The aims of this thesis are threefold: (1) To investigate cancer patients’ satisfaction with and utilisation of an Individual Psychological Support (IPS) intervention. (2) To evaluate the effects of Individual Support (IS), comprising IPS combined with Intensified Primary Health Care and Nutritional Support, on psychological distress and quality of life during the first year after diagnosis. (3) To explore to what extent aspects of quality of life and emotional functioning one year after diagnosis can be predicted by medical, psychological and socio-demographic factors at diagnosis. The analyses are based on data from the Support-Care-Rehabilitation project, using a prospective randomised design to compare four conditions: (1) Individual Support (IS) starting at diagnosis, (2) Group Rehabilitation (GR) starting three months later, (3) a combination of IS and GR, and (4) Standard Care (SC). The study sample consisted of patients newly diagnosed with breast cancer, colorectal cancer, gastric cancer or prostate cancer. A total of 481 patients were randomised and followed for 24 months. The IPS was an individually tailored, problem-focused intervention based on psychosocial oncology and cognitive behaviour therapy. Half of the patients receiving IPS had more than 2 sessions. Patients reporting that they had problems to address received more IPS sessions and reported more benefits of the intervention. Receiving an extensive medical treatment, young age, and not having someone besides the family to rely on in times of difficulties increased the odds of receiving tree or more sessions of IPS. The IS had limited impact on psychological distress and quality of life in intention-to-treat analyses. Additional analyses with stratification for baseline anxiety and/or depression levels suggested that for IS patients with higher levels of anxiety and/or depression, these problems continued to diminish below those of Control patients during the first year after diagnosis. Linear regression models were used to explore, one year after diagnosis, quality of life aspects indicative of rehabilitation needs. High levels of baseline anxiety and / or depressive symptoms were associated with lower levels of Emotional Functioning, and high self-rated well-being was associated with higher levels of Emotional Functioning. Extensive medical treatment and presence of comorbid conditions during the year before diagnosis predicted a low Global Quality of Life, whereas self-rated wellbeing predicted a high Global Quality of Life. Advanced disease, one or more comorbid conditions and high age were found to be associated with lower levels of Physical Functioning. A high level of activities outside the home during the year before diagnosis and high self-rated wellbeing were predictive of a better Physical Functioning. In conclusion, a large proportion of cancer patients offered IPS in conjunction with diagnosis and primary treatments seized this opportunity to discuss their situation, and perceived the experience as beneficial. Thus, offering newly diagnosed cancer patients these psychosocial support services may facilitate their situation.

The aims are to investigate cancer patients' perceived satisfaction with a Group Rehabilitation (GR) intervention, to evaluate its effects, and to explore the extent to which the patient's coping style (monitoring, blunting) modulates the effects of the GR. An additional aim is to investigate to what extent some aspects of health-related quality of life (HRQOL) [Physical Functioning (PF), Emotional Functioning (EF) and Global Quality of Life (QoL)] one year after diagnosis can be predicted on the basis of medical, socio-demographic and psychological data collected att diagnosis. Patients (n=481) newly diagnosed with breast, gastrointestinal or prostate cancer, were randomly assigned (Support-Care-Rehabilitation project) to one of four alternatives: 1. “Individual Support” (IS) starting at diagnosis; 2. “Group Rehabilitation” (GR) starting approximately four months later; 3. A combination of IS and GR; or 4. Standard Care (SC). All patients were monitored for two years. The GR comprised eight weekly sessions and one booster session after two months. The 2.5 hour meetings dealt with information about cancer, treatment, nutrition, cognitive behavioural therapy (CBT), light physical training and relaxation. Patients rated the physical and informative components as somewhat more beneficial than the CBT component. Meeting others was also rated as beneficial. However, there were limited effects on quality of life and anxiety. The monitoring concept was useful for distinguishing a subgroup of cancer patients (prostate cancer monitors) who benefited from the GR programme. Regression analyses demonstrated that the presence of advanced disease at diagnosis predicted a reduced physical function one year later. Having one or more comorbid conditions predicted lower PF and QoL, EF was predicted only by lower mental well-being and being classified as a case on the basis of the HADS. Indications for offering rehabilitative programs to cancer patients are critically discussed.

