Licentiatavhandlingar / Institutionen för medicin
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Item Environmental determinants of healthy eating in a Swedish region - Food promotions and the COVID-19 pandemic(2025) Mjöberg, MelissaPurpose: The overall purpose of this thesis was to examine selected food environments in relation to healthy diets in Western Sweden. Specifically, we investigated food marketing and pandemic policy restrictions as environmental factors that can impact diet and lifestyles. Methods: Study I employed a quantitative content analysis of weekly supermarket advertisements. Food promotions were categorized by healthfulness according to the Nordic Nutrition Recommendations and linked to store locations stratified by a socioeconomic index. Categorical data were summarized using frequencies, percentages, and 99% confidence intervals [CI]. Logistic regression analyses assessed the association between area-level disadvantage and the promotion of unhealthy foods. Study II is a qualitative study involving semi-structured interviews with youth participants from the Swedish IDEFICS/I.Family cohort. Topics included diet, physical activity, sleep, and general well-being. Interviews were transcribed verbatim and analyzed using reflexive thematic analysis. Results: In Study I, a total of 488 advertisement sheets were collected over four weeks, comprising 29,958 individual food promotions. Of these, 66.7% were classified as either ‘unhealthy’ or ‘most unhealthy.’ Food items promoted in less advantaged areas had 25% higher odds of being ‘most unhealthy’ (OR 1.25; 99% CI: 1.17–1.33). However, the association was attenuated when adjusting for clustering at the chain. In Study II, fourteen youths aged 15–21 participated. The thematic analysis generated three key themes: Living off the clock – disrupted routines indicate that youths’ organized activities contribute to a daily structure which were disrupted during the pandemic and led to more irregular lifestyle habits. Disconnected yet digitally connected – the remote life paradox reflects that youths spent more time online during the pandemic and became socially disconnected from others than their family members. v Increased household impact on the health of meals refers to how the availability of food in the youths’ living environment changed during the pandemic, which affected their eating habits. Conclusion: These studies highlight how structural factors, such as food marketing practices and pandemic-related disruptions, operate across societal levels, shaping peoples’ food environments, and potentially counteracting healthy eating at the individual level. Further research is warranted to explore how these determinants interact within the Swedish context and to identify leverage points for promoting healthier dietary behaviors.Item Patients' experiences and effects of dietary changes when living with irritable bowel syndrome - Various impacts of dietary treatment(2024) Weznaver, CeciliaIrritable bowel syndrome (IBS) is a complex disorder of gut-brain interaction. The causal explanations for this condition remain unclear, however, dietary factors appear to play a significant role in symptom generation and alleviation for these patients. The aim of this thesis was to gain more knowledge about the role of diet concerning the severity of IBS symptoms and the patients' perceived experiences to implement the requested dietary changes to achieve alleviation in IBS. In Paper I, we compared two restrictive dietary treatments and medical treatment for patients with IBS in a 4-week randomized controlled trial (RCT) including 294 participants. Although all three treatments showed significant alleviation in the severity of IBS symptoms, both dietary groups showed a more pronounced effect than in the medical treatment. The dietary groups also presented a lasting effect on improvements in gastrointestinal (GI), extraintestinal, and psychological symptoms over 6 months. In Paper II, inductive content analysis was used to investigate the participants' experience of implementing the dietary changes included in the dietary treatments in the RCT (Paper I). Three themes describe the dietary changes as Supportive, educational, and motivating, Multidimensional challenges, and Reflective and developing. The need for support to initiate the dietary changes became clear. Despite structured support, the dietary changes were experienced as challenges and were related to the participants' personal life situation. Going through the dietary changes started a process that resulted in more than a reduction in the severity of GI symptoms, it also gave new knowledge and