Bakgrund: Under de senaste årtiondena har ett stort antal väpnade konflikter ägt rum på olika platser i världen. De väpnade konflikterna har fått till följd att Sverige tagit emot många asylsökande. En asylsökande är en person som kommit till ett land för att söka skydd men som ännu inte fått besked om uppehållstillstånd. När asylsökande behöver vård ska de i första hand vända sig till primärvården där det första mötet ofta handläggs av sjuksköterskor/distriktssköterskor. Sjuksköterskan/distriktssköterskan har en viktig uppgift i att tillhandahålla rätt vård och hänvisa asylsökande till rätt hälso-och sjukvårdsinstans. Syfte: Syftet med studien var att belysa sjuksköterskans/distriktssköterskans erfarenheter av mötet med asylsökande inom primärvården. Metod: Studien genomfördes med en kvalitativ induktiv ansats med semistrukturerade intervjuer. Tre distriktssköterskor och sju sjuksköterskor deltog. En kvalitativ manifest innehållsanalys användes som analysmetod. Resultat: Studien resulterade i tre kategorier. Att möta andra kulturer beskrev erfarenheten av tillfredställande möten, kulturella aspekter samt tillvägagångssätt i mötet. Förutsättningar som krävs för mötet beskrev hur sjuksköterskans/distriktssköterskans förhållningsätt och kompetens inverkade på mötena samt hur samarbeten erfors kunna underlätta mötena. Utmaningar i mötet beskrev att frustration, tidsbrist kommunikation och patientsäkerhet var utmaningar som sjuksköterskan/distriktssköterskan ställdes inför. Slutsats: Mötet med asylsökande erfors vara positivt och givande men kunde skapa frustration och samvetsstress hos sjuksköterskan/distriktssköterskan. Tydligare riktlinjer, utbildning i transkulturell omvårdnad och samarbete med andra aktörer kan underlätta mötet med asylsökande. För att säkerställa kommunikationen och patientsäkerheten bör tolk användas. / Background: In recent decades a large number of armed conflicts occurred in the world. As a consequence of the armed conflicts Sweden has received many asylum seekers. An asylum seeker is defined as a person who has arrived to a country to seek protection but have not yet received a residence permit. When asylum seekers need care they often turn to primary health care where the first meeting often is handled by nurses/district nurses. The nurses/district nurses have an important role in providing the right care and refer asylum seekers to the appropriate health care facility. Purpose: The purpose of this study was to illustrate the nurses/district nurses experiences of meeting asylum seekers in primary health care. Method: The study was conducted with a qualitative inductive approach with semi-structured interviews. Three district nurses and seven nurses participated. A qualitative manifest content analysis was used as the analytical method. Result: The study resulted in three categories. Meeting other culture described the experience of satisfactory meetings, cultural aspects and approaches in the meeting. Conditions required in the meeting described how the nurses/district nurses attitudes and skills affected the meeting and how cooperation was perceived to facilitate the meeting. Challenges in the meeting described that frustration, lack of time, communication and patient safety were challenges that the nurses/district nurses faced. Conclusion: The meetings with the asylum seekers were experienced as positive and rewarding but could create frustration and stress of conscience of the nurses/district nurses. Clearer guidelines, training in transcultural nursing and cooperation with other actors can facilitate the meeting with asylum seekers. To ensure communication and patient safety, interpreters should be used.