Syftet med denna studie var att hos patienter som varit på besök inom primärvårdenundersöka nöjdhet/tillfredställelse med besöket, hur delaktig patienten känt sig isjukskrivningsbeslut i förekommande fall samt eventuella skillnader avseende detta mellankvinnor och män, samt sjukskrivna och icke sjukskrivna.Enkäter som handlade om patientens tillfredsställelse med besöket delades ut till patientermellan 18 och 64 år som besökte läkare vid Tierps vårdcentral under nio vardagar i oktober2009. Totalt 129 patienter ingick i studien.Av dem som diskuterat sjukskrivning med läkaren kände sig nästan alla delaktiga i det beslutsom togs. Den stora majoriteten av besökarna var helt och hållet nöjda med sitt besök. Ettfåtal av besökarna var inte alls nöjda med sitt besök på Tierps vårdcentral. De mönster somkan ses i tillfredställelse med besöket är att kvinnor var mer nöjda än män samt att ickesjukskrivna var nöjdare än de sjukskrivna.De skillnader som påvisades mellan grupperna var inte signifikanta men hade kanske varittydligare om studien haft fler deltagare. De mått som användes visade ingen större variation,ett annat instrument hade kanske kunnat påvisa större skillnader. / The aim with this study was to investigate, among patients who have visited a physician in aprimary care setting, the satisfaction with the encounter, to what extent the patient felt thatthey participated in decisions regarding sick leave, and potential differences regarding thisbetween women and men and people on sick leave and people not on sick leave.A questionnaire concerning patient satisfaction with their visit to a physician was handed outto patients between the ages of 18 and 64 that visited a physician at a primary care centre inTierp during nine weekdays in October 2009. A total of 129 patients were included in thestudy.Almost all of those who discussed sick leave with their physician felt that they participated inthe decision that was made. The majority of the visitors were completely satisfied with theirvisit. A few of the visitors were not at all satisfied with their visit. Observed patterns were thatwomen were more satisfied than men and people not on sick leave were more satisfied thanpeople on sick leave.The observed differences between the groups were not statistically significant but perhapsthey would have been more apparent if the number of participants had been greater. Themeasures used did not show a lot of variation, a different instrument might have showngreater differences.

Elderly patients experiences of palliative care – a rewire The purpose of this paper was to study elderly patient’s experience of palliative care with present knowledge as starting point. The questions were; what criteria do the elderly, dying person think is most important to fulfill in palliative care? and how satisfied is the elderly, dying person with the palliative care that are giving to him/her? The information were collected by a data based search trough science magazines and technical literature. Four relevant studies were found; Costello (2001), Heyland (2005), Wilson (1999) and Formiga (2004). Results in this studies show that the communication between patients, physicians and nurses need to improve. The elderly patients demands better, straighter and clearer information from the nurses and physicians, especially about their condition. The elderly demands more emotional and spiritual support from the health care and people with chronic diseases like COPD and CHF seems to bee less satisfied with palliative care then those with cancer. The reason for this can bee that, this group of patients is less likely to not being offered palliative care at all, much because it is harder for the physicians to set a proper medical prognosis. Keywords: palliative care, elderly, patient- satisfaction

