O presente estudo desenvolve-se numa perspectiva prática, visando à integração de conhecimentos gerados pela pesquisa a atividades assistenciais no hospital geral universitário, dirigindo-se, especificamente, à questão da detecção da depressão. A depressão é um problema de saúde pública no mundo inteiro, transtorno mental de alta prevalência, com elevado custo para os sistemas de saúde. Entre pacientes clínicos e cirúrgicos, hospitalizados, aumenta a complexidade dos tratamentos, implica maior morbidade e mortalidade, importando também no aumento do tempo e dos custos das internações. Por outro lado, a depressão é subdiagnosticada. Este estudo, originado de um projeto cujo objetivo foi criar um instrumento para a detecção de depressão, utilizável na rotina assistencial, a partir da avaliação do desempenho de escalas de rastreamento já existentes, desdobra-se em três artigos. O primeiro, já aceito para publicação em revista indexada internacionalmente, é a retomada de estudos anteriores, realizados no final da década de 1980. É apresentada a comparação da detecção de depressão, realizada por médicos não-psiquiatras e por enfermeiros, no Hospital de Clínicas de Porto Alegre (HCPA), em 1987 e em 2002. O segundo artigo apresenta o processo de construção da nova escala, a partir da seleção de itens de outras escalas já validadas, utilizando modelos logísticos de Rasch. A nova escala, composta por apenas seis itens, exige menos tempo para sua aplicação. O terceiro artigo é um estudo de avaliação de desempenho da nova escala, denominada Escala de Depressão em Hospital Geral (EDHG), realizado em uma outra amostra de pacientes adultos clínicos e cirúrgicos internados no HCPA. O segundo e terceiro artigos já foram encaminhados para publicação internacional. Esses estudos, realizados em unidades de internação clínicas e cirúrgicas do Hospital de Clínicas de Porto Alegre, permitiram as seguintes conclusões: a) comparando-se os achados de 1987 com os de 2002, a prevalência de depressão e o seu diagnóstico, em pacientes adultos clínicos e cirúrgicos internados, mantêm-se nos mesmos níveis; b) foi possível selecionar um conjunto de seis itens, que constituíram a nova Escala de Depressão em Hospital Geral (EDHG), baseando-se no desempenho individual de cada um dos 48 itens componentes de outras três escalas (BDI, CESD e HADS); c) a EDHG apresentou desempenho semelhante aos das escalas que lhe deram origem, usando o PRIME-MD como padrão-ouro, com a vantagem de ter um pequeno número de itens, podendo constituir-se num dispositivo de alerta para detecção de depressão na rotina de hospital geral. / This study unfolds from a practical perspective. Its purpose is to integrate knowledge generated by research into care provided in general hospitals, specifically to detecting depression. Depression is a public health problem all over the world. It is a highly prevalent mental disorder that generates high costs to the health system. Depression increases treatment’s complexity, morbidity and mortality rates, time and costs of clinical and surgical hospitalizations. On the other hand, depression is under diagnosed. This study was originated from a project to develop an instrument for the detection of depression in general hospitals inpatients. This instrument was based on the evaluation of the performance of other already existing rating scales and was designed to be integrated in clinical routine. This study was developed as three papers. The first paper, accepted for publication in an international indexed journal, compares depression detection carried out by non-psychiatric physicians and nurses of Hospital de Clínicas de Porto Alegre (HCPA) between 1987 andandand 2002. The second paper describes the developing process of a new depression scale by Rasch models using items from other previously validated scales. The new scale, with only six items, requires less time for its use. The third paper is the performance evaluation of the new scale, General Hospital Depression Scale (GHDS). This evaluation was conducted in a sample of clinical and surgical adult inpatients at HCPA. The second and third papers have already been submitted to international journals for publication. The conclusions from these studies are: a) comparing the findings of 1987 and 2002, the prevalence rates and the diagnosis of depression in clinical and surgical adult inpatients have not significantly changed; b) it was possible to select a subset of six items to create the new General Hospital Depression Scale (GHDS); these items were selected by individual performance analysis of 48 items from three other scales (BDI, CESD and HADS); c) GHDS has similar performance, using PRIME-MD as gold-standard, to the three other scales from which the items were selected. GHDS has the advantage of a smaller number of items, and may serve as an alert instrument to depression in general hospitals routine.

Magister Artium (Medical Anthropology) - MA(Med Ant) / Women are the principle providers of their families when it comes to issues of health care, even though their health needs and efforts are neglected. The contributions that they make to health development seem to be undervalued, and their working conditions ignored. Societies depend heavily on women as role players in the welfare of their families and of national economics together with their physical well-being which determines the ability to be productive. The study has provided an overview of the experiences of women concerning primary health care and the quality of service in Nolungile PHC Khayelitsha, Cape Town. Primary health care (PHC) forms an integral part both of the country‘s health system and the overall social and economic development of the community. Central to the PHC approach is full community participation in the planning, provision, control and monitoring of services. Priority has to be given to the improvement of women‘s social and economic status.A much neglected perspective in health issues is that, a number of questions arise from the provision of PHC. Does PHC rely on the contribution of women and if so, why women? Women in their communities have joined their hands together as community health workers, educating community members on issues of health. The study has provided an insight of the work that women are doing in their communities, and how do they give meaning to their experiences in PHC. The study also answered questions that raise fundamental issues on gender stereotyping and disparities in PHC. The study gave me an opportunity to work closely with the women while observing the challenges that they are facing and how to they overcome them in the daily lives.Changes are called towards the attitudes of health care providers working in the formal and nonformal sectors. The provision of health education for women ultimately empowers them as health educators for the community.

