Uppsatsen utgår ifrån hur socialarbetares vittnesmål problematiserar det sociala arbetets struktur gällande ekonomisk utsatthet bland barnfamiljer. Genom kvalitativa intervjuer undersöker studien hur barnfamiljer med svag ekonomi upplever att vardagen påverkas av deras ekonomiska situation, vad de tvingas avstå ifrån samt vilket stöd de erfarit från myndigheter och civilsamhälle. Studiens teoretiska ansats utgörs av Baumans teori om konsumtionssamhället, Goffmans Stigma, Bourdieus kapital samt Beckers stämplingsteori.  Uppsatsens resultat påvisar hur familjernas upplevelser av ekonomisk utsatthet i Sverige 2018 skiljer sig ifrån varandra samtidigt som beröringspunkter kan uttydas; föräldrarnas krympta valmöjligheter att samt deras kamp för att ge sina barn möjligheter att delta i samhället på samma villkor som andra. Familjernas upplevelser av att tvingas avstå från saker som andra har av ekonomiska skäl förklarar den ekonomiska utsatthetens skiftningar och hur deprivationens omfattning varierar mellan studiens deltagare. Familjernas erfarenheter av stöd genom statliga myndigheter i samband med ekonomiska problem kan sammanfattas genom deras negativa erfarenheter av socialtjänstens bemötande. De flesta föredrar att vända sig till civilsamhällets ideella organisationer när de behöver stöd: ekonomiskt såväl som känslomässigt. Innebörden av familjernas upplevelser av att avvika från normen i konsumtionssamhället kan ifrågasätta tanken bakom en skälig levnadsnivå och statliga myndigheters förhållningssätt gentemot ekonomiskt utsatta barnfamiljer.

Det är viktigt att ha god språkförmåga och ett brett ordförråd för kunskapsinhämtning och kommunikation. Idag ställs det höga krav på språkförståelse, därtill förståelse av metaforer. Metaforer är en typ av figurativt språk vars tolkning inte är bokstavlig. Därtill behövs det mer kunskap om figurativt språk hos gruppen ungdomar med cochleaimplantat (CI). Syftet med examensarbetet var att undersöka metaforkunskap hos svensktalande ungdomar med CI i relation till ålder när deltagarna fick sitt första cochleaimplantat (CI1), expressivt ordförråd och pragmatisk förmåga. I studien ingick 17 svensktalande ungdomar med CI i åldern 12 – 20 år. Deltagarna rekryterades via mottagningen för hörselimplantat vid Karolinska universitetssjukhuset. Sexton deltagare hade bilaterala CI och en hade bimodal hörsel (ett CI och en hörapparat). Genomsnittlig ålder för CI1 var 15 månader. Metaforkunskap bedömdes med hjälp av en norsk metaforuppgift översatt till svenska, expressivt ordförråd med Boston namning test (BNT) och pragmatisk förmåga med ett föräldraformulär (CCC-2). Deltagarnas svarsmotiveringar av metaforuppgiften transkriberades och analyserades med en kvalitativ svarsanalys. Resultaten visade att ungdomar med CI uppvisar metaforförståelse. Dock varierar den inom gruppen avseende antalet korrekt valda svarsalternativ. Ytterligare fynd indikerar att det finns ett måttligt negativt statistiskt signifikant samband mellan ålder vid CI1 och resultatet på metaforuppgiften. Ju yngre ålder vid CI1, desto bättre resultat på metaforuppgiften. En slutsats är att det finns en stor variation gällande metaforkunskap inom gruppen ungdomar med CI. Den kvalitativa analysen visar på en hög grad av diskrepans mellan val av rätt svarsalternativ, och otillräcklig eller felaktig motivering av det aktuella svarsalternativet. Tidig ålder vid CI tycks ha en gynnsam effekt på högre språkliga förmågor som metaforkunskap. Dock behövs det fler liknande studier, i större kohorter och med hörande kontrollgrupp. / It is important to have good language skills and a broad vocabulary for knowledge acquisition and communication. Today, there are high demands on language comprehension, which includes the understanding of metaphors. Metaphors are one type of figurative language whose interpretation is not literal. Therefore, more knowledge about figurative language in the group of teenagers and young adults with cochlear implant (CI) is needed. The aim of the study was to investigate metaphor knowledge in Swedish - speaking teenagers and young adults with CI in relation to implantation age of the first CI (CI1), expressive vocabulary and pragmatic ability. The study included 17 participants with CI between the ages of 12 and 20 years. They were recruited by the Hearing Implant Clinic, Karolinska University Hospital. Sixteen participants had bilateral CI and one had bimodal hearing (one CI and one hearing aid). The average age at CI1 was 15 months. Participants' metaphor knowledge was assessed using a Norwegian metaphor task translated to Swedish, expressive vocabulary with the Boston Naming Test (BNT), and pragmatic ability with a parent questionnaire (CCC-2). The participants' motivations in the metaphor task were transcribed and analyzed using a qualitative response analysis. The results showed that young people with CI exhibits metaphor understanding. However, it varies within the group regarding the number of correctly selected responses. Further findings indicate that there is a moderate negative statistically significant relationship between age at CI1 and the results of the metaphor task. One conclusion is that there is a large variation regarding metaphor knowledge within the group of teenagers and young adults with CI. The qualitative analysis shows a high degree of discrepancy between the choice of correct answer option and insufficient or incorrect justification of the given answer. Early age at CI1 appears to have a beneficial effect on higher language abilities such as metaphor knowledge. However, further studies are needed, preferable in larger cohorts and with a hearing control group.