diet-related reflections, and where maintained dietary changes were related to what was perceived to be practical and healthy habits. In summary, the results from this thesis confirm that diet plays an important role in the treatment of IBS. Restrictive dietary treatments reduce the burden of symptoms in IBS. With the support to implement the dietary changes for patients with IBS, a process can be initiated that leads to individualized adjusted dietary changes that are varied and can be maintained in the long term.Item Dietary quality, greenhouse gas emissions related to food consumption, and human health: A population-based cohort study in northern Sweden(2022) Strid, AnnaThe overall aim of this thesis was to assess dietary quality and dietary-related greenhouse gas emissions (GHGEs), and their association with health outcomes, in a population-based cohort in northern Sweden. Dietary data were collected among participants within the cohort Västerbotten Intervention Programme by a food frequency questionnaire between 1990–2016. Dietary GHGEs were estimated using the RISE Food and Climate Database. Dietary nutrient density was calculated by the Nutrient Rich Foods (NRF) index in Study I and Study II. In Study I, fifteen variants of the NRF index were evaluated and the index version that best predicted all-cause mortality was further used to estimate participants' nutrient density in Study I and Study II. In Study III, diet quality was assessed by the Swedish Healthy Eating Index for Adults 2015 (SHEIA15), based on the 2015 Swedish food-based dietary guidelines. Cox proportional hazard regressions were performed to investigate associations between dietary aspects and health outcomes. Study I investigated associations between the NRF index and all-cause mortality, as well as associations between diets with varying levels of nutrient density and GHGEs, and all-cause mortality. The NRF11.3 index was indicated as a predictor of mortality hazard. The study also showed that diets with higher nutrient density and lower GHGEs were associated with lower mortality hazards in women, and that diets with lower nutrient density and lower GHGEs were associated with higher mortality hazards in men. Study II investigated associations between diets with different levels of nutrient density and GHGEs, and myocardial infarction (MI), and stroke. The NRF11.3 index was not indicated as a predictor of MI or stroke. A negative association was however shown between diets with lower GHGEs and MI hazard in men. Study III investigated the association between SHEIA15, and both all-cause mortality and dietary GHGEs. Lower all-cause mortality hazards and lower dietary GHGEs were indicated with higher SHEIA15 scores. This thesis demonstrated both potential co-benefits and trade-offs between dietary quality, GHGEs of self-reported diets, and health outcomes in a Swedish population. Furthermore, two indices assessing different aspects of dietary quality of Swedish diets were suggested as predictors of all-cause mortality, of which one was further suggested as a predictor of dietary GHGEs.Item Men and Masculinities in Sexual Healthcare: Exploring Notions and Discourses among Healthcare Professionals(2022) Persson, TommyAim: Healthcare professionals (HCP) have been described as vital for men’s experiences of sexual healthcare (SHC). However, HCPs in SHC have to a low extent been included in research on men and masculinity. The aim of this thesis was to explore HCPs’ attitudes, notions and discourses on men and masculinities in the SHC context. Notions about men and masculinities were explored in Study I. How HCPs construct gendered social location in SHC was explored in Study II. Methods: Data were gathered through seven focus group interviews (n=35) with HCPs working with men’s SHC at a primary healthcare clinic and at sexual health clinics in Sweden. HCPs notions of men and masculinities were analysed using qualitative content analysis. The construction of the gendered social location in SHC was analysed using critical discourse analysis. Results: In the analysis we identified that notions of men and masculinities were elusive and hard to grasp but easy to exemplify with normative, idealised and stereotypical masculinity. Further, men and masculinities seemed to be potentially challenging, and some types of masculinities were considered more challenging and situated further from the idealised masculinity. Experienced organisational deficiencies, lack of education and training on men’s sexual health and notions of men and masculinities appeared as interrelated. Moreover, we identified that masculinity was considered as something that should