Bakgrund: Kunskapen om compassion fatigue behöver belysas i den palliativa vårdens kliniska vardag. Att arbeta med palliativ vård innebär komplexa relationer med patienter och närstående samt dagliga möten med lidande, död och sorg. Vårdpersonal inom vårdgivande yrken har stor risk att drabbas av compassion fatigue. Syfte: Syftet var att beskriva upplevelsen av compassion fatigue hos vårdpersonal som utför palliativ vård. Metod: En systematisk litteraturöversikt har genomförts av vetenskapliga forskningsresultat genom användandet av reflexiv tematisk analys. Fynden i resultatet har relaterats till det vårdvetenskapliga teoretiska ramverket Compassion Fatigue Model. Resultat: Fyra teman framkom: upplevelser av bristande resurser, upplevelser av svåra relationer i vårdandet, upplevelser av existentiell stress och bristande palliativt sammanhang samt upplevelser av otillräcklig coping och egenvård. Vårdpersonalens upplevelser av compassion fatigue grundades i de känslor som blev ohanterliga i samband med vårdandet av svårt sjuka patienter och närstående. Hög arbetsbelastning och bristen på återhämtning bidrog till att dränera vårdpersonalen på energi, vilket gav dem obalans mellan deras professionella och privata liv. För att minska risken att drabbas av compassion fatigue blev det palliativa sammanhanget, coping och egenvård betydelsefullt. Slutsats: Compassion fatigue kunde påverka vårdpersonalens hela livsvärld. Vårdpersonal är självmedvetna, men behöver bli bättre på att förstå hur betydelsefullt egenvård och positiv coping är för att bibehålla sin hälsa. Arbetsmiljöns betydelse för vårdpersonalens upplevelser av compassion fatigue är väsentlig. Arbetsgivare behöver uppmärksamma och prioritera resurser som förstärker vårdpersonalens hälsa. Palliativ vård är en vårdform som är resurskrävande och det behövs empatisk vårdpersonal som orkar vara närvarande i den vårdande relationen. / Background: Compassion fatigue is a concept that needs to be further established in the line of palliative care praxis. The concept compassion fatigue is well studied within scientific research. Compassion fatigue occurs as physical, mental, and emotional damage through work-related stress. Healthcare professionals are at high risk of suffering from compassion fatigue. Working in palliative care involves daily encounters with suffering, death, and grief through relationships with patients and relatives. Awareness of compassion fatigue needs to be highlighted and studied within the work field of palliative care. Aim: The purpose of this study was to describe experiences of compassion fatigue in healthcare professionals who work within palliative care settings. Method: A systematic literature review has been conducted on scientific research papers using reflexive thematic analysis. The findings in the results have been related to the theoretical framework Compassion Fatigue Model. Results: Four themes were identified: experience with lack of resources, experiences of difficult relationships in care, experience of existential stress and lack of palliative context, as well as the experience of insufficient self-care and coping. The care staff's experiences of compassion fatigue were based on the emotions that became unmanageable in connection with the care of seriously ill patients and relatives. High workload and lack of recovery contributed to draining healthcare staff of energy, giving them an imbalance between professional and private life. To reduce the risk of suffering from compassion fatigue, the palliative context, coping and self-care became important. Conclusion: Compassion fatigue could affect the entire lifeworld of healthcare professionals. Healthcare professionals do have self-awareness but need to improve their knowledge about the importance of self-care and positive coping strategies to maintain their health. A healthy work environment is essential for the healthcare professionals’ experiences of compassion fatigue. Employers need to pay attention and prioritize resources that strengthen the health of healthcare professionals. Palliative care requires resources and empathic healthcare professionals who can be present when caring for patients and their relatives.

Indiana University-Purdue University Indianapolis (IUPUI) / Intimate partner violence (IPV) has been declared a public health epidemic. Initial and annual training of healthcare providers regarding guidelines for identification and response to intimate partner violence has been mandated by the Joint Commission and endorsed by the Institute of Medicine. However, many providers/institutions lack the preparation necessary to implement such guidelines. The purpose of the feasibility study was to test the efficacy of an existing IPV training curriculum on participants’ perception of knowledge, cultural competence, confidence (self-efficacy), and attitudes related to identifying and responding to victims of IPV. A sample of convenience including twenty-three registered nurse home-visitors and one social work intern participated in the mandatory one-day training program. However, consent to enroll in the study was voluntary and indicated by completing the study instruments. Participants were asked to complete three evaluative measures: The 11-item Plunkett Demographic Questionnaire (pre-training), a 15-item Training Program Evaluation (post-training), and the 21-item Instructional Measurement Subscales across three time points (pre-Training, post-Training, and six weeks follow-up). All items were numerically coded so the higher the score, the more favorable the response. Data were analyzed using descriptive and inferential statistics (percentages; minimum-maximum, mean, and composite scores; standard deviations; repeated measures analysis of variance; and, paired samples dependent t tests). Four hypothesis statements were made regarding participation in the training program on IPV: “There will be an overall increase in healthcare providers’ perceived level of knowledge and cultural competence,” (hypothesis 1); “There will be an overall increase in healthcare providers’ perceived level of confidence in implementing routine enquiry,” (hypothesis 2); “There will be an overall positive change in healthcare providers’ attitudes towards routine enquiry,” (hypothesis 3); and, “There will be an overall positive change in healthcare providers’ attitudes towards victims of abuse following participation in Improving the Health Care Response to Domestic Violence,” (hypothesis 4). Findings supported previous research outcomes that presently recognized barriers to routine screening/ assessment for IPV can be overcome and positive changes can persist over time as a result of participation in a standard IPV training program. Future research involving larger, random sample populations, are needed to confirm these results.

