Sammanfattning Bakgrund Ett välfungerande samarbete mellan vårdpersonal och tolk är en förutsättning för en jämlik och rättssäker vård. Området logopedi är utmanande för tolkar eftersom översättningen ofta blir en del av den kliniska bedömningen. Tidigare studier har visat att utmaningar i ett logoped-tolk samarbete innefattar otydlig rollfördelning, tidsbrist och avsaknad av rutiner. Det har även framkommit osäkerheter kring hur exakt översättningen blir när tolken medlar. Dessvärre saknas svenska studier som kartlägger vad som skulle krävas för att uppnå ett optimalt samarbete mellan tolk och logoped i Sverige. Syfte Syftet med föreliggande studie var att synliggöra logopedens erfarenheter, känslor och attityder till tolksamarbete. Författarnas förhoppning var att lyfta fram såväl framgångsfaktorer som utmaningar och kartlägga logopedens syn på vad som krävs för ett optimalt samarbete. Metod Huvudsaklig metod utgjordes av två fokusgruppsintervjuer. Utifrån de fynd som framkom från intervjuerna utformades en webbenkät. Syftet med webbenkäten var att undersöka ifall de åsikter som framkommit under fokusgruppsintervjuerna delades av andra logopederrunt om i landet. Sammanlagt medverkade 79 deltagare, varav 9 i fokusgrupperna. Resultat De främsta utmaningarna som identifierades i studien var tidsbrist, att få tag på tolkar med tillräcklig kompetens, brister rutinerna samt osäkerheter kring hur precis översättningen blir. Samtidigt beskrevs tolksamarbeten som både underlättande och positivt av många deltagare. För att skapa ett så gynnsamt samarbete som möjligt föreslår studiens deltagare tydligare riktlinjer, tillgång till fler tolkar med erfarenheter av logopedsamarbete, samt att det ska finnas färdiga instruktioner och dokument att förbereda tolken med. Lättare tillgång till utbildade och auktoriserade tolkar uttrycktes även från flertal deltagare. Slutsats Svenska logopeder beskriver samarbetet med tolk som viktigt, givande och ytterstnödvändigt, men samtidigt även som svårt och tidskrävande. Många uttrycker oro inför hur tillförlitlig och högkvalitativ patientbesöken blir när tolk är involverad. Logopederna i denna studie påpekar flera förbättringsförslag vad gäller tillvägagångssätt samt rutiner och riktlinjer som skulle kunna höja kvaliteten på samarbetet mellan logoped och tolk. Ytterligare studier krävs för att undersöka hur förbättringsförslagen ska implementeras iden logopediska verksamheten.

Objectives. The first aim was to examine the effects of secondary prevention with a focus on determinants in the risk of recurrent coronary heart disease (CHD). The second aim was to analyse the effects of a cognitive behavioural therapy (CBT) intervention on the risk of recurrent cardiovascular disease (CVD) and to investigate the psychosocial situation of CHD patients. Material and methods. Papers I and II were based on the Swedish Acute Myocardial Infarction Statistics Register, 1969 to 2001: 775,901 events in 589,341 subjects. Papers III and IV were based on The Secondary Prevention in Uppsala Primary Care project (SUPRIM), a randomized controlled clinical trial in 362 CHD patients. Results. The risk of a recurrent acute myocardial infarction (AMI) event was highly dependent on time from the previous event, with the greatest risk immediately after an AMI event. In addition, sex, age, and AMI number influenced the general risk level. Furthermore, there has been a major decline in recurrence risk over 30 years, and there were considerable geographical differences in risk, best explained by residential area population density, with a high recurrent AMI risk in areas with the lowest and the highest population densities, and the lowest risk in areas with moderate population density. Disease status and sex were determinants of psychological well-being the first year after a CHD event. Sex seemed to be the stronger determinant. The CBT intervention focused on stress management during one year in patients with CHD.  There was significantly improved outcome in the intervention group on recurrent CVD and recurrent AMI during a 9 year follow up. A dose-response relationship was demonstrated between attendance rate at intervention group meetings and outcome, the higher the attendance rate the better the outcome. Conclusions. The risk of a recurrent AMI event was dependent on time from the previous event, with major improvement seen in recent decades. Regional differences were best explained by population density. Female CHD patients were at high risk concerning well-being after a coronary event, which deserves special attention. The CBT intervention for CHD patients improved outcomes concerning the risk of recurrent CVD and AMI events.