Submitted in fulfillment of the requirements for the Master’s Degree in Technology: Homoeopathy, Durban University of Technology, Durban, South Africa, 2016. / Introduction Homoeopathy is recognised as a well established form of alternative medicine in the private healthcare sector of South Africa (Caldis, McLeod, Smith, 2001). Whilst local research supports the viability of homoeopathy as a primary healthcare resource; patient perception and experience with the homoeopathic service remain largely unknown (Smillie, 2010). The study addresses shortfalls in existing literature on homoeopathy, providing a qualitative evaluation of the homoeopathic healthcare service in the context of public healthcare in South Africa. The task of the study was to develop substantive theory with the aim to better understand health behaviour of patient’s utilising homoeopathic and allopathic healthcare services. Methods The study employed a qualitative study design, and explored the perceptions and experiences of patients receiving homoeopathic care at the Kenneth Gardens Homoeopathy Clinic, within the context of primary healthcare services and public sector healthcare. Data was generated through in-depth, semi-structured interviews conducted with 14 participants. Data was systematically analysed using grounded theory methods to generate substantive theory (Glaser and Strauss, 1967; Schreiber and Stern, 2001; Holloway and Wheeler, 2010). Results Data analysis revealed five main themes of influences affecting the utilisation of homoeopathic services at the Kenneth Gardens Clinic; these include context specific factors to healthcare utilisation, factors influencing healthcare utilisation, health beliefs and practices, health outcome factors and trust. The study results illustrate that participants trusted their homoeopathic provider and homoeopathic treatment outcomes; and subsequently demonstrate the direct positive influence which trust had on the utilisation of homoeopathic services in the study population. Discussion The discussion explores the significance of influences, barriers and discerning factors identified in the study on decision-making pathways in healthcare utilisation behaviour of homoeopathic and allopathic healthcare services. The significance of trust in healthcare utilisation behaviour is explored as the principle finding of the study. The study’s conceptual model is based on Anderson’s (2005) behavioural model of health service utilisation and has been adapted to demonstrate the relationship in health seeking behaviours between homoeopathic and allopathic care modalities. Recommendations The relationship between the variables illustrated in the study’s proposed adapted model need to be further tested using quantitative research methods. Trust in healthcare, and in particular with homoeopathy, is a subject which merits further exploration. / M

Thesis (MCur)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Simulation refers to a teaching method that is used to teach students clinical skills. The use of mannequins is the most common type of simulation. Given the pivotal role that simulation plays in teaching students clinical skills, it is important to understand the experience and perceptions students have utilizing simulation laboratories. The aim of the study was to explore the experience and perceptions of primary health care students utilizing simulation laboratories. The researcher posed the following research question as a guide for this study: “What are the experiences and perceptions of primary health care students utilizing simulation laboratories?” A qualitative approach with a phenomenological research design was applied. A purposive sample of n=10 and a focus group of 7 participants was drawn from a total population of 232 primary health care students. An interview guide was designed based on the objectives of the study and validated by experts in Nursing, Education and the Ethics Committee at the Faculty of Health Sciences, Stellenbosch University. Experts in the field of teaching and learning, nursing and research methodology were consulted to determine the feasibility and content of the study, to evaluate the research process and outcome. Two (2) trained fieldworkers were responsible for collecting the data. Data was collected by means of individual interviews and by interviewing a focus group. The transcription of the interviews was done by the researcher. The data that emerged from the data analysis was coded and categorised into themes and subthemes. The five themes that emerged were simulation as a teaching method; a mannequin offering effective learning; confidence in clinical practice; structure of the course; and a support system. The researcher compiled a written account of the interpretations that emerged from the data analysis and verified this with the fieldworkers. In addition, member checking was done on two (2) of the participants from the focus group as well as two (2) of the participants from the individual interviews, to validate the transcribed data. The Conceptual Theoretical Framework of Bloom supports the findings of this study. The findings suggest that the mannequins should be upgraded regularly and should