Survival following critical illness is associated with a significant burden of physical and psychosocial morbidity and recovery is often protracted and/or incomplete. Recovery has been measured using, almost exclusively, generic health-related quality of life (HRQoL) questionnaires. There is, however, an inexorable lack of consensus on the conceptual definition of HRQoL, and existing measures have tended to reflect overtly biomedical concerns such as morbidity and impairment at population level. Limited empirical or theoretical work has examined the extent to which widely used measures reflect the individual’s concerns, “health”-related and otherwise. The primary aims of this PhD are to examine HRQoL among a rarely studied sub group of the critically ill patient population: survivors of prolonged critical illness, and to explore the extent to which professionally endorsed measures capture their experiences of and perspectives on the recovery process. The implications of “patient-centredness” are both diverse and far-reaching in terms of policy, practice and critical care outcomes research, and are discussed throughout. A review of the literature among a well studied sub group of the patient population (survivors of Adult Respiratory Distress Syndrome) identified the widespread use of generic and ancillary measures which were invariably developed for use among other patient populations. This approach was seen to offer limited insight to the putative relationship between critical illness-related morbidity and HRQoL. Reflecting existing professional recommendations and practice, the Short Form 36 (SF-36) and the EuroQoL were administered by post to 20 survivors of prolonged critical illness at up to 6 months following ICU discharge. Each subsequently participated in a semi-structured interview, the purpose of which was to explore experiences and perceptions of ongoing morbidity within the contexts of the critical illness “journey” and, importantly, everyday life. A small number (n=5) participated in cognitive interview in order to explore both the everyday logistics of questionnaire completion and the often startling inconsistencies between verbal and questionnaire response. Analysis here revealed the unexpectedly diverse and normally hidden processes through which survivors interpreted and responded to standardised questionnaire items, challenging traditional (i.e. psychometric) notions of validity. Data from the semi-structured interviews were “mapped” onto the dimensions of the SF-36, revealing the highly contextualised and complex inter-relatedness of biomedically defined and ostensibly discrete aspects of experience. Morbidity was conceptualised by survivors in terms of the adaptive and interpretive processes adopted in everyday life (as opposed to a source of loss) and was generally under-reported in questionnaire form. An alternative explanatory framework for HRQoL was subsequently developed. Data were also analysed with reference to the “biographical narrative” of critical illness, a strategy which revealed the significance of survivors’ own stock of “life experience” (health-related and otherwise) in these interpretive and adaptive processes. The unexpectedly phlegmatic nature of survivors’ accounts directed attention to the narrative form, lending credibility to survivors’ claims that “things weren’t that bad”; accounts of seemingly intolerable morbidity were perceived, for example, as “a lucky escape”. This data also revealed, however, the influence of shortfalls in the processes and delivery of acute hospital rehabilitation upon the efficacy of these interpretive and adaptive processes. Mixed methods approaches to HRQoL, in summary, offer significant insights into survivors’ conceptualisations of morbidity, recovery, quality of life and the complex inter-relationships therein. Attention to the processes of adaptation also offers significant potential for the development of patient-centred measures of outcome and the expedition of the recovery process in ways which are most meaningful to survivors.

