<p>The psychosocial work environment in human service organizations is in many respects rewarding from the aspect of human interaction. However, it has also been described in several research reports as demanding and stressful both physically and mentally, resulting in a negative impact on employee health and a high degree of sickness absence. From a public health perspective it is important to focus on determinants of health in occupational groups that are characterized by caring and human relations. This thesis aims at identifying determinants of individual and organizational health in human service professions from a multifactorial perspective.</p><p>Based on both cross-sectional and longitudinal data, four studies of various aspects of psychosocial work exposures are carried out. Study I, an explorative and qualitative study, examines determinants of the psychosocial work environment in the Church of Sweden. Study II consists of a retrospective, randomized study assessing effects of goal clarity work on organizational well-being in the Church. Study III examines exposures resulting in stress-related sick leave among elderly care employees. Study IV is a longitudinal study that assesses effects of organizational change on health and sickness absence among elderly care employees. </p><p>The results show some positive experiences, despite overall demanding work conditions within both of the studied professions. In the Church (Paper I), experiences of freedom and influence at work and the Christian values tend be factors with modifying effect on health. Four patterns are identified for negative health impact; these include unclear organization, a sense of being different, stressful work and destructive communication style. Effects of goal clarity work (Paper II) indicate an overall positive impact on organizational well-being. In elderly care (Paper III), the results suggest, in general, a positive work climate and high effectiveness. Work related exhaustion was significantly higher among employees with stress related sickness absence. Factors of risk for being absent due to stress are approximately three times higher among employees dissatisfied with both their work and their social situations. Finally, measuring effects of organizational change (Paper IV), the results reveal evidence of unchanged self-rated health (SRH), work satisfaction and work exhaustion after reorganization. However, sickness absence increased across time and there is an indication of impaired levels of the anabolic hormone DHEA-S among those individuals affected by the reorganization. </p><p>The results point to a challenge for further research on the interplay between perceived stressors, resources available, biological stress markers and health in order to find adequate measures for improvements in psychosocial work environment in human service professions.</p>

This thesis presents the findings of an exploratory study undertaken to investigate the illness experience of fibromyalgia in the context of South Africa. It contains the literature review and conceptual framework that guided the study. The theoretical discussions reflect the approaches to health and illness, illness experience and narrative study, context, diagnosis, prognosis, sickness, illness career, treatment, institutional interactions and social support. Following this, the methodological approaches and tools used in conducting this study are explained. In-depth interviews and diaries were used to collect narratives from 15 participants and one practitioner. Additionally, a brief media content analysis was included in order to assess the public perceptions of fibromyalgia in South African news articles. The themes of legitimacy, credibility, flexibility, and accommodation are continually developed throughout the thesis. The Analysis of Findings chapter presents and discusses the evidence gathered from the investigations undertaken in this study. This chapter shows how the contested and confusing illness experience of fibromyalgia can be understood, by viewing the interactions that patients have with their practitioners, families, peers and colleagues. The meanings ascribed to fibromyalgia as a label, and the uncertain prognosis attached to the diagnosis, as well as infrequently effective treatment options are explored here. The gains found in successful practitioner-patient interactions, and the limitations of medical aid coverage for chronic conditions like fibromyalgia in South Africa are discussed in this chapter. The role of family and peers, as well as workplaces and colleagues in offering support to those living with fibromyalgia is analysed. Finally, the conclusions arising from this study are presented, and recommendations for areas of future engagement and research are offered in order to attain a better understanding of the experience and impact of fibromyalgia in the South African context.

Allergies have taken on cultural meanings other than those offered by biomedicine. Interviews with allergic and non-allergic Americans were used to investigate the explanatory models of the lay population. This thesis uses ethnographic data to examine explanatory models of allergic conditions, highlighting metaphorical uses of allergies in American culture. The explanatory models of the subjects were contrasted to the biomedical model and the stereotypes created by the media in the United States. Important topics addressed in the analysis of the interview material were: what are the explanatory models of allergies in America, how do allergies influence the selfimage of someone with that condition, and how Americans with and without allergies perceive the allergic individual. / by Micheline M. Hilpert. / Thesis (M.A.)--Florida Atlantic University, 2011. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2011. Mode of access: World Wide Web.