Because of evidence of regional variation in health and healthcare use, this thesis used health equity and access to care theory to examine regional differences in access to primary care, using survey- as well as secondary data in four empirical studies. First, a systematic literature review was used to categorize forms and reasons for regional healthcare shortages and access barriers, with a particular focus on rural areas. After information extraction from the selected studies and a thematic content analysis, the forms and causes identified in the literature were grouped and discussed. Following the literature-based review of these thematic foundations, a study was then designed to evaluate patient-reported access to primary care in exemplary German regions and assess empirical differences in rural vs. urban populations. This allowed the importance to patients of different access dimensions to be evaluated. For a subgroup of study participants with multidisciplinary care needs, care coordination failures and the supportive role of the general practitioner as a primary point of access was investigated. Finally, regional factors that are associated with variations in need, health, and utilisation beyond individual health determinants were identified, and placed on different regional framework conditions. These health-related factors were summarised in a regional deprivation measure and small-scale regions in Germany were differentiated by their regional deprivation by the main dimensions (material, social, ecological). Finally, their association to regional health outcomes were cross-sectionally estimated. To reduce unwarranted access variation, while also taking the patient perspective (by region) into account, the thesis concludes with a chapter on implications. Here, concepts for regional and multidimensional access monitoring, as well as further regulatory measures in capacity and distribution planning of primary care, are discussed.:Content Tables ........................................................................................................................... V Figures ....................................................................................................................... VI Abbreviations ........................................................................................................... VII 1. Background and research objectives .................................................................. 9 1.1. Health equity and access to health care ........................................................ 10 1.2. Regional variation as a contradiction to the equity principle ....................... 16 1.3. Reducing unwarranted regional variation in health care .............................. 20 1.4. Research objectives and thesis structure ...................................................... 24 References ............................................................................................................... 28 Legal sources .......................................................................................................... 33 2. Rural health care shortages and access barriers ............................................. 34 3. Regional access and satisfaction with primary care........................................ 35 Appendix 3 .............................................................................................................. 36 4. Access to primary care and outpatient care coordination .............................. 48 4.1. Introduction .................................................................................................. 49 4.2. Background ................................................................................................... 51 4.2.1. The patient perspective of care coordination ......................................... 51 4.2.2. Coordinating mechanisms ..................................................................... 52 4.3. Methods ........................................................................................................ 55 4.3.1. Data collection and sample .................................................................... 55 4.3.2. Measures ................................................................................................ 