Health care providers (HCPs) who work in adult palliative care occasionally encounter children who have a parent who is dying. This grounded theory (GT) study examines how adult palliative care providers respond to the needs of children who have a parent in palliative care. I use Adele Clarke’s (2005) situational analysis method, a postmodern iteration of GT. Clarke’s situational map acts as an analytical tool to identify and analyze different actors and elements in the situation of concern. Five semi-structured qualitative interviews were conducted with adult palliative care providers. Provisional theorizing resulted in three sub processes emerging from the data. First, adult palliative care providers must be cautious when identifying and responding to the needs of children who have a parent in palliative care, particularly because of the nefarious presence of dominant grief discourse (DGD). Second, these same adult palliative care providers, who are often distressed when supporting children who have a dying parent, benefit when they get comfortable with being uncomfortable. Third, adult palliative care providers tend to see themselves as part of a larger interdisciplinary team that informs their interactions with children who have a parent in palliative care. The entire analysis is imbued with a critical perspective of DGD, including its race, gender and class dimensions. This critique of DGD is informed by Foucauldian interpretations of discourse, power and subjectivity. Opportunities for resistance and social justice are explored. In accordance with my own research paradigm, I make a concerted effort to render my influence as a researcher visible throughout. / Graduate / 0452 / ianbscott@gmail.com

Bakgrund: Personer med ADHD har ofta nedsatta exekutiva funktioner, vilket kan försvåra social interaktion. Även vid autismspektrumtillstånd förekommer exekutiv dysfunktion, och där har tidigare studier visat ett behov av att ta hänsyn till detta vid vårdrelaterat bemötande. Det finns begränsad kunskap om hur personer med ADHD upplever bemötande inom hälso- och sjukvården.  Syfte: Syftet var att utforska hur personer med ADHD upplever bemötande inom hälso- och sjukvården. Metod: I studien tillämpas en kvalitativ design med deskriptiv ansats. Semistrukturerade intervjuer genomfördes med åtta personer med ADHD-diagnos. Resultat: Tre huvudkategorier kunde formuleras utifrån intervjumaterialet: Brist på tydlighet, bristande respekt för individ och autonomi samt begränsad kunskap om ADHD hos vårdpersonal. Informanter upplevde otydlighet i kommunikation och struktur och en känsla av att vårdpersonalen inte hade respekterat deras person eller autonomi. De beskriver också hur tidsaspekten blir ett problem: att behöva vänta på olika moment och inte veta hur länge de behöver vänta. Okunskapen om ADHD kändes besvärande. Informanter upplevde att vårdpersonalen hade låst sig vid en begränsad kunskap om ADHD istället för att se personen de hade framför sig. Studiens teoretiska referensram, Joyce Travelbees interaktionsteori, understryker betydelsen av kommunikation och interaktion i omvårdnadssituationen för att adekvat vård ska kunna ges till den unika patienten, och att en förutsättning är att sjuksköterskan vill hjälpa men också har förmågan att göra det.  Slutsats: Informanter i studien upplevde brister inom i huvudsak tre områden: tydlighet i kommunikation och struktur, respekt för deras person och autonomi samt vårdpersonalens kunskapsnivå gällande ADHD. Det är viktigt att patienter bemöts efter sina särskilda förutsättningar. Patienter med ADHD är inte en homogen grupp: graden och omfattningen av svårigheter kan skilja mycket, även mellan individer som uppfyller samma subdiagnos. Sjuksköterskan kan använda dessa kunskaper för att förbättra individanpassningen av bemötande och omvårdnad av personer med ADHD. / Background: People with ADHD often have impaired executive functions, which can hamper social interaction. Also in autism spectrum disorders executive dysfunction occurs, and here previous studies have demonstrated a need to take that into account in health-related personal treatment. There is limited knowledge about how people with ADHD are experiencing personal treatment in health care. Aim: The aim was to explore how people with ADHD are experiencing personal treatment in health care. Method: The study applied a qualitative design with descriptive approach. Semi-structured interviews were conducted with eight people with ADHD diagnosis. Results: Three main categories could be formulated on the basis of the interview material: Lack of clarity, lack of respect for individual and autonomy, and healthcare professional’s limited knowledge about ADHD. The informants experienced a lack of clarity in communication and structure and a feeling that the staff had not respected their person or autonomy. They also describe how the time factor becomes a problem: having to wait for different moments and not knowing how long they will have to wait. Ignorance of ADHD was perceived troublesome. Informants felt that caregivers often stuck to limited understanding of ADHD instead of seeing the person they had in front of them. The study's theoretical framework, Joyce Travelbee’s interaction theory, emphasizes the importance of communication and interaction in the nursing situation to care adequately for the unique patient, and that a prerequisite is that the nurse wants to help but also has the ability to do so. Conclusion: Informants in the study experienced shortcomings in mainly three areas: clarity in communication and structure, respect for their person and autonomy, as well as the healthcare professionals' level of knowledge regarding ADHD. It is important that patients are treated according to their particular conditions. Patients with ADHD are not a homogeneous group: the severity and the extent of the difficulties can be very different, even between individuals who meet the same subdiagnosis. Healthcare professional’s can use this knowledge to improve the personalization of treatment and care of people with ADHD.