be able to register a response. It is recommended that a mannequin should be designed which is computer programmed according to different conditions which will include the signs and symptoms of those diseases for example tuberculosis. The participants need to be placed in the clinical environment at a much earlier stage in their programme. Peer group teaching and assessment should be introduced in the programme. Further research is recommended since institutions and disciplinaries working with simulation were not included in the study. / AFRIKAANSE OPSOMMING: Simulasie verwys na ’n onderrigmetode wat gebruik word om studente kliniese vaardighede aan te leer. Die gebruik van mannekyne is die mees algemene vorm van simulasie. Gegee die deurslaggewende rol wat simulasie speel in die onderrig van kliniese vaardighede aan studente, is dit belangrik om die ervaring en persepsies van studente wat gebruik maak van simulasie-laboratoriums, te wete te kom. Die doel van hierdie studie was om die ervaring en persepsies van primêre gesondheidssorgstudente wat van simulasie-laboratoriums gebruik maak, te ondersoek. Die navorser het die volgende navorsingsvraag as ’n riglyn vir hierdie studie gestel: “Wat is die ervaringe en persepsies van primêre gesondheidssorgstudente wat simulasielaboratoriums gebruik?” ’n Kwalitatiewe benadering met ’n fenomenologiese navorsingsontwerp is toegepas. ’n Doelbewuste steekproef van n=10 en ’n fokusgroep van 7 deelnemers is geneem vanuit ’n totale bevolking van 232 primêre gesondheidsorgstudente. ’n Onderhoudgids is ontwerp, gebaseer op die doelwitte van die studie en gevalideer deur kundiges in Verpleging, Opvoedkunde en die Etiese Komitee van die Fakulteit van Gesondheidswetenskappe aan die Universiteit van Stellenbosch. Kundiges op die gebied van onderrig en leer, verpleging en navorsingsmetodologie is geraadpleeg om die haalbaarheid en inhoud van die studie te bepaal vir die evaluering van die navorsingsprosedure en uitkomste. Twee (2) opgeleide veldwerkers was verantwoordelik om die data te versamel. Die data was versamel deur middel van individuele onderhoude en ‘n onderhoud met ‘n fokus groep. Die onderhoude was getranskribeer deur die navorser. Die data wat uit die analise gekom het, is geënkodeer en gekategoriseer in temas en subtemas. Die vyf temas wat hieruit voortgespruit het, is simulasie as ’n onderrigmetode; ’n mannekyn wat effektiewe leer bied; vertroue in die kliniese praktyk; die struktuur van die kursus; en ’n ondersteuningssisteem. Die navorser het ’n geskrewe verslag saamgestel van die weergawe van die data-analise wat saamgestel en deur die veldwerker geverifieer is. Bykomend is die kontrole van lede van twee (2) van die deelnemers van die fokusgroep, asook twee (2) van die deelnemers vanuit die individuele onderhoude gedoen, om die getranskribeerde data se geldigheid te verklaar. Die Konseptuele Teoretiese Raamwerk van Bloom rugsteun die bevindinge van hierdie studie. Die bevindinge beveel aan dat die mannekyne gereeld opgegradeer behoort te word en dat hulle ’n respons moet kan registreer. Dit word aanbeveel dat ’n mannekyn ontwerp behoort te word wat rekenaar geprogrammeerd is volgens die verskillende toestande wat die tekens en simptome van siektes soos tuberkulose insluit. Die deelnemers behoort in ’n baie vroeë stadium van die program in die kliniese omgewing geplaas te word. Verdere navorsing word aanbeveel, aangesien inrigtings en dissiplines wat met simulasie gemoeid is, nie in hierdie studie ingesluit is nie.

Thesis (MCur)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Member states of the United Nations accepted eight Millennium Development Goals in 2000. Millennium Development Goal number four addresses the improvement of child health. The purpose of goal number four is to decrease the child mortality rate by 60% for the period 1990 to 2015. South Africa is one of twelve countries where the incidence of child mortality increased during this period. Guided by the research question “What are the experiences and perceptions of mothers utilizing child health services”, a study was done. A qualitative, descriptive phenomenological methodology was applied to explore the experiences and perceptions of mothers utilizing child health services for children younger than two years. The goal of this study was to determine the experiences and perceptions of mothers utilizing child health services. The objectives were to explore their experiences and perceptions, with specific reference to the service they receive regarding: - immunization - nutrition assessment - the growth of the child - the growth chart - other underlying illnesses Ethical approval was obtained from Stellenbosch University and various health authorities. Validity was assured by adhering to the principles of trustworthiness, namely credibility, transferability, dependability, and conformability. The population for this study was mothers who utilized ten clinics in a demarcated area of Cape Town for child health services. Purposive sampling was utilized to consciously select three clinics (N =10), and at each of the clinics four mothers were purposively selected to participate. A total of seventeen mothers participated in the study. An