55 4.3.3. Data analysis .......................................................................................... 58 4.4. Results .......................................................................................................... 59 4.5. Discussion and limitations ............................................................................ 62 4.6. Implications .................................................................................................. 65 References ............................................................................................................... 69 Appendix 4 .............................................................................................................. 73 5. Area deprivation and its impact on health ....................................................... 76 6. Summary of implications ................................................................................... 77 6.1. Establishing a framework to assess primary care access and performance .. 77 6.2. Strengthening patient involvement in health care structure planning .......... 81 6.3. Strengthening access to GPs as outpatient care coordinators ....................... 84 6.4. Including regional deprivation factors in health care structure planning ..... 86 References ............................................................................................................... 90

Thesis (PhD)--University of Stellenbosch, 2002. / ENGLISH ABSTRACT: An increasing number of children in South Africa are deprived of adequate parental care. Factors exacerbating the situation are the deaths of parents due to HIV/AIDS and contextual stressors like poverty and violence. Children removed from family care in accordance with stipulations of the Act on Child Care, were all exposed to factors of inadequate care like a lack of basic means of existence and/or physical, emotional or spiritual neglect or sexual abuse. The current thesis tried to determine to what extend these factors influence the social development of children. Theories of psychosocial development have shown that optimal social development starts with securing a strong positive and reciprocal emotional bond with the primary caregiver. This is the basis of personal security and interpersonal trust upon which further developmental elements like a positive self image, autonomy, pro-social behaviour, emotional well-being, moral values, the ability to find solutions to problems, self control and expectations about the future, will be based. Schema theory has confirmed the importance of positive developmental experiences in establishing positive expectations about social interaction. Negative developmental experiences will lead to dysfunctional schemas and selective processing of information. This will negatively influence emotional well-being, the ability to solve interpersonal problems and realistically assessing the self and others. Dysfunctional interpersonal patterns, inappropriate social behaviour and a less positive expectation of the future, will follow. Patterns of parental care are still important in adolescence and influence body image, sexual identity, academic achievement, career aspirations, values, autonomy and emotional well-being. Negative patterns of parenting, like loveless over-control and child abuse, lead to dysfunctional interpersonal expectations. Residential care increases the risk of diffused bonding, unless sufficient preventive measures are put in place. In the current thesis ten elements of interpersonal schemas were identified according to the above theories. Statistical comparisons of the elements were done using two groups of adolescents. Adolescents in the first group were removed from parental care in accordance with the Act on Child Care, while adolescents in the second group experienced continuous and adequate parental care. The results supported all of the hyphotheses, with a measure of ambivalence about autonomy. Psychosocial history was proved to be a measurable discriminating factor in adolescent interpersonal schemas. Sex proved to be a further discriminating factor in some elements. Girls were influenced most by the presence or lack of family security. In a second section, current programmes for social empowerment in use in children's homes, were evaluated according to the above results. Indications were given about possible adaptations and additions to therapeutic and skills programmes, the role of substitute families and character traits of staff that may help in limiting the risks of residential care. / AFRIKAANSE OPSOMMING: 'n Toenemende getal kinders in Suid-Afrika ontbeer deurlopende en toereikende gesinsorg. Faktore wat hiertoe bydra, is ouersterftes weens MIVNIGS en kontekstuele stressors soos armoede en geweld. Kinders wat uit gesinsorg verwyder word weens die bepalings van die Wet op Kindersorg, was almal blootgestel aan faktore van ontoereikende sorg soos gebrekkige bestaansmiddele en/of fisieke, emosionele of geestelike verwaarlosing