Bakgrund: Kvinnor som utsätts för våld i nära relation söker oftare vård, men alla får inte den hjälp som behövs. Vårdpersonal kan sakna beredskap och kunskap för att identifiera våldsutsatta kvinnor. Oupptäckt våld i nära relation medför negativa konsekvenser för kvinnan och samhället. Syfte: Undersöka hur kvinnliga patienter upplever att få frågan om våld i nära relation, hur de vill bli tillfrågade och hur de upplever det att inte bli tillfrågad. Metod: En integrativ litteraturöversikt baserad på 10 kvalitativa artiklar från databaserna PubMed och CINAHL. Resultat: Kategorier som framkom ur resultatet var upplevelser av att bli tillfrågad, upplevelser av olika tillvägagångssätt och upplevelser av att inte bli tillfrågad. Från dessa kategorier bildades underkategorier som samlade patienters tankar och känslor. De flesta kvinnor uppskattade att bli tillfrågade om våld i nära relation, för andra uppstod det en rädsla inför frågan. Kvinnor som inte blev tillfrågade kände att de inte var prioriterade Vårdpersonalen behöver definiera våld, eftersom våldet kan ha normaliserats och deras bemötande vid tillfrågandet samt miljön har betydelse om kvinnan väljer att erkänna sin våldsutsatthet. Frågan bör ställas vid olika tillfällen. Slutsats: Frågan om våld i nära relation är uppskattad, kvinnor kan dock uppleva rädsla av att svara på frågan. Det är viktigt att sjuksköterskan vågar fråga om våldsutsatthet vid olika tillfällen och ger ett bra bemötande i en trygg miljö. Kvinnor kan känna sig mindre prioriterade om inte frågan ställs. / Background: Women that are victims of intimate partner violence seek care more often, but not all of them receive the care that they need. Caregivers can lack knowledge and preparedness to identify abused women. Undetected intimate partner violence can result in negative consequences for both the woman and society. Aim: To describe women’s experiences of being asked about violence in intimate partnership, how they want to be questioned and how they felt when they did not get the question. Method: An integrative literature review based on 10 qualitative articles from the databases PubMed and CINAHL. Results: The categories that emerged was; experiences of being questioned, experiences of different approaches, and experiences of not being asked. From these categories, subcategories were built that gathered patients’ thoughts and feelings. Most of the women appreciated being asked about intimate partner violence, but some felt scared when they got the question. Women who were not asked felt that they were not prioritized. Caregivers should define abuse, because the abuse could have been normalized. The caregivers’approach when questioning and the environment are significant if the women choose to admit they are exposed to violence. The question should be asked at different occasions. Conclusion: The question about intimate partner violence is appreciated, but it can also lead to a feeling of fear when answering the question. It is important that nurses dare to ask about violence exposure at different occasions and that the women are well treated in a safe environment. Women can experience that they are not prioritized if no one asks the question.

Dans le cadre d'une interdisciplinarité, cette thèse analyse les réseaux médico-sociaux et mesure la performance de la communication au sein même de ces réseaux.D'après les préceptes de l'épistémologie constructiviste, l'observation de la réalité scientifique repose non pas uniquement sur l'observance objective du réel mais aussi sur la connaissance du réel de par sa propre expérience. Nous avons donc mené une analyse à travers une démarche d'enquête longitudinale et prospective par questionnaires, réalisée sur 161 patientes atteintes de cancer du sein : en parallèle, des entretiens qualitatifs ont été réalisés auprès de 40 représentants du personnel soignants.Nous cherchons tout d'abord à mettre en évidence la distanciation communicationnelle entre le personnel soignants et les soignés en mettant l'accent sur l'analyse du traitement de l'information dans un but d'aider les patientes à modifier leurs schémas dysfonctionnels pour aboutir à des schémas fonctionnels par l'intermédiaire des questionnaires.Les résultats d'analyse des enquêtes quantitatives et qualitatives réalisées pendant 14 mois, nous ont permis de mettre en place une approche systémique au sein d'un établissement de santé dans le cadre d'un projet de portail communicationnel entre soignants et soignés. Les analyses prospectives ont en effet révélé l'importance des théories systémiques qui s'appuient elles-mêmes sur les théories de la communication et se fondent sur un modèle de causalité circulaire pour s'intéresser au système au sein duquel l'individu interagit. / In the context of an interdisciplinarity, this thesis analyses the socio-medical networks and the performance of communication within these networks. Following the precepts of constructivist epistemology, the observation of the scientific reality is not only based on the objective observance of the reality, but also on the experience-guided knowledge of the reality. We have thus realized an analysis throughout a longitudinal and prospective survey approach by questionnaires, within 161 breast cancer patients. In parallel, qualitative interviews were taken with 40 representatives of the health care staff.First of all, we want to highlight the communicational detachment between the health care providers and the patients by accentuating on the analysis of information handling, with the objective to help the patients to modify their dysfunctional schemas to functional schemas, via questionnaires.The analysis results from the quantitative and qualitative surveys realized during 14 months permitted us to set up a systemic approach within the health care establishment in the form of a project for a communicational portal between health care providers and patients. In fact, the prospective analyses revealed the importance of systemic theories which are themselves based on communication theories and circular causality models to be interested in the system in which the patient interacts.

