Tidigare forskning pekar på försämrad kommunikationsförmåga som ett av de mest uppmärksammade symtomen vid demenssjukdom. För att förmedla ett budskap till sin omgivning använder dementa som alla andra människor både verbala och icke-verbala signaler. Med tiden försämras deras verbala uttrycksätt och de börjar istället att i allt högre grad använda sig av de icke-verbala signalerna, som till exempel ansiktsuttryck, kroppsspråk, gester, paraspråk och liknande. Eftersom dementas olika kommunikativa uttryckssätt ibland kan vara väldigt svåra att tolka av andra i deras närhet, är det av stor betydelse att ta reda på de förutsättningar som påverkar detta. Syftet med denna studie är att utifrån vårdpersonalens berättelser belysa vilka faktorer som påverkar deras tolkning av dementas olika kommunikativa uttryckssätt under omvårdnadsmötet. För att svara på detta syfte har jag använt mig av fokusgruppsintervjuer som metod för att samla in data, vilken sedan analyserades med hjälp av kvalitativ innehållsanalys. Resultatet visar att de faktorer som påverkar vårdpersonalens tolkning av dementas olika kommunikativa uttryckssätt är (1) kunskap, (2) yrkeskompetens och (3) institutionella aspekter som psykosocial miljö och tid. Den föreliggande studiens resultat kommer förhoppningsvis att bidra till en bättre kommunikation mellan dementa och vårdpersonal.

Aim. To describe patients who have got a recommendation by a telenurse to visit the emergency department and how many of these patients could have received care in the primary health care instead. Further on, the aim was to describe if there are patients not following the recommendations. Methods. Quantitative, descriptive study, with an examination of medical records of the patients, which the telenurses recommended to visit the emergency department, during one week. Assessments whether the patient could seek medical care at the primary health care was made, firstly based on the telenurses documentation and secondly on both the telenurses and the emergency department´s documentation. Results. 15 % of the patients could have gotten care at the primary health care center, based on the first assessment. 33 % could have gotten care at the primary health care center, according to the second assessment. One fifth of the patients chose not to visit the emergency department even though the telenurses recommended it. Conclusion. The telenurses recommended the patients to the right level of care in seven out of ten cases. We consider the telenurses' assessments to work well. / Syfte. Att beskriva vilka patienter som blir rekommenderade av sjukvårdsrådgivningen att söka till akutmottagningen, samt hur stor andel av dessa patienter som hade kunnat få vård i primärvården istället. Syftet var vidare att beskriva vilka och hur många patienter som blivit rekommenderade av sjukvårdsrådgivningen till akutmottagningen som inte följer denna rekommendation. Metod. Kvantitativ, beskrivande studie, med journalgranskning av de patienter som rekommenderas till akutmottagningen av sjukvårdsrådgivningen under en veckas tid. Bedömning av huruvida patienten kunde söka vård i primärvården gjordes, först utifrån sjukvårdsrådgivningen dokumentation och sedan utifrån både sjukvårdsrådgivningens och akutmottagningens dokumentationen. Resultat. Sjutton av de 111 patienterna (15 %) hade kunnat få vård i primärvården, bedömt utifrån sjukvårdsrådgivningens dokumentation. 33 % hade kunnat få vård i primärvården, bedömt utifrån både sjukvårdsrådgivningens och akutmottagningens dokumentation. En femtedel av patienterna valde att inte komma till akutmottagningen trots att sjukvårdsrådgivningen rådde dem till detta. Slutsats. Totalt sett rekommenderade telefonsjuksköterskorna patienterna till rätt vårdnivå i sju fall av tio, trots de svårigheter som rådgivning och bedömning via telefon medför. Därför anser vi att sjukvårdsrådgivningens bedömningar fungerar bra. En femtedel av patienterna valde att inte komma trots rekommendationen och till detta har vi inte funnit något särskilt skäl.

