Assisting smokers to quit and stay quit is the most important intervention clinicians can undertake to improve the length and quality of life of patients who use tobacco. The chronic, relapsing nature of tobacco dependence complicates tobacco treatment. Tobacco treatment counseling programs provide on-going support to help patients avoid relapse. Assistance with a referral increases the likelihood that patients will participate in counseling, but few clinicians regularly assist with referrals to tobacco treatment programs. This dissertation examined health system processes and clinician attitudes that influence the likelihood that clinicians will refer their patients for tobacco treatment counseling. Three papers examined health system processes, clinician attitudes, and frequency of referrals. A systematic review of the literature was conducted to evaluate strategies to increase the frequency of clinician referrals and effects on quit rates in primary care. The most effective strategies were those that combined clinician education with integrated referral systems. Integrated referral systems include non-clinician staff and clinician and staff prompts with algorithms or protocols for referrals. The second paper reports the findings of a pilot study using qualitative methods to explore experiences and strategies used for tobacco treatment by clinician champions practicing in independent primary care practices. Tobacco champions (N = 11) described experiences counseling patients but not assistance with referrals. Themes identified were: sources of knowledge and experience, understanding dependence, role perception, and treatment strategies. The final paper reports the findings of a cross- sectional, non-experimental study to examine clinician attitudes toward counseling, health system processes that facilitate referrals, and referrals to tobacco treatment counseling. Attitudes about the efficacy of tobacco counseling and the presence of processes that facilitate referrals predicted referrals. Clinicians sampled in these studies held favorable attitudes toward tobacco treatment but lacked confidence in the efficacy of community-based counseling for tobacco treatment. These findings have implications for health care policies to improve integration of processes that facilitate referrals and clinician education that includes information about counseling resources to improve chronic care for the treatment of tobacco dependence.

This thesis explores the argument that inherent in medical treatment interventions for chronic hepatitis C, there are certain implicit ontological assumptions about the relationship between the body, disease, and society. Focusing primarily on biomedical practices, it is argued that these assumptions might have a profound effect on the world-views of patients undergoing them. This in turn, might have far-reaching sociological implications. Using a methodology specifically developed for the purpose of explicating the ontological assumptions inherent in medical treatment, the visual and narrative texts produced by thirteen hepatitis C positive participants are examined. A deconstructive analytical approach is then applied to these texts as they relate to the treatment interventions pursued by participants. An exploration of the way participants engage with, negotiate, and/or resist the discourses and assumptions inherent in biomedicine, traditional Chinese medicine, and to some extent naturopathy, is conducted. Two broad ways in which the participants visualise the relationship between disease and their bodies, relating to treatment undertaken, are identified. The possible social implications of these are then suggested. The first, and predominant view, is aligned with biomedicine. The relationship between disease and the body is antagonistic in this view. It is suggested that this way of seeing might naturalise xenophobic attitudes and perpetuate social conflict. The marginal view is related to non-biomedical treatments for hepatitis C. The relationship in this case is the result of a negotiated accommodation with the disease. It is suggested that such a view might allow for non-resistant social tolerance of that which is perceived of as new and different. This qualitative study contributes to the body of knowledge in the field of the sociology of health and illness in two ways: Firstly, it proposes a methodology that may be taken up or adapted for future sociological research, and secondly, it suggests something of the social and political nature of treatment decisions made by people living with chronic hepatitis C.

Chronic pain is a public health problem that is likely to increase as the population ages, and has few effective treatments. Although viewed by many as profoundly distressing and disabling, there are a surprising number of people (approximately 30%) who cope well with their chronic pain and do not continue to seek treatment. There is little theory to explain how and why these individuals manage their pain well. This means there is limited knowledge about the approaches used by people who cope well and whether these strategies could help those who have more difficulty. This thesis presents a substantive grounded theory of living well with chronic pain, the theory of re-occupying self. Seventeen individual interviews were recorded, with data collection, analysis and theory generation following classical grounded theory methodological approach. Constant comparison, theoretical sampling, theoretical coding, and theoretical sensitivity were used to identify the main concern of people who cope well with pain. This concern is achieving self-coherence, and is resolved by re-occupying self. Resolution involves making sense to develop an idiographic model of their pain; deciding to turn from patient to person, facilitated or hindered by interactions with clinicians and occupational drive; and flexibly persisting where occupational engaging and coping allow individuals to develop future plans. By completing this process, individuals form a coherent self-concept in which they re-occupy the important or valued aspects of themselves. This study supports using Acceptance and Commitment Therapy because of its functional contextual view of people and their actions. This study illustrates that coping strategies are used in different ways depending on the primary goal within that context. Occupations, or active; purposeful; meaningful; contextualised and human activities, are used by people to make sense of their situation, and as a key motivation for developing coping strategies. These findings lead to new research questions about values-aligned activity, coping with identity change, and acceptance.

