Introduction: Currently, there are one billion migrants worldwide, with Sweden being a common host country. In Swedish primary care, physiotherapists are usually the first instance for patients with musculo-skeletal complaints, ASPs included. Currently, there are no physiotherapeutic guidelines addressing the management and treatment for ASPs. Furthermore, there are some qualitative studies discussing the interaction between health care providers and ASPs or migrant patients, however, none of them are exclusively exploring the phenomenon from the physiotherapists’ perspective. The aim of this study was to explore Swedish primary care physiotherapists’ experiences and professional needs when encountering ASPs. Methods: Using a qualitative methodology with an inductive approach, a case-study consisting of four semi-structured interviews with primary care physiotherapists located in Västerbotten county were conducted between the 13th of March and the 6th of April 2018. Thematic analysis (TA) was used to analyze data. Results: Two main themes were identified; Our most challenging patient group and Demand for knowledge and frameworks. These were discussing the reasons behind the challenges when encountering ASPs, and the desire for an increased organization on a higher level to prepare physiotherapists for their encounters with ASPs. Conclusion: Findings suggest there are challenges and a request for an increased knowledge among primary care physiotherapists when encountering ASPs. These findings serve as a foundation for further research in the matter and for future adjustments in how the physiotherapeutic bachelor program is designed, how employers and the Physiotherapy union (Fysioterapeuterna) provide their employees and members with adequate knowledge, preparing them for encountering ASPs in the best possible way.

Cette recherche doctorale concerne la professionnalisation des masseurs-kinésithérapeutes. Le courrier électronique, une des nombreuses formes de l’écriture professionnelle, est utilisé dans cette recherche comme un analyseur (Lourau, 1969). Les courriels modifient les pratiques professionnelles et en même temps ils permettent d’observer la professionnalisation des masseurs-kinésithérapeutes, comprise comme institutionnalisation de la profession, dans leur vie quotidienne. En m’appuyant sur une démarche ethnographique et sur le cadre théorique de l’analyse institutionnelle, je relève dans le quotidien des masseurs-kinésithérapeutes salariés les changements de pratiques, de valeurs ainsi que les résistances aux transformations en cours.Le parcours de la chercheuse, ici praticienne-chercheuse, est pris en compte en ce qu’il est lui-même impliqué dans l’objet de recherche. L’analyse des implications professionnelles des masseurs-kinésithérapeutes salariés est menée pour comprendre le processus de professionnalisation et d’universitarisation à partir des observations de terrain.En modifiant les pratiques de communication et d’organisation autour du patient, le courriel agit également sur la structuration du corps professionnels et sur l’activité quotidienne des masseurs-kinésithérapeutes. Cependant, comme en résistance à la progression du numérique, l’attachement à la centralité du corps dans les implications professionnelles des masseurs-kinésithérapeutes salariés reste central. / This doctoral research grant is about physiotherapists’ professionalization. E-mails, one of the numerous forms of professional writing, are employed as an analyzer in this research (Lourau, 1969). As e-mails modify professional practices, they allow us to notice physiotherapists’ professionalization, understood as a daily life institutionalization of their job. Based on an ethnographical approach and on the theoretical setting of institutional analysis, I’m taking, in employed physiotherapists’ daily life, their changes of practices, of values and their reluctance to current developments.The researcher’s record, here a practitioner-researcher, is taking into consideration because it is also involved in the research work. Salaried physiotherapists’ professional involvement analysis is taken to understand professionalization and universitarisation process, from ground observations. By changing communication and organization practices, e-mails are also working on professional body structure and on physiotherapists’ daily practice. As a reluctance to digital progress, the attachment to patient’s body central place in professional physiotherapists’ involvement stay crucial.