be disregarded to stay gender neutral in relation to patients in SHC and that notions of masculinities were situated in a context of personal and private relationships. Romantic and sexual preferences were used to describe preferable masculinity. In the analysis of how the gendered social location in SHC was constructed we found that SHC was positioned in opposition to masculinity in society, which was described as unconducive with SHC. Furthermore, HCPs’ discourses did not reflect a shared approach to men and masculinity and HCPs seemed to lack a shared professional discourse on masculinity. We identified compensatory strategies for the lack of professional discourse. Another finding was that SHC, as an arena, was construed as predominantly feminine in descriptions of its history, practice, staff and patients. The analysis identified that masculinity was constructed as a violation of norms and as a problem that men in SHC need help with. The discourses seemed to position HCPs as agents of change with a mission to transform masculinity, and men as reluctant patients that need extra efforts. Conclusion: The findings in this qualitative study indicate that HCPs balance private and professional notions of men and masculinities in SHC, and that the discourses on men and masculinities might lead to othering, rather than including, the diversity of men. A shared approach and professional discourse to men and masculinities could contribute to the creation of a more consistent and knowledge-based treatment of men. To achieve this and to manage the experienced organisational and educational challenges health system interventions are needed, including training and education on men’s sexual health, gender and masculinities. Future studies are needed to further explore HCPs’ experiences, and in particular, how HCPs’ attitudes, notions and discourses are associated with treatment seeking and satisfaction for men in need of SHC.Item Osteoporosis in murine SLE - Treatment with a tissue-selective estrogen complex(2021-10) Nordqvist, JauqulineSystemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting mainly young women. Almost every organ in the body can be affected and SLE patients often suffer from co-morbidities such as cardiovascular disease and osteoporosis. Postmenopausal women with SLE have a three-fold increase in fractures compared with the healthy population. Treatment with bisphosphonates is associated with side effects and newer anti-osteoporotic treatments need to be tested in SLE patients. MRL/lpr mice spontaneously develop lupus-like symptoms. We show that ovariectomized MRL/lpr mice also develop an osteoporotic bone phenotype and can be used as a model for osteoporosis in postmenopausal SLE. Estrogen has been known to worsen SLE, however there are also contradictory findings available. A tissue-selective estrogen complex (TSEC) comprising estrogen and a selective estrogen receptor modulator (SERM) facilitates the positive effects by estrogen on for example bone, while the negative estrogenic effects on for example the endometrium is blocked by the SERM. The TSEC consisting of conjugated estrogens and the SERM Bazedoxifene (Bza) is approved for treatment of vasomotor symptoms and prevention of postmenopausal osteoporosis. In this thesis we show that treatment with TSEC and Bza protects from trabecular bone loss in ovariectomized MRL/lpr mice, without affecting uterus or lupusassociated disease parameters. B lymphopoiesis and antibody production are regulated by estrogens. We show that TSEC share the estrogenic inhibitory effect on B lymphopoiesis and stimulatory effect on antibody production in healthy mice. These findings have increased the knowledge regarding TSEC as a potential future drug for treating osteoporosis in postmenopausal SLE patients.Item Critical conditions for co-workership in healthcare organizations: A workplace health promotion perspective(2018) Bergman, Caroline; Department of Public Health and Community Medicine, Institute of Medicine; Sahlgrenska akademin, Göteborgs universitetThe workplace is well-established as one of the priority settings for promoting health in a large population. To achieve a good work environment, cooperation between managers and employees is essential. However, there is a large discrepancy between the amount of management and leadership research that has been performed and the amount of research investigating the impact of important factors of co-workership. Thus, the overall aim of this thesis was to increase knowledge about critical conditions for co-workership in healthcare organizations from the employee’s point of view. This thesis has also a