Bakgrund: Tobaksrökning är den största och vanligaste orsaken till sjukdom. Över en miljon svenskar röker. Behandling med rökavvänjning har visat sig vara den mest effektiva metoden för att uppnå ett rökfritt liv. Syfte: Att undersöka hur personer som deltar i rökavvänjningskurser inom primärvården uppfattar dessa kurser. Ett ytterligare syfte var att undersöka om det finns skillnader i uppnådd rökfrihet mellan personer som får rådgivning individuellt respektive i grupp. Metod: Studien är en deskriptiv enkätstudie med 27 deltagaresom deltar/ deltagit i rökavvänjning i syfte att sluta röka. Resultat: Den främsta anledningen till att deltagarna slutade röka var för att de ville, det var deras beslut. Stöd i grupp och i allmänhet var bra med kursen och det var viktigt att vara starkt motiverad för att lyckas sluta. Det fanns ett stort intresse för att utföra lungfunktionstest. Få personer träffade, och ville träffa, andra yrkeskategorier än sjuksköterska/distriktssköterska. Bästa tiden för rådgivningvar på eftermiddagen. Det fanns ingen skillnad i rökfrihet mellan dem som deltagit i grupp respektive individuell rådgivning då alla deltagarna har blivit rökfria under kursen. Slutsats: Gruppstöd, god information, den egna viljan samt stark motivation och hjälp till motivation ansågs vara en förutsättning för lyckad rådgivning. Det kunde ej utrönas huruvida individuell rådgivning eller rådgivning i grupp påverkade rökfrihet. Då rådgivningen i hela Uppsala län baseras på samma underlag och inga tidigare utvärderingar finns bör ytterligare studier göras som utvärderar insatsen. / Abstract: Smoking tobacco is the greatest and most common cause of disease. More than a million Swedes smoke. Treatment with smoking cessation courses has proved to be the most efficient method to attain a life without smoking. Aim/purpose: To study how people who participate in smoking cessation courses provided by primary care perceived the courses. A secondary aim was to investigate whether there were any differences in attaining a nonsmoking life between participants in smoking cessation courses given individually or in groups. Method: The study is a descriptive survey study with 27 participants whose goal in participating in smoking cessation courses was to quit smoking. Results: The main reason for participants to quit smoking was that they wanted this themselves, it was their decision. Support from the group and in general was a positive aspect of smoking cessation courses and a strong motivation was considered important in order to succeed. An ample interest in performing pulmonary function tests was noted. Few participants met, or had interest in meeting, professionals other than nurse/district nurse. The ideal time to attend smoking cessation courses was during the afternoons. No difference was noted in success to quit smoking between courses given individually or in group, as all participants had quit smoking. Conclusion: Group support, good information, own will/motivation and help to be motivated were considered to be the makings of a successful course. It was not possible to conclude whether smoking cessation courses held individually or in group affected success in quitting to smoke. As all smoking cessation courses in Uppsala County are based on the same material and no prior evaluation has been made, further research in this field is recommended.

The aim of this study was to examine to what extent patients remained silent to the health care system after they experienced abusive or wrongful incidents in health care. Female patients visiting a women’s clinic in Sweden (n = 530) answered the Transgressions of Ethical Principles in Health Care Questionnaire (TEP), which was constructed to measure patients’ abusive experiences in the form of staff’s transgressions of ethical principles in health care. Of all the patients, 63.6% had, at some point, experienced staff’s transgressions of ethical principles, and many perceived these events as abusive and wrongful. Of these patients, 70.3% had remained silent to the health care system about at least one transgression. This silence is a loss of essential feedback for the health care system and should not automatically be interpreted as though patients are satisfied. / <p>funding agencies|Nordic Council of Ministers||Swedish Research Council|2009-2380|</p>

Syfte: Att beskriva faktorer av betydelse för patienttillfredsställelse på akutmottagningen.Metod: En litteraturstudie med beskrivande design. Data baserades på 13 artiklar sökta i databasen PubMed.Resultat: Totalt identifierades sju faktorer av betydelse för patienttillfredsställelsen av vården på akutmottagningen. Faktorerna var patientens bakgrund, vårdpersonalens bemötande, information, kommunikation, triageprocessen, väntetid och miljö. Resultatet visade att den viktigaste faktorn som hade betydelse för patientens tillfredställelse på akutmottagningen var väntetiden, ovissheten kring denna och triageprocessens påverkan.Slutsats: Faktorerna visade sig vara viktiga var för sig och ännu viktigare i kombination med varandra. Om patienterna var missnöjda med en faktor påverkade det ofta tillfredställelsen av de andra faktorerna under besöket på akutmottagningen. Väntetiden tyder sig vara den mest betydande faktorn för patienttillfredsställelse i kombination med att triagesystemet påverkade hur länge patienterna faktiskt väntade på akutmottagningen. Forskning finns om vilka faktorer som var betydande för patienterna på akutmottagningen, ändå var patienterna fortsatt otillfredsställda och ovetande på akutmottagningen. Ytterligare forskning behövs kring samband mellan faktorer som är betydande för patienttillfredsställelsen på akutmottagningen och specifikt triagesystemets betydelse för väntetider och patienttillfredsställelse. Även forskning om triagesystemet är ett fungerande system, då samband visats med väntetider. / Aim: To describe the factors of patient satisfaction in the emergency department. Method: A literature review with descriptive design. The data was based on 13 articles searched in the PubMed database.Result: In total, seven factors of patient satisfaction of care were identified in the emergency department. The factors were the patient's background, health professional response, information, communication, the triage process, waiting time and the environment. The result showed that the main factor that had an impact on patient satisfaction in the emergency department was waiting time, the uncertainty surrounding this and the impact of the triageprocess. Conclusion: The factors shown to be important in itself, and more importantly, in combination with each other. If patients were dissatisfied with one factor it often affected the satisfaction of the other factors during the visit to the emergency department. The waiting time suggest being the most significant factor for patient satisfaction and the triage system affected how long the patients actually waited in the emergency department. Research exists on what factors that are significant for patients in the emergency department. Yet patients continued to be unsatisfied and unaware in the emergency department. Further research is needed about the relationship between the factors that are important for patient satisfaction in the emergency department and specific the triage system's impact on waiting times and patient satisfaction. Also research on the triage system as a functioning system, as association showed to waiting times.