This research is inserted in Line of Formation, Knowledge and Teacher Professional Development , of the Education Master s Degree at Universidade Federal de Santa Maria, and had as main goal to understand how occurs the constituent processes of higher education for teachers physiotherapists who acts in the Course of Physical Therapy, in the context of the Universidade Federal de Santa Maria, concerning the integration between the knowledge acquired in graduation and the knowledge of teaching higher. Of this goal result three specific objectives, that are: understanding how occurs the formation process of the teachers physiotherapists; recognize which knowledge the Physical Therapy s teachers mobilizes in their pedagogical action; understand how teachers physiotherapists narrate the integration between knowledge of the graduate to the knowledge necessary for teaching practice. The theoretical contribution was composed by studies that concerns of the theme Higher Education / University Pedagogy (Zabalza, 2004; Garcia, 1999; Lucarelli, 2004, 2008; Anastasiou, 2002, 2007; Anastasiou e Alves, 2003; Pimenta e Anastasiou, 2005; Tardif, 2002; Cunha, 2004; Bolzan, 2008; Isaia e Bolzan, 2004, 2006, 2007; Bolzan e Isaia, 2006, entre outros) and authors that treats of the Physiotherapy and its trajectory (Rebelatto e Botomé, 2008; Haddad et al., 2006; Andrade, Lemos e Dall Ago, 2006), among others. To achieve the goals, we conducted a search of the type qualitative narrative, whose tools of data collection were narrative interviews, realized from a guide of topics. The people were six teachers of the UFSM s course of Physiotherapy. Besides the interviews, we request each teacher to available the didactic material of their discipline, to complement the analysis of narratives. Made part of the analysis as the background, the Pedagogic Project of the course of Physiotherapy. Through the content analysis it was possible to build three categories. The strength of the graduation of physical therapist was characterized by elements that showed the importance attached to the practice of the profession for the teaching role, when the subjects showed a large appreciation of the professional knowledge, or when give prominence mobilizing elements of teaching, related to Physiotherapy. Challenges facing the teaching was marked by the recurrence of elements that showed the difficulties of the teachers in front of teaching performance, at the beginning of their career in this profession for which were not initially prepared, or at their continued exercise, when they reporting practices and concepts that courses to the traditional model of education. The category learning to be a teacher presented evidence narratives of a learning process teaching, demonstrating a capability in the teaching of these people in the direction of processes of teaching and learning that take into account the people learners, especially favored by DCN for courses of Physiotherapy (2002). We understand that the constitutive processes of the higher education, for teachers physiotherapists, occur in the entwine of knowledge of the profession and the knowledge learned of the and about teaching, which occurs across the course of trajectory oh these teachers. This process is stimulated when there is the possibility of sharing between people, so that the reflection on their actions promotes an awareness of them and thus its transformation. / Esta pesquisa insere-se na Linha Formação, Saberes e Desenvolvimento Profissional Docente, do Programa de Pós-Graduação em Educação da UFSM e teve como objetivo principal compreender como ocorrem os processos constitutivos da docência superior para os professores fisioterapeutas que atuam no Curso de Fisioterapia, no contexto da Universidade Federal de Santa Maria, tendo em vista a integração entre os saberes adquiridos na formação inicial e os saberes da docência superior. Desse objetivo decorreram três objetivos específicos, que são: compreender como ocorre o processo formativo dos professores fisioterapeutas, explicitado através de suas narrativas; reconhecer quais saberes os professores de Fisioterapia mobilizam na sua ação pedagógica; compreender como os docentes fisioterapeutas explicitam em suas narrativas a integração entre saberes da formação profissional aos saberes necessários à prática docente. O aporte teórico constituiu-se por estudos que tratam da temática referente ao Ensino Superior e à Pedagogia Universitária (Zabalza, 2004; Garcia, 1999; Lucarelli, 2004, 2008; Anastasiou, 2002, 2007; Anastasiou e Alves, 2003; Pimenta e Anastasiou, 2005; Tardif, 2002; Cunha, 2004; Bolzan, 2008; Isaia e Bolzan, 2004, 2006, 2007; Bolzan e Isaia, 2006, entre outros) e autores que tratam da Fisioterapia e sua trajetória (Rebelatto e Botomé, 2008; Haddad et al., 2006; Andrade, Lemos e Dall Ago, 2006), entre outros. Para alcançar os objetivos, realizamos uma pesquisa do tipo qualitativa narrativa, cujos instrumentos de coleta foram entrevistas narrativas, realizadas a partir de roteiro de tópicos-guia. Os sujeitos foram seis docentes do curso de Fisioterapia da UFSM. Além das entrevistas, solicitamos a cada sujeito que disponibilizasse o material didático de sua disciplina, a fim de complementar a análise das narrativas. Fez parte da análise, como pano de fundo, o projeto pedagógico do curso de Fisioterapia. Por meio da análise de conteúdo, foi possível construirmos três categorias. A força da formação de fisioterapeuta caracterizou-se por elementos que evidenciaram a importância atribuída à prática da profissão para a atuação docente, quando os sujeitos demonstraram uma grande valorização dos saberes profissionais, ou quando destacaram elementos mobilizadores da docência, relacionados à Fisioterapia. Desafios pedagógicos face à docência caracterizou-se pela recorrência de elementos que explicitaram as dificuldades dos professores de Fisioterapia frente à atividade docente, seja no início da carreira nesta profissão para a qual não foram, inicialmente, preparados, seja no exercício continuado da mesma, ao relatarem práticas e concepções que se direcionam ao modelo tradicional de ensino. Já a categoria Aprendendo a ser professor apresentou evidências narrativas de um processo de aprendizagem docente, demonstrando uma potencialidade presente na prática pedagógica destes sujeitos, na direção de processos de ensino e de aprendizagem que levam em conta os sujeitos aprendentes, sobretudo favorecidos pelas DCN para os cursos de Fisioterapia (2002). Compreendemos que os processos constitutivos da docência superior, para os professores fisioterapeutas, ocorrem no entrelaçamento de saberes próprios da profissão e de saberes aprendidos da e sobre a docência, o que se dá ao longo de toda a trajetória destes profissionais. Este processo é alavancado quando existe a possibilidade de compartilhamento entre os sujeitos, de maneira que a reflexão sobre suas ações favoreça uma tomada de consciência sobre as mesmas e, assim, a sua transformação.