interview guide was used to conduct interviews with participants. The researcher conducted and recorded the interviews after obtaining written informed consent from each participant. A field diary was kept for notation of observations. Data analysis involved the transcribing of digitally recorded interviews, the coding of the data, the generating of themes and sub-themes, interpretation and organization of data and the drawing of conclusions. The Modeling Role-Modeling Nursing theory of Erickson, Tomlin and Swain were utilized as conceptual theoretical framework to facilitate application to the broad population. Findings of the study indicated varied experiences. All mothers did not receive information about the RtHB or RTHC. Not all mothers developed a relationship of trust with caregivers or were afforded the respect of becoming part of the child’s health care team. According to the mothers integrated child health care services were not practised. The consequences were missed opportunities in immunization, provision of Vitamin A, absence of growth monitoring, feeding assessment and provision of nutritional advice. Hospitals and private practitioners equally did not provide immunization services or offered holistic care. Simple interventions such as oral rehydration, early recognition and treatment of diseases, immunization, growth monitoring and appropriate nutrition are not diligently offered; that could reduce the incidence of child morbidity and mortality. The following recommendations are made: determine why hospitals do not immunize children. The root causes must be addressed to change practice. Rendering of child services must happen in an integrated approach. Staff must be empowered with skills regarding procurement, in particular regarding vaccines. / AFRIKAANSE OPSOMMING: In 2000 het die lidlande van die Verenigde Volke Organisasie die Millenium Ontwikkelingsdoelwitte aanvaar. Die Millenium Ontwikkelingsdoelwit nommer vier roer die kwessie van kindergesondheid aan. Die strategie om die voorkoms van kindersterftes met 60% te verminder vanaf 1990 tot 2015 is die vierde millenium doelwit. Suid Afrika is een van twaalf lande in die wêreld waar die kindersterftes vir hierdie tydperk toegeneem het. ‘n Studie is gedoen om te bepaal “Wat die ervaring en persepsies van moeders is wat van kindergesondheidsdienste gebruik maak. ‘n Kwalitatiewe, beskrywende, fenomenologiese studie is gedoen,om die ervaring en persepsies van moeders wat kinders jonger as twee jaar na klinieke geneem het, te bepaal. Die doel van die studie was om die ervaring en persepsies van moeders ten opsigte van kindergesondheidsdienste vas te stel. Spesifieke doelwitte was die bepaling van die ervaring en persepsies rondom: - immunisasiedienste - groeimonitering - voedingsvoorligting - die groeikaart - behandeling van siektes Etiese goedkeuring was verkry vanaf die Universiteit van Stellenbosch en die verskeie gesondheidsowerhede. Geldigheid van die studie is verseker deur die beginsels van geloofwaardigheid na te kom naamlik, aaneemlikheid, betroubaarheid, oordraagbaarheid en inskiklikheid. Die bevolking betreffende die studie was moeders wat kliniekdienste gebruik het vir hulle kinders in ‘n spesieke area van Kaapstad, bestaande uit tien klinieke. Drie klinieke (N=10) is doelgerig geselekter vir deelname. Vier moeders is doelgerig by elk van die drie klinieke geselekteer vir deelname. Onderhoude is met sewentien deelnemers gevoer. ‘n Onderhoudsgids is gebruik en die navorser het rekord gehou van waarnemings. Die navorser het onderhoude gevoer en opgeneem na skriftelike toestemming daarvoor van elke deelnemer verkry is. ’n Veldwerkdagboek is gehou van alle waarnemings. Data-analise het behels: digitale opnames wat woordeliks beskryf , tematies ontleed en geïnterpreteer is en volgens temas georganiseer is. Toepassing na die breër populasie is bevorder deur die gebruik van die verpleegteorie van Erickson, Tomlin en Swain. Bevindinge van die studie het getoon dat moeders verskillende ervaringe gehad het. Nie alle moeders het inligting ontvang omtrent die RtHB of RTHC nie. Nie alle moeders het vertroue in die kliniek nie en moeders word nie erken as bepalende faktore in die sorgspan nie. . Volgens die moeders is geïntegreerde gesondheidssorg nie beoefen nie. Die gevolge is dat geleenthede nie benut word om te immuniseer nie, vitamien A te verskaf, groei te kontroleer, voeding te bepaal en voedingsadvies te verskaf. Die voorraadvlakke van entstof word nie oral doeltreffend beheer nie. Hospitale en dokters beoefen nie altyd immunisering en holistiese kindergesondheidsdienste nie. Eenvoudige intervensies, wat die voorkoms van kindermorbiditeit en kindermortaliteit kan bestry, word nie verskaf nie. Voorbeelde van sulke intervensies is mondelinge rehidrasie, vroeë diagnose en behandeling van siektes, immunisering, groeimonitering en geskikte voedingsinligting. Daar word aanbeveel dat daar indringend bepaal word hoekom hospitale nie kinders immuniseer nie en dat die oorsake aangespreek word. Integrasie van dienste by klinieke moet as prioriteit gesien en geïmplimenteer word. Personeel se vaardighede betreffende beheer van voorraad moet verbeter word, veral t.o.v. entstof voorraad.