Arbetsplatsen har kommit att bli en viktigt arena där hälsan och förutsättningarna för hälsan kan påverkas. De senaste åren har det skett en positiv utveckling gällande den fysiska arbetsmiljön men inte gällande den psykosociala arbetsmiljön där speciellt anställda inom hälso- och sjukvården upplever en allt mer pressad arbetssituation. Litteraturgenomgången kring psykosociala arbetsförhållanden visar att det finns lite forskning gjord kring positiva aspekter av socialt stöd och hälsa. Detta ses som ett problem då det i arbetsmiljön ligger en avsevärd potential i främjandet av hälsa och att fokus bör förflyttas från det patogena till det salutogena synsättet. Syftet var att ur ett salutogent perspektiv se det sociala stödets betydelse på arbetsplatser inom privat hälso- och sjukvård samt undersöka medarbetarnas självuppskattade hälsa och upplevelser av arbetsplatsen och arbetssituationen. Metoden var en kvantitativ tvärsnittsstudie. En strukturerad webenkät användes för att samla in data. Totalt deltog 91 medarbetare inom närsjukvården på ett privat hälso- och sjukvårdsföretag, vilket innebar en svarsfrekvens på 43 %. Resultaten visar ett direkt positivt samband mellan socialt stöd och olika arbetsrelaterade faktorer samt hälsa. Socialt stöd medierar även effekterna av kontroll på nivån av den självuppskattade hälsan. Dock fanns det inget underlag för att socialt stöd har en större betydelse än andra arbetsrelaterade faktorer i relation till hälsa. Konklusionerna var att ett gott emotionellt klimat bidrar till gynnsamma hälsoeffekter. Ett viktigt perspektiv i det hälsofrämjande arbetet är att skapa och främja goda relationer på arbetsplatsen. Exempelvis är formella samtalsgrupper effektiva vid främjandet av goda relationer, samt bidragande till minskningen av stressupplevelser vilket även fångar in den preventiva tillämpningen. Hälsa berör flera aspekter och bör ses så holistiskt som möjligt. / The workplace has become an important arena where health- and the prospects of health can be affected. In recent years there have been positive developments regarding the physical work environment but not concerning the psychosocial development environment where employees especially in the health care system is experiencing an increasingly tight labor situation. The literature review on psychosocial working conditions show that there is little research done on the positive aspects of social support and health. This is seen as a problem when the work environment is a considerable potential in the promotion of health, and that the focus should move from the pathogenic to the salutogenic approach. The aim of this thesis was from a salutogenic perspective to study the importance of social support at workplaces in the private healthcare, and examine employees' self-estimated health and perceptions of the workplace and working conditions. The Method was a quantitative cross-sectional study. A structured web-based survey was used to collect data. A total of 91 employees of the local health services in a private healthcare company participated, representing a response rate of 43%. The Results showed a direct positive relationship between social support and various work-related factors and health. Social support also mediates the effects of control on the level of self-estimated health. However, there was no basis for social support as a greater factor than other work-related factors in relation to health. The Conclusions were that a good emotional climate contributes to beneficial health effects. An important perspective in health promotion is to create and foster good relationships in the workplace. For instance are formal discussion groups effective in the promotion of good relations, as well as contributing to the reduction of stress experiences, which also captures the preventive view. Health concerns several aspects and should be seen as holistic as possible.

The purpose of this paper is to investigate how social workers, working in a management position in the health care system, perceive the encounter of the medical and social perspective. With seven qualitative interviews, the study tries to conclude whether or not social workers are accepted at managerial positions within the health care sector. The social worker is, as a manager in health care, a leader but at the same time in a professional alienation from the medical caregivers. Organizations in the health care sector are often multi professional and have their own long standing tradition, history and culture. The results show that the conditions for social workers, working in a management position in health care appear to be agreeable. Collaboration works well, there is mutual respect, and the social perspective are considered valuable. Generally, the respondents agree upon what qualities distinguish a good leader and most believe that social work training provides a good foundation for the management role. Many argue that leadership is personalized and not dependent on the educational background. The social worker in a leadership position, is received well, is accepted and respected in the medical health care. Social workers, according to this study, assume the leadership role in the same ways as other professionals in health care. The social worker brings a psychosocial holistic approach which gives attention to both patients and employees alike. To meet future needs in health care in Sweden, the social worker is a good competence contributor.

