facilitate the identification of the factors for optimal functionality and the eventual measurement of it.

CHARGE syndrome is characterized by impaired vision and hearing, as well as physical malformations. The aim of this study is to describe the characteristics of the malformations and the health care consumption during the first year, in a Swedish sample having CHARGE syndrome. Three of the five individuals fulfilled all the traditional criteria for a clinical diagnosis of CHARGE syndrome. All infants were hospitalized from 26 to 230. days, subjected to 10-34 different diagnostic procedures and prescribed 10-28 different medications during their first year. Coordinated and individually adapted care is urged, as these infants and their families are in of need multiple health care contacts.

Introduction: Physical inactivity is one of the biggest current public health problems. Few adolescents with autism spectrum disorder (ASD) achieve the recommendation of daily physical activity (PA). The reasons for not being physically active depend on several complex factors, yet not comprehensively described from the adolescents’point of view. The absence of their perspective means that intervention strategies for health enhancing physical activity may not encompass the experiences of the adolescents themselves. Therefore the purpose of this study was to develop an understanding of the perceptions, experiences and reflections of adolescents with ASDs’participation in PA.

Participants and methods: Twenty-four adolescents, diagnosed with ASD without a co-occurring intellectual disability, aged 12-16 years, participated in the study.Data was collected using qualitative interviews and inductively analyzed using qualitative content analysis.

Results: Adolescents with ASD were a heterogeneous group in regard to their current PA habits and preferences. Their willingness to participate in PA was conditioned regarding; what, where, when and with whom. They described challenges in the activity and the social context during PA, especially during the mandatory physical education. Perceived demands, freedom of choice, physical ability and sense of control affected their PA participation.

Conclusion: Findings indicate that the adolescents’willingness to participate was associated with interacting and individual-related conditions, which can be misinterpreted as unwillingness to participate in PA. Thus aspects of autonomy and knowledge about individual conditions and needs have to be recognized when intervention strategies for health enhancing physical activities are planned for this population.

The overall aim of this thesis was to investigate physiotherapeutic perspectives on balance after stroke, in terms of exercises, experiences and measurements. Study I was a pilot randomized controlled trial with 46 persons who had had a stroke, 24 of whom were included in the intervention group and 22 who were included in the control group. The intervention consisted of 8 weeks of body awareness therapy (BAT). There were no significant differences over time between the groups in the outcome measures of balance, walking, self-reported balance confidence and quality of life. Study II had a qualitative design using content analysis. Participants in the intervention group from Study I and the four physiotherapists who had been in charge of the BAT were interviewed. One overall theme emerged: "Simple yet challenging", which was based on six categories. Study III investigated the validity and test-retest reliability of the Six-Spot Step test (SSST), an instrument used to assess the ability to take load on each leg. A cross-sectional design with 81 persons who had had stroke was performed. The convergent validity was strong to moderate, and the test-retest reliability was good. In Study IV a mixed method design including both qualitative and quantitative data collection was used. The participants’ experiences of balance and its influence in everyday life were presented in two themes: "Feeling dizzy and unstable is a continuous challenge" and "Feeling trust and confidence despite dizziness and unsteadiness". Taken together, the different data sets provided complementary and confirmatory information about balance. All participants experienced the balance limitations as a continuous challenge in everyday life, yet they also felt trust and confidence.

In summary, BAT can be a complement in physiotherapeutic stroke rehabilitation and the SSST can be used as a measuring instrument of walking balance in persons with stroke. Living with balance limitations was experienced as a challenge but the participants were still able to manage their everyday life and activities.