Orientador: Everardo Duarte Nunes / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-17T22:47:40Z (GMT). No. of bitstreams: 1 Oliveira_AnaLuizadeOliveirae_M.pdf: 4201694 bytes, checksum: 0c5f03689fb7ead860abfe74c9495f18 (MD5) Previous issue date: 2011 / Resumo: A partir da análise sócio-histórica dos anos 1930 e 1940 no município de São Paulo, a pesquisa se propôs estudar como se organizavam as práticas fisioterapistas como uma prática profissional singular anterior à institucionalização da Fisioterapia como profissão. É um estudo que combina fontes primárias e secundárias, como a coleção dos livros de registros de fiscalização do exercício profissional, documentos pessoais de Godoy Moreira, Rezende Puech e Raphael de Barros, além de fotografias e a legislação federal e estadual do período em análise. O alinhamento de fontes diversas permitiu alcançar um conjunto de elementos que determinaram a existência de uma expertise própria no campo da saúde circundante ao problema da pesquisa. O olhar histórico possibilitou compreender como se estabeleceram as relações entre saber e prática no movimento de constituição da profissão. Tratou-se de verificar os indícios das práticas fisioterapistas e sua relação com os profissionais médicos(as) e enfermeiros(as) em sua trama histórica. Analisadas sob a lente da sociologia das profissões, os conceitos desenvolvidos por Eliot Freidson como expertise, credenciamento e autonomia emolduram o trajeto do estudo. Os pressupostos levantados constatam a dependência institucional da prática fisioterapista para ser aceita como ciência médica e posterior credenciamento pelo Estado, antes mesmo de uma estruturação formal de ensino. Os argumentos e fatos, em nome do movimento de institucionalização e regulamentação da profissão, concentram-se no encontro, no interior da instituição hospitalar, de médicos e enfermeiros, além de um contexto sócio-histórico permeado pela necessidade social em estabelecer as práticas fisioterapistas em São Paulo nos anos 1930 e 1940. Os dados do trabalho comprovam que havia uma aproximação entre os saberes e práticas. O estudo termina por revelar que a fisioterapia se consolida como profissão a partir da criação do "Curso técnico operador em fisioterapia Raphael de Barros" no interior da Faculdade de Medicina da Universidade de São Paulo, provocando um movimento que tomou força, culminando na institucionalização da profissão concretizada em 1969. Abrem-se, assim, novas possibilidades de estudos que desejam compreender a prática fisioterapista a partir de sua trama histórica / Abstract: This research proposed to study the way in which physiotherapeutic practices were organized prior to the institutionalization and regulation of physiotherapy as a profession, starting from a socio-historical analysis of the emergence of singular practice, the physiotherapist practice, in São Paulo during the 1930's and 1940's. The research combined data arising from different historical sources, such as the collection of books regarding the oversight of the professions, personal documents of Godoy Moreira, Resende Puech and Raphael de Barros, photographs and federal and state legislation of the period being studied. The analysis of different sources allowed a set of elements that demarcated knowledge in the health field surrounding the research question. The historical overview allowed the understanding of how relationships between knowledge and practice were established in the constitution of the profession. It worked to substantiate evidence of the physiotherapists practice as an expertise and its relation with physicians and nurses in the health field. Examined under the lens of sociology of professions, the concepts developed by Eliot Freidson such as expertise, autonomy and accreditation mold the path of study. The assumptions raised demonstrate the institutional dependency of the physiotherapist practice to be accepted as a medical science and its posterior accreditation by the State even before a formal structure of education. The reasons that set up the movement of institutionalization and regulation of the profession are focused in encounters of physicians and nurses inside the hospital as well as in a socio-historical context permeated by the social need to establish a physiotherapist practice in São Paulo in 1930-1940. The research finishes by revealing that physiotherapy as a profession is consolidated by the creation of the technical course in physiotherapy, titled Raphael de Barros, leading the movement which was strengthened after the regulation of physiotherapy was established in 1969. The research opens up new possibilities for studies yearning to understand the physiotherapist practice from its historical plot / Mestrado / Ciências Sociais em Saúde / Mestre em Saude Coletiva