Hintergrund: Häusliche Gewalt ist ein allgegenwärtiges Problem mit multiplen negativen Gesundheitsauswirkungen für Betroffene und hohen Folgekosten für das Gemeinwesen. Aufgrund der direkten und indirekten Gesundheitsfolgen nehmen Betroffene häufig medizinische Hilfe in Anspruch. Diese Kontakte sind wesentlich häufiger als die Inanspruchnahme spezifischer nichtmedizinischer Hilfeeinrichtungen. Gesundheitsfachkräften kommt hiermit eine wesentliche Rolle bei der Identifizierung häuslicher Gewalt, der Versorgung ihrer Folgen und auch der Prävention weiterer Gewalt zu. Um Fachkräfte im Gesundheitswesen für das Thema zu sensibilisieren und zu qualifizieren, wurde in den Jahren 2008-2010 das Projekt „Hinsehen – Erkennen – Handeln“ (HEH) durchgeführt. Es wurden ein Dokumentationsbogen für Sachsen sowie Informationsmaterialien für Betroffene entwickelt und gemeinsam mit dem bereits bestehenden ärztlichen Leitfaden in berufs- und fachgruppenspezifischen Veranstaltungen vorgestellt. Die Evaluation der Veranstaltungen fand kontinuierlich Eingang in die Weiterentwicklung der Materialien. Das Projekt wurde begleitet durch Befragungen von Gesundheitsfachkräften, mit einer Ersterhebung 2009 und einer Folgeerhebung 2010. Basierend hierauf beauftragte das Sächsische Staatsministerium für Gleichstellung und Integration 2015 die Erstellung eines „Maßnahmenkatalogs zur Einbindung des Gesundheitswesens in die Hilfenetzwerke zur Bekämpfung häuslicher Gewalt in Sachsen“ und in Vorbereitung dazu eine erneute Befragung aller sächsischen (Zahn-)Ärztinnen und (Zahn-) Ärzten. Die drei genannten Befragungen sind Gegenstand der hier vorgelegten Promotionsschrift. Methoden: Bei den Befragungen 2009 und 2010 wurden 4787 bzw. 4812 Fachkräfte im Gesundheitswesen angeschrieben (Angehörige des Universitätsklinikums, ambulant tätige Ärzt*innen, Psycholog*innen, Hebammen, Physiotherapeut*innen und Pflegekräfte aus Dresden und Chemnitz). Der Fragebogen umfasste 74 Items in den Bereichen: Person und Beruf, Informationsstand zum Thema, Umgang mit Betroffenen, Bekanntheit von Arbeitshilfen und Beratungsstellen, sowie Einstellung zu Fortbildungen zum Thema. Der Rücklauf betrug 1107 (23%) bzw. 788 (16%). Unter den Antwortenden der Re-Befragung 2010 befanden sich 132 von insgesamt 931 Teilnehmern von Schulungen im Rahmen des Projektes HEH. Für die Befragung 2015 wurden alle 20.712 sächsischen (Zahn-)Ärztinnen und (Zahn-)Ärzte (16.757 bzw. 3.955) angeschrieben. Der Fragebogen enthielt 78 Items in den vorgenannten Themenbereichen; zusätzlich sollte ein beigelegter Dokumentationsbogen bewertet werden. Der Rücklauf betrug 1346 (6.5%). Von den weiblichen Angeschriebenen antworteten 8,3%, von den männlichen 4,3%. Die Auswertung der Antworten erfolgte mit Hilfe deskriptiver Statistik. Vergleiche wurden durchgeführt zwischen Berufsgruppen, zwischen den Städten Dresden und Chemnitz, zwischen den Befragungszeitpunkten 2009 und 2010, sowie zwischen Schulungsteilnehmern und Nicht-Schulungsteilnehmern. Bei der Auswertung der Befragung 2015 wurden zusätzlich Beziehungen zwischen der Beantwortung einzelner Items hergestellt. Ergebnisse: a) Informationsstand zum Thema Häusliche Gewalt: Auf einer mehrstufigen Skala zur subjektiven Informiertheit lagen in den jeweiligen Gesamtkollektiven die Antworten mehrheitlich nahe dem Mittelwert; es fanden sich keine Unterschiede nach Befragungsjahren, Städten oder Berufsgruppen. Allerdings fühlten sich niedergelassene Ärztinnen und Ärzte in Dresden im Jahr 2010 signifikant besser informiert als in Chemnitz (p=0.02); in 2015 war dieser Unterschied nicht mehr vorhanden. Unter den Antwortenden 2010 fühlten sich diejenigen, die an einer Schulung teilgenommen hatten, hochsignifikant besser informiert als Nicht-Schulungsteilnehmer (p<.001); dies sowohl im Vergleich innerhalb Dresdens (Effektstärke d=0.59) als auch zwischen den Städten als auch im Vergleich mit dem Gesamtkollektiv 2009. Schränkt man die Vergleiche auf diejenigen Personen ein, die angaben, auf beide Befragungen geantwortet zu haben, war die Effektstärke zwischen Schulungsteilnehmern und Nicht-Schulungsteilnehmern aus Dresden noch etwas höher (d=0.61); zusätzlich fand sich sogar ein Unterschied unter den Nicht-Schulungsteilnehmern 2009 und 2010 (p<0.001; d=0.19). Dieser letzte Unterschied war für die Antwortenden aus Chemnitz nicht vorhanden. Gebeten um eine Schätzung der Lebenszeitprävalenz von Erlebnissen häuslicher Gewalt, antworteten in allen drei Befragungskollektiven nur ein Viertel nahe der tatsächlichen Ziffer für Frauen von 20-30%; für Männer wurde die Ziffer deutlich geringer geschätzt, wobei verlässliche epidemiologische Zahlen nicht vorliegen. Unterschiede zwischen den Untergruppen von Befragten waren nicht zu erkennen. b) Umgang mit Betroffenen: In allen drei Befragungen wurde die vermutete berufliche Kontakthäufigkeit zu Betroffenen als sehr gering eingestuft; einzige Ausnahme bildete die Berufsgruppe der Psycholog*innen. Die Bereitschaft, Betroffene anzusprechen, wurde mit 40-100% als durchaus hoch eingeschätzt, es fanden sich jedoch signifikante Unterschiede zwischen den Berufsgruppen (niedriger bei Hebammen und Pflegekräften, höher bei Ärzt*innen und Psycholog*innen). Die Zufriedenheit mit den Möglichkeiten, Betroffenen zu helfen, wurde durchweg als gering berichtet; lediglich Psycholog*innen gaben eine bessere Einschätzung. Für den Vergleich zwischen Schulungsteilnehmern und Nicht-Schulungsteilnehmern fand sich in der Befragung 2010 ein Trend (p=0.09). c) Bekanntheit von Arbeitshilfen und Beratungsstellen: Von den zur Auswahl gestellten Arbeits- und