Infant dental enucleation (IDE) is a practice consisting of the removal of deciduous canine tooth buds in infants. Practiced mainly in Eastern Africa, the purpose is to treat or to prevent bodily symptoms and diseases. IDE can cause both general and oral complications. The occurrence of IDE among Eastern African immigrants in a few European countries has been reported. However, knowledge surrounding the practice in Sweden was poor. The overall aim of this work was to explore IDE in the Swedish context. Four studies were conducted. Paper I presents a review of scientific publications. An overview of IDE was gained, and some knowledge gaps were identified. Paper II describes a cross-sectional study to determine the prevalence of IDE in small children. Dental records of 1133 children (mean age 4.6 years, SD 1.4) from a multi-ethnic area were studied. Missing deciduous canines without any registered reason were documented. One or more deciduous canines were missing in 21% of the children with known Eastern African origin (n=101), compared to only three children in the rest of the population (n=1032). Six adults of Somali origin were interviewed to explore their experiences and perceptions of IDE (paper III). These experiences and perceptions were categorised in four essentially different ways: an effective and necessary treatment, a disputed tradition, an option to failure and a desperate measure. Their experiences and perceptions were found to be highly influenced by contexts. In the final study (paper IV), the knowledge, experiences and attitudes among dental and health care personnel were examined. Questionnaires were sent to licensed personnel working in emergency departments, midwifery and child health centres, school health services and public dental health services in ten municipalities. Less than 20% had any knowledge of IDE, while 12.5% of the respondents encountering children had seen at least one patient subjected to IDE. Different attitudes were reported between clinical settings regarding responsibilities and possibilities concerning the management and prevention of IDE. From the findings presented in this thesis, it was concluded that there is a need for initiatives to increase awareness of and knowledge on IDE among dental and health care professionals. Legally obligated responsibilities in these professions regarding IDE need to be clarified, and initiatives should include guidelines regarding both the management of IDE and its prevention in Sweden. Educational programmes should also be produced for residents of Eastern African origin to change their perceptions of IDE, and a culturally sensitive approach should be adopted to ensure that such programmes are effective.

Early childhood intervention and habilitation services for children with disabilities operate on an interdisciplinary basis. It requires a common language between professionals, and a shared framework for intervention goals and intervention implementation. The International Classification of Functioning, Disability and Health (ICF) and the version for children and youth (ICF-CY) may serve as this common framework and language. This overview of studies implemented by our research group is based on three research questions: Do the ICF-CY conceptual model have a valid content and is it logically coherent when investigated empirically? Is the ICF-CY classification useful for documenting child characteristics in services? What difficulties and benefits are related to using ICF-CY model as a basis for intervention when it is implemented in services? A series of studies, undertaken by the CHILD researchers are analysed. The analysis is based on data sets from published studies or master theses. Results and conclusion show that the ICF-CY has a useful content and is logically coherent on model level. Professionals find it useful for documenting children's body functions and activities. Guidelines for separating activity and participation are needed. ICF-CY is a complex classification, implementing it in services is a long-term project

The overall aim of this thesis is to explore how the labour market situation appears to persons with different types of disabilities in Sweden. Study I (n=4 359) examined the importance of the person’s type of disability for the possibility of having a job. Study II (n=3 396) examined whether there were differences in occupational attainment between persons with different types of disabilities and between persons with and without a disability (n=19 004). Study III (n=4 359) examined perceived discrimination in the workplace among persons with different types of disabilities. Study IV (n=2 268) examined whatsupport and adaptation persons with different types of disabilities need in their actual workplace or to enter the labour market. In studies I–III the respondents were divided into six disability types, and in study IV the respondents were divided into four disability types.

Overall, it can be concluded that a person’s type of disability is of importance for the situation in the labour market, where persons with psychological disabilities encounter barriers to a greater extent than other groups, both difficulties at the present workplace and difficulties entering the labour market. Further, they were subjected to discrimination and they expressed a great need for adaptations to acquire employment and at their actual workplace. It can also be concluded that there are discriminatory mechanisms against women, who have more difficulties than men in acquiring employment, and that men, despite lower education, can more easily progress in the labour market. It is suggested that, in order to achieve inclusion and recognition, factors in the environment, such as existing support systems, need to be changed and developed, and social prejudices vis-à-vis people with disabilities must also be addressed.

There is a need of community-based treatment methods with focus on everyday occupations, for persons with severe mental disabilities. The importance of occupation in achieving health has been highlighted in large mental hospitals and community-based service/support designed for people with severe mental disabilities who today live in society. Despite this support these people are in a vulnerable position, as they often have extensive difficulties in carrying out daily occupations which also leads to poorer well-being and health conditions. In the rehabilitation process, it is necessary to enable the person to use her own effort to perform activities. Occupational therapy has a unique role in community-based efforts for people with severe mental disabilities through their person-centered practices approaches and knowledge of daily occupations and how these can be used as therapeutic means of recovery and development of the self.

The purpose of the study is to use theory about social action to contribute theoretical understanding about how everyday occupations are used as a therapeutic means for people with severe mental disabilities in occupational therapy, with the goal of contributing to their recovery and development of self. A qualitative, interpretative approach is used in the study to examine how everyday life can be used as a therapeutic tool. Empirical data of 11 events were generated from interviews with four occupational therapists. A theoretical tool developed by George Herbert Mead’s social psychological theory of the social act, were used as a frame for new-descriptions. Through abductive analyses reconstructed events are given new (theoretical) understanding.