of seksuele misbruik. Hierdie proefskrif het probeer vasstel in watter mate dié faktore die sosiale ontwikkeling van kinders beïnvloed. Teorieë omtrent psigososiale ontwikkeling toon aan dat optimale sosiale ontwikkeling begin by die vestiging van 'n sterk positiewe en wederkerige emosionele band met 'n primêre bindingsfiguur. Dit vorm die basis van persoonlike sekuriteit en interpersoonlike vertroue, waarop ontwikkelingselemente soos 'n positiewe selfsiening, outonomie, pro-sosialiteit, emosionele welstand, morele waardes, probleemoplossingsvaardighede, selfbeheer en toekomsverwagting gebaseer is. Skema-teorie bevestig die belang van positiewe ontwikkelings-ervarings in die daarstel van positiewe verwagtings omtrent sosiale interaksie. Negatiewe ontwikkelings-ervarings lei tot disfunksionele skemas, waarin inligting selektief verwerk word. Dit het 'n negatiewe uitwerking op emosionele welstand, die vaardigheid om interpersoonlike probleme op te los en realisties oor die self en ander te oordeel. Die gevolg is patrone van interpersoonlike wanaanpassing, ontoepaslike sosiale optrede en 'n minder positiewe toekomsverwagting. In adolessensie speelouerskapspatrone steeds 'n rol ten opsigte van liggaamsbeeld, geslagsidentiteit, akademiese prestasie, beroepsideale, waardes, outonome optrede en emosionele welstand. Negatiewe ouerskapspatrone, soos oormatige en liefdelose beheer en kindermishandeling, lei tot disfunksionele interpersoonlike verwagtings. Residensiële sorg verhoog die risiko vir diffuse bindingsgedrag, tensy doeltreffende voorsorgmaatreëls daargestel word. In die proefskrif is tien elemente van interpersoonlike skemas aan die hand van die teoretiese uiteensetting geïdentifiseer. 'n Statistiese vergelyking ten opsigte van die elemente is gedoen met twee groepe adolessente. Die eerste groep is weens wetlike bepalings uit ouersorg verwyder, terwyl die tweede groep deurlopende en toereikende ouersorg ervaar het. Die resultate het al die hipoteses ondersteun, met 'n mate van ambivalensie omtrent outonomie. Psigososiale geskiedenis was dus 'n meetbare onderskeidingsfaktor ten opsigte van interpersoonlike skemas in adolessensie. Geslag was 'n verdere meetbare faktor by sommige elemente. Dogters was die meeste beïnvloed deur die teenwoordigheid van óf gebrek aan gesinsekuriteit. In 'n tweede afdeling, is die bestaande programme van sosiale bemagtiging in kinderhuise geëvalueer in die lig van bogenoemde resultate. Aanbevelings is gedoen oor die aanpassing en uitbouing van terapeutiese en vaardigheidprogramme, die rol van substituut-gesinne en die eienskappe van personeel wat kan bydra om die risiko's van inrigtingsorg te verminder.

Thesis (MA (Psychology))--Stellenbosch University, 2008. / In recent years, the issue of fathers’ involvement with their families has increasingly gained support and currently more research focuses on fathers’ involvement and what fathers must do to become more involved with their families. The aim of this study was to gain insight into boys’ perception of fathers’ involvement in the lives of boys. The participants were boys in Grade 7 and 8 whose parents are married and who both live in the same house with them. The data of this explorative, qualitative study were gathered by means of focus group discussions. The 18 participants who complied with the inclusion criteria were randomly divided into three focus groups of six participants each. The groups were asked an open question and the discussion was audio-recorded. The group discussions were transcribed, after which the data were loaded onto the Atlas.ti program for analysis. In this analysis technique, related aspects (termed ‘codes’, which are formed by related quotations by participants) are grouped to form families (of codes). Based on the description by Lamb, Pleck, Charnov and Levine (1987) of fathers’ involvement and the qualitative data analysis, content could be given to the families responsibility, accessibility and engagement. The family responsibility, which includes any activities of the father regarding the child’s direct care or arrangements regarding the care of the child, is the largest family in terms of number of codes and quotations. The most prominent code in this family in terms of number of quotations compared to the other codes, is to provide. This is followed by the codes discipline, set right and protect. Accessibility is the second largest family and entails the father being present as well as his availability to his son. The most important codes in this family are talking, to be there for the child and to pay attention to the child. The third family, engagement, includes the experience of caring, direct contact and interaction between the father and his son. The most important codes that emerged in this family are to demonstrate love and to hug. The specific content given to the three components of fathers’ involvement can be applied with success in the development and presentation of parent guidance programmes.