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: This research study aims at enhancing the utilisation of primary mental health care services in Dodoma, Tanzania. Primary health care (PHC) according to the Alma Ata conference 1948 is an essential part of the health care system for bringing health care closer to where people live and work, is people-centred, affordable and achieves better health outcomes, and is considered to contribute to communities’ social and economical development. PHC facilities in Tanzania are health centres and dispensaries, which are within five kilometres from where people live. In the 1980s’ countries integrated mental health into PHC to improve the mental health status of their people. To facilitate delivery of Primary Mental Health Care (PMHC), Tanzania has formulated a mental health policy and trained PHC workers on mental health. Despite of these efforts, people still go to referral hospitals for mental health care services. However, authors commented that “when comprehensive primary health is implemented fully” it will bring about security, safety and hope to people and therefore, they will continue to fend for health for all. The main aim was to explore and describe why people go to referral hospitals instead of utilising PMHC services closer to them. A qualitative descriptive clinical ethnographic research design was employed to examine the mental health care-giving within the context of this research. Purposive non-probability sampling was utilised. Sample size was determined by the saturation. Data collection methods were in two phases. Phase one was participative observation on mental health care-giving in the Primary Health Care (PHC) facilities for a period of at least four weeks, and phase two was by use of an in-depth interview with family members at referral hospitals who had passed Primary Health Care facilities. Data analysis was an open thematic coding. Trustworthiness of the research was established through credibility, dependability, conformability, triangulation and a thick description. The findings of this research suggested that there is inadequate service delivery at PHC facilities, disrespect of patients and lack of knowledge on available services and on referral systems, which led to not utilising the available Primary Mental Health Care services. In conclusion the researcher expresses the recommendations of this research in the form of strategies. / AFRIKAANSE OPSOMMING: Hierdie navorsing is daarop gemik om die gebruik van primêre geestesgesondheidsorg dienste in Dodoma, Tanzanië te bevorder. Volgens die Alma Ata verklaring van 1948 is primêre gesondheid sorg (PGS) ʼn noodsaaklike deel van die gesondheidsorg stelsel ten einde gesondheidsorg nader na mense werkplek en tuistes te neem. PGS is persoons-gesentreerd, bekostigbaar en het beter gesondheids resultate, dit word aanvaar dat PGS bydra tot die sosiale en ekonomoiese ontwikkeling van gemeenskappe. PGS fasiliteite in Tanzanië is hoofsaaklik gesondheidsentra en apteke, wat binne ʼn radius van vyf kilometere vanaf mense se woninigs is. Gedurende die 1980’s het lande geestesgesondheid integreer in die PGS stelsel in ’n poging om die geestesgesondheidstatus van mense te verbeter. Ten einde die lewering van primêre geestesgesondheid sorg (PGGS) te verbeter het Tanzanië ʼn geestesgesondheidsbeleid geformuleer en primêre gesondheidsorg werkers opgelei in geestesgesondheidsorg. As omvattende primêre gesondheidsorg ten volle implementeer is sal dit bydra tot sekuriteit, veiligheid en hoop en mense sal aanhou veg vir ”gesondheid vir almal”. Die hoofdoel van hierdie navorsingstudie was ʼn ondersoek en beskrywing ten opsigte van die redes waarom mense eerder verwysings hospitale as PGS fasiliteite nader aan hulle besoek. Die navorser het gebruik gemaak van ʼn kwalitatiewe, beskrywende kliniese etnografiese studie ten einde geestesgesondheidsorglewering te ondersoek binne die konteks van hierdie studie. Die navorser het doelgerigte nie-waarskynlikheids steekproefneming gebruik en die versadigingsvlak is bereik deur middel van data-saturasie. Data is tydens twee fases ingesamel. Fase een was gekenmerk deur deelnemende observasie ten opsigte van geestesgesondheidsorg lewering in ʼn PGS fassiliteite. Tydens fase twee het die navorser in-diepte onderhoude gevoer met famililede van die persoon wat eerder die verwysings hospitaal as PGS fasiliteit besoek het. Data analise is gedoen deur tematiese, kwalitatiewe kodering te gebruik. Betroubaarheid van die navorsing is verkry deur middel van vertrouenswaardigheid, eerbaarheid, triangulasie en in-diepte beskrywing. Die bevindings van hierdie navorsings studie suggereer die teenwoordigheid van ondoeltreffende diens lewering by PGS fasiliteite, onrespekvolle hantering van pasiënte en gebrekkige kennis rondom die beskikbare dienste en verwyssings stelsel in plek, derhalwe maak pasiënte eerder gebruik van die verwysings hospitale. Gevolglik beveel die navorser aan dat strategieë gebasseer op die resultate van hierdie navorsings geïmplementeer word.