Chronic disease is a major health burden in the United States, affecting about half of adults, and leading to poor health, disability, and death. However, the burden of chronic disease is not shared equally among Americans, with some groups (created by determinants such as race/ethnicity and socioeconomic resources) experiencing higher rates of morbidity and mortality. When measures of health and socioeconomic resources are examined together, a stepwise gradient pattern emerges. This social gradient has been established for individual measures, such as household income and social class, and several measures of morbidity and mortality. However, nationally, little research has been conducted using area-level measures, such as county economics, to examine its relationship with chronic disease. Three studies were completed using data from the Behavioral Risk Factor Surveillance System (BRFSS). County economic status was determined using unemployment, per capita market income, and poverty. The first study examined the relationship between county economic status and chronic disease and risk factors, both nationally and by metropolitan classification, using data from BRFSS 2013. Further, the social gradient was explored. The second study also used data from BRFSS 2013 to examine county economic status and prevalence of hypertension, arthritis, and poor health, after controlling for known risk factors. This study also examined results by US region. Finally, the third study assessed changes in disparities between persistently poor and persistently affluent counties for heart disease, hypertension, arthritis, and diabetes using data from BRFSS 2001-2010.

Bakgrund: Kronisk sjukdom är en sjukdom av långvarigt tillstånd och har generellt en långsam utveckling. När ett barn diagnostiseras med en kronisk sjukdom upplever föräldrar att deras livsvärld förändras. Föräldrar till ett barn med kronisk sjukdom måste göra omfattande försök att anpassa sig till de nya omständigheterna. Syfte: Studiens syfte var att beskriva erfarenheter av att vara förälder till ett barn med kronisk sjukdom. Metod: Syftet besvarades genom en litteraturstudie av tio vetenskapliga kvalitativa artiklar. Resultat: När barnet blev diagnostiserat med en kronisk sjukdom upplevde föräldrar emotionell chock. Behandlingen kring barnets sjukdom upplevdes som svår att hantera i början men med tiden blev det lättare. Vardagen blev sig inte lik och familjerelationer förändrades. Föräldrarna lärde sig att omvärdera livet både som individer och som familj vilket resulterade i en ny relation till det värdefulla i det mänskliga livet. Föräldrar upplevde att stöd från andra föräldrar med liknande erfarenheter hade en positiv verkan på deras välbefinnande. Föräldrarna behövde ta kontroll över sin nya livssituation och gjorde detta genom olika copingstrategier. Slutsats: Resultatet i denna litteraturstudie har visat tydliga likheter i föräldrars erfarenheter oberoende av vilken enskild kronisk sjukdom som drabbar barnet. För att hantera den emotionella bördan kring barnets kroniska sjukdom uppgav föräldrar att det primära stödet kom från andra föräldrar med liknande erfarenheter. Sjuksköterskan bör introducera föräldern till olika stödgrupper eller patientföreningar för att minska deras oro och inge hopp om barnets framtida välbefinnande. Klinisk betydelse: Denna litteraturstudie kan bidra med kunskap om föräldrars erfarenheter av att leva med ett barn med kronisk sjukdom. En medvetenhet kring vikten av stöd och hur stöd påverkar familjer med ett barn med kronisk sjukdom kan ses som ett verktyg för att skapa god omvårdnad vilket är sjuksköterskans kompetensområde. / Background: Chronic illness is a long-term condition that generally has a slow development. When a child is diagnosed with a chronic illness parents experience that their lived world is changing. Parents of the chronically ill child need to make extensive efforts to adapt to the new circumstances. Aim: The aim of the study was to describe experiences of being a parent of a child with a chronic illness. Method: The aim was answered with a literature review of ten scientific qualitative articles. Result: When the child was diagnosed with a chronic illness the parents experienced emotional shock. To manage the illness was by the parents experienced as difficult in the beginning, but over time it eased. The everyday life was not the same and the relationships within the family changed. The parents learned to reevaluate their lives as individuals and as a family, which resulted in a new relation to the valuable in human life. The parents experienced that the support from other parents with similar experiences had a positive effect on their prosperity. The parents needed to take control over their new life situation and accomplished that throughout different strategies of coping. Conclusion: The results in this literature review have shown clear similarities in parents’ experiences regardless of the individual chronic illness that affects the child. To manage the emotional burden of the child’s chronic illness parents reported that the primary support came from other parents with similar experiences. The nurse should introduce the parent to different support groups or patients associations to reduce their anxiety and inspire hope of the child’s future wellbeing. Clinical significance: This literature review could contribute knowledge about parents experiences of living with a child with a chronic illness. An awareness of the importance of support and how support affects families with a child with a chronic illness can be seen as a tool to create good caring which is the nurse’e area of competence. / <p>Röda Korsets sjuksköterskeförening stipendium 2015</p>