The result indicate that the social acts have met such difficulties that they have almost ceased and at the same time risk losing their meaning. The therapist adjusts the activity to find the level at which the person can participate with his/her own experience in the implementation of the everyday action. This gives the person with severe mental disabilities opportunities to use one self in the social process which eventually makes the person regain the ability to perform everyday activities

I det här kapitlet diskuteras fenomenologisk filosofi och dess influenser på olika forskningsmetoder som deskriptiv fenomenologi och fenomenografi. I kapitlet kommer även att visas hur man kan göra en deskriptiv fenomenologisk analys. Utgångspunkten för analysen är fyra korta berättelser som skrivits av fyra flickor som deltagit i en kurs inom ett s.k. individuellt program. Syftet med kapitlet är att visa hur en deskriptiv fenomenologisk analys kan ge en fördjupad förståelse för flickors erfarenheter av sociala relationer samt när och hur de upplevt besvikelser i relationer till andra.

OBJECTIVES: The aim of this qualitative study was to describe the experience and perceived effects on everyday life for people with multiple sclerosis after participating in a balance exercise programme focusing on core stability, dual tasking, and sensory strategies (the CoDuSe programme).

METHODS: A qualitative approach was chosen, using face-to-face interviews analysed with content analysis. Twenty-seven people with multiple sclerosis (20 women, 7 men) who had participated in the CoDuSe programme were included. All could walk 20 m with or without walking aids but could not walk further than 200 m. The CoDuSe programme was given twice weekly during a 7-week period.

RESULTS: The analysis revealed five categories. Learning to activate the core muscles described how the participants gained knowledge of using their core muscles and transferred this core muscle activation into everyday life activities. Improved bodily confidence covered narratives of being more certain of the ability to control their bodies. Easier and safer activities showed how they could now perform activities in everyday life more safely and easily. Increased independence and participation involved the participants' improved ability and self-confidence to execute activities by themselves, as well as their increased participation in activities in daily living. Experiences of the balance exercise programme revealed that they found the programme novel and challenging. The overall theme was balance exercise facilitates everyday life.

CONCLUSION: Participating in the CoDuSe programme was perceived to facilitate everyday life for people with multiple sclerosis. Taking part in the balance exercise programme taught the participants how to activate and use the core muscles, which increased their bodily confidence. Having increased bodily confidence helped them to perform everyday life activities with more ease and safety, which increased their independence and participation. The participants described the CoDuSe programme as novel and challenging, yet feasible.

Purpose: To study the quality of life (QoL) and psychosocial consequences in terms of sick leave and audiological rehabilitation given to patients with severe to profound hearing impairment.

Method: A retrospective study of data on 2319 patients with severe to profound hearing impairment in The Swedish Quality Register of Otorhinolaryngology, followed by a posted questionnaire including The Hospital Anxiety and Depression Scale (HADS). 

Results: The results indicate greater levels of anxiety and depression among patients with severe or profound hearing impairment than in the general population, and annoying tinnitus and vertigo had strong negative effects on QoL. The proportion of sick leave differed between the studied dimensions in the study. The proportion of patients who received extended audiological rehabilitation was 38% in the present study. 

Conclusions: Treatment focused on anxiety, depression, tinnitus and vertigo must be given early in the rehabilitation process in patients with severe or profound hearing impairment. Because sick leave differs greatly within this group of patients, collaboration with the regional Social Insurance Agency is crucial part of the rehabilitation. The study also shows that presently, only a small proportion of patients in Sweden with severe to profound hearing impairment receive extended audiological rehabilitation. Implications for Rehabilitation

• Greater levels of anxiety and depression have been found among patients with severe or profound hearing impairment than in the general population, and annoying tinnitus and vertigo have strong negative effects on QoL in this group of patients.

• Only a small proportion of patients with severe to profound hearing impairment receive extended audiological rehabilitation today, including medical, technical and psychosocial efforts.

• Extended audiological rehabilitation focused on anxiety, depression, tinnitus and vertigo must be given, together with technical rehabilitation, early in the rehabilitation process in patients with severe or profound hearing impairment.

Background: EHR systems are widely used in hospitals and primary care centres but it is usually difficult to share information and to collect patient data for clinical research. This is partly due to the different proprietary information models and inconsistent data quality. Our objective was to provide a more flexible solution enabling the clinicians to define which data to be recorded and shared for both routine documentation and clinical studies. The data should be possible to reuse through a common set of variable definitions providing a consistent nomenclature and validation of data. Another objective was that the templates used for the data entry and presentation should be possible to use in combination with the existing EHR systems.