Purpose: In the United States, stroke is the leading cause of disability. The majority of survivors sustain permanent physical and/or cognitive impairments. Stroke survivors with impairments experience depression, loss of functional independence, and poor quality of life (QOL). Stroke disparities exist among different racial and ethnic groups of the US population. Latinos experience a first time stroke at a younger age compared to non-Latino Whites. As a result, Latinos live with impairments for a greater number of years. The vast majority of stroke survivors return to live in their communities. Reintegrating into home and social activities is key to survivors’ perceived QOL. This dissertation project sought to understand from an ecological framework the post-stroke community reintegration experiences of Latino older adults in an urban New York City neighborhood. The study also sought to examine the viewpoints of health and social service providers, whose opinions, actions, and programs can support stroke survivors’ reintegration into community. Methods: Qualitative in-depth interviews were conducted with 30 Latino stroke survivors 50 years of age and older who had experienced a disabling stroke within 36 months. In addition, 20 health and social service providers based in a large medical center, and multiple senior centers in the northern Manhattan section of New York City were interviewed. The stroke survivor data was analyzed using a phenomenological approach. A thematic analysis approach was used to analyze the data from the health and social service informants. Data analysis identified physical, psychological, social, and environmental factors pertinent to stroke survivors’ community integration experiences. These identified factors were categorized into macro-, exo-, meso-, and micro-levels to capture the psycho, social, and environmental ecology in which community reintegration takes place for Latino stroke survivors. Results: Qualitative accounts of survivors revealed several microsystem factors, including a struggle to maintain a positive self-concept and to engage in activities associated with valued identities and roles, while simultaneously suffering chronic pain, fatigue, and functional limitations. Changes in their affect lead survivors to socially isolate themselves. In addition, they relied more on women than men for social support, a salient mesosystem factor. Survivors encountered significant exosystem level barriers in the environment that limited their ability to travel and access activities. For some, these barriers inadvertently left survivors homebound. Survivors also encountered a societal culture, a macrosystem factor, which stigmatized them due to their impairments. Interviews with health and social service professionals revealed various factors that influenced community reintegration of people with stroke. At the macrosystem level, funding for programs and healthcare financing dictated services and eligibility criteria. In the exosystem, a segmented medical model of care postponed the conversation on community integration. Professional practices, organizational level constraints and culture were mesosystem level factors that influenced community reintegration. The confluence of these factors created an ecological system that influenced stroke survivors’ opportunities to socially engage in their home and community life. Conclusion: An ecological approach provides a useful framework to understand the complexity and potential interplay of factors that contribute to community integration post-stroke for Latino older adults in an urban area.