Syftet är att undersöka Läns-SLAKO, samrådsorganet inom vård- och omsorgsområdet mellan kommunerna och landstinget i Östergötland. Målsättningen är att ge kunskap om de bakomliggande orsakerna till uppbyggnaden av Läns-SLAKO, att ge kunskap om hur samrådet fungerar idag samt möjliga förklaringar till varför samverkan fungerar eller inte. Fokus ligger på att undersöka vilken betydelse tillit mellan de ingående parterna har, för att åstadkomma en fungerande samverkan. Syftet är också att undersöka huruvida graden av tillit påverkar legitimiteten för Läns-SLAKO som politiskt organ.   Studien har utförts som en fallstudie med Läns-SLAKO som enda undersökningsobjekt. Det är en lämplig metod när syftet är att undersöka en nutida företeelse på djupet och i dess verkliga sammanhang. Den empiriska undersökningen bygger på skriftlig dokumentation, huvudsakligen sammanträdesprotokoll, och på samtalsintervjuer.   Undersökningen visar ett klart samband mellan parternas ömsesidiga förtroende för varandra och en fungerande samverkan som kommer medborgarna till del. Nödvändigheten av att nå konsensus i Läns-SLAKO försvåras av att såväl kommuner som landsting är komplexa organisationer med sinsemellan olika styrlogiker. Statliga beslut inom vård-och omsorgsområdet påverkar såväl vilka uppgifter Läns-SLAKO arbetar med som hur väl samrådet fungerar och detta har varierat över tid. För närvarande står frågan om överflyttning av hemsjukvården från landstinget till kommunerna på agendan. Om Läns-SLAKO misslyckas att finna en konsensuslösning kan det få allvarliga följder för den fortsatta samverkan. Om tilliten försvinner mellan parterna kan processen att återuppbygga den bli både lång och mödosam. / The purpose was to examine Läns-SLAKO as a model for cooperation in healthcare issues for municipalities and the County Council of Östergötland, Sweden. The study aimed at increasing the knowledge concerning the forming and development of Läns-SLAKO. The study also aimed at finding relevant factors to explain why or why not the cooperation is successful. The study focuses on evaluating if the      organization of the network   the      degree of trust and reciprocity the      link between trust and legitimacy are factors of relevance. The study was designed as a case study. The method is suitable for an empirical study investigating a contemporary phenomenon in depth and within its real-life context. The empirical study is based on interviews with key-persons and mainly on meeting protocols.   The study suggests a clear connection between reciprocity and trust and successful cooperation. The influence of the precondition to reach consensus highly increases complexity. The participants need to have the same weight of mandate within their own organizations. With a lower degree of trust and reciprocity the cooperation may be at risk although the participants know they may benefit. The trust and reciprocity is currently under pressure by the central decision to transfer part of the responsibility for the home based care from the county council to the municipality. The government has left the organizations to find an agreement. If Läns-SLAKO fails a severe lack of trust may result. This may impact future cooperation. To loose trust may be a quick process. To regain trust takes time.

Background: The Social Insurance is part of the Swedish welfare system that is intended to create economic security for citizens in the event of unemployment, sickness, functional disability, and old age. The Swedish sickness‐benefit insurance is based on the standard insurance principle meaning that sickness benefits are related to level of lost income. The increasing number of sick listed people and people with disability pension (DPs) in Sweden may lead to marginalisation of individuals as they are not part of the labour market. The government has decided that the number of sick‐listed people should be halved by 2008, which means a tougher judgment of the applications for sick leave compensation. To be qualified for sickness benefit the disease has to impair the work ability in relation to the specific demands of the work of that person. The evaluation of the work ability in a percentage is an important element with regard to the policy on disability. The social insurance officers (SIOs) who are assessing the work ability are dependent on judgments from the physicians as expertise, and the guidelines in the social insurance act. The eligibility criteria for DP and the process of dealing with applications for DP is scarcely studied. Objectives: The overall aim of the thesis was to explore demographic and health differences between those, who were granted and those, who were not granted disability pension. The second aim was to study how the process from applications to decisions on disability pensions were executed and perceived by the social insurance offices and to elucidate their working conditions during the decision process. Material and methods: The first two studies explored differences between those granted DP and those not granted DP. Study I was a register‐based retrospective case‐control study carried out in the area of a county in Sweden. The cases were all individuals rejected a full disability pension 1999‐2000, in all 99 cases. Controls were every tenth person who was granted a full DP during the same period, 198 controls. Determinants were recorded from the Social Insurance (SI). In study II demographic data and medical diagnoses were obtained from the SI records. Data concerning self‐reported health, HRQoL, social networks and use of health care were collected by a postal questionnaire. The study objects were the same as in study I. In study III and IV indepth interviews were carried through to study the social insurance officers’ perspective on the process from application to decision on disabilitypensions as well as their experiences of prerequisites and hindrances in their work with DP applications. The transcribed data were analysed by an inductive content analysis. Results: Unemployment, living in the main municipality and age below 50 years were determinants for rejection of DP. Medical status as described in the Social Insurance records had less association with the outcome. There are variations in praxis of rejection of applicants between social insurance boards in different geographical areas due to other reasons than medical. The nDP group had more often multiple diagnoses, and lower self‐reported health and HRQoL compared to those granted DP. Those not granted DP also had significantly smaller social networks. The SIOs perceived that they had to make rapid decisions within a limited time frame, based on limited information, mainly on the basis of incomplete medical certificates, and with no firm criteria for the regulations on the individual case level. Communication among the various authorities as employment offices and social services suffered from lack of common goaldirected strategy. In study IV the SIOs described their working conditions when executing the applications for DP. The SIOs perceived recurrent changes in rules and regulations as frustrating as they at the same time had to face the client. The large number of clients prevented them from being able to offer clients activities and support them in the way they were supposed to do. The SIOs powerful position and how their discretion was implemented made them feel responsible for performing their work well. SIOs are to be considered as typical street‐level bureaucrats as they have to perform their work between the policy, rules and clients. Conclusions: The individuals had an increased risk to be rejected DP if they were younger than 50 years, unemployed, and lived in the main city. No evident differences in medical diagnoses were found between the groups. The results indicate that there may be other reasons than medical in praxis. Contrary to expectations, those not granted DP do not seem to have better health, but rather to suffer from more sickness than those, who were granted DP. Unemployment leads to inability to qualify for compensation and benefits that are associated with participation on the labour market. The group not granted disability pension appears to be a disadvantaged group in need for a co‐ordination between different parts of the social welfare system. The different perspectives were perceived as obvious obstacles in the communication between professionals in the welfare system as they had other goals and demands. Clients, that have comprehensive problems and are in need of coordinated measures from many authorities to get entrance to the labour market still suffer from lack of coordination. One question is how the different public officers use their discretion when handling clients and how the cooperation can be improved. / The electronic version of the printed dissertation is a corrected version.