Methods: We have designed and developed a template based system (called Julius) that was integrated with existing EHR systems. The system is driven by the medical domain knowledge defined by clinicians in the form of templates and variable definitions stored in a common data repository. The system architecture consists of three layers. The presentation layer is purely web-based, which facilitates integration with existing EHR products. The domain layer consists of the template design system, a variable/clinical concept definition system, the transformation and validation logic all implemented in Java. The data source layer utilizes an object relational mapping tool and a relational database.

Results: The Julius system has been implemented, tested and deployed to three health care units in Stockholm, Sweden. The initial responses from the pilot users were positive. The template system facilitates patient data collection in many ways. The experience of using the template system suggests that enabling the clinicians to be in control of the system, is a good way to add supplementary functionality to the present EHR systems.

Conclusion: The approach of the template system in combination with various local EHR systems can facilitate the sharing and reuse of validated clinical information from different health care units. However, future system developments for these purposes should consider using the openEHR/CEN models with shareable archetypes.

With the introduction of EHR two-level modelling and archetype methodologies pioneered by openEHR and standardized by CEN/ISO, we are one step closer to semantic interoperability and future-proof adaptive healthcare information systems. Along with the opportunities, there are also challenges. Archetypes provide the full semantics of EHR data explicitly to surrounding systems in a platform-independent way, yet it is up to the receiving system to interpret the semantics and process the data accordingly. In this paper we propose a design of an archetype-based platform-independent testing framework for validating implementations of the openEHR archetype formalism as a means of improving quality and interoperability of EHRs.

The openEHR foundation has developed an innovative design for interoperable and future-proof Electronic Health Record (EHR) systems based on a dual model approach with a stable reference information model complemented by archetypes for specific clinical purposes.A team from Sweden has implemented all the stable specifications in the Java programming language and donated the source code to the openEHR foundation. It was adopted as the openEHR Java Reference Implementation in March 2005 and released under open source licenses. This encourages early EHR implementation projects around the world and a number of groups have already started to use this code. The early Java implementation experience has also led to the publication of the openEHR Java Implementation Technology Specification. A number of design changes to the specifications and important minor corrections have been directly initiated by the implementation project over the last two years. The Java Implementation has been important for the validation and improvement of the openEHR design specifications and provides building blocks for future EHR systems.

BACKGROUND: Exchange of Electronic Health Record (EHR) data between systems from different suppliers is a major challenge. EHR communication based on archetype methodology has been developed by openEHR and CEN/ISO. The experience of using archetypes in deployed EHR systems is quite limited today. Currently deployed EHR systems with large user bases have their own proprietary way of representing clinical content using various models. This study was designed to investigate the feasibility of representing EHR content models from a regional EHR system as openEHR archetypes and inversely to convert archetypes to the proprietary format.

METHODS: The openEHR EHR Reference Model (RM) and Archetype Model (AM) specifications were used. The template model of the Cambio COSMIC, a regional EHR product from Sweden, was analyzed and compared to the openEHR RM and AM. This study was focused on the convertibility of the EHR semantic models. A semantic mapping between the openEHR RM/AM and the COSMIC template model was produced and used as the basis for developing prototype software that performs automated bi-directional conversion between openEHR archetypes and COSMIC templates.

RESULTS: Automated bi-directional conversion between openEHR archetype format and COSMIC template format has been achieved. Several archetypes from the openEHR Clinical Knowledge Repository have been imported into COSMIC, preserving most of the structural and terminology related constraints. COSMIC templates from a large regional installation were successfully converted into the openEHR archetype format. The conversion from the COSMIC templates into archetype format preserves nearly all structural and semantic definitions of the original content models. A strategy of gradually adding archetype support to legacy EHR systems was formulated in order to allow sharing of clinical content models defined using different formats.

CONCLUSION: The openEHR RM and AM are expressive enough to represent the existing clinical content models from the template based EHR system tested and legacy content models can automatically be converted to archetype format for sharing of knowledge. With some limitations, internationally available archetypes could be converted to the legacy EHR models. Archetype support can be added to legacy EHR systems in an incremental way allowing a migration path to interoperability based on standards.