Magister Public Health - MPH / Human Immune-deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) is a major public health problem. Globally, the number of new HIV infections is decreasing but the total number of people living with the disease is increasing. An estimated 5.7 million South Africans are currently living with the disease. The life expectancy of people living with HIV (PLHIV) in South Africa has slowly increased due to the availability of Anti-Retroviral Therapy (ART). The progressive "chronicity" of HIV may be associated with a variety of impairments and disabilities for people living with HIV. This emphasising the increasingly important role that physiotherapists play to minimize the disabling impact of the disease and improve quality of life for PLHIV. The aim of study was to determine the HIV/AIDS knowledge, attitudes and the occupational risk perception of physiotherapists practicing in the Eastern Cape Province, South Africa. This study utilized a cross sectional descriptive quantitative survey to collect data. The data was collected via a structured self-administered postal questionnaire. The questionnaires were captured in Microsoft Excel and analysed statistically using CDC Epi-Info version 3.5.1. Data was analysed descriptively and the chi-square test, T-tests and ANOVA was used to identify any statistically significant relationship between variables. The results of the study identified that the physiotherapists in the study have "high" general HIV related knowledge, although major gaps regarding HIV prevention and transmission still exists. The physiotherapists expressed a positive attitude towards PLHIV, while they perceive themselves to be at low risk of HIV transmission risk when managing PLHIV. The physiotherapists with more than 10 years' experience had significantly better HIV related knowledge compared to those with less than 10 years' experience while the attitudes of married physiotherapists towards PLHIV were significantly less favourable than those who were not married. There is a need for intervention strategies to address the HIV knowledge gaps of physiotherapists. Intervention strategies need to address physiotherapists HIV prevention and transmission knowledge.

Introduktion: Hästunderstödd terapi är en behandlingsform där man ägnar sig åt ridning och andra aktiviteter med hästen för att främja fysisk och psykisk hälsa. Hästen har en central roll och bidrar till en icke-dömande och trygg plats för patienterna. Vidare har stallet och naturen positiva effekter inom behandlingen. Syfte: Belysa synen på hästunderstödd terapi hos fysioterapeuter som arbetar eller har arbetat med hästunderstödd terapi som behandlingsmetod. Metod: Fyra semistrukturerade intervjuer med legitimerade fysioterapeuter/sjukgymnaster, med erfarenhet av hästunderstödd terapi, genomfördes via telefon. Intervjuerna analyserades sedan med kvalitativ innehållsanalys utifrån en induktiv ansats. Resultat: Analysen resulterade i temat “Hästen ger möjlighet till en unik och omfattande behandling”, som beskriver bredden av behandlingen, hur kroppen och psyket påverkas samt vilken roll hästen, stallet och naturen har inom behandlingen. De fem kategorierna som identifierades var Mångsidig behandling som möter olika behov, Stallet och naturen blir ett annorlunda behandlingsrum, Hästen som stöttande behandlare, Personlighet och kropp tar stora steg framåt samt Ökad dialog och delaktighet genom hästen. Kategorierna inkluderar delar av behandlingsmetoden, vilka patientgrupper man kan komma i kontakt med, vilken roll hästen har samt effekterna av behandlingen. Konklusion: Hästunderstödd terapi lyftes fram som en bred behandlingsform av fysioterapeuterna. De upplevde behandlingen som speciell i förhållande till annan behandling genom dess möjlighet att påverka flera delar samtidigt, både för kroppen och psyket. Fler studier bör genomföras med större undersökningsgrupper; både fler fysioterapeuter, men även patienters erfarenheter bör lyftas fram.

Diss. (sammanfattning) Umeå : Umeå universitet, 2009. / Härtill 4 uppsatser.