Informationshilfen war unter (Zahn-)Ärztinnen und (Zahn-)Ärzten das bundesweite Hilfetelefon (geschaltet seit 2011) mit 45% die bekannteste, gefolgt vom sächsischen Ärzteleitfaden (in allen drei Jahrgängen gleichbleibend ca. 30%). Von den örtlichen Beratungsstellen und Hilfeeinrichtungen waren in der Befragung 2015 das Institut für Rechtsmedizin (68%) und die Frauenhäuser (61%) die bekanntesten; lediglich 31% kannten die lokalen spezialisierten Beratungsstellen. In den Jahren 2009 und 2010 waren es sogar nur 9% bzw.13% gewesen. Durchweg waren die Kenntnisse in anderen Berufsgruppen deutlich geringer. Schulungsteilnehmer hatten in der Befragung 2010 signifikant höhere Kenntnisse als Nicht-Schulungsteilnehmer. Diejenigen Antwortenden 2015 mit den geringsten Kenntnissen von Informationsmaterialien und Hilfeeinrichtungen hatten auch die geringste Zufriedenheit mit der Möglichkeit zu helfen angegeben. d) Einstellung zu Fortbildungen zum Thema: Über alle Befragungen hinweg zeigten sich ca. 70% der Ärztinnen und Ärzte an Fortbildungen zum Thema interessiert. Ein zeitlicher Umfang von bis zu zwei Stunden wurde stark bevorzugt. Pflegekräfte hatten ähnliche Präferenzen, Hebammen und Psycholog*innen tendierten zu längeren Fortbildungsdauern. Von möglichen Inhalten wurden am häufigsten genannt: konkrete Handlungsanleitungen, Informationen über Beratungsstellen, rechtliche Aspekte sowie Hinweise zur Gesprächsführung mit Betroffenen. Schlussfolgerung: Die geschilderten Befragungen aus Sachsen zeigen, dass Fachkräfte im Gesundheitswesen, darunter gleichermaßen Ärztinnen und Ärzte wie Angehörige anderer Berufsgruppen, wenig vorbereitet sind, ihre wesentliche Schlüsselrolle bei der umfassenden Hilfe für Betroffene von häuslicher Gewalt einzunehmen und zur Geltung zu bringen. Sie signalisieren zwar einerseits eine hohe Bereitschaft, Betroffene anzusprechen, sehen sich in ihrer Berufsausübung aber in nur sehr geringem Kontakt zu Betroffenen und sind wenig zufrieden mit den Möglichkeiten zu helfen. Gleichzeitig ist die Kenntnis verfügbarer Informationsmaterialien und bestehender Hilfeeinrichtungen unvollständig oder sogar gering. Der offenkundige Bedarf an Awareness-Steigerung einerseits und Kenntnis-Vermittlung andererseits wurde im Projekt HEH adressiert. Die Befragungen zeigen eindeutig, dass derartig fokussierte Schulungen und Fortbildungen einen positiven Effekt haben, gleichzeitig aber, dass sie longitudinal besser verankert werden müssen. Die Befragung hat zusätzlich herausgearbeitet, dass Fortbildungen durchaus auf Interesse stoßen, und welche Formate und Inhalte dabei die größte Akzeptanz finden.:1 EINLEITUNG 1 2 HINTERGRUND: HÄUSLICHE GEWALT UND GESUNDHEITSWESEN 3 2.1 Politische Relevanz 3 2.2 Definition: Häusliche Gewalt 4 2.3 Art der Gewalttaten bei häuslicher Gewalt 4 2.4 Prävalenz häuslicher Gewalt 5 2.5 Prävalenz häuslicher Gewalt in Sachsen 7 2.6 Gesundheitliche Folgen häuslicher Gewalt 9 2.7 Schlüsselstelle Gesundheitswesen 11 2.8 Netzwerke zur Bekämpfung häuslicher Gewalt 11 2.9 Europäische Interventionsprojekte zu häuslicher Gewalt 12 2.10 Interventionsprojekte zu häuslicher Gewalt im Gesundheitswesen in Deutschland 13 2.11 Maßnahmen zum Thema häusliche Gewalt im sächsischen Gesundheitswesen 15 2.12 Maßnahmen zum Thema häusliche Gewalt in der Stadt Dresden 17 3 PROJEKT „HINSEHEN-ERKENNEN-HANDELN“ (HEH) 18 3.1 Strategisches Vorgehen 18 3.2 Digitale Verfügbarkeit der Materialien 21 3.3 Fortbildungsformate 21 3.4 Prozessbegleitung und Evaluation der Veranstaltungen 24 3.5 Fachveranstaltung und Öffentlichkeitsarbeit 25 3.6 Zielstellung: Befragungen medizinischer Fachkräfte 26 4 METHODEN 27 4.1 Befragung von Fachkräften im Gesundheitswesen im Jahr 2009 28 4.2 Re-Befragung von Fachkräften im Jahr 2010 34 4.3 Vergleich Befragung Dresden-Chemnitz 2009 und Re-Befragung 2010 36 4.4 Befragung von (Zahn-)Ärztinnen und (Zahn-)Ärzten Sachsen im Jahr 2015 37 4.5 Statistik 42 5 ERGEBNISSE 44 5.1 Ergebnisse Befragung im Jahr 2009 44 5.2 Ergebnisse Re-Befragung Fachkräfte im Jahr 2010 59 5.3 Ergebnisse Befragung im Jahr 2015 71 5.4 Befragungsergebnisse im Vergleich 83 6 DISKUSSION 98 6.1 Hauptergebnisse aus den Fragebogenuntersuchungen 98 6.2 Limitationen und Stärken der Untersuchungen 102 6.3 Klinische Implikationen und Konsequenzen für die politische Willensbildung 104 6.4 Fazit 108 7 ZUSAMMENFASSUNG 110 8 LITERATUR 117 9 TABELLEN 123 10 ABBILDUNGEN 125 11 ABKÜRZUNGEN 129 12 ANHANG 129 13 DANKSAGUNG 155 14 ERKLÄRUNGEN ZUR ERÖFFNUNG DES PROMOTIONSVERFAHRENS 156 15 ERKLÄRUNG ZUR EINHALTUNG RECHTLICHER VORSCHRIFTEN 157 / Background: Domestic violence is an omnipresent problem with multiple negative consequences for those affected and high costs for the community. Due to direct and indirect health impacts, medical attention is sought frequently. Contact with medical professionals is much more common than with specialized non-medical counseling facilities. Therefore, health care providers play a key role in the identification of domestic violence, treatment of the consequences, and thus prevention of further violence. The 2008-2010 project 'Hinsehen–Erkennen–Handeln' (HEH: Look at–Recognize-Act) was initiated in order to sensitizing and training medical professionals. Information material and a documentation form for Saxony were developed and presented at focused training modules together with existing medical guidelines. The project was flanked by two surveys of health care providers, first in 2009, then in 2010. Based on that, the Saxon Ministry of Equality and Integration in 2015 commissioned a 'Catalog of Measures for