Publications by authors named "Anncristine Fjellman-Wiklund"

36 Publications

Gender matters in physiotherapy.

Physiother Theory Pract 2021 Sep 1:1-14. Epub 2021 Sep 1.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

The World Health Organization states that gender has implications for health across the course of a person's life in terms of norms, roles and relations. It also has implications in rehabilitation. In this article, we argue the need of gender perspectives in the field of physiotherapy; gender matters and makes a difference in health and rehabilitation. We highlight a number of central areas where gender may be significant and give concrete examples of social gender aspects in physiotherapy practice and in diverse patient groups. We also discuss why it can be important to consider gender from an organizational perspective and how sociocultural norms and ideals relating to body, exercise and health are gendered. Further we present useful gender theories and conceptual frameworks. Finally, we outline future directions in terms of gender-sensitive intervention, physiotherapy education and a gendered application of the ICF model. We want to challenge physiotherapists and physiotherapy students to broaden knowledge and awareness of how gender may impact on physiotherapy, and how gender theory can serve as an analytical lens for a useful perspective on the development of clinical practice, education and research within physiotherapy.
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http://dx.doi.org/10.1080/09593985.2021.1970867DOI Listing
September 2021

Retrospective experiences of individuals two decades after anterior cruciate ligament injury - a process of re-orientation towards acceptance.

Disabil Rehabil 2021 Aug 13:1-10. Epub 2021 Aug 13.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Purpose: Individual perspectives of long-term consequences decades after anterior cruciate ligament (ACL) injury are unexplored. We addressed experiences and the impact on life of former athletes >20 years post-ACL injury.

Methods: Individual interviews, analysed using Grounded Theory, were conducted with 18 persons injured mainly during soccer 20-29 years ago.

Results: A theoretical model was developed with the core category overarching three categories illustrating the long-term process post-injury. Initially the persons felt like disaster had struck; their main recall was strong pain followed by reduced physical ability and fear of movement and re-injury. In the aftermaths of injury, no participant reached the pre-injury level of physical activity. Over the years, they struggled with difficult decisions, such as whether to partake or refrain from different physical activities, often ending-up being less physically active and thereby gaining body weight. Fear of pain and re-injury was however perceived mainly as psychological rather than resulting from physical limitations. Despite negative consequences and adjustments over the years, participants still found their present life situation manageable or even satisfying.

Conclusion: ACL injury rehabilitation should support coping strategies e.g., also related to fear of re-injury and desirable physical activity levels, also with increasing age.IMPLICATIONS FOR REHABILITATIONMore than 20 years after the ACL injury, the individuals despite re-orientation towards acceptance and a settlement with their life situation, still had fear of both pain and re-injury of the knee, with concerns about physical activity and gaining of body weight.Patients with ACL injury may need better individual guidance and health advice on how to remain physically active, to find suitable exercises and to maintain a healthy body weight.Education related to pain, treatment choices, physical activity, injury mechanisms in participatory discussions with the patient about the ACL injury may be beneficial early in the rehabilitation process to avoid catastrophizing and avoidance behaviour.ACL injury rehabilitation needs to address coping strategies incorporating the psychological aspects of suffering an ACL injury, including fear of movement/secondary injury, in order to support return-to-sport and/or re-orientation over time.
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http://dx.doi.org/10.1080/09638288.2021.1962415DOI Listing
August 2021

Conceptualizing the clinical decision-making process in managing temporomandibular disorders: A qualitative study.

Eur J Oral Sci 2021 Jun 17:e12811. Epub 2021 Jun 17.

School of Dental Sciences, Newcastle University, Newcastle, UK.

Management of patients with temporomandibular disorders (TMD) appears to be more challenging than for other dental conditions. This study aimed to explore the decision-making process in TMD management, and thereby to conceptualize the decision-making process in dentistry. Individual semi-structured interviews were conducted during 2018 and 2019 with a purposive sample of 22 general dental practitioners from the Public Dental Healthcare Services and private practices in the Region of Västerbotten, Northern Sweden. The interviews were analysed using the Grounded Theory approach of Charmaz. Data analysis resulted in the core category 'Combining own competence and others' expectations in the desire to do the right thing'. The dentists showed interest in and a desire to apply professional knowledge, but also reflected on challenges and complexity in the decision-making process for TMD. The challenges were primarily related to organisational factors and lack of self-confidence. This identifies a need for re-organisation of daily clinical management in dentistry, and a need for more postgraduate training to improve self-confidence. The complexity of the decision-making process for TMD makes the study findings applicable in other dental situations.
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http://dx.doi.org/10.1111/eos.12811DOI Listing
June 2021

How children and adolescents with juvenile idiopathic arthritis participate in their healthcare: health professionals' views.