BAKGRUND Bakgrunden till denna avhandling är att erbjuda ett alternativt sätt att förstå habiliteringspraktik. Den teoretiska ramen i avhandlingen är Pierre Bourdieus fältteori, vilket innebär ett antagande att det sociala livet bygger på symboliska och kulturella trossystem med hithörande doxor, med egna slags symboliska ekonomier och dominansförhållanden. Analysen har inneburit att rekonstruera och analysera ett kampfält, det vill säga att studera agenter som företräder olika intressen och deras kamp för erkännande och tolkningsföreträde. Vad som framkommer i denna avhandling kan hjälpa till att belysa varför habiliteringen blev som den blev. SYFTE Avhandlingens syfte är att analysera trosföreställningar och symbolisk makt inom habiliteringsområdet - det vill säga det symboliska kraftfält som skapades av specifika gruppers formering, intressen och ställningstaganden kring barn och ungdomar med handikapp i Sverige under perioden 1960-1980. METOD Avhandlingen har en historiesociologisk ansats. I analysen har intressepositioner rekonstruerats utifrån tidskrifter som är knutna till fackförbund, intresseorganisationer samt till det socialmedicinska forskningsfältet. Bakom dessa tidskrifter finns således mobiliserade grupper som agerar kollektivt genom sina föreningar och förbund. Tidskrifterna är knutna till yrkesgrupper: läkare, sjukgymnaster, arbetsterapeuter, förskollärare, socionomer och psykologer samt till Förbundet för utvecklingsstörda barn, ungdomar och vuxna - FUB, Riksförbundet för Rörelsehindrade barn och ungdomar - RBU och Handikapporganisationernas centralkommitté - HCK (idag HSO). Även arkivmaterial avseende löner för de olika yrkesgrupperna har använts. Analysen har huvudsakligen rört gruppernas positioneringar i förhållande till den dominanta doxan men också den sociala basen för gruppernas positioner. RESULTAT Avhandlingens konklusion visar betydelsen av: a) historiska strukturer avseende medicinens särställning i samhället och utvecklingen av hälso- och sjukvården i stort samt omhändertagandet av barn med funktionshinder. b) offentliga utredningar som konsekrationsinstanser och sociala mobiliseringsprocesser var viktiga delar i uppbyggandet av symboliska ekonomier. c) myter och ideologier i utövandet av symbolisk makt. d) allianser mellan stat och medicinen samt mellan yrkesgrupper och klienter. Avhandlingen visar också styrkan i doxorna och vilka konsekvenser det kunde innebära att lämna ett socialt fält man var skolad inom. Samklangen mellan doxa och fält fanns inte riktigt i det nya sammanhanget, vilket innebär ett slags strukturella glapp. Konsekvenserna kunde vara att man hamnade i en parialiknande situation utan skydd från det fält man lämnade, likt en "avfälling" och dessutom att det mottagande fältet inte riktigt erkände dem. SLUTSATS Inom medicinens fält konstituerades under den här tidsperioden en "habiliteringssfär" där medicinens doxa var dominant. Genom sociala mobiliseringsprocesser och klassificeringsstrider bidrog dessa till skapandet av olika grupperingar, symboler och ömsesidiga erkännanden av vissa symboliska värden rörande hur man skulle se på omhändertagandet av barn med handikapp.BAKGRUND Bakgrunden till denna avhandling är att erbjuda ett alternativt sätt att förstå habiliteringspraktik. Den teoretiska ramen i avhandlingen är Pierre Bourdieus fältteori, vilket innebär ett antagande att det sociala livet bygger på symboliska och kulturella trossystem med hithörande doxor, med egna slags symboliska ekonomier och dominansförhållanden. Analysen har inneburit att rekonstruera och analysera ett kampfält, det vill säga att studera agenter som företräder olika intressen och deras kamp för erkännande och tolkningsföreträde. Vad som framkommer i denna avhandling kan hjälpa till att belysa varför habiliteringen blev som den blev. SYFTE Avhandlingens syfte är att analysera trosföreställningar och symbolisk makt inom habiliteringsområdet - det vill säga det symboliska kraftfält som skapades av specifika gruppers formering, intressen och ställningstaganden kring barn och ungdomar med handikapp i Sverige under perioden 1960-1980. METOD Avhandlingen har en historiesociologisk ansats. I analysen har intressepositioner rekonstruerats utifrån tidskrifter som är knutna till fackförbund, intresseorganisationer samt till det socialmedicinska forskningsfältet. Bakom dessa tidskrifter finns således mobiliserade grupper som agerar kollektivt genom sina föreningar och förbund. Tidskrifterna är knutna till yrkesgrupper: läkare, sjukgymnaster, arbetsterapeuter, förskollärare, socionomer och psykologer samt till Förbundet för utvecklingsstörda barn, ungdomar och vuxna - FUB, Riksförbundet för Rörelsehindrade barn och ungdomar - RBU och Handikapporganisationernas centralkommitté - HCK (idag HSO). Även arkivmaterial avseende löner för de olika yrkesgrupperna har använts. Analysen har huvudsakligen rört gruppernas positioneringar i förhållande till den dominanta doxan men också den sociala basen för gruppernas positioner. RESULTAT Avhandlingens konklusion visar betydelsen av: a) historiska strukturer avseende medicinens särställning i samhället och utvecklingen