Kroniskt obstruktiv lungsjukdom är en underdiagnostiserad sjukdom som drabbar allt fler individer. Sjukdomen förekommer främst bland rökare men även icke-rökare kan drabbas. De mest förekommande symtomen vid kroniskt obstruktiv lungsjukdom är andfåddhet och andnöd. Symtomen påverkar varandra och kan ge upphov till en känsla av ångest hos patienterna. Syftet med litteraturstudien var att belysa upplevelsen av att leva med kroniskt obstruktiv lungsjukdom med fokus på ångestsymtom. Studien genomfördes som en litteraturstudie innehållande 13 kvalitativa och kvantitativa artiklar. Andningssvårigheter beskrevs som den största faktorn bakom ångest vilket i sin tur påverkade patientens fysiska och psykiska välmående. Ångest i kombination med ett begränsat andningsflöde bidrog till att patienterna upplevde en känsla av att kvävas. Andningen beskrevs som fruktansvärd och patienterna jämförde tillståndet som att andas genom ett sugrör. Många patienter avvaktade kontakt med sjukvård i hopp om att symtomen spontant skulle avta. När symtomen förvärrats och kontakt initierades ansågs sjukvårdskontakten ändå vara betydelsefull för patienterna. Studien kan bidra med viktig information vid vård av patienter med kroniskt obstruktiv lungsjukdom. Studien kan också ge värdefull information till den fortsatta forskningen kring sjukdomens symtom. / Chronic Obstructive Pulmonary disease is an underdiagnosed disease that today affects more and more individuals. The disease appears mainly with smokers but non-smokers can be affected too. The most occurring symptoms at chronic obstructive pulmonary disease are breathlessness and shortness of breath. The symptoms affect one another and can create a feeling of anxiety. The aim of the study was to illuminate the experience of living with chronic obstructive pulmonary disease with focus on the symptom anxiety. The study was conducted as a literature review containing 13 qualitative and quantitative articles. Difficulties to breathe were described as one of the biggest reasons behind anxiety which affected both the physical and psychological well-being of the patients. The limited airflow and symptoms of anxiety involved a feeling of one being suffocated. The breathing was described as a dreadful situation and the patients compared the condition to breathing through a straw. Many of the patients chose to postpone the contact with medical care thinking that the symptoms would moderate. When the symptoms accelerated medical care yet seemed important for the patients. The study can contribute with meaningful information to the care of patients with chronic obstructive pulmonary disease. The study can also give valuable input to further research studies, especially on patients’ view on health related quality of life related to the symptoms of the disease.