Chirurgische Eingriffe werden bei 10% der Patienten mit Komplikationen der chronischen Pankreatitis erforderlich. Neben Ableitungsoperationen kommt bei fokaler Akzentuierung der Erkrankung die Resektion von Teilen der Bauchspeicheldrüse zum Einsatz. Entzündliche Tumoren des Korpus und des Schwanzbereichs werden durch linksseitige Resektion, wenn möglich Milz erhaltend, entfernt. Zu den klassischen Resektionsverfahren von Pankreaskopfprozessen gehören die Duodenopankreatektomie (DPE) nach Kausch- Whipple und die Pylorus erhaltende Kopfresektion (PPPD). Im eigenen Krankengut wurden von Oktober 1993 bis Mai 2001 373 Patienten mit chronischer Pankreatitis behandelt. 104 Patienten wurden reseziert (27,9%). Neben 13 Linksresektionen, davon 5 Milz erhaltend, wurden 91 DPE durchgeführt (54 Kausch-Whipple, 37 PPPD). Von den 91 Patienten, die einer DPE unterzogen wurden, hatten 25,2% der Patienten einen Diabetes mellitus. Konservativ unbeeinflussbare Schmerzen bestanden in 93% der Fälle, ein Verschlussikterus war bei einem Drittel der Patienten aufgetreten. Der Gewichtsverlust in dieser Gruppe betrug median 14 (3–30) kg. Nach der Operation traten bei 28 Patienten (30,8%) Komplikationen auf. Fünf Patienten aus dieser Gruppe mussten reoperiert werden, keiner verstarb im postoperativen Verlauf. Für die Langzeitergebnisse konnten in einem Beobachtungszeitraum von median 20 Monaten bisher 49 Patienten nachuntersucht werden. Vier Patienten (8,2%) waren nach einer medianen Überlebenszeit von 22 Monaten verstorben. Von den verbleibenden 45 Patienten nach DPE hatten 51,1% im Median 7 (1–27) kg an Gewicht zugenommen. Postoperativ ist ein De-novo-Diabetes in 5 Fällen (11,1%) aufgetreten. Dreimal (6,1%) war nach DPE kein Diabetes mehr nachweisbar, 61,5% der Patienten wurden wieder arbeitsfähig. Wenn auch die untersuchte Patientengruppe noch klein ist, Spätergebnisse bisher nur an einem Teil der Behandelten erhoben werden konnten und der Vergleich verschiedener Serien nicht zulässig ist, scheint die klassische DPE bei der Kopfpankreatitis nach wie vor ein vertretbares Operationsverfahren zu sein. / Classic Resection Procedures in Patients with Chronic Pancreatitis Surgery is needed in 10% of patients with chronic pancreatitis. In cases with focal inflammation of the pancreatic head or tail, bypass procedures or partial resections are performed. If possible, the left part of the pancreas is resected, with preservation of the spleen. Duodenopancreatectomy (DPE) according to Kausch-Whipple and the pylorus-preserving resection of the pancreatic head (PPPD) belong to the classic resections. Between October 1993 and May 2001, 373 patients with chronic pancreatitis were admitted to our department. Resection was necessary in 104 patients (27.9%). 13 left-sided resections, with splenic preservation in 5 cases, and 91 DPE were performed, 54 of them as Kausch- Whipple operations and 37 as PPPD. In the group of 91 DPE, 25.2% of the patients were diabetic and 93% suffered from conservatively uncontrollable pain. One third of the patients presented with obstructive jaundice and median weight loss of 14 (3–30) kg. Early postoperative complications were observed in 28 cases (30.8%); no patient died. Up to now longterm results could be achieved in 49 patients, with a median follow-up of 20 months. Four patients (8.2%) died after a median survival time of 22 months. 51.1% of the 45 survivors after DPE gained 7 (1–27) kg of weight. De novo diabetes occurred postoperatively in 5 patients (11.1%). In 3 patients (6.1%) diabetes disappeared postoperatively, 61.5% returned to work. Although this group is small, long-term results are still incomplete and the comparison of different series does not allow to draw any significant conclusions, the classic DPE for chronic pancreatitis still seems to lead to quite remarkable results. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