av hälso- och sjukvården i stort samt omhändertagandet av barn med funktionshinder. b) offentliga utredningar som konsekrationsinstanser och sociala mobiliseringsprocesser var viktiga delar i uppbyggandet av symboliska ekonomier. c) myter och ideologier i utövandet av symbolisk makt. d) allianser mellan stat och medicinen samt mellan yrkesgrupper och klienter. Avhandlingen visar också styrkan i doxorna och vilka konsekvenser det kunde innebära att lämna ett socialt fält man var skolad inom. Samklangen mellan doxa och fält fanns inte riktigt i det nya sammanhanget, vilket innebär ett slags strukturella glapp. Konsekvenserna kunde vara att man hamnade i en parialiknande situation utan skydd från det fält man lämnade, likt en "avfälling" och dessutom att det mottagande fältet inte riktigt erkände dem. SLUTSATS Inom medicinens fält konstituerades under den här tidsperioden en "habiliteringssfär" där medicinens doxa var dominant. Genom sociala mobiliseringsprocesser och klassificeringsstrider bidrog dessa till skapandet av olika grupperingar, symboler och ömsesidiga erkännanden av vissa symboliska värden rörande hur man skulle se på omhändertagandet av barn med handikapp. / The dissertation examines the formation of specific groups, their interests and positions related to children with disabilities and their education and care in Sweden developed during 1960―1980. The theoretical framework is based on Pierre Bourdieu’s sociological theory of social space, which assumes that social life is based on symbolic and cultural systems of beliefs with respectively specific doxas and symbolic economies. Consequently, the analysis has focused on the agents’ position-takings and their struggle for recognition and preferential rights of interpretations. The reconstruction of a “habilitation sphere” was conducted through agents, their positions of interests and position-takings as analytical tools. The positions were mainly reconstructed on articles in journals of 10 professional organizations covering 6 occupations and 4 disability organizations. The occupational groups were paediatric doctors/child psychiatrists, physiotherapists, occupational therapists, social workers, psychologists and pre-school teachers. The other positions were related to the county council union, four disability organizations (DHR, FUB, RBU and HCK), two of which were parent organizations and in addition, the research field of social medicine. Other materials were e.g. reports of commissions of inquiry. In order to explore the social foundations of the occupational positions, materials from archives have been used. The conclusion shows the significance of: a) historical structures related to the exceptional position of medicine in society, the development of the Swedish health care system in general and the organizations of “special” children b) commissions of inquiry as consecration authorities and processes of social mobilization, both important contributions in shaping symbolic economies, c) myths and ideologies in the exercising of symbolic power, d) alliances between the state and medicine, and between occupational groups and clients. The analysis also shows the strengths of the doxas which could work as a shield for the agents but also as obstacles for external agents when entering the habilitation sphere. / Finns även tillgänglig för synskadade i s.k. DAISY-format.

Les troubles douloureux de l’épaule (TDE) affectent jusqu’à 55% de la population générale et sont souvent difficiles à traiter. L’objectif de cette thèse était de développer une intervention de mobilisation des connaissances permettant d’implanter les recommandations de guides de pratique clinique (GPC) couvrant la prise en charge des TDE. Pour ce faire, un processus basé sur le cadre conceptuel Knowledge-to-Action a été utilisé. D’abord, une revue systématique des recommandations des GPC à implanter pour améliorer la prise en charge des TDE a été effectuée. Puis, les écarts dans la pratique des cliniciens ont été identifiés à l’aide d’un sondage documentant la prise en charge des TDE ainsi qu’une étude évaluant la concordance entre les physiothérapeutes et les orthopédistes au niveau du diagnostic et de la prise en charge des TDE. Ensuite, les déterminants à l’implantation des recommandations des GPC ont été identifiés en procédant à deux études qualitatives ciblant les expériences et les attentes des patients vivant avec un TDE, puis les barrières et facilitateurs à l’implantation des recommandations des GPC identifiés par les cliniciens. Enfin, l’utilisation du Behaviour Change Wheel et des déterminants ont permis d’identifier des stratégies visant à implanter les recommandations de GPC sur la prise en charge des TDE en première ligne de soins. La revue systématique des GPC a permis de déterminer qu’initialement, les TDE ne requièrent généralement pas d’imagerie médicale et de référence à un médecin spécialiste, mais qu’un programme de réadaptation actif est requis. Selon les résultats du sondage, les médecins de famille (n=76) ont recommandé plus d’imagerie que les physiothérapeutes (n=175). Jusqu’à deux physiothérapeutes sur