The ability to work can be reduced if a person has health problems which may lead to periods of sick leave. In Sweden sickness certification is issued by physicians. Many general practitioners (GPs) find sickness certification to be problematic. Some studies indicate that collaboration with other health care professions could be beneficial. The aim of the thesis was to provide knowledge on how the work with the sick leave process in primary health care can be improved and how occupational therapists’ (OT) assessment could be used prior to the decision on sick leave and rehabilitation. Initially seven focus groups were held, four with OTs and three with physicians. The discussions in the focus gropes were analysed by qualitative content analysis. An intervention project was initiated, where four health care centres in northern Sweden tested a working approach where sick listed patients were offered a supplementary assessment of activity and work-related problems by an OT. Data on sick leave, sickness certificates and patient questionnaires were collected from intervention health care centres (IHCC) and other health care centres (OHCC). Interviews were conducted with patients, GPs and OTs. The quality of the information in the collected sickness certificates was evaluated. Average values of sick leave were compared between the IHCCs and the OHCCs in the county. The interviews with sick listed patients were analysed by qualitative content analysis. In order to analyse the implementation of the intervention the Consolidated Framework for Implementation Research, CFIR, was used. An overall theme and four categories emerged from the focus groups. The theme expressed work ability as an obscure, complex and unique concept. The four categories illustrate the affecting factors and confirmed the complex structure of work ability: the person, the context of life, the work, and the society. No significant differences between IHCCs and OHCCs in data on sick leave or the mandatory information in the certificates were found. Thirty-four percent of the collected sickness certificates did not contain all requested information. More certificates issued for women than certificates issued for men lacked the required information. Full-time sick leave was significantly more often prescribed for male patients than for female. Two themes revealed that highlight important areas for persons on sick leave in their healthcare encounters. The theme ‘Trust in the relationship’ contains categories describing the patients’ feelings of participation, being believed, confirmed, and listened to. The second theme ‘Structure and balance’ contains the participants’ views on important factors that could facilitate the return-to-work process such as a structured plan and support to balance activity. The analysis with CFIR clarified that coaching and education for all the users are crucial to get fidelity when new interventions are tested as well as involvement by the clinical department manager. The work with sick leave issues in primary health care can be improved by developing cooperation with several different professionals. To achieve an increased cooperation new working approaches are required. These working approaches must be anchored in management and requires an applied implementation strategy. More focus on the quality of encounters with healthcare professionals can also improve the sick leave process in primary health care centres. The healthcare encounters must build on a mutual trust and sick-listed persons’ return to work can be facilitated by providing a clear structure in the process and support in occupational balance. For issuing sickness certification further education about the descriptions of functioning and the tasks included in the patient’s work is needed. A better gender awareness in the health care encounters is also necessary.