practical aim of providing information that can be used and applied in establishing a holistic and sustainable health-promoting workplace. A qualitatively-driven mixed-methods approach was applied, combining different qualitative methods to gather and analyze data. Study I used data collected through observations, interviews, focus group interviews, and feedback seminars, analyzed with content analysis and descriptive statistics. Study II used data collected from twelve focus group interviews with 68 employees, analyzed with phenomenography. The results from Study I show that the communication flow and organization of the observed meetings varied in terms of physical setting, frequency, time allocated, and duration. The topics for the workplace meetings were mainly functional with a focus on clinical processes. Overall, the meetings were viewed not only as an opportunity to communicate information from the top downwards, but also as a means by which employees could influence decision-making and development at the workplace. The results from Study II show that the phenomenon of coworkership was experienced as a collective process, which included colleagues but not did explicitly include managers. Five categories emerged, representing different conceptions of co-workership: group coherence and striving toward a common goal, cooperation over professional and organizational boundaries, work experience and trusting each other’s competence, social climate and sense of community, and participation and influence. The conclusion of this thesis is that conditions such as participation and influence, social support, and communication were mostly related to the employees’ everyday work, especially the clinical work, and were not seen in relation to the overall organization. Workplace meetings seemed to be a well-functioning setting for conditions of importance for co-workership, although the outcomes of these meetings varied to a large extent. This knowledge provided in this thesis can be of importance for future strategies to develop health-promoting workplaces.Item FENO and polymorphisms in the NOS genes SNP- and haplotype-based association analyses(2013) Dahgam, Santosh; Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of GothenburgKoncentrationen av kväveoxid i utandningsluft (FENO) är en biomarkör för inflammation i luftvägarna. Variabiliteten mellan individer i FENO är betydande i den allmänna populationen och faktorer som bidrar till variabiliteten är bl.a. fysiologiska, genetiska samt miljöfaktorer. Syftet med studierna i denna avhandling var att tillämpa metoder inom bioinformatik för att karaktärisera variationen hos de tre kväeoxidsyntasgenerna NOS1; NOS2 och NOS3 genom att använda en metod baserad på s.k. tag-SNPar (markör-varianter med förändring i en DNA bas) samt utvärdera det genetiska bidraget till variation i FENO-nivåer hos vuxna. I delarbete 1 utfördes först analys av sambandet mellan 49 SNPar i de tre NOS generna och FENO, en SNP i taget, i en studie-population av 1733 individer. Baserat på graden av association skapades en lista av rangordnade SNPar som sedan användes i en framåt stegvis regressionsanalys för att identifiera ett mindre antal SNPar med starkast oberoende association. Två SNPar (rs9901734 and rs3729508) i NOS2 och en SNP (rs7830) i NOS3 visade oberoende association med FENO-nivå. Individer med NOS2 SNP rs9901734 hade 5.3% (95% CI, 1.0% – 9.7%) högre FENO-nivåer för varje Gallel, och individer med genotyperna CC eller CT NOS2 för SNP rs3729508 hade 9.4% (95% CI 3.1% – 15.2%) högre FENO-nivåer jämfört med TT genotyp. Individer med GT eller TT genotyp i NOS3 SNP rs7830 hade 5.6% (95%CI, 0.4% – 11.1%) högre FENO-nivåer jämfört med GG genotypen. Effekten av denna SNP var starkare hos individer med astma: 21.9%, 95% CI 4.6% – 42.0%. I delarbete 2 undersöktes sambandet mellan haplotyper i NOS2 genen och FENO hos 5912 individer. Tio SNPar utspridda över hela NOS2 genen valdes ut baserat på tidigare kunskap om association med FENO. Sju haplotyper kunde urskiljas, och dessa representerade 84% av alla haplotyper. En haplotyp ('ACCTT)' var signifikant associerad med lägre FENO-nivåer och tre haplotyper ('ACCTC', 'GGCTC' and 'GGCTT') var signifikant associerade med högre FENO-nivåer jämfört med referens-haplotypen ('ACTCT'), med ett globalt p-värde på 3.8×10-28 för haplotyp-distributionen. Associationen mellan haplotyp 'ACCTT' och FENO varierade med astma-status. Sammanfattningvis tyder resultaten på att NOS2 är den av NOS-generna som har störst inverkan på variabiliteten av FENO hos den friska, vuxna befolkningen, och även spelar en roll hos individer med astma. Dessutom indikerande