Bakgrund: Bröstcancer är den vanligaste cancerformen bland kvinnor och i Sverige diagnostiseras cirka 7000 nya fall per år. Behandlingsstrategierna vid bröstcancer är i första hand kirurgi följd av eventuell strålbehandling och läkemedelsbehandling. Efter genomförd mastektomi erbjuds alla svenska kvinnor plastikkirurgisk rekonstruktion. Rekonstruktion är frivilligt men många kvinnor väljer att rekonstruera för att känna sig mer kvinnliga, mer självsäkra i sin kropp och sin sexualitet och som en “hel” människa igen. Det är framför allt yngre och ensamstående kvinnor som tycker det är viktigt med rekonstruktion. Syfte: I denna studie undersöktes livskvalitet hos mastektomerade kvinnor med eller utan efterföljande rekonstruktion, att jämföra uppfattning mellan grupperna och beroende på ålder, och hur de upplevde stödet från vården. Metod: Kvalitativ intervjustudie. 7 kvinnor intervjuades utifrån 8 öppna frågor rörande psykosocial situation relaterad till kroppsbild, sexualitet, beslutsfattande och stödbehov. Intervjuerna spelades in, transkriberades och analyserades med hjälp av innehållsanalys. Resultat: Innehållsanalysen delades in i 2 teman, livskvalitet och bröstcancerkirurgin, som delades in i 5 kategorier, psykisk hälsa, kroppsuppfattning, psykosocial hälsa, upplevelse av vården och valet: rekonstruktion/ej rekonstruktion. Oavsett om kvinnorna genomfört rekonstruktion eller inte så skattade de sin livskvalitet som god. De kvinnor som genomgått rekonstruktion skattade sin livskvalitet högre efter rekonstruktionen än innan. Beslutet om rekonstruktion togs utifrån personliga känslor och tankar. Kvinnorna som inte hade gjort rekonstruktion upplevde ingreppet som riskfyllt och onödigt. De kvinnor som genomförde rekonstruktionen ville inte känna sig stympade och efter operation upplevde att de kände sig mer kvinnliga och som en hel människa igen. Vården uppfattade kvinnorna som bra, men med ökat behov av eftervård och bättre kontinuitet. Slutsats: Oavsett om kvinnorna gjort rekonstruktion eller inte är de nöjda med sitt enskilda val och skattar sin livskvalitet god. Kvinnorna uppfattar bemötandet från vården bra men det finns ett behov av ökad kontakt efter behandlingsslut. / Background: Breast cancer is the most common cancer among women and in Sweden approximately 7000 new cases are diagnosed every year. The primary treatment for breast cancer is surgery with possible subsequent radiation therapy and chemotherapy. Following mastectomy all women in Sweden are offered a surgical breast reconstruction. This is an optional choice, but many women choose reconstruction in order to feel more feminine, more confident in their bodies and their sexuality, and as a more "whole" woman. It is mainly the younger and single women who chose to do a reconstruction. Purpose: This study examines the health related quality of life within women who did or did not undergo breast reconstruction, depending of choice, age and how they experienced the healthcare support. Method: Qualitative interview study with seven women who participated in the study. The interview contained eight open questions concerning psychosocial situation related to body image, sexuality, decision-making and support needs. The interviews were recorded, transcribed and analysed with Graneheim- and Lundmans content analysis. Results: The analysis from the transcript was categorized into 2 groups: Quality of life and the breastcancer surgery. These two groups were divided into psychic health, body image, psychosocial health, and experience of the health care and the choice of reconstruction. Both the women who chose to do the reconstruction and those who do not, rate their health related quality of life as high. The women who underwent reconstruction rated their quality of life higher after the reconstruction than before. The decision regarding reconstruction was based on personal thoughts, and women who did not do reconstruction wished to focus on wining their fight against cancer and that thought that breast reconstruction was a major surgery with a high risk of complications. Decision about reconstruction was based on feeling truncated without breasts and with the new breast they feel feminine and whole again. Conclusion: Whether the women have made a reconstruction or not they are satisfied with their individual choices and rate their quality of life as high. The women also have experienced the communication to health care staff as good, but they even experience a huge need for follow-ups. / Hälsorelaterad livskvalitet och psykosocial situation bland kvinnor från olika kulturer efter bröstcancerkirurgi med eller utan rekonstruktion.

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Chronic disorders of the locomotion organs belong to serious civilization diseases deteriorating the quality of human life. Medical literature generally accepts the opinion that the way of life is responsible for 50 % of our physical condition. Healthy lifestyle requires that we move regularly. Perceived as a kind of physical exercise, locomotion activities are expected to meet certain criteria - they should be attractive, easy to do, time unlimited, not expensive, and generally available. These criteria seem to be satisfied by what is known as Nordic Walking, an activity recently much promoted. This diploma paper uses a sample of 43 patients / clients suffering locomotion problems to evaluate the effect that Nordic Walking, as applied at the Rehabilitation Spa Sanatorium at Vráž, may have on the Health-Related Quality of Life (HRQoL), and it assesses the NW for its suitability of inclusion into the spa treatment as a part of group physical exercises. The sample of respondents comprised Czech patients having completed full spa treatment no shorter than 21 days, and German clients of the Spa, who paid for 3-week treatments between 1 July 2007 to 30 November 2007. The practical section of the paper relied on a quantitative method applied through the questionnaire technique, specifically the SF-36 HRQoL Questionnaire and the EDUTOOL Questionnaire. The SF-36 Questionnaire was used to investigate the health-related quality of life in eight principle areas, namely the physical functions; physical limitation of roles; emotional limitation of role; physical and emotional limitation of social functions; pain; mental health; vitality; and overall perception of the state of own health. The ninth area of investigation, employed primarily for internal supervision, rested in the changes of own health. The EDUTOOL Questionnaire (its balneology version designed to assess the basic nutritious, regimen and movement habits) was used to review the results of the educational interventions into the health & social sphere, and specify the period of their effectiveness after the balneology procedures were completed. The paper identified the procedure of Nordic Walking as an activity fit to be incorporated into the spa treatment, and proved it to be capable of improving the health-related quality of the patients' lives. Hypotheses formulated: a) Nordic Walking will enhance the health-related quality of life - confirmed b) The results will depend on proper observance of instructions and consistent application of stereotypes and habits instilled by the education - confirmed c) The German-speaking clients will be more consistent in the application of what they were taught than the Czech-speaking patients - confirmed The diploma paper can be a useful tool of social education suitable to enhance the awareness of this topic.

The dissertation {\clq}qHealth Related Quality of Life (HRQoL) in Eating Disorders`` is divided into theoretical and practical part. In the theoretical part is analyzes the problems with eating disorders. It is especially focused on its two basics forms, anorexia nervosa and bulimia which are illnesses occasioned by hypothrepsia. The next part drala with history, symptoms, cause, medication, process, prognosis and complications resulting from these disorders, including the main diagnostic criteria and prevalence data. Women are affected by both diseases more frequently than man. Mental anorexia occurs mostly between the 14th and 15th year of the life, mental bulimia at the age of 13 to 20 years. The second part is practicaly aimed at evaluation of SF-36 forms, where I verify hypotheses how eating disorders influence quality of life of theirs carriers and how the changes in quality of life are dependant on the grade of education. The analysed results indicate the difference between the sick and the healthy individuals and also the fact the level of education is important too.