Integrating the Health Care System into the Help Network Combating Domestic Violence in Saxony'. In preparation for that, another survey of all physicians and dentists in Saxony was employed. Those three surveys are the subject of the current thesis. Methods: The 2009 and 2010 surveys were sent to 4787 and 4812 professionals, respectively (members of the university clinic, outpatient doctors, psychologists, midwives, physiotherapists and care personnel from Dresden and Chemnitz). They comprised 74 items on: personal information and profession, level of information, handling of those affected, familiarity with work aids and counseling facilities, as well as interest in continued education on the topic. The rates of return were 1107 (23%) and 788 (16%), respectively. Among those who answered in 2010 there were 132 out of a total 931 participants of training modules from the HEH project. The 2015 survey went out to all 20,712 Saxon physicians and dentists (16,757 and 3,955 respectively). It covered 78 items on the same topics. In addition, a proposed documentation form was to be evaluated. There were 1346 replies (6.5%). The rates were 8.3% for female and 4.3% for male recipients. Analysis of the answers was done by descriptive statistics. Points of comparison were: professions, the cities Chemnitz and Dresden, survey year 2009 or 2010, and participation of training modules. For the 2015 survey, relations between different items were analysed. Results: a) Level of Information about Domestic Violence: Answers on the subjective information about the topic mostly converged around the mean irrespective of year of the survey, city, or profession. However, Dresden physicians in private practice felt significantly better informed than those in Chemnitz in 2010 (p=0.02) but not so in 2009. The difference disappeared again in 2015. In 2010, those respondents who attended training modules felt themselves to be much more informed than those who did not (p<0.001), an effect which held true for the comparison within Dresden (effect strength d=0.59), between the cities, and with the 2009 survey. When limiting the comparisons to those who responded to both the 2009 and the 2010 surveys, this effect was even higher comparing Dresdners who attended training modules and those who did not (d=0.61). In addition, there was even a difference between 2009 and 2010 for respondents from Dresden who did not attend training modules (p<0.001; d=0.19), an effect that could not be observed in Chemnitz. When asked to estimate the lifetime prevalence of domestic violence, only a quarter of respondents of all three surveys came close to the actual rate for women, 20-30%. The rate for men was estimated to be significantly lower. There were no divergences between the subgroups of respondents. b) Dealing of those affected: Participants of all three surveys estimated the frequency of their professional contact with those affected to be very low, the only exception being psychologists. Readiness to approach the affected was rated relatively high with 40-100%, but significant differences were found between professions (lower for midwives and nurses, higher for physicians and psychologists). Satisfaction with options for offering help was generally low, only psychologists saw them more positive. Here, the 2010 survey showed an upward trend between those who participated in training modules and those who did not (p=0.09). c) Familiarity with work aids and counseling facilities: For physicians and dentists, among the information and work aids mentioned in the survey, the federal help hotline (started in 2011) was best known with 45%, followed by the Saxon guideline for physicians with 30% for all three surveys. In 2015, the list of local counseling and aid facilities was topped by the institute for forensic medicine (68%) and by women's shelters (61%). Only 31% of respondents knew of the more specifically dedicated local counseling facilities, a number that grew from 9% and 13% in 2009 and 2010, respectively. For other professions, familiarity with these options was markedly lower. Participation in the training modules indicated significantly higher rates of familiarity in the 2010 survey. In 2015, those with the least knowledge of informational material and counseling facilities were least satisfied with the options for offering help. d) Interest in continued education: Across all surveys, around 70% of physicians showed interest in continued education, strongly favoring units at a length of two hours. Nurses showed very similar preferences, while midwives and psychologists tended towards longer durations. The subjects most commonly called for were concrete guidelines for action, counseling facilities, legal aspects, and conversational skills. Conclusion: The surveys from Saxony show how ill prepared medical professionals are to enact their key role in the comprehensive care for people affected by domestic violence. They show a high readiness to address those affected, but estimate their professional contacts to such cases to be rare. They are unhappy with their ability to help, while having only incomplete or even poor familiarity with informational material and counseling facilities. The project HEH addressed the obvious need for raising awareness and imparting information. The surveys clearly demonstrated that offering training modules had a positive effect. However, more continued education is needed in the long run. Fortunately, there is a high interest in such training. The surveys revealed suggestions for educational subjects and formats.:1 