In a culture that values independence and productivity, non-normative bodies are understood as broken and useless. Disability is framed in medical terms, as a problem that should be resolved with prevention or cure. In response to this ableist perception of disability, the disability community has long argued that disability is not a medical issue but a social one, and its focus has been on increasing physical access and ending discrimination. Though the disability rights movement has made gains for some disabled people with this approach, they have excluded many others, including the chronically ill, who are disabled both by society and by their bodies themselves. Thus, chronically ill young adults in America face social exclusion and isolation, living in a culture where neither the mainstream nor the primary counter-narratives surrounding disability encompass their experiences. This thesis uses interviews conducted with chronically ill young adults to explore these issues, touching on disability identity, success narratives, and the Tumblr chronic illness community, ultimately arguing that the disability community needs to base its understanding of disability on a relational/political model that is politicized and inclusive.

This qualitative study sought to answer: How may I, as an artist, use art for my own transformation and healing? I am an artist and teacher living with chronic pain and fatigue and wanted to find healing through art and inspire others to do the same. During the three month study, I made artwork, reflected in my journal, and practiced guided imagery. The journal was used to reflect on my health, the creative process, and to record ideas generated through guided imagery. Findings showed that short term relief was provided during the act of creation, but no long-term relief was achieved. The primary conclusion was that I was able to use art for healing and transformation, but only after experimentation and reflection. By adapting the creative process to accommodate for my illness, I was able to include art making as part of a healthy life.

The association between pain and depression is well documented across various populations, but not in puerperal women. This study examined the association of childbirth pain with postpartum depression (PPD) in a nationally representative sample of Canadian women. Data from the Canadian Maternity Experiences Survey (n=6421) was used. Multivariate logistic regressions and partial proportional odds models were fitted and included socio-demographic, obstetric, health, psychological, and psychosocial factors. Chronic pain sufferers at mean 7.3 months postpartum had adjusted odds of PPD of 2.4 (95% CI: 1.6, 3.6) compared to women without pain. Adjusted odds of PPD increased with the number of areas of chronic pain, reaching 4.2 (95% C.I.: 0.7, 25.0) for 3 or more areas. Immigration, obesity, cesarean section and social support increased the strength of the association while smoking and the use of pain relief were protective effect modifiers. Persistent postpartum pain is a major risk factor for PPD.

Objective: The increased survival rate amongst female breast cancer survivors creates a need for an understanding of chronic disability after surgery. The objective of this study is to explore the association between impairments (e.g., pain, mobility, strength) and the personality trait, fear of physical activity, and chronic daily activity limitations for women who had their surgery at least six months prior to the study. Hypothesis: The study hypothesis is that women with high levels of physical impairments and the personality trait of fear of physical activity will also have higher levels of daily activity limitations six months or more after their breast cancer surgery. Design: A cross-sectional design. Outcome Measures: Disabilities of Shoulder, Arm, and Hand (DASH), Visual Analog Scale for Pain (VAS-Pain), Fear Avoidance Belief Questionnaire – Physical Activity (FABQ-PA), and objective measures of shoulder mobility and strength. Participants: Women who had been diagnosed and undergone surgery for breast cancer, stage 1-3. They must have had their surgery at least six months previously and have completed chemotherapy or radiation therapy. Both English- and French-speaking women from the Ottawa-Gatineau region were eligible. Results: Data from twelve women were analysed with a mean age of 58.0±8.9 years and post-operative time of 4.0± 2.8 years. DASH scores mean was 12.2 ± 11.38. VAS-Pain (rs=0.819; p<.001), FABQ-Physical Activity (rs=0.746; p<.005) were significantly associated with DASH score, whereas non-significant associations were found with supraspinatus strength (rs = 0.182; p < .572) or infraspinatus strength (rs=0.553; p<.062) using the Spearman Rho test. Also, no significant relationships were observed between range of motion (hand-behind-back; p =.366; hand-behind-head; p=.390) and DASH scores using a Kruskal-Wallis test. Conclusion: The results of this exploratory study suggest that the reported daily activity limitations of women who have had breast cancer surgery may be related to the participant pain perception and/or fear of physical activity.