Age, male sex, hypertension, smoking, diabetes, dyslipidaemia, and obesity are considered as established risk factors for cardiovascular diseases. Several of these established cardiovascular risk factors are strongly influenced by lifestyle. Novel biomarkers from different mechanistic pathways have been associated with cardiovascular risk, but their clinical utility is still uncertain. The overall objective of the thesis was to evaluate the associations between certain lifestyle factors (physical activity and snuff use), biomarkers reflecting the haemostatic and the inflammatory systems and risk of a future first-ever myocardial infarction.  A prospective incident nested case-control study design was used with a total of 651 cases of myocardial infarction and 2238 matched controls from the population-based Northern Sweden Health and Disease Study.  The effects of commuting activity, occupational and leisure time physical activity on risk of myocardial infarction were studied. A clearly increased risk of myocardial infarction was found for car commuting compared to active commuting (walking, cycling or going by bus). High versus low leisure time physical activity was associated with decreased risk of myocardial infarction. Low occupational physical activity was associated with risk of myocardial infarction in men.  The risk of myocardial infarction or sudden cardiac death was studied in male snuff users compared to non-tobacco users. No increased risk was found for myocardial infarction or sudden cardiac death among snuff users without a previous history of smoking. However, for sudden cardiac death the study did not have statistical power to detect small differences in risk.  Plasma levels of haemostatic markers have previously shown to be associated with risk of myocardial infarction, but as haemostatic markers are also acute-phase reactants, it is not clear if their association with myocardial infarction is independent of inflammatory markers. In the present study, the haemostatic markers D-dimer, von Willebrand factor (VWF), tissue plasminogen activator (t-PA), and tissue plasminogen activator/plasminogen activator inhibitor-1 complex (t-PA/PAI-1 complex) were associated with risk of myocardial infarction after adjustment for established risk factors and the inflammatory markers C-reactive protein (CRP) and interleukin 6 (IL-6). Furthermore, the addition of eight haemostatic and inflammatory markers could improve the predictive ability for future myocardial infarction beyond that of a model utilizing only established risk factors.  Established risk factors and novel biomarkers were explored as potential mediators of the reduced risk of myocardial infarction related to active commuting. A combination of established risk factors, haemostatic and inflammatory markers appeared to explain a substantial proportion (40%) of the difference in risk for myocardial infarction between active commuters and car commuters. IL-6, t-PA, t-PA/PAI-1 complex, apo B/apo A-1 ratio, and BMI seemed to be the largest potential mediators when tested individually. In conclusion, regular physical activity such as active commuting is associated with reduced risk of a first-ever myocardial infarction. This effect could in part be mediated through a beneficial influence on haemostasis and inflammation, as well as a positive impact on established risk factors. Several haemostatic markers are associated with risk of myocardial infarction independent of established risk factors and inflammatory markers. The combination of haemostatic and inflammatory markers may enhance predictive ability beyond established risk factors. Our findings do not support the hypothesis that snuff use increases the risk of myocardial infarction.