EINLEITUNG 1 2 HINTERGRUND: HÄUSLICHE GEWALT UND GESUNDHEITSWESEN 3 2.1 Politische Relevanz 3 2.2 Definition: Häusliche Gewalt 4 2.3 Art der Gewalttaten bei häuslicher Gewalt 4 2.4 Prävalenz häuslicher Gewalt 5 2.5 Prävalenz häuslicher Gewalt in Sachsen 7 2.6 Gesundheitliche Folgen häuslicher Gewalt 9 2.7 Schlüsselstelle Gesundheitswesen 11 2.8 Netzwerke zur Bekämpfung häuslicher Gewalt 11 2.9 Europäische Interventionsprojekte zu häuslicher Gewalt 12 2.10 Interventionsprojekte zu häuslicher Gewalt im Gesundheitswesen in Deutschland 13 2.11 Maßnahmen zum Thema häusliche Gewalt im sächsischen Gesundheitswesen 15 2.12 Maßnahmen zum Thema häusliche Gewalt in der Stadt Dresden 17 3 PROJEKT „HINSEHEN-ERKENNEN-HANDELN“ (HEH) 18 3.1 Strategisches Vorgehen 18 3.2 Digitale Verfügbarkeit der Materialien 21 3.3 Fortbildungsformate 21 3.4 Prozessbegleitung und Evaluation der Veranstaltungen 24 3.5 Fachveranstaltung und Öffentlichkeitsarbeit 25 3.6 Zielstellung: Befragungen medizinischer Fachkräfte 26 4 METHODEN 27 4.1 Befragung von Fachkräften im Gesundheitswesen im Jahr 2009 28 4.2 Re-Befragung von Fachkräften im Jahr 2010 34 4.3 Vergleich Befragung Dresden-Chemnitz 2009 und Re-Befragung 2010 36 4.4 Befragung von (Zahn-)Ärztinnen und (Zahn-)Ärzten Sachsen im Jahr 2015 37 4.5 Statistik 42 5 ERGEBNISSE 44 5.1 Ergebnisse Befragung im Jahr 2009 44 5.2 Ergebnisse Re-Befragung Fachkräfte im Jahr 2010 59 5.3 Ergebnisse Befragung im Jahr 2015 71 5.4 Befragungsergebnisse im Vergleich 83 6 DISKUSSION 98 6.1 Hauptergebnisse aus den Fragebogenuntersuchungen 98 6.2 Limitationen und Stärken der Untersuchungen 102 6.3 Klinische Implikationen und Konsequenzen für die politische Willensbildung 104 6.4 Fazit 108 7 ZUSAMMENFASSUNG 110 8 LITERATUR 117 9 TABELLEN 123 10 ABBILDUNGEN 125 11 ABKÜRZUNGEN 129 12 ANHANG 129 13 DANKSAGUNG 155 14 ERKLÄRUNGEN ZUR ERÖFFNUNG DES PROMOTIONSVERFAHRENS 156 15 ERKLÄRUNG ZUR EINHALTUNG RECHTLICHER VORSCHRIFTEN 157

Bakgrund: Endometrios är en kronisk inflammatorisk sjukdom som drabbar en av tio kvinnor i fertil ålder. Vanliga symtom är intensiv smärta i samband med menstruation, kraftiga och oregelbundna blödningar, samlagssmärta och infertilitet. Det tar ofta flera år innan kvinnor får en diagnos vilket medför ett stort lidande. Forskning om endometrios går framåt men det finns fortfarande okunskap inom vården och vårdpersonalen behöver fortbildning för att kunna ge stöd och råd. Den teoretiska referensram som användes var Joyce Travelbees omvårdnadsteori samt personcentrerad omvårdnad. Syfte: Att belysa hur kvinnor med endometrios upplever bemötandet i vården. Metod: Litteraturstudien genomfördes med en kvalitativ ansats. Efter kvalitetsgranskningen återstod tio artiklar som användes i litteraturstudien. Resultat: De tio artiklar som ligger till grund för resultatet kommer från Sverige, Ungern, Australien, Storbritannien och Nederländerna. Dataanalysen genererade i tre kategorier: Vårdpersonalens förminskande attityd, Kunskap och information samt Fertilitet, med sex subkategorier som representerade olika aspekter av upplevelsen av bemötandet i vården. Kvinnorna upplevde att de fört en kamp under flera år för att få en diagnos, vårdpersonalen tog dem inte på allvar samt normaliserade deras symtom. Kvinnorna upplevde även att vårdpersonalen hade bristande kunskaper om sjukdomen samt fokuserade för mycket på fertiliteten. Positiva upplevelser var när vårdpersonalen lyssnade och bekräftade dem. Konklusion: Kvinnorna hade övervägande negativa upplevelser av bemötandet i vården och saknade stöd från vårdpersonalen. Det är viktigt att höja kunskapsnivån för att minska det långdragna lidandet. Sjuksköterskan behöver arbeta empatiskt och personcentrerat för att kunna tillgodose kvinnornas behov. / Background: Endometriosis is a chronic inflammatory disease that affects one in ten women in their fertile age. Typical symptoms of endometriosis are dysmenorrhea, heavy irregular bleedings, dyspareunia and infertility. The diagnostic delay is often many years, which could cause suffering. Research of endometriosis is progressing, yet there still exists ignorance in health care and health care staff need training to be able to provide support. The theoretical frameworks used were the nursing theory by Joyce Travelbee and person-centered nursing. Aim: To illustrate how women with endometriosis experience health care encounters. Method: The literature review was performed with a qualitative approach. After the quality review ten articles remained that were included in the literature review. Results: The ten articles used in the literature review came from Sweden, Hungary, Australia, United Kingdom and the Netherlands. The data analysis generated three categories: Health care provider ́s diminishing attitude, Knowledge and information and Fertility, with six subcategories that represented different aspects of the experience in the health care encounter. The women fought several years to get a diagnosis, health care providers did not take them seriously and normalized their symptoms. The women also felt that the health care providers lacked knowledge about the disease and focused too much on fertility. Positive health care encounters were when the health care providers listened and confirmed them. Conclusion: Women mostly had negative experiences of health care encounters and lacked support from the health care staff. It is significant to raise the level of knowledge in order to reduce women’s suffering from the disease. The nurse needs to work empathically with a person-centered approach to be able to meet the women’s needs.