Disabil Rehabil 2020 Sep 2:1-8. Epub 2020 Sep 2.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Background: The study explores how healthcare professionals view participation of children and adolescents with juvenile idiopathic arthritis, in healthcare encounters.

Methods: This qualitative study includes focus groups of HCPs from different professions. The interviews were analysed with qualitative content analysis.

Results: The theme "Creating an enabling arena" illuminates how HCPs face possibilities and challenges when enabling children to communicate and participate in clinical encounters. HCPs, parents, and the healthcare system need to adjust to the child. The sub-theme "Bringing different perspectives" describes how children and their parents cooperate and complement each other during healthcare encounters. The sub-theme "Building a safe and comfortable setting" includes how HCPs address the child's self-identified needs and make the child feel comfortable during encounters. The sub-theme "Facilitating methods in a limiting organisation" includes how HCPs' working methods and organization may help or hinder child participation during encounters.

Conclusions: HCPs encourage children and adolescents to make their views known during healthcare encounters by creating an enabling arena. Collaboration and building good relationships between the child, the parents and the HCPs, before and during the healthcare encounters, can help the child express their wishes and experiences. Clinical examinations and use of technology, such as photos, films and web-bases questionnaires can be a good start for a better child communication in healthcare encounters.IMPLICATIONS FOR REHABILITATIONHealthcare professionals in JIA teams experience that they can facilitate communication and participation with children and adolescents in healthcare encounters.When healthcare professionals enable both children, adolescents and their parents to bring their perspectives, these views complement one another and enrich information during healthcare encounters.Children and adolescents are more empowered to participate, when healthcare professionals create a good relationship with the child and their parents, and strengthen the child's knowledge, confidence and autonomy.
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http://dx.doi.org/10.1080/09638288.2020.1811406DOI Listing
September 2020

Restoring confidence in return to work: A qualitative study of the experiences of persons with exhaustion disorder after a dialogue-based workplace intervention.

PLoS One 2020 31;15(7):e0234897. Epub 2020 Jul 31.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Background: Stress-induced exhaustion disorder (SED) is a primary cause for sickness absence among persons with mental health disorders in Sweden. Interventions involving the workplace, and supporting communication between the employee and the supervisor, are proposed to facilitate return to work (RTW). The aim of this study was to explore experiences of persons with SED who participated in a dialogue-based workplace intervention with a convergence dialogue meeting performed by a rehabilitation coordinator.

Methods: A qualitative design based on group interviews with 15 persons with SED who participated in a 24-week multimodal rehabilitation program was used. The interviews were analyzed with the methodology of grounded theory.

Results: The analysis resulted in a theoretical model where the core category, restoring confidence on common ground, represented a health promoting process that included three phases: emotional entrance, supportive guidance, and empowering change. The health promoting process was represented in participant experiences of personal progress and safety in RTW.

Conclusions: The intervention built on a health-promoting pedagogy, supported by continuous guidance from a rehabilitation coordinator and structured convergence dialogue meetings that enhanced common communication and collaboration with the supervisor and others involved in the RTW process. The intervention balanced relationships, transferred knowledge, and changed attitudes about SED among supervisors and colleagues in the workplace. The inclusion of a rehabilitation coordinator in the intervention was beneficial by enhancing RTW and bridging the gaps between healthcare, the workplace, and other organizational structures. In addition, the intervention contributed to a positive re-orientation towards successful RTW instead of an endpoint of employment. In a prolonged process, a dialogue-based workplace intervention with convergence dialogue meetings and a rehabilitation coordinator may support sustainable RTW for persons with SED.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234897PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394387PMC
September 2020

Hopeful struggling for health: Experiences of participating in computerized cognitive training and aerobic training for persons with stress-related exhaustion disorder.

Scand J Psychol 2020 Jun 29;61(3):361-368. Epub 2020 Jan 29.

Department of Psychology, Umeå University, Umeå, Sweden.

It is important to understand how people with exhaustion disorder (ED) perceive interventions aiming to facilitate cognitive functioning. Therefore, the overall aim of this study was to explore experiences from persons with ED after participating in a 12-week intervention of either computerized cognitive training or aerobic training. Both interventions were performed in addition to a multimodal rehabilitation programme. Thirteen participants, 11 women and 2 men, were interviewed about pros and cons with participating in the training. The interviews were analysed with Qualitative Content Analysis. The analyses resulted in the theme hopeful struggling for health and the categories support, motivation and sensations. It was hard work recovering from ED. Support from others who are in the same situation, family members, and technology and routines for the training were strongly emphasized as beneficial for recovery. Timing, i.e., matching activities to the rehabilitation programme, getting feedback and perceiving joy in the training were important for motivation. Participants in both interventions experienced positive sensations with improved memory performance, everyday life functioning and increased faith in the prospect of recovery. However, it is important to consider various aspects of support and motivation in both computerized cognitive training and aerobic training to enable participants to pursue their participation.
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http://dx.doi.org/10.1111/sjop.12623DOI Listing
June 2020

Implementing a Physical Activity Promoting Program in a Flex-Office: A Process Evaluation with a Mixed Methods Design.