Background: Patients older than 75 years with heart failure (HF) are at increased risk for mortality and hospital admissions. Echocardiography and brain natriuretic peptides (BNP, NTproBNP) are important diagnostic tools but sparsely evaluated in elderly PHC patients. Aims: Validate the clinical diagnosis of HF, investigate the types of HF and underlying cardiovascular disorders with focus on sex and age differences. Explore the sensitivity, specificity, negative and positive predictive values (NPV, PPV) of BNP and NT-proBNP in patients with systolic HF. Study the associations of HF or NTproBNP on all-cause and cardiovascular mortality. Study the prognostic value of different biomarkers and HF, on all-cause and cardiovascular hospitalizations. Methods: Patients with suspected HF were recruited from one selected PHC and registered on a prespecified record and referred for an echocardiographic examination and a final cardiologist consultation. Blood samples for natriuretic peptides were stored frozen at – 70° C. Death certificates were used to register all-cause mortality and cardiovascular mortality. To register hospitalisations, medical records were used and classification was defined according to ICD-10. Results The GPs identified 121 women and 49 men with suspected HF of whom 39% (51 women and 16 men) were above 80 years. Myocardial infarction (OR:4,3 CL: 1,8-10,6) hypertension (OR:3,4 CI:1,6-6,9) atrial fibrillation (OR:2,8 CL:1,0-7,9) predicted a confirmed diagnosis of HF. Confirmed HF was verified in 45% of the patients and was significantly more common in men than women (p=0,02). The best NPV was 88 % for NT-proBNP (200 ng/L) and 87 % for BNP (20 pg/ml). Age and male gender were independently associated with higher levels of NT-proBNP. During the 10-year follow up, 71 out of 144 patients died. In univariate Cox regression analysis, significant associations were found for overall HF (hazard ratio [HR]: 1.86; 95% confidence interval [CI]:1.15- 3.01), isolated systolic HF (HR:1.95; 95% CI:1.06-3.61), and combined (systolic and diastolic) HF (HR:3.28; 95% CI:1.74-6.14) with all-cause mortality, but not for isolated diastolic HF. In multivariable analysis, age (HR: 1.11; 95% CI: 1.06-1.17), kidney dysfunction (HR:1.91; 95% CI:1.11- 3.29), smoking (HR:3.70; 95% CI:2.02-6.77), and NTproBNP (HR:1.01; 95% CI:1.00-1.02), but not any type of HF, significantly predicted all-cause mortality. During ten years, 136 (80%) patients were hospitalised with 660 and 207 for all-cause and cardiovascular hospitalisations, respectively. Age (OR:1.1; 95% CI:1.01-1.15) and underlying heart disease (OR:3.5; 95% CI:1.00-11.89), significantly predicted all-cause hospitalisation. Overall HF (HR:1.8; 95% CI:1.06-2.94) significantly predicted time to first all-cause hospitalisations. For cardiovascular hospitalisations age (OR:1.1;95%CI:1.01-1.12), underlying heart disease (OR:3.4;95%CI:1.04-11.40) and NTproBNP ≥800 ng/L (OR:4,3;95%CI:1.5-12.50) were significant predictors. Conclusion: A confirmed diagnosis of HF was present in 45% of the patients. NPV was high, but not as high as in younger patients with HF. Patients with systolic HF had a higher mortality than patients with diastolic HF compared to patients with no HF. Patients with combined HF were at even higher risk for all-cause mortality and cardiovascular mortality. Age, kidney dysfunction, NTproBNP and smoking predicted mortality. Age and underlying heart diseases were predictors for all-cause hospitalisations and together with NTproBNP they also predicted cardiovascular hospitalisations.

Bakgrund: Psykisk ohälsa är vanligt förekommande hos Sveriges befolkning och räknas till en av folksjukdomarna. Personer med psykisk ohälsa kan drabbas av psykiska eller fysiska besvär och söker sig då till primärvården och kommer där att möta sjuksköterskor och annan vårdpersonal. Syfte: Syftet var att belysa vårdpersonals upplevelse av att bemöta patienter med psykisk ohälsa inom primärvården. Metod: En litteraturöversikt baserad på nio vetenskapliga kvalitativa artiklar genomfördes. Resultat: Två huvudkategorier med fyra subkategorier framkom. Den första huvudkategorin ”Kommunikationens betydelse för bemötandet” bestod av subkategorierna Verbal kommunikation och Icke-verbal kommunikation. Kommunikationen, både den verbala och icke-verbala, mellan vårdpersonal och patient hade stor betydelse för hur det upplevdes att bemöta patienten. Den andra huvudkategorin ”Begränsningar som påverkar bemötandet”, bestod av följande subkategorier: Begränsningar i den egna professionen och Begränsningar i organisationen. Brist på kunskap hos personalen eller brist på resurser i organisationen påverkade personalens möjlighet att bemöta patienten så som var önskvärt. Slutsats: Vårdpersonal behöver ta mer eget ansvar för att tillgodogöra sig ny forskning och information om bemötande och patienters sjukdomar, samtidigt bör staten fortsätta med uppmaningar och uppmuntran till utveckling av sjukvården och fortbildning av personal. / Background: Mental illness is common among the Swedish population and is one of the endemic diseases. People with mental illness can be sticken with psychological or physical inconveniences and then turn to primary health care and will there meet nurses and other health care professionals. Aim: Was to illustrate health care professionals experience of encounter patients with mental illness in primary health care. Method: A literature review was carried out based on nine scientific qualitative articles. Result: Two main categories and four subcategories emerged. The first category ”To experience the meaning of communication to the encounter” consisted of the subcategories Verbal communication and Non-verbal communication. The communication, both verbal and non-verbal, meant a lot for the experience to encount the patients. The other main category: ”To experience limitations that affect the encounter” consisted of following subcategories: Limitations within the own profession and Limitations within the organization. Lack of knowledge within the staff or lack of resources within the organization affected the staffs’ ability to encount patients as desirable. Conclusion: Health care professionals have their own responsibility to utilize new research and information about the encounters with and the diseases of patients. The government should continue to request and encourage to develop the health care.