trois ont sélectionné des traitements non recommandés par les GPC. Les résultats de l’étude de concordance démontrent que l’accord entre physiothérapeutes et orthopédistes était bon au niveau du diagnostic et modéré au niveau du triage des candidats chirurgicaux. Les patients souffrant de TDE interrogés (n=13) ont mentionné, dans la première étude qualitative, avoir attendu que leur douleur soit incapacitante avant de consulter un professionnel. Ces participants s’attendaient alors à recevoir un diagnostic clair et à être référés pour des tests d’imagerie. Finalement, ils espéraient recevoir des explications complètes et se voir proposer des options pertinentes de traitements. Les 19 physiothérapeutes et 16 médecins de famille interrogés dans la deuxième étude qualitative ont indiqué comme barrières à l’utilisation des recommandations des GPC : le manque de connaissances, le manque d’habileté à réaliser une évaluation clinique de l’épaule et la crainte de ne pas détecter une pathologie grave, si présente, sans un test d’imagerie. Le temps insuffisant de consultation avec les patients, leurs attentes et le manque d’accès à certains soins ont aussi été indiqués comme des barrières. Les principales stratégies identifiées suivant ces études incluent donc des interventions éducatives, la préparation de champions cliniques et la création d’équipes cliniques interdisciplinaires. À l’aide de ces stratégies, l’implantation pilote de l’intervention sera réalisée dans des groupes de médecine familiale. L’impact potentiellement bénéfique de cette implantation pourrait, à terme, améliorer la prise en charge des patients atteints de TDE. / Shoulder pain is a common and difficult to manage condition that can affect up to 55% of the general population. To optimize shoulder pain management in primary care, the main objective of this thesis was to develop a knowledge mobilization intervention to implement the recommendations from clinical practice guidelines (CPGs) covering the management of different shoulder disorders. A knowledge mobilization process based on four steps of the Knowledge-to-Action framework was used in this thesis. First, a systematic review of CPGs was performed to identify recommendations to be implemented for improving shoulder pain management in primary care. Then, the evidence-practice gaps were assessed using a survey documenting family physicians and physiotherapists shoulder pain management as well as in a study evaluating the concordance between physiotherapists and orthopedists for shoulder pain diagnosis and management. The determinants influencing CPGs recommendations’ implementation were identified by conducting two qualitative studies. The first study explored the experiences and expectations of patients living with shoulder pain and the second aimed to interview clinicians for identifying barriers and facilitators to the implementation of CPGs recommendations. Finally, based on the identified determinants and using the Behaviour Change Wheel method, we identified strategies for implementing CPGs recommendations covering the management of shoulder pain in primary care. Based on the systematic review of shoulder CPGs, we identified that shoulder pain generally does not initially require diagnostic imaging and referral to a medical musculoskeletal specialist, but that an active rehabilitation program is required. According to the survey results, family physicians (n=76) recommended more imaging than physiotherapists (n=175) for rotator cuff tendinopathy and adhesive capsulitis, although this is not indicated. Up to two out of three physiotherapists selected treatments not recommended by CPGs in the management of shoulder pain. The results of the concordance study showed that the agreement between physiotherapists and orthopedists was good in terms of diagnosis and moderate in terms of triage of surgical candidates. Patients (n=13) interviewed in the first qualitative study reported waiting until their shoulder pain was disabling before seeing a family physician or a physiotherapist. Participants expected a clear diagnosis and imaging tests to explain their shoulder pain. They also wished to receive clear and thorough explanations and relevant treatment options. The 19 physiotherapists and 16 family physicians that participated in focus groups indicated as barriers to the use of CPGs recommendations: lack of knowledge, poor skills in performing a clinical evaluation and fear of not identifying a serious pathology without medical imaging. Patients’ expectations, insufficient consultation time with patients and lack of patients’ access to certain care, such as rehabilitation treatments were also identified as barriers. The main strategies identified following these studies therefore include educational interventions, the preparation of clinical champions and the creation of interdisciplinary clinical teams. Using these strategies, pilot implementation of the intervention will be carried out in family medicine groups. The potentially beneficial impact of this implantation could ultimately improve the management of patients with shoulder pain in primary care.