Objectives The aim of this thesis was to assess the importance of general practitioners (GP) and patient related factors for the GPs’ decision to sick certify or not to sick certify the patients. Study population and methods The data were obtained from a cross-sectional questionnaire study of GP-patient consultations. 65 GPs responded to one questionnaire about themselves and one questionnaire about each of the altogether 642 consultations. The patients responded to a questionnaire about themselves and the consultation, altogether 521 consultations. Various combinations of the three questionnaires were used in the four papers on which this thesis is based. Results Among GPs, long experience of family medicine and working part-time were significant determinants for issuing more sick leave certificates. Complaints perceived as clearly somatic by the physician decreased the chance of sick certifications, and complaints resulting in severe limitation of occupational work capacity, as assessed by the patient as well as the physician, increased the chance of sick certification, as did appointments for loco-motor complaints. Among work related factors, high ‘authority over decisions’ and high ‘social support’ were associated with reduced sickness certification probability. Worrying about illness or injury risks from work increased sickness certification. GPs and their patients took a fairly similar view to statements on health related and insurance system related matters. GPs’ opinions seem to have a greater impact than patients’ on the GPs’ decision to sickness certify a patient or not. Conclusions A number of patient and GP related factors were associated with the probability of getting sick certified. The patient’s own judgement of impaired work ability was important for sickness certification, but a shared judgement and decision between the GP and the patient appears probable in most cases. / Försäkringsmedicin

Medical treatments with statins are prescribed to patients with increased risk of cardiovascular events. The benefits from statin treatment are well documented in clinical trials, but long-term adherence in patients is low, indicating that patients have an uncertainty about the necessity and benefits of treatment. The aims of this thesis were to investigate how patients and doctors view different aspects of statin treatment. Further aims were to investigate if the cardiovascular risk level in patients affects their views about different aspects of statin treatment. Yet further aims were to compare health behaviours and views about risk factors in patients using statins to a non-treated population. Data was obtained from patients (n = 829), doctors (n = 330) and a population sample (n = 720) using postal questionnaires. Views about the effect of statin treatment were assessed in different ways for patients and doctors. Patients based their assessments on their own situation, and doctors’ treatment decisions and assessments of anticipated effect of treatment were based on two hypothetical patient cases. The results indicate that patients greatly overestimate the general effect of statins, compared to efficacy results reported from clinical trials. Patients’ previous coronary heart disease or high overall risk were factors not associated with their views and expectations of treatment effect. Statin users with an internally perceived health control and patients satisfied with their doctor’s treatment explanation reported higher beliefs in treatment necessity and benefits. Statin users reported having better health behaviours and generally rated risk factors as more important than the non-treated population. Doctors had suboptimal understanding of the number of patients expected to benefit following five years of statin treatment and had a varying understanding of statins’ ability to prolong life. Overall the results illustrate that patients and doctors have different perspectives and views of the benefits from statin treatment which puts emphasis on how statin treatment is discussed in the clinical setting.

Objectives. To study whether birth weight (BW) was correlated to cardiovascular risk factors, coronary heart disease (CHD), cardiovascular disease (CVD), and prostate cancer (PCA) at adult ages, whether a possible relationship depended on mediating factors from birth time, hereditary circumstances, and adult life variables, and what importance possible associations might have for the rate of the complaint in the general population. Material and methods. Population-based cohorts of men born in 1913 and followed up until old age. Risk of outcome was estimated using Cox’s and Poisson regressions. The results were transformed to population attributable risk percentage (PAR%) of the complaint that could be attributed to low or high BW, given causality between exposure and outcome. Results. After adjustment for the influence of covariates, systolic blood pressure at age 50 decreased by 3.7 mmHg per 1000 g increase in BW, the prevalence of antihypertensive treatment decreased by 32%, diabetes by 53%, serum total cholesterol decreased by 0.20 mmol L-1, and being in top quintile of serum cholesterol decreased by 23%. The adjusted risks were somewhat more marked relative to the crude risks. CHD and CVD incidence and mortality were virtually unaffected by BW. In the general population, the risk percentage attributable to a BW ≤3000 g was 18% for diabetes, 2.5% for cholesterol, and ≤1% for antihypertensive treatment and CHD and CVD incidence and mortality. PCA incidence and mortality risk increased by 62% and 82%, respectively, among those whose BW was ≥4250 g compared with those whose BW was 3001-4249 g. The risk percentages attributable to a BW ≥4250 g in the general population for PCA incidence and mortality were 7.8% and 10.8%. Conclusions. Low BW seemed to affect cardiovascular risk factors but not incidence and mortality from CHD and CVD. A high proportion of diabetes on the community level could be attributed to low BW, while the proportional burden of other cardiovascular complaints that could be attributed to low BW was modest. PCA incidence and mortality seemed to be affected by high BW.