Clinical research is on the threshold of a new era in which electronic health records (EHRs) are gaining an important novel supporting role. Whilst EHRs used for routine clinical care have some limitations at present, as discussed in this review, new improved systems and emerging research infrastructures are being developed to ensure that EHRs can be used for secondary purposes such as clinical research, including the design and execution of clinical trials for new medicines. EHR systems should be able to exchange information through the use of recently published international standards for their interoperability and clinically validated information structures (such as archetypes and international health terminologies), to ensure consistent and more complete recording and sharing of data for various patient groups. Such systems will counteract the obstacles of differing clinical languages and styles of documentation as well as the recognized incompleteness of routine records. Here, we discuss some of the legal and ethical concerns of clinical research data reuse and technical security measures that can enable such research while protecting privacy. In the emerging research landscape, cooperation infrastructures are being built where research projects can utilize the availability of patient data from federated EHR systems from many different sites, as well as in international multilingual settings. Amongst several initiatives described, the EHR4CR project offers a promising method for clinical research. One of the first achievements of this project was the development of a protocol feasibility prototype which is used for finding patients eligible for clinical trials from multiple sources.

The majority of all surgeries are performed as day surgery. After discharge, patients are expected to take responsibility for their postoperative recovery themselves. Recovery Assessment by Phone Points (RAPP) is an e-assessment developed for assessing and providing follow-up on postoperative recovery, which includes the Swedish web-version of the Quality of Recovery questionnaire (SwQoR). It also enables the patient to get in contact with the day surgery unit. The overall aim of this thesis was to further develop and evaluate a systematic follow-up of postoperative recovery using a mobile app in adult persons undergoing day surgery, as well as to describe their experiences of postoperative recovery when using the mobile app. Study I: This study included three steps. Equivalence testing between the paper and app versions of the SwQoR showed agreement (n=69). The feasibility and acceptability evaluation showed that participants (n=63) were positive towards using a mobile phone application during postoperative recovery. Content validity of the SwQoR reduced the original 31 items to 24. Studies II and III: A multicentre, two-group, parallel, single-blind randomized controlled trial including 997 participants was conducted to investigate the effect of e-assessment on postoperative recovery (II) and cost-effectiveness (III) in a RAPP group compared with a control group. The RAPP group reported significantly better quality of postoperative recovery on postoperative days 7 and 14 compared with the control group. Moreover, RAPP may be cost-effective as it provides low-cost care. Study IV: Explored experience of postoperative recovery in participants using a mobile phone app during their postoperative recovery. Qualitative inductive semi-structured interviews (n=18) were performed. Findings showed that feeling safe is important during postoperative recovery. This feeling can be created by patients themselves, but sufficient support and information from health care and next of kin is needed. Overall, this thesis showed positive results for RAPP, suggesting that RAPP is a solution that may benefit patients after day surgery.

Background: There is an emerging trend to perform surgeries as day surgery. After a day surgery, most of the recovery period takes place at home, and patients are responsible for their own recovery. It has been suggested that electronic health (eHealth) technologies can support patients in this process. A mobile app has recently been developed to assess and follow up on postoperative recovery after a day surgery.

Objective: The aim of this study was to explore experiences associated with postoperative recovery after a day surgery in patients using a mobile app to assess the quality of their recovery.

Methods: This is a qualitative interview study with an explorative and descriptive design. Participants were recruited from 4 different day surgery units in different parts of Sweden. The study included 18 participants aged >17 years who had undergone day surgery and used the Recovery Assessment by Phone Points, a mobile app for follow-up on postoperative recovery after day surgery. Participants were purposively selected to ensure maximum variation. Semistructured individual interviews were conducted. Data were analyzed using thematic analysis.

Results: A total of two themes and six subthemes emerged from the data: (1) the theme Give it all you’ve got with the subthemes Believing in own capacity, Being prepared, and Taking action, where participants described their possibilities of participating and themselves contributing to improving their postoperative recovery; and (2) the theme The importance of feeling safe and sound with the subthemes Feeling safe and reassured, Not being acknowledged, and Not being left alone, which describe the importance of support from health care professionals and next of kin.

Conclusions: It is important that patients feel safe, reassured, and acknowledged during their postoperative recovery. They can achieve this themselves with sufficient support and information from the health care organization and their next of kin. Using a mobile app, both for assessment and to enable contact with the day surgery unit during the postoperative recovery period, can improve care and create a feeling of not being alone after surgery. We propose that postoperative recovery starts in the prerecovery phase when patients prepare for their recovery to get the best possible outcome from their surgery.

This article uses the philosophy of critical realism to overcome the problem that most contemporary guidelines for interdisciplinary research fail to provide would-be researchers with adequate advice. It arrives at five important steps in the interdisciplinary research process: an initial planning phase; a disciplinary phase; a teamwork phase characterized by cross-disciplinary understanding; and a transdisciplinary, creative phase that involves epistemic emergence, and that results in the integration of knowledge. The fifth phase is the result of the integrative fourth phase; it provides a holistic interdisciplinary understanding of the involved structures and mechanisms of the issue at hand. To make interventions derived from interdisciplinary research useful, they must be disseminated in such way as to include a return to reality, that is, there must be a movement from epistemology to ontology.