Huvudsyftet med studien har varit att utvärdera hur en fem timmar lång kommunikationsutbildning riktad till sjukgymnaster på habilitering påverkar sjukgymnasternas kommunikativa stil i interaktion med barn/ungdomar som på grund av cerebral pares saknar tal. Utbildningen utformades som en inlärningsmodell i åtta delmoment (åttastegsmodellen). I utbildningen och studien ingick sex habiliteringssjukgymnaster som interagerade med var sitt barn/ungdom som till följd av cerebral pares kommunicerar med alternativt och kompletterande kommunikation (AKK) i form av kommunikationskartor. Interaktionen videofilmades vid tre separata tillfällen: en inspelning före utbildning, en inom två veckor efter utbildningen samt en sista filmning tre månader efter avslutad utbildning. Analys av videomaterialet gjordes med hjälp av en kombination av kvantitativ och kvalitativ analysmetod. Analysformuläret KOMMUNIKATIV användes för att analysera sjukgymnasternas kommunikation och kompletterades med en mer detaljerad kvalitativ samtalsanalys (Conversation Analysis, CA) där interaktionen mellan individerna analyserades. Utöver detta besvarade sjukgymnasterna en enkät. Utbildningens utformning baserades på tidigare forskning i form av av miljömodifierande strategier, responsiv kommunikationsstil samt AKK-modell i form av att pekprata. Resultatet av KOMMUNIKATIV påvisade en statistiskt signifikant förändring av sjukgymnasternas kommunikativa beteende efter avslutad utbildning. Det fanns även en fortsatt mätbar, men inte statistiskt signifikant, förändring mellan andra och tredje mättillfället. Sjukgymnasterna möjliggjorde, efter utbildning, att barnen/ungdomen i större utsträckning kunde kommunicera med sin kommunikationskarta. De pekpratade i större utsträckning och var mer lyhörda för barnets/ungdomens kommunikation. Endast en av tio kommunikativa förmågor som analyseras i KOMMUNIKATIV försämrades: sjukgymnastens förmåga att förtydliga sig. Samtalsanalysen bekräftade den kvantitativa analysen på flera sätt och visade att barnet/ungdomen efter utbildning anpassade sig till sjukgymnasternas förändrade beteende och uttryckte sig i längre fraser. Interaktionsmönstret ändrades från att före utbildning vara mer styrt av sjukgymnasten till att barnet/ungdomen efter utbildning kunde införa nya ämnen och delta i reparerande sekvenser. Samtalsanalysen visade även hur sjukgymnasterna ändrade sin användning av en engagerad röstkvalitet. Före kursen användes den i flera olika kontexter, inklusive problematiska kommunikativa kontexter där den snarare förvärrade problemen. Efter kursen varierade sjukgymnasterna sina strategier för att lösa olika typer av problematiska situationer, och undvek därmed i högre grad kommunikativa problem. Åttastegsmodellen som provades i genomförandet av kursen var framgångsrik på två olika sätt. Dels medgav den att varje deltagare fick en individuell målsättning baserad på en förmätning, och dels medförde modellen ett aktivt lärande vilket bidrog till att befästa den nya kunskapen. En slutsats av utvärderingen är att en interventionsutbildning enligt åttastegsmodellen med fördel kan användas för att lära ut kommunikativa strategier till habiliteringspersonal. / The main purpose of this study was to examine how a five hour communication course given to physiotherapists working at a habilitation center changes their communication when interacting with non-speaking children and teenagers with cerebral palsy. An instructional model for teaching learning strategies in eight steps was tested. Six physiotherapists took part of a five hour communication course on three occasions. The course contained receptive communication, environmental arrangements and aided language stimulation as suggested by previous research. Interaction between physiotherapist and child/teenager communicating with a communication board was videotaped just before the course, within two weeks after the course and also three month later. The course was analyzed using a combination of quantitative and qualitative methods. KOMMUNIKATIV is a quantitative method measuring ten communication abilities of the physiotherapists. Conversation Analysis (CA) was used as a detailed qualitative complementary analysis to KOMMUNIKATIV in order to examine the interaction between physiotherapist and child/teenager. Results from KOMMUNIKATIV showed a statistically significant change within two weeks after the course. Continued changes were measured between the second and the third point of measure but that change was not statistically significant. These results strongly indicate that the physiotherapists adopted a more receptive communication style after the course. They made it possible for the child/teenager to communicate with the communication board and they increased the number of AAC-modeling. One aspect, the physiotherapists’ ability to simplify the communication, declined from the first to the second and third point of measure. The child´s/teenager´s communication adapted in some ways to the changed communicational behavior of the physiotherapists. After the course, the child/teenager used longer phrases and started to make repairs. The detailed interaction analysis verified the change in communicative behavior in several ways. One significant change was the way the physiotherapists used an engaged voice quality to encourage the child/teenager to respond to requests for action. Before the course this voice quality was used in many different contexts, including communicatively problematic contexts, where it increased the problems. After the course the physiotherapists used a more varied set of strategies to solve problematic situations, thereby avoiding communicative problems. The instructional model for teaching communicative strategies in eight steps that was used in the study was successful in two ways. Firstly, the model provides the possibility to set individual goals for each member based on preassessments. Secondly, this model enables active learning which seem to consolidate the new ability. A conclusion from the evaluation of the eight step model is that it can be used for teaching communicative strategies to professionals.