Frailty poses a complex challenge for some people through their experience of ageing. In Wales, devolution requires organisations to use a whole systems approach with a model of partnership to deliver public services. An integrated care approach is offered to meet the service user focus or ‗value demand‘ which impacts on clinical, professional, organisational and policy levels within the system. Therefore, the aim of this study was to explore whether there was a difference between integrated health and social care day services and non- integrated health and social care day services. In doing so, answering the questions, how were these services different, what were the differences as perceived by the participants, why were they different, what could be learned from this study and how could health and social care services integrate in practice? The study utilized Gadamer‘s interpretative hermeneutics with a single intrinsic case study design. Using this approach ensured that the unique voice of the individual lived experience was heard and interpreted within the whole system of the study. The participants were service users, carers and staff in a day hospital, an outpatient clinic, day centre, reablement team and a joint day care facility. The methods included a survey questionnaire (SF12v2 and London Handicap Scale), in-depth interviews, observations; and historical and service documents; and reflective diary. Data collection occurred January 2005 to December 2006. Quantitative and qualitative data were analysed separately. The qualitative data was analysed using Gadamer‘s five stage approach developed by Fleming et al (2003) and Nvivo 7.0. The embedded quantitative data was analysed using SPSS version 13.0. Triangulation was achieved through the use of a meta matrix which merged the qualitative and quantitative data. The difference between integrated and non integrated services is expressed through the four themes, ‗the study participants‘, ‗commissioning and decommissioning integrated services‘, ‗the journey within day services‘, ‗navigating services and orchestrating care‘. The four themes were developed through a strategy used for interpreting the findings, which was to follow the study questions, propositions and ‗emic‘ questions. The differences between the integrated and non integrated services were in the meaning of their purpose, culture, level of integration, team orientation of practice and the model of service user/carer relationship observed within the services. The thesis identified challenges in respect of integrated working such as concept confusion, negative experiences of care for frail or older people, a vertical gap in knowledge transfer between strategic organisation, the operational services and service users. Mapping each service level of integration and team orientation to the model of service user and carer relationship, found that the level of team orientation and integration does not appear to be proportionate to the service user and carer relationship. The thesis concludes that in order to attempt to answer the question as to whether these day services can integrate in the practice, all levels of the system should focus on the service user/carer relationship. We need to understand service user diagnosis, how its characteristics and effect are interpreted by the service user, carer, professional and wider society in relation to independence and autonomy. It argues that knowledge emerges at this micro level (service user and carer relationship) and how we engage with this relationship and manage the knowledge we gain from it (both vertically and horizontally), will lead us to understand how we can ensure that integration occurs and that services in the future are person focussed.