Background. In Sweden 10 percent (550,000) of the labour force, aged 18 to 65 years are disability pensioners and about four percent are on sick leave. The knowledge of the course from healthy individual to disability pensioner is not well known and was the theme of this thesis. Objectives, Material and Methods. The aims of the thesis were to follow the study population regarding sickness absence, health care utilisation, quality of life, and survival. Population based data including 14,538 women and men from three cities in Sweden were used, of whom 1,952 were granted a disability pension at baseline or received one during follow up. Register data, including sickness spells, health care utilisation, and mortality data during 30 years of follow up, and questionnaire data including socio-economic and quality of life data were used. Results. The most powerful determinant for being granted a disability pension was cumulative annual sick leave days, more powerful than all other tested determinants together. The degree of explanation for all determinants combined was 96%. Health care utilisation among disability pensioners continued to be high also after disability pension, 2.3 times higher for hospital admissions and 8 times higher for primary health case appointments than among referents. Disability pensioners had lower quality of life than non-pensioners and old age pensioners. For those who became disability pensioners after the baseline measurements quality of life measures decreased progressively until disability pension was granted and were then stabilised on a low level. During follow up 525 (7.6%) subjects died. Compared with subjects who did not become disability pensioners the hazards ratio was 2.78 among women and 3.43 among men, even when the effect of a number of other outcome affecting variables were taken into account. The mortality differences were not explained by underlying disease. Conclusions. The risk of disability pension may be predicted but only late in the course of events. Disability pensioners continue to have a high level of health care utilisation, and have a worse quality of life development and a higher mortality rate than non-pensioners. Given the unfavourable outcome of disability pension, other means of managing the reduced work capacity might be considered.

Aims. The overall aim was to examine the severity, treatment and level of control in patients with asthma in primary care in Sweden. The specific aims were to assess what matters to asthma patients, evaluate symptoms, medication and identify factors related to asthma severity, compare the extent of asthma control in 2001 and 2005, and investigate the development of asthma and degree of asthma control in adolescents and young adults who had reported asthma six years earlier. Methods. The first study was a telephone interview of a representative sample of Swedish asthmatics. In the second study a random sample of 1,136 patients answered two questionnaires. A classification of the asthma severity similar to that in the GINA guidelines was made. In the third study two surveys were performed, in 2001 and in 2005, with a random sample of 1,012 and 224 asthma patients, respectively, and a classification of asthma control similar to the recent GINA guidelines was made. In the fourth study 71 individuals who reported physician-diagnosed asthma in a population-based survey in 1997 and were defined as current asthmatics, were reinvestigated in 2003 with a skin prick test, methacholine challenge test, eucapnic voluntary hyperventilation test and measurement of exhaled nitric oxide. Results. Common situations causing symptoms of asthma were physical exertion and contact with pets. Nocturnal symptoms were frequent. In primary care 35% of the women and 24% of the men were classified as having severe asthma. Female sex, increasing age, not filling the asthma prescription owing to cost, daily smoking, and pollen allergy increased the odds of having severe asthma. In 2001, 37% had achieved asthma control, as compared with 40% in 2005. Uncontrolled asthma was more common in women and smokers. In the 2003 study of adolescents and young adults with asthma six years earlier, the definition of current asthma was fulfilled by 50 of the 71 subjects and one third had achieved asthma control. Conclusions. The majority of the asthmatics reported a large number of symptoms and limitations in their daily living. Many asthma patients in primary care have insufficient asthma control. One reason for lack of control might be undertreatment with inhaled corticosteroids.