The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) has adopted a multifactorial understanding of functioning and disability, merging a biomedical paradigm with a social paradigm into a wider understanding of human functioning. Altogether there are more than 1400 ICF-categories describing different aspects of human functioning and there is a need to developing short lists of ICF categories to facilitate use of the classification scheme in clinical practice. To our knowledge, there is currently no such standard measuring instrument to facilitate a common validated way of assessing the effects of hearing loss on the lives of adults. The aim of the project is the development of an internationally accepted, evidence-based, reliable, comprehensive and valid ICF Core Sets for Hearing Loss. The processes involved in this project are described in detail and the authors invite stakeholders, clinical experts and persons with hearing loss to actively participate in the development process.

Purpose: In May 2001, to integrate biological, psychological, and social aspects of human functioning, the World Health Assembly endorsed the International Classification of Functioning, Disability and Health (ICF). The aim of this article is to describe the creation of Comprehensive and Brief ICF Core Sets for Hearing Loss. The core sets consist of the most relevant ICF categories for hearing loss. Method and Results: Four preparatory studies were carried out and presented at a consensus conference, resulting in a Comprehensive ICF Core Set for Hearing Loss, consisting of 117 ICF categories, and a Brief ICF Core Set for Hearing Loss, consisting of 27 categories (of the 117). Conclusion: The Comprehensive ICF Core Set for Hearing Loss can be a user-friendly tool for conducting comprehensive, multidisciplinary assessments. The Brief ICF Core Set can be used for many purposes, such as research and population studies. However, its most common use is by individuals seeking to provide a brief description and assessment of functioning of a person with hearing loss.

Globally, psychological health problems are currently among the most serious public health challenges. Adolescent girls suffer from internalizing problems, such as somatic symptoms and mental health problems, at higher rates than in decades. By age 15, over 50 % of all girls experience multiple health complaints more than once a week and one in five girls reports fair or poor health.

The overall aim of this study was to investigate the effects of and experiences with an after-school dance intervention for adolescent girls with internalizing problems. The intervention comprised dance that focused on resources twice weekly for 8 months. Specifically, this thesis aimed to: I) investigate the effects on self-rated health (SRH), adherence and over-all experience; II) evaluate the effects on somatic symptoms, emotional distress and use of medication; III) explore the experiences of those participating in the intervention; and IV) assess the cost-effectiveness.

A total of 112 girls aged 13 to 18 years were included in a randomized controlled trial. The dance intervention group comprised 59 girls, and the control group 53. In paper I, the dance group showed increased SRH scores compared to the control group (p = .02). Girls in the intervention group showed high adherence and a positive overall experience. In paper II, the dance group exhibited a decrease in somatic symptoms (p = .021), emotional distress (p = .023) and use of medication (p = .020) compared to the control group. In paper III, a strategic sample of 24 girls was interviewed. Qualitative content analysis was performed, and five generic categories emerged. Two were “An Oasis from Stress” and “Supportive Togetherness”, which was shown to represent the fundamental basis and setting of the intervention. The main category, participants’ central experience, was understood as “Finding embodied self-trust that opens new doors”. Paper IV revealed that, due to decreased number of visits to the school nurse and an increase in health related quality of life; the intervention was considered to be cost-effective (combined with the usual school health services). In summary, the results of this thesis show that this dance intervention for adolescent girls with internalizing problems generated positive health effects and proved to be cost-effective. For this target group, a non-judgmental environment and supportive togetherness proved to be of importance for participation. The results of this study may provide practical information for school health care staff and caregivers in designing future interventions.

Objective: To investigate whether dance intervention influenced self-rated health for adolescent girls with internalizing problems.

Design: Randomized controlled intervention trial with follow-up measures at 8, 12, and 20 months after baseline.

Setting: A Swedish city with a population of 130 000.

Participants: Girls aged 13 to 18 years with internalizing problems, ie, stress and psychosomatic symptoms. A total of 59 girls were randomized to the intervention group and 53 were randomized to the control group.

Intervention: The intervention comprised dance classes twice weekly during 8 months. Each dance class lasted 75 minutes and the focus was on the joy of movement, not on performance.

Main Outcome Measures: Self-rated health was the primary outcome; secondary outcomes were adherence to and experience of the intervention.

