In Sweden and elsewhere there is evidence of poorer cancer survival for patients of low socioeconomic status (SES), and in some settings differences in treatment by SES have been shown. The aim of this thesis was to explore factors which influence cancer treatment decisions, such as knowledge reaped from clinical trials, patient-related factors, and physician-related factors. In a register study of colorectal cancer, all stages, patients were stratified for SES-factors. Differences were seen with regards to clinical investigation, surgical and oncological treatment and survival, with the highly educated group being favored. Survival was better for highly educated patients in stages I, II and III but not in stage IV. In a Scandinavian cohort of newly metastasized colorectal cancer patients, recruitment to clinical trials was studied. Patients entering clinical trials had better performance status and fewer cancer symptoms than those who were treated with chemotherapy outside of a clinical trial. Median survival was 21.3 months for trial-patients and 15.2 months for those treated with chemotherapy outside a  trial. Those not treated with chemotherapy had a median survival of just 2.1 months. Patients in clinical trials are highly selected and conclusions drawn from studies cannot be applied to all patients. In the same cohort, treatment and survival were stratified for education, smoking and indicators of social structure. Highly educated patients did not have a survival advantage. Patients who lived alone were offered less combination chemotherapy and surgery of metastases than other patients and had 4 months shorter survival than those who lived with a spouse or child. In a fourth study, 20 Swedish gastrointestinal oncologists were interviewed on which factors they considered when deciding on oncological treatment. Oncologists feared chemotherapy complications due to lack of social support, and ordered less combination chemotherapy for patients living alone. Highly educated patients were seen as well-read and demanding, and giving in to these patients’ requests for treatment was regarded as a way of pleasing patients and relatives and of avoiding conflict.

As an effort to guide patients toward being more informed and more involved as healthcare decision makers in the clinical processes, health care organizations have adopted a new technology referred to as an integrative social media platform (ISMP). This ISMP combines features of mobile technology and those of social media technology, integrating healthcare systems in order to support a more patient-centered healthcare process. However, users, both physicians and patients, have showed varied usages of ISMP, as a results, have shown mixed results of ISMP. To provide a better understanding of the use of ISMP, especially the interaction between patients and physicians, I turned to the concept of affordances. Affordances describe the possibilities for goal-oriented actions that a technical object offers to a user. Using a mixed-method approach with real archival event log data, conversation texts, documents, interview, and focus-group data from a large hospital which had adopted an ISMP, I confirmed three types of affordance: perceived affordance, behavioral affordance, and interactive affordance. I identified two key affordances of ISMP that lead to patient-centered care, namely ubiquitous access and virtual healthcare consultation, which represent a behavioral affordance and an interactive affordance, respectively. I also explored how different types of affordances are actualized and how they interact with each other to contribute to patient-centered care.

Les recommandations de bonne pratique, issues de la médecine des preuves, s’insèrent dans un processus ancien visant à asseoir la légitimité médicale sur la science et se sont déployées en tant qu’instrument politique de rationalisation des pratiques.Comment rencontrent-elles les valeurs professionnelles et l’exercice de la médecine ?La question est traitée dans le cadre de la médecine générale et de l’hypertension artérielle (HTA) dont la mise en recommandations est exemplaire de la construction d’un risque en santé publique.La première partie s’intéresse à l’origine de la médecine des preuves et en quoi ce mouvement est porteur de continuité et de modification dans les relations entre Médecine et État, au sein de la profession, entre médecin et patient.La seconde partie, centrée sur une microsociologie des consultations de patients hypertendus, montre que les recommandations constituent un appui pour le travail médical de prise de conscience par le patient de la réalité pathologique de l’HTA et des risques cardiovasculaires associés. Mais le généraliste inscrit son action dans la durée et, sous influence du patient, négocie et fait des compromis voire déroge aux « bonnes pratiques », considérant que ce qui n’est pas réalisable aujourd’hui le sera demain.Les recommandations sont intégrées dans les pratiques sous forme d’un modèle hybride associant la référence aux données scientifiques et l’adaptation à la singularité de la situation. La figure du patient statistique porté par la médecine des preuves est confrontée à la réalité sociale de l’individu plus ou moins doté d’autonomie et de ressources dont il s’agit pour le médecin d’acquérir la confiance et de la conserver. / Best practice recommendations, stemming from evidence based medicine, are part of a well versed process aiming to claim medical legitimacy based on science and are used as policy tools in practice. How do they relate to professional values, and to the practice of medicine?This question is examined within the framework of recommendations regarding the treatment, control and prevention of arterial hypertension (AH) in general practice which can be said to exemplify the construction of a public health risk.The first part of this work is centred on the origins of evidence based medicine, and the way in which it brings continuity as well as change to the relationships between: medical professionals; the institution of medicine and the state; doctors and patients.The second part, a microsociological study of GP consultations with hypertensive patients, shows that recommendations are used to reinforce the doctor’s efforts to increase patients’ awareness of AH and the ensuing cardiovascular risks. However, GPs use their influence over a long time period and, influenced by their patients, they negotiate, compromise and even disregard some of the best practice recommendations, considering that what may not be achievable in the present, may be achievable in the long term. Recommendations are therefore used in practice in hybrid form, where science is merged with an adaptation to each unique situation. The ‘average patient’ as the basic unit of evidence based medicine is opposed with the social reality of an individual with a certain level of autonomy and resources whose trust the doctor needs to gain and maintain.

I used multiple methods to study gender issues associated with health lectures that hospitals offer to the public. My purpose was not to evaluate the health-related content, but rather to study the gender messages that accompanied the health messages. One main reason hospitals offered lectures was to attract clients. While many lectures were offered to both sexes, women's lectures outnumbered men's lectures ten to one. One reason to target women was because hospitals offered more services to women than to men. Yet a main finding is that many women's offerings were not based solely on providing services to benefit women themselves, but also on assumptions about women's caregiving of others. Thus, while men were generally marketed to as men, women were often marketed to as mothers or other caregivers. Most speakers engaged in marginalization: while both men and women lecture attendees were treated in ways that denied their status as competent adults, women were also marginalized as women, that is, treated as "other" to a male norm. Additionally, some speakers presented a single interpretation of procedures or conditions as the only interpretation, despite the fact that other interpretations were equally plausible. Examples included offering positive interpretations of unpleasant screening procedures or treatments; attributing gender roles to biology; and attributing women's stress to personality traits. Medicalization and other forms of boundary blurring between health and other topics occurred more frequently for women than men. While some of this difference did not represent gender inequality, some did, such as gender differences in the emphasis placed on physical appearance. Similarly, while all exhibits showing men's nudity were medically instructive, that is, used to demonstrate anatomy or self-examination procedures, some women's nudity was not medically instructive, and thus unnecessary While some caregiving resources were offered to both sexes, many were offered only to women. Targeting caregiving resources to women went beyond merely reflecting the gendered division of caregiving; it also symbolically reproduced it. Further, when "women's" health resources were intended to benefit children and husbands, the boundary between self and others was blurred for women in a way that had no counterpart for men. / Sociology