OBJECTIVE: Personalized genomic medicine (PGM) has been lauded as the future of medicine, as new human genomic research findings are applied towards the development of screenings, diagnostic tools and treatments that are tailored to the genomic profiles of individuals. However, the development of PGM is still in its nascent stages, therefore, some have supported the development of clinical tools and treatments based on population-level characteristics, such as race or ethnicity. Race-based medicine (RBM), has been, and continues to be, promoted as an interim form of PGM, and although an academic debate has flourished over medical, social and ethical concerns related to RBM, to date, there have only been a few small studies that have examined lay beliefs and attitudes regarding RBM. The extent to which the greater American public would believe in the effectiveness of RBM and indicate an intention to use RBM is unclear. Furthermore, it is possible that racial and ethnic groups would differ in their beliefs and attitudes regarding RBM, considering RBM implies the controversial and contested conceptualization of race as having some genetic basis. Therefore, the purpose of this dissertation study was to use, for the first time, a nationally representative sample of adult Americans and examine the importance of race with respect to the following: beliefs and attitudes regarding RBM; the extent to which these beliefs and attitudes can be influenced by mass media messages about the relationship between race and genetics; and how beliefs and attitudes regarding RBM compare with those regarding PGM. METHODS: In order to answer these questions, this dissertation study used a nationally representative sample of self-identified non-Hispanic white, non-Hispanic black and Hispanic U.S. residents who participated in an online survey examining beliefs and attitudes regarding RBM and PGM, and the effect of a vignette experiment using mock news articles that varied in their messages about the relationship between race and genes on these beliefs and attitudes. The survey assessed the following constructs using new measures designed for this dissertation study: RBM's effectiveness at the individual, clinical level; PGM's effectiveness at the individual, clinical level; preferences for using RBM; preferences for using PGM; and RBM's ability to address health inequalities in the U.S. Means, frequencies, mean-difference tests and multiple regression were used to examine the effect of race and/or the vignette experiment on beliefs and attitudes regarding RBM and PGM. RESULTS: The results of this dissertation study show that the majority of white, black and Hispanic Americans equally agreed that RBM would not be clinically effective at the individual level, but the majority of all groups also equally agreed that they would prefer to use RBM if it was available. More than forty percent of all respondents who did not believe RBM would be effective at the individual level, still preferred to use a race-specific treatment if it was available. The three racial/ethnic groups examined in this study did diverge in belief in RBM's ability to reduce health inequalities. Greater portions of the black and Hispanic respondents believed RBM would be effective at reducing health inequalities than white respondents. Racial differences were also seen in the effect of the vignette experiment on RBM beliefs and attitudes. While the vignette experiment had no effect on whites' beliefs and attitudes regarding RBM, vignettes that stated or implied a genetic basis to racial difference were associated with lower endorsement of RBM beliefs and attitudes among the black respondents. Finally, the results indicated that both white and black Americans endorsed PGM's effectiveness at the individual level at greater levels than RBM's effectiveness, and both groups indicated greater preferences for using PGM than RBM. However, while most white respondents indicated that they believed PGM would be effective at the individual level and that they would prefer to use PGM if it was available, nearly half of the black respondents did not believe PGM would be clinically effective, and 1 out of 4 black respondents did not prefer to use PGM. CONCLUSIONS: The results suggest that white, black and Hispanic Americans do not significantly differ in their beliefs and attitudes regarding the effectiveness of or preferences for using RBM. This finding diverges from prior studies that showed racial differences in beliefs and attitudes regarding RBM. The lack of racial difference may be due to a lack of familiarity with this concept, for the results also suggested that once respondents were exposed to varying mock news article messages about the relationship between race and genes, racial differences began to emerge. The results also showed discordance between belief in RBM's effectiveness and preferences for using RBM. This finding suggests that there is still an incentive for the pharmaceutical and diagnostic testing industries to develop and market RBM even if there is generally low public opinion regarding RBM's effectiveness. PGM has been promoted by the biomedical industry as a potential solution to racial and ethnic health disparities both in the U.S. and globally, and RBM has been promoted as an interim form of PGM until it is further developed. Despite noted clinical, social and ethical concerns regarding RBM specifically, proponents of RBM have focused on promoting the message of its potential to mitigate racial and ethnic health disparities. The results from this study indicate that on the surface at least, this argument may in fact resonate with black and Hispanic Americans. In addition to being the first nationally representative study to examine potential racial differences in RBM beliefs and attitudes, this dissertation was also the first nationally representative study to examine potential racial differences in beliefs and attitudes regarding PGM. Although the results clearly showed that all Americans endorsed the effectiveness of and preferences for using PGM at greater levels than RBM, whites were significantly more likely than blacks to believe PGM would be clinically effective and to indicate a preference for using PGM. Thus, while the merits of PGM may seem apparent to the clinical and academic communities, the results of this study indicate that there is not universal support for PGM among the public. Cautious support for PGM from black respondents may reflect more general mistrust towards the medical community and new forms of health technologies. Even though racial and ethnic minority populations seem open to RBM and PGM as potential strategies to address health inequalities, support for both could change as the public becomes more familiar with both concepts, whether through exposure to mass media messages, mass marketing of treatments and genetic testing, or through their clinical providers. The findings from this dissertation study significantly advance our knowledge of the American public's beliefs and attitudes regarding RBM and PGM, particularly with respect to racial differences, and should be considered by stakeholders in current and future debates surrounding efforts to develop and promote both.

<p>This paper discusses the medical treatment of intersex infants: children born with ambiguous genitalia, chromosomes, or hormones. The central thesis is that unnecessary surgery, defined as surgery that is not necessary to preserve the life or physical health of the infant, is unethical when performed on infants and should be postponed until the patient is able to participate in, and contribute to, the decision. Three lines of argument are presented: One based on the lack of clinical evidence supporting unnecessary surgery; one based on how unnecessary surgery limits the child’s future choices; and one based on how problematic notions of gender have resulted in problems in practice. Together and separately, the three arguments lead to the conclusion that performing unnecessary surgery on intersex infants is unethical, and wherever possible surgery should be delayed until the patient can participate in the decision.</p>

<p>The general aim of this thesis was to empirically explore the organisational characteristics of quality systems of hospital departments, to develop and empirically test models for the organisation and implementation of quality systems, and to discuss the clinical implications of the findings.</p><p>Data were collected from hospital departments through interviews (n=19) and a nation-wide survey (n=386). The interviews were analysed thematically and organisational models were developed. Relationships among aspects of organisation and implementation were hypothesised and analysed with structural equation modelling.</p><p>The result was a new framework with three organisational aspects of quality systems each with two sub-aspects: structure (resources and administration), process (culture and cooperation), and outcome (evaluation of goal achievement and development of competence).</p><p>Strong positive relationships were confirmed among structure, process, and outcome. Quality systems could therefore be classified into three organisational degrees. For instance, quality systems of high organisational degree often had adequate resources and administration as well as positive organisational cultures and high cooperation among different professions. </p><p>Advanced designs required quality systems of high organisational degrees. Examples of such designs were coordination between departments, random check ups, and accreditation.</p><p>The organisationally demanding quality systems had been implemented through cooperative implementation, that is, directed by managers while at the same time giving opportunities for staff to participate in planning and designing.</p><p>The results can be useful to managers, quality coordinators, and clinicians when they describe, develop, implement, and evaluate the effectiveness and efficiency of quality systems in hospital departments.</p>