Results: The dance intervention group improved their self-rated health more than the control group at all follow-ups. At baseline, the mean score on a 5-point scale was 3.32 for the dance intervention group and 3.75 for the control group. The difference in mean change was 0.30 (95% CI, −0.01 to 0.61) at 8 months, 0.62 (95% CI, 0.25 to 0.99) at 12 months, and 0.40 (95% CI, 0.04 to 0.77) at 20 months. Among the girls in the intervention group, 67% had an attendance rate of 50% to 100%. A total of 91% of the girls rated the dance intervention as a positive experience.

Conclusions: An 8-month dance intervention can improve self-rated health for adolescent girls with internalizing problems. The improvement remained a year after the intervention

Bakgrund: Buller är benämningen på icke önskvärda ljud och blir skadliga när ljudnivåerna blir tillräckligt höga. Effekterna av bullerexponering är många. Höga ljudnivåer förekommer bl.a. inom förskolor. Trots att detta är allmänt känt saknas det en del forskning kring hur just förskolepersonal upplever och påverkas av den höga ljudnivån på arbetet.

Syfte: Syftet med studien är att undersöka ljudnivån på en förskola samt hur förskolepersonalen upplever och påverkas av ljudmiljön på arbetet.

Metod: En egen tillverkad enkätundersökning riktad till förskolepersonal samt dosmätning genomfördes på en småbarnsavdelning och en äldrebarnsavdelning. Enkäten berörde frågor gällande ljudnivån på förskolan samt förskolepersonalens upplevelse och påverkan.

Resultat: De ekvivalenta ljudnivåerna på småbarnsavdelningen låg mellan 73,2 – 78,5 dB(A) och på äldrebarnsavdelningen 71,7 – 78,1 dB(A). Impulstoppvärdena på småbarnsavdelningen låg mellan 110,6 – 135,7 dB(C) och på äldrebarnsavdelningen 116,5 – 143,4 dB(C). Majoriteten av förskolepersonalen upplever hög ljudnivå på arbetet dagligen.

Slutsatser: Resultatet visar att förskolepersonalen inte utsätts för högre ekvivalenta ljudnivåer än tillåtet. Trots detta upplever majoriteten av förskolepersonalen att de dagligen utsätts för höga ljudnivåer på arbetet. En orsak till detta kan vara att impulstoppvärdena i vissa fall överskrider insatsvärdena. Denna studie är dock inte representativ för populationen, utan är enbart en deskriptiv studie för denna specifika förskola.

Introduction: Persons with deafblindness may have additional physical and psychological health problems. In this study we have focused on health from a work-life perspective in persons with Usher syndrome type 2 (USH2), a disorder with sensorineural hearing loss and retinitis pigmentosa. The aim of this study was to investigate the relationship between work and disability pension and physical and psychological health in persons with USH2.

Methods: Participants were recruited from the Swedish Usher database. Eighty-four persons (aged 18 to 65 years) received a health-related questionnaire and 67 (36 women and 31 men) agreed to participate. The participants formed two groups (working group, n = 34; disability pension group, n = 33). A Swedish Health on Equal Terms questionnaire comprising questions on psychological and physical health, living conditions, work activity, and social relationships was used. A chi-square test of significance was used with a significance level of p < 0.05.

Results: The two groups did not differ in terms of age, gender, degree of hearing loss, visual acuity, or visual field loss. The working group had statistically significant better health compared to the disability pension group in areas such as being overweight, handling problems, concentration, feeling unhappy, depressive symptoms, and feelings of worthlessness. Suicidal thoughts and attempts were significantly more common in the disability pension group.

Discussion: Persons with USH2 generally reported very poor physical and psychological health, with significant differences between persons who were working and those who were not. This study highlights the need for early rehabilitation, vocational training, and opportunities to access the labor market. Implications for practitioners: It is important that persons with USH2 receive vocational support from an early age and that professionals in the field of rehabilitation always include work activity as a key element of interventions.

A comprehensive computerized questionnaire was developed to obtain the anamnesis of patients seeking contact with a physician for any type of new problem. The purpose of this pilot study was to investigate ifa structured questionnaire filled out by the patient and complementing an interview at the physician’s office would contribute to a better quality of the total anamnesis and/or lead to savings in time at the visit. The results encourage further developments in this direction. The potential uses proposed are, in addition to being used to improve a visit, the correct assessment of the history for prioritization and scheduling of visits and in some situations, the anamnesis obtained over the net may be the basis for medical advice without a visit. This study emphasizes the great improvement of information captured by this type of questionnaire based on medical knowledge about associated symptoms and relevant questions depending on the problem presented compared to the results obtained by a simple open question used in many e-health services today.