resultaten att en SNP i NOS3 (rs7830) samt en specifik haplotyp ('ACCTT') i NOS2 bidrog mer till variationen av FENO hos individer med astma. Analysen med haplotyper i NOS2 genen kunde påvisa det NOS2-relaterade bidraget till variationen i FENO starkare än analysen med individuella SNPar. Denna studie understryker också potentialen med att kombinera SNP- och haplotyp-baserade metoder för att identifiera och karaktärisera NOS-genernas bidrag till variation i FENO.Item Creating proactive boundary awareness - Observations and feedback on lowerlevel health care managers’ time commitments and stress(2012) Tengelin, EllinorAim. The aim of this thesis was to deepen the knowledge concerning health care managers’ everyday work experiences and their handling of stress and balance. Background. Health care managers’ work is characterized by daily hassles, conflicting perspectives, and unclear boundary setting. They could therefore use support in boundary and stress management. Methods. A qualitatively driven mixed methods approach was used. Qualitative interviews, focus groups and workplace observations were used for data collection in Study I. Physiological stress indicators, stress self-assessments, workplace observations and interviewing were used in Study II. Analyses were mainly carried out on the interview data, using grounded theory methodology (Study I) and conventional content analysis (Study II). Results. Paper I shows that a first step in managers’ boundary setting is to recognize areas at work with conflicting expectations and inexhaustible needs. Strategies can then be formed through proactive, continuous negotiating of their time commitments. These strategies, termed ‘boundary approaches’, are more or less strict regarding the boundary setting at work. Paper II shows that nonnormative, interactive feedback sessions could encourage understanding and meaningfulness of previous stress experiences through a two-step appraisal process. In the first appraisal in the study, feedback was spontaneously reacted on, while in phase two it was made sensible and given meaning. However, during the sessions, some obstacles appeared to managers’ learning about their stress, preventing a second appraisal of the feedback. Conclusions. Awareness and continuous negotiation regarding boundary dilemmas can be effective as a proactive stress management tool among managers. Further, non-normative feedback on stress indicators may initiate key 3 processes of sensemaking which can aid managers’ stress management by increasing awareness and supporting learning about their stress. Proactive boundary awareness is a concept leading to better understanding of lower-level managers’ management of their time commitments and stress, which can be supported by continuous reflection, feedback situations and a supportive context.Item Asthma and COPD Diagnoses and prescriptions in Swedish primary care(2012) Weidinger, PaolinaAims: The overall aim of this thesis was to evaluate the quality of the diagnoses and the prescribing of medication to patients with asthma and COPD (Chronic Obstructive Pulmonary Disease) in Swedish primary care. The specific aims were to study the adherence to recommended guidelines and quality indicators in diagnosis and treatment of patients with asthma and COPD and to survey the relationship between the diagnosis of asthma/COPD and the prescribing of asthma/COPD medication. Methods: All visits to health care centres in Skaraborg, Sweden, are documented in computerized medical records constituting the Skaraborg Primary Care Database (SPCD). In a register-based retrospective observational study, all patients were identified; patients diagnosed with asthma or COPD during 2000–2005 (n = 12,328) and all individuals with at least one prescription of asthma/COPD medication issued during 2004–2005 (n = 14,101) regardless of diagnoses. In a detailed analysis for a 5 % random sample (n = 945) data from patients’ medical records were manually extracted. Information on performed investigations at initial visits and at follow-up was collected and compliance with procedures as recommended by national guidelines was used for quality assessment. For prescriptions information about indication, number and type of prescriptions was retrieved. Results: Among 499 patients with asthma 167 (33 %) were investigated with spirometry or Peak Expiratory Flow (PEF) during initial visits in agreement with guidelines. Correspondingly, 40 out of 124 patients with COPD (32 %) were investigated with spirometry. During follow-up evaluation in agreement with guidelines was performed on 130 (60 %) of patients with asthma and on 35 patients out of 77 (45 %) with COPD. The prescribing of inhaled corticosteroids (ICS) reached quality target, still every second patient with asthma made an acute visit during follow-up. Asthma/COPD medication was prescribed in primary care to approximately 6 % of the total population in Skaraborg. In total 54 % of the medication users had recorded diagnoses of asthma, COPD or both. Consequently 46 % had no recorded asthma/COPD diagnosis. The incongruence between diagnosis and medication was present in all age-groups. Among patients with recorded asthma 37 % had no medication prescribed. Conclusions: • There is incongruence between diagnoses of asthma or COPD and prescription of medication, consistent in all age-groups, which indicates that the levels of asthma/COPD medication cannot be used as proxy for asthma/COPD disease prevalence. • Asthma/COPD medication is often prescribed outside recommendations and used both as a diagnostic tool and in an offlabel manner. • Patients with asthma seem to be inadequately treated, since approximately one third of all patients with recorded diagnoses of asthma are non-medicated, one third use medication sparsely and only one third use medication continuously. • Adherence to recommended guidelines is low since only one third of the patients with diagnoses of asthma or COPD during initial visits, and about half of the patients during follow-up, had a clinical evaluation, including spirometry or PEF, in agreement with recommendations. • The prescribing of ICS-treatment reaches the quality indicator target, still patients with asthma seem to be uncontrolled in their disease, since acute visits were common, indicating that treatment targets are not reached and that adherence to medication is low. • There is substantial room for quality improvement in the clinical evaluation of patients with asthma and COPD and there is a need to observe the extent of off-label prescribing in asthma/COPD medication.Item Betydelsen av personlighet och uppfattning om läkemedel för följsamhet till astmamedicinering(2010) Emilsson, MariaEn okontrollerad astma kan leda till komplikationer i lungor och luftvägar. Astma kan kontrolleras med läkemedelsbehandling men fullständig astmakontroll uppnås inte alltid. Den vanligaste orsaken till att astmakontrollen inte uppnås är brister i följsamheten till astmamedicinering. Syfte: 1) Att undersöka om personlighetsdrag hos unga vuxna med astma var relaterad till astmakon-troll och hälsorelaterad livskvalitet, samt belysa samband mellan personlighetsdrag och följsamhet till regelbunden astmamedicinering. 2) Att belysa samband mellan personlighetsdrag, uppfattning om läkemedel och följsamhet till astmamedicinering. Material och metod: I Studie I ingick 268 individer (165 kvinnor och 103 män) i åldern 22 år (±1år). I Studie II ingick 35 patienter (25 kvinnor och 10 män) med en medelålder av 52.8 år. I studierna an-vändes frågeformulär för att samla in data om personlighet, följsamhet, astmakontroll, hälsorelaterad livskvalitet och uppfattning om läkemedel. Resultat: Personlighet hade samband med följsamhet till astmamedicinering, uppfattningar om läke-medel, astmakontroll och hälsorelaterad livskvalitet. I Studie I framkom att de som skattade sig mer impulsiva rapporterade lägre följsamhet. Ett negativt samband fanns mellan höga värden i personlig-hetsdraget alexitymi (bristande intresse att förstå och prata om känslor) och följsamhet till astmamedi-cinering hos unga vuxna män. Likaledes framkom ett negativt samband mellan personlighetsdraget antagonism och följsamhet hos unga vuxna män. Hos båda könen var personlighetsdraget negativ af-fektivitet relaterat till dåligt kontrollerad astma. Det indikerades att personlighet kan påverka den men-tala hälsan hos både unga kvinnor och män, medan den fysiska hälsan hade samband med astmakon-troll och fysisk aktivitet. I Studie II framkom att fyra av fem personlighetsdrag hade samband i olika riktningar med uppfattningar om läkemedel. Högt värde i Specefikt-nödvändighetsskalan (uppfattning om nödvändigheten av förskrivna läkemedel) var relaterat till hög grad av följsamhet. Personlighets-draget målmedvetenhet var relaterat till hög följsamhet hos män. Känslomässig instabilitet hade sam-band med lägre värden i följsamhet också hos män. Konklusion: Kunskapen om personlighetens betydelse behöver fördjupas, men uppsatsens resultat indikerar behovet av att identifiera individuella skillnader i personlighet för att öka patienternas följ-samhetsbeteende, stärka deras uppfattning om nödvändigheten av läkemedelsbehandling och minska deras oro för läkemedelsbehandling, vilket har betydelse för både astmakontroll och hälsorelaterad livskvalitet.