Aims: The main aim of this research was to add depth of understanding and a human voice to existing research on the maternal experience of having a child with night-time sleep difficulties. It was hoped that this increased understanding could be used by counselling psychologists, not only in their own clinical practice but also when supporting physical health practitioners who have direct contact with this client group. Method: Five semi-structured interviews were conducted with mothers who had children over the age of one who were experiencing night-time sleep difficulties. The interviews were transcribed and analysed in accordance with grounded theory methods. A constructivist version of grounded theory was utilised as outlined by Charmaz (2006). Analysis: A central story line of ‘no choice but to function’ emerged. This refers to the place where these mothers found themselves after attempts to solve their child’s sleep problem had proved ineffective, and describes a state of both ‘coping’ and immense struggle. A number of categories were identified which contribute to this central storyline. A process was identified that outlined the stages that all participants moved through as they encountered and adapted to this experience. Personal Conflicts were also identified which described the experience and impact of fatigue, uncertainty and conflicting emotions. Categories of Responsibility and Isolation also emerged and were found to potentially lead to many personal needs not being met iii and a lack of engagement with support (including that of health professionals). Furthermore, a category of Coping highlighted not only the participants’ reflections on how they coped but also potential future avenues of support. Conclusion: The aims of this research were met with a deeper understanding of this population being obtained and a human voice being added to the existing research on this subject. Findings from this research offer a theoretical model which highlights not only the physical, emotional and systemic struggles encountered by the participants that were interviewed, but also provides suggestions based on these findings for future research and clinical practice.

The thesis examines the Children’s Centre Programme in England and develops an understanding of its development at national and local level by using Kingdon’s (1995) streams model. Central to the thesis is a case study of the Children’s Centre Programme which looks at influential factors in the development at national level and implementation of the programme in one local authority. Traditionally Kingdon’s (1995) model has been used to understand the way that a wide range of factors interact to enable policy change at national level but a small number of authors have also used the model at local level showing that the range of factors that impact on the local implementation of a policy are also many and varied. One of the most well know aspects of Kingdon’s model is in showing how the problem, policy and politics streams come together to create a window of opportunity which allows or drives policy change and or enactment. This thesis will use the model in a broader sense showing that although this window of opportunity is important the interaction of the three streams is ongoing and not only does it lead to significant policy change but it also informs debates and policy development on an ongoing basis.

The following thesis presents the results of a mixed-design study (quasi-experimental and true experimental) testing an integrated model of human risk-taking behavior, defined statistically as a preference for variance in outcomes. The research presented examines the relationships among early-life environmental conditions (i.e., harshness and unpredictability), life-history strategy, and risk-taking behavior for primary resources under various "resource-budget" conditions consisting of deprivation and non-deprivation in two areas: (1) Social-inclusion and (2) caloric "Energy-budget." Two hundred and forty seven (N=247) university students participated in the research. In session one, participants completed multiple questionnaires assessing levels of environmental harshness and unpredictability experienced during development and individual life-history strategy. In session two, participants were pseudo-randomly assigned to experience laboratory induced deprivation or non-deprivation in one of two possible areas: Social-inclusion or caloric "Energy-budget." Following the experimental manipulations, participants played two different behavioral risk-taking tasks: (1) The Wheel Spin Risk Task which required participants to select between a low variance "safe" wheel and a high variance "risky" wheel in an attempt to earn either points or food rewards (depending upon study condition). (2) The Operant Risk Taking Task which required participants to select between a low variance "safe" keyboard key which produced constant rewards and a high variance "risky" keyboard key which produced variable rewards (points or food, depending upon study condition). The results of the multivariate analyses supported main effects only (no moderation) between the characteristics of the early-life environment, life-history strategy, and the experimental manipulations on risk-taking behavior. Specifically, early-life harshness was significantly associated with a faster life-history strategy in participants. Participants with a faster life-history strategy were significantly more likely to select the risky spin wheel on the Wheel Spin Risk Task than were slower life-history strategy participants who were more likely to select the safe spin wheel. Furthermore, participants who experienced the deprivation experimental manipulations behaved more risky on the Operant Risk-Taking Task (for reward amount) than did participants exposed to the non-deprivation manipulations in the study. Interestingly, this effect was domain-general in that deprivation in either Social-inclusion or Energy-budget was associated with risk taking for both social points and for food rewards. The results of this study suggest that life-history strategy is predictive of instrumental risk-taking behavior for reward amount and that deprivation in adaptive areas like Social-inclusion and Energy-budget enhances risk-taking behavior for primary rewards in a domain-general manner as opposed to a domain-specific manner.

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