Background: Considerable attention has been paid to evaluating the roles and relationships of professionals participating in team-based or collaborative practice; however, less attention has been paid to exploring the patients’ views and impact of such practice despite claims of it being patient-centred. Objectives: To examine the relationship between patient and provider characteristics and patients’ ratings of measures of quality of care and integration, and to explore the patient views of care delivered in a patient-centred collaborative study involving chiropractors and physicians. Design: Cross-sectional survey. Method: A mixed methods sequential approach with a quantitative priority was used in data analysis. Quantitative data were collected from 2597 patients participating in a collaborative study involving chiropractors and physicians and 530 patients attending chiropractors not involved in collaborative care. All participants presented with musculoskeletal pain. The Primary Care Assessment Survey (PCAS) was modified and scores from six of its scales were used to assess attributes of quality patient-centred care between the two study groups. Qualitative transcript-based data from six purposefully selected focus groups was analyzed using an interpretivist approach. Results: The revised PCAS demonstrated acceptable psychometric properties. Patients in both study groups received quality, patient-centred care. Patients’ reporting being completely satisfied and feeling improved by their care was positively associated with rating chiropractors as high performers on all scales. Survey findings were confirmed in focus groups of study patients. Patients appreciated positive interpersonal interactions, sharing in the treatment decision-making process, having a choice in provider and treatment, and the provision of holistic care. Patients perceived that collaboration between chiropractors and physicians varied, favouring those who were co-located. Patients with chronic or co-morbid conditions desired greater involvement in their care. Patients felt sharing of clinical information was more important than co-location as facilitating coordination and integration of collaborative care. Conclusion: The study suggests that patients suffering from musculoskeletal pain benefit from interprofessional collaborative care that includes improved access to and choice of providers and treatment options, as well as enhanced interprofessional communication and coordination of care.

Background: Few studies have determined the contribution of maternity care provider and hospital factors to the variation in Trial of Labour (TOL) and successful TOL rates. Objective: To determine sources of variation in TOL and successful TOL rates at the provider and/or hospital level. Methods: Retrospective cohort study of 12,170 women with previous caesarean who gave birth in Ontario in 2007. Hierarchical linear model was used to determine variation in rates by provider and hospital characteristics, adjusting for maternal characteristics, and for clustering of data. Results: TOL rate was 23%; successful TOL rate 75%. Women attending family doctors and female doctors for prenatal care were more likely to have TOL. There were no provider factors associated with successful TOL. Women giving birth at teaching hospitals were more likely to have TOL and successful TOL. Conclusions: Policies aimed at prenatal care providers and hospitals could impact the low TOL rate.

Background: Few studies have determined the contribution of maternity care provider and hospital factors to the variation in Trial of Labour (TOL) and successful TOL rates. Objective: To determine sources of variation in TOL and successful TOL rates at the provider and/or hospital level. Methods: Retrospective cohort study of 12,170 women with previous caesarean who gave birth in Ontario in 2007. Hierarchical linear model was used to determine variation in rates by provider and hospital characteristics, adjusting for maternal characteristics, and for clustering of data. Results: TOL rate was 23%; successful TOL rate 75%. Women attending family doctors and female doctors for prenatal care were more likely to have TOL. There were no provider factors associated with successful TOL. Women giving birth at teaching hospitals were more likely to have TOL and successful TOL. Conclusions: Policies aimed at prenatal care providers and hospitals could impact the low TOL rate.