Objectives. To assess outcome of manual therapy in addition to stay-active care in sub-acute low back pain patients and to investigate the predictive power of pain drawing sketch variables for return to work. Materials and methods. The study was designed as a randomised controlled trial with a factorial design, and included 160 patients with acute or sub-acute low back pain allocated to one of the four treatment groups during 10 weeks. Group 1 received stay-active care only, Group 2 the same treatment as in Group 1 + muscle stretching, Group 3 the same treatment as in Group 2 plus manual therapy, and Group 4 the same treatment as Group 3 plus steroid injections. Outcome included pain intensity, pain extension, functional and health related quality of life variables and return to work. Results. Pain intensity and disability rating improved faster in Groups 3 and 4 than in Groups 1 and 2 (p<0.05 and p<0.05). Also health related quality of life was affected by the treatments given; the more treatment options the better the effect (trend across the groups p<0.05). Pain extension as described on a pain drawing sketch decreased in all groups across the study period. The pain modality ‘numbness’ was the most painful one among patients with no pain radiation. Pain radiation according to the pain drawing sketch was the strongest predictor for return to work (p=0.03, Wald χ2=4.56). Conclusions. The manual therapy concept used in this study reduced pain intensity and disability rating better than the stay active concept. The effects on health related quality of life were greater the larger the number of treatment modalities available. Pain drawing information was significantly correlated with pain and functional variables. Pain radiation according to the pain drawing adds significant information to the prediction of return to work.

As the occurrence of obesity increases amongst young people, so increases the risk of more people suffering from heart failure as early as during middle age. The aim is to describe the life experiences of middle aged persons living with chronic heart failure. The literature study is based on twelve published, qualitative, and scientifically proved articles derived from MedLine and Cinahl using queries representing the subject, as well as from manual searching in ScienceDirect and LIBRIS. These articles have been analyzed from a life world perspective. Four main themes and four sub themes were identified from the articles' results. The main themes are "The social life", "Quality of life", "Body failing", and "the Economical impact of chronic heart failure". These represent the main areas where the patients feel the greatest loss due to their condition. The discussion reveals the importance of informing the patients of the common prevalence of the feelings described in this study. Also, the nurse should function as a coach for self-care with continuous follow-ups. The result of this study will hopefully increase the understanding of the heart diseased patients' life situations. / I takt med att förekomsten av kraftig övervikt ökar bland unga, ökar även risken för att fler personer drabbas av hjärtsvikt redan i medelåldern. Syftet är att utifrån befintlig forskning beskriva medelålders personers upplevelser av hur det är att leva med kronisk hjärtsvikt. Litteraturstudien baseras på 12 publicerade, kvalitativa och vetenskapliga artiklar efter sökning i MedLine och Cinahl med specifika sökord som representerade ämnet. Manuella sökningar utfördes i ScienceDirect och LIBRIS. Artiklarna har analyserats utifrån ett livsvärldsperspektiv. Ur artiklarnas resultat identifierades fyra teman och sex subteman. Huvudteman är ”Det sociala livet”, ”Livskvalitet”, ”Kroppen sviker” och ”Ekonomiska aspekter”. Huvudteman skildrar patienternas upplevdelser av att leva med kronisk hjärtsvikt. I diskussionen framkommer att det är viktigt för en patient med kronisk hjärtsvikt att få bekräftat att upplevda känslor är vanligt förekommande. Vidare bör sjuksköterskan fungera som en vägledare för egenvård med kontinuerliga uppföljningar. Förhoppningen är att resultatet från denna studie ska öka förståelsen för hjärtsjuka patienter inom ramen för hälso- och sjukvård.