<p>This thesis deals with a behavioural medicine approach to the management of patients with persistent musculoskeletal pain in primary health care physical therapy. The main aims of the thesis were; to develop, and evaluate the psychometric properties of, a screening instrument for risk of disability and; to evaluate the implementation and effects of a targeted and tailored treatment. </p><p>The studies comprise four samples of patients with musculoskeletal pain exceeding one month. All subjects were recruited when consulting physical therapists in Swedish primary health care settings. For development and evaluation of the Pain Belief Screening Instrument (PBSI) four samples were used; two samples (n₁ = 215 and n₂ = 93) in Study I, one sample (n = 168) in Study II, and one sample (n = 45) in Study III. For evaluation of implementation and effects of targeted and tailored treatment the 32 patients who completed treatment in Study III were used. In Study IV treatment documents of 18 patient cases from Study III were studied to evaluate treatment integrity. </p><p>The concurrent and predictive validity of the PBSI was good, and the instrument was therefore used to define subgroups with either a high or low risk for disability. A low treatment dosage of a tailored treatment for low risk patients was tried and found equally efficient as a longer treatment focusing physical exercise. Subjects who received a treatment tailored to individual patient characteristics perceived a better global outcome of treatment compared to subjects in the control group. However, no between-group differences in the disability measures were found. The evaluation of treatment integrity displayed low therapist adherence to the treatment rationale for the tailored treatment. </p><p>The studies demonstrate ways to systematically integrate a behavioural medicine approach and physical therapy. The results indicate efficiency in managing patients with persistent musculoskeletal pain in primary health care.</p>

<p>The general aim of this thesis was to evaluate different aspects of patient education for people with type 2 diabetes in Swedish primary health care. </p><p>The evaluation was conducted in a primary health care setting in central Sweden and in Swedish primary health care in its entirety. Seven centres in central Sweden had implemented the empowerment programme for patients with type 2 diabetes. Data on 16 care providers’ views on implementing the programme were collected in focus-group interviews. The effect and the patients’ experiences of the programme were evaluated in a randomized controlled trial (RCT) (n=101) and in individual interviews (n=28). In the RCT, 50 patients were assigned to the programme and 51 patients to routine diabetes care. The patients answered a 27-item questionnaire and BMI and HbA1c were measured, before the intervention and at one-year follow-up. Further, data from 485 primary health care centres with 91,637 diabetic patients were collected to evaluate patient education in Swedish primary health care in its entirety. </p><p>The care providers experienced conflicting roles in changing from expert to facilitator in the empowerment programme. The programme improved patients’ confidence in diabetes knowledge and contributed to their experience of self-control, while patients in the routine diabetes care experienced external control. Of the 485 centres, 50% reported having checklist-driven individual counselling and 8% that they individualized the counselling based upon patients’ needs. Most centres (>90%) set individual goals, but only one-third involved patients in the final decisions regarding their goals. Setting individual goals was found to have an impact on patients’ possibilities to reach national treatment targets. </p><p>In conclusion, the implementation of empowerment in patient education demands support to care providers in order to influence patients’ self-care. Furthermore, patients need to reflect upon necessary self-care changes and also set individual goals to facilitate the reaching of national treatment targets.</p>