Satisfactory collaboration regarding children and youth in need of a comprehensive support is particularly important. Despite extensive research on collaborative work, knowledge of long term development of the collaboration process is lacking. The present thesis concerns inter-organizational collaboration within the framework of a former Swedish policy effort – focusing collaboration between schools, social services, police and the child and youth psychiatry – for the benefit of children and young people in distress or at risk. Applying a critical realist perspective, the overall aim of the thesis is to describe how former collaboration projects develop over time, and to identify significant mechanisms within this development. Through three questionnaire studies, the collaborative process development within the same collaborative settings is described (n=66) over a period of close to seven years. Estimations of 58 collaboration quality indicators within three categories *rules and regulations, *structural aspects and *shared perspectives/ consensus were collected at baseline in 2008, after one year at the final project stage in 2009, as well as five years after the project period (and the policy effort) ended, in 2014 (n=38). Two developmental trends occur: I) an overall positive trend and II) a negative trend on a comprehensive level. I) Collaboration on the target group has increased over time, are mainly incorporated into permanent organizational structures and is judged to have worked well/very well over time. II) Overall deteriorations of high estimates of the 58 quality indicators for collaborations is seen over the five year period, following the project period. However, less dramatic changes is noted on quality indicators concerning shared perspectives/consensus than on matters regarding rules and regulations and structural aspects. Five mechanisms of particular importance for the collaboration development are identified: anchoring, holistic perspectives, engagement, knowledge and clarity.

Bakgrund: Jämlik vård är att alla ska bemötas, behandlas och vårdas på lika villkor oavsett enskilda faktorer. I hörselrehabiliteringen ingår det flera delar och varje del ska utgå från helhetsperspektivet och ske i samverkan med den enskilde. Audionomen ska inte påverkas av faktorer såsom kön eller ålder. Tidigare studier visar dock att ålder är en avgörande faktor i många fall, det råder en form av ålderism och åldersdiskriminering inom vården. Inga tidigare studier har hittats på hur den tekniska rehabiliteringen påverkas av ålder inom hörselvården varför detta låg i vårt intresse.

Syfte: Syftet med studien är att undersöka hur jämlik den tekniska rehabiliteringen är inom hörselvården beroende på patienternas ålder.

Metod: Studien är deskriptiv retrospektiv och är gjord genom journalgenomgång.

Resultat: Resultatet visar inte några tydliga skillnader i den tekniska rehabiliteringen beroende på patientens ålder. Patienternas behov varierade mycket både inom grupperna och mellan grupperna. Skillnader kunde dock ses gällande patienter med samma behov och typ av hörapparat där patienter oavsett ålder kunde ha fått olika typer av hörapparater trots samma behov/mål.

Slutsatser: Inga generella slutsatser kan dras huruvida den tekniska hörselrehabiliteringen är jämlik eller ej. Fler studier behövs inom ämnet där urvalet är större.

A central part of the nursing profession is the performance of practical skills. In order to provide adequate care, maintain patient-safety, and feel comfortable in the profession, registered nurses (RNs) need to be equipped with requisite skills. Overall aim: To explore and describe how learning and development of practical skills occurs during the preparatory phases and within the nursing profession. Method: Qualitative (I, III, IV) and quantitative methods (II) were used. Data were collected through individual interviews (I, IV), questionnaires (II) and participant observations, including informal talks (III, IV). Results: Both students and new RNs expressed a need to learn and develop practical skills (I, II, III, IV). Less than half of the new RNs had access to a clinical skill laboratory (CSL), where they could learn and practice practical skills (II). The students described that learning at a CSL had been meaning for their clinical practice. They also expressed a great need for continuing learning in real patient situations (I, III, IV). During clinical practice, preceptors and students took different approaches which affected student’s learning processesö (I, III, IV). There was a tension between learning at a CSL and learning in clinical practice sites because students perceived differences in the performance of skills. Students described that they understood that performance of skills could be done in different ways without injuring patients. However, the data also showed deviations in performances that could jeopardize patientsafety. In these situations, student’s behavior differed (I, IV). One third of new RNs deviated from evidence based guidelines when they performed practical skills which they were unfamiliar with (II). Both students and new RNs reported that reflection in connection with the performance of practical skills was not common (I, II III, IV). Conclusions: Cooperation between university CSLs and clinical settings must be intensified in order to enhance the understanding of learning processes regarding practical skills. A consensus regarding academic approaches should be reached. Universities need to support preceptors in educational issues where the importance of reflection is clarified and exemplified. Increasing patient-safety requires that new RNs receive opportunities for training in artificial environments, and that a culture that reinforces the use of guidelines and a reflective stance is cultivated.