The psychosocial work environment in human service organizations is in many respects rewarding from the aspect of human interaction. However, it has also been described in several research reports as demanding and stressful both physically and mentally, resulting in a negative impact on employee health and a high degree of sickness absence. From a public health perspective it is important to focus on determinants of health in occupational groups that are characterized by caring and human relations. This thesis aims at identifying determinants of individual and organizational health in human service professions from a multifactorial perspective. Based on both cross-sectional and longitudinal data, four studies of various aspects of psychosocial work exposures are carried out. Study I, an explorative and qualitative study, examines determinants of the psychosocial work environment in the Church of Sweden. Study II consists of a retrospective, randomized study assessing effects of goal clarity work on organizational well-being in the Church. Study III examines exposures resulting in stress-related sick leave among elderly care employees. Study IV is a longitudinal study that assesses effects of organizational change on health and sickness absence among elderly care employees. The results show some positive experiences, despite overall demanding work conditions within both of the studied professions. In the Church (Paper I), experiences of freedom and influence at work and the Christian values tend be factors with modifying effect on health. Four patterns are identified for negative health impact; these include unclear organization, a sense of being different, stressful work and destructive communication style. Effects of goal clarity work (Paper II) indicate an overall positive impact on organizational well-being. In elderly care (Paper III), the results suggest, in general, a positive work climate and high effectiveness. Work related exhaustion was significantly higher among employees with stress related sickness absence. Factors of risk for being absent due to stress are approximately three times higher among employees dissatisfied with both their work and their social situations. Finally, measuring effects of organizational change (Paper IV), the results reveal evidence of unchanged self-rated health (SRH), work satisfaction and work exhaustion after reorganization. However, sickness absence increased across time and there is an indication of impaired levels of the anabolic hormone DHEA-S among those individuals affected by the reorganization. The results point to a challenge for further research on the interplay between perceived stressors, resources available, biological stress markers and health in order to find adequate measures for improvements in psychosocial work environment in human service professions.

This paper discusses the medical treatment of intersex infants: children born with ambiguous genitalia, chromosomes, or hormones. The central thesis is that unnecessary surgery, defined as surgery that is not necessary to preserve the life or physical health of the infant, is unethical when performed on infants and should be postponed until the patient is able to participate in, and contribute to, the decision. Three lines of argument are presented: One based on the lack of clinical evidence supporting unnecessary surgery; one based on how unnecessary surgery limits the child’s future choices; and one based on how problematic notions of gender have resulted in problems in practice. Together and separately, the three arguments lead to the conclusion that performing unnecessary surgery on intersex infants is unethical, and wherever possible surgery should be delayed until the patient can participate in the decision.

The general aim of this thesis was to empirically explore the organisational characteristics of quality systems of hospital departments, to develop and empirically test models for the organisation and implementation of quality systems, and to discuss the clinical implications of the findings. Data were collected from hospital departments through interviews (n=19) and a nation-wide survey (n=386). The interviews were analysed thematically and organisational models were developed. Relationships among aspects of organisation and implementation were hypothesised and analysed with structural equation modelling. The result was a new framework with three organisational aspects of quality systems each with two sub-aspects: structure (resources and administration), process (culture and cooperation), and outcome (evaluation of goal achievement and development of competence). Strong positive relationships were confirmed among structure, process, and outcome. Quality systems could therefore be classified into three organisational degrees. For instance, quality systems of high organisational degree often had adequate resources and administration as well as positive organisational cultures and high cooperation among different professions. Advanced designs required quality systems of high organisational degrees. Examples of such designs were coordination between departments, random check ups, and accreditation. The organisationally demanding quality systems had been implemented through cooperative implementation, that is, directed by managers while at the same time giving opportunities for staff to participate in planning and designing. The results can be useful to managers, quality coordinators, and clinicians when they describe, develop, implement, and evaluate the effectiveness and efficiency of quality systems in hospital departments.