Övervikt och fetma hos barn är ett allvarligt och växande problem. Det är ett tillstånd som för med sig många olika sjukdomar och i och med att antalet överviktiga barn ökar hastigt kommer det att vara en stor belastning för den framtida hälso- och sjukvården. Prevalensen är särskilt stor i vissa delar av världen och inom vissa grupper i samhället. Föräldrar spelar en väsentlig roll i huruvida barnen lever hälsosamma liv eftersom de bär ansvaret för barnen. Syftet med denna litteraturstudie var att undersöka föräldrars påverkan i utvecklingen av övervikt och fetma hos barn och genom en systematisk bearbetning av litteraturen granskades och bearbetades slutligen 19 vetenskapliga artiklar till resultatdelen i studien. Socioekonomiska faktorer, faktorer inom familjen och föräldrars roll var tre teman som utmärkte sig där det under varje rubrik beskrivs hur föräldrar påverkar med att bidra till eller motverka riskfaktorer till en ohälsosam viktstatus hos barn. Föräldrar har ett behov av stöd i form av information och kunskap och hälso- och sjukvården bär ett stort ansvar i att stödja föräldrar, förebygga sjukdom och främja hälsa. / Overweight and obesity in children are serious conditions, with many negative consequences to the health of individuals and the health care system as a whole. The prevalence is particularly great in certain groups of people and the frequency of these conditions is increasing at an alarming rate. Parents, as the primary caregivers, play a vital role in determining whether or not their children lead a healthy lifestyle. The aim of this literature review was to establish the influence that parents have on the development of overweight and obesity in their children. 19 articles were systematically reviewed and the results showed three main areas of influence; socio-economic factors, factors within the family and the role of the parent. In each of these areas, risk factors of developing overweight and obesity in children were identified. In general, parents lack information about these conditions and are in need of support from nurses and other health care professionals, who in turn carry the responsibility to support the parents, promote good health and prevent disease.

Det är sjuksköterskans ansvarsområde att uppmärksamma, förebygga och behandla malnutrition. Ädelreformen, där ansvaret för äldre vårdtagare har flyttats från landstingsnivå till kommunnivå, har bland annat inneburit att tillgången till sjuksköterskor i hemsjukvården är liten i förhållande till antal vårdtagare. Detta tillsammans med låg kunskapsnivå om nutrition hos omvårdnadspersonalen om nutrition samtidigt med stor vårdtyngd, har lett till att brister i omvårdnaden inom nutrition kan fortgå en längre tid innan de uppdagas. Syftet var att undersöka sjuksköterskans förmåga att uppmärksamma och åtgärda malnutrition hos äldre vårdtagare inom hemsjukvården och särskilt boende. En litteraturstudie med 20 vetenskapliga artiklar utfördes. Kunskapen om nutrition är överlag låg bland sjuksköterskor och övrig omvårdnadspersonal, bara en liten del av omvårdnadspersonalen kände till metoder för nutritionsbedömning och ännu färre använde nutritionsbedömningen i praktiken. Det individuella energibehovet för de äldre i studierna tillgodosågs inte i de flesta fall men ökat näringsintag med näringsberikad mat eller näringsdryck hade en positiv effekt för att motverka malnutrition. Vidare forskning om svenska förhållanden, där kunskapen hos omvårdnadspersonalen inventeras, skulle vara relevant för vidare utveckling av hemsjukvården. / It is the nurse’s responsibility to observe, prevent and treat malnutrition. The reform of geriatric care, where the responsibility for the elderly residents has been moved from county council into municipality, has implied that access to nurses in Home Care Service is deficient in proportion to the amount of residents. This matter together with poor knowledge in nutrition among the nursing care staff, accompanied by high burden of care, have led to deficiencies in nutritional care, which can remain for a long time before revealed. The aim of the literature study was to examine the nurse’s ability to discover and treat malnutrition in elderly Home Care residents. A literature study based on 20 scientific articles was made. The nutritional knowledge among nurses and members of nursing care staff is generally low, only a small amount of the nursing care staff had knowledge in nutritional screening methods and even fewer used screening methods in practice. The individual requirement of energy for the elderly in the studies was in most of the cases not met, but increased energy intake through energy enriched food or supplement drinks, had a positive effect to counteract malnutrition. Further research in Swedish conditions, where the knowledge among the nursing care staff ought to be inventoried, is highly relevant for further development of the Home Care Services.

The thesis examines the privatisation of China's health care since the 1980s, focusingon the privatisation of primary health care at the county level. The research choosesprivate clinics as research objects, includes a brief historical description of privatehealth care evolution and the existing health care system in China; based on theempirical data collected in the field work, it provides a current picture of private clinicand its privatisation process in a Chinese city, discusses the problems in privatemedical practice and challenges private clinic faces, and the influence of privatisationon health sector performance.The thesis notes the privatisation of primary health care by private clinics supplies analternative way for health care services. It plays a significant role in compensatingpublic system and promotes more equal health access, although the radicalprivatisation of all health sectors undermines the accessibility and quality of healthservices in general. Currently the private health sector in China is still small and yet toform a mature market, and there are multiple challenges for its further development,but it can be expected that the private sector in the health care area will expand rapidly,and China could hopefully find a suitable way of public/private mix under the newhealth reform.