Int J Environ Res Public Health 2019 12 18;17(1). Epub 2019 Dec 18.

Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, 90187 Umeå, Sweden.

The aim of this study was to investigate facilitating and hindering factors when implementing a physical activity (PA)-promoting program among office workers moving to a flex office, by conducting a process evaluation. Additionally, we evaluated self-reported and perceived PA behaviors. With a mixed methods design, analyses were based upon data from interviews with 70 employees and repeated questionnaires from 152 employees. The PA-promoting program was fully implemented and supported by management. There was a strong health promoting culture, encouraging PA in the organization already at the start of the study. The lecture and the office design were rated as the most motivating program components. The use of stairs, breaks during meetings and social acceptance for standing and walking at work increased. Employees described a strive for variation, and how managers, the office environment, productivity and ergonomic aspects influenced sedentary behavior (SB) and PA. The need for the PA-promoting program was questioned, and the timing of the program was debated. To conclude, a strong organizational health culture combined with a facilitating physical environment can create sustainable positive PA behaviors in office settings. A thorough understanding of organizational needs and a participatory process are needed to tailor organizational interventions to decrease SB.
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http://dx.doi.org/10.3390/ijerph17010023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982266PMC
December 2019

Act with respect: Views of supportive actions for older workers after completion of comprehensive vocational rehabilitation services.

Work 2019 ;62(4):585-598

Department of Community Health and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Background: The number of older workers will expand during the next decades. Older workers have more long-term health problems and related limitations.

Objective: This study examined supportive actions provided in occupational healthcare services to older workers after vocational rehabilitation. An additional purpose was to explore occupational healthcare professionals' views on how to realize and improve adequate support activities.

Methods: Qualitative and quantitative methods were used, including a postal questionnaire and focus group discussions. Sixty-seven occupational healthcare service units participated in the postal questionnaire. Eight occupational healthcare professionals participated in two focus group discussions. The qualitative data was analyzed using qualitative content analysis.

Results: The qualitative analysis resulted in one theme (Act with respect), and four categories (Need for cooperation, Collaborative resources of involved stakeholders, Individual needs for support, and Gender as homogenous and separate groups). Quantitative results revealed that the workers' initiative strongly influenced the support carried out. Recommendations from the rehabilitation clinic were almost always considered when deciding on supportive actions. Focus group discussions brought up gender differences especially highlighted in the category Gender as homogenous and separate groups.

Conclusions: Appropriate support of older workers requires cooperation between involved stakeholders, including occupational healthcare services. Provided support should be based on individual needs, but a mutual practice of determining needed support is requested.
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http://dx.doi.org/10.3233/WOR-192896DOI Listing
July 2019

Patients' perceived treatment need owing to temporomandibular disorders and perceptions of related treatment in dentistry-A mixed-method study.

J Oral Rehabil 2019 Sep 24;46(9):792-799. Epub 2019 May 24.

Department of Clinical Oral Physiology, Faculty of Medicine, Institution of Odontology, Umeå University, Umeå, Sweden.

Background: To easily identify patients who could benefit from a temporomandibular disorder (TMD) examination, three screening questions (3Q/TMD) have been introduced in large parts of Sweden. The questions are related to a TMD diagnosis. However, how the questions relate to a treatment need is unknown.

Objectives: The first aim of the study was to identify predicting factors for perceived treatment need among adult individuals who screened positive to the 3Q/TMD. The second aim was to explore individuals' thoughts and experiences related to treatment of their TMD complaint.

Methods: This mixed-method study with a case-control design was conducted in Västerbotten, Sweden, during 2014. Individuals who screened positive to at least one of the 3Q/TMD questions were allocated 3Q-positives, whereas those with negative answers to all questions were allocated 3Q-negatives. In total, 300 individuals (140 randomly selected 3Q-positives, and 160 age- and gender-matched 3Q-negatives) were included. All individuals answered questions related to treatment need. The answers were analysed in a qualitative approach with qualitative content analysis.

Results: In total, 81% of 3Q-positives expressed a treatment need related to their TMD symptoms. The perceived treatment need was predicted by frequent pain (Q1) and frequent functional disturbances (Q3). Among the 3Q-positives, 54% reported mistrust in dentists' ability to treat TMD symptoms. The informants expressed a need for information about their symptoms and possible treatment options.

Conclusion: Affirmative answers to 3Q/TMD were associated with TMD treatment need. Dentists should give advice to patients with TMD symptoms and address their concerns.
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http://dx.doi.org/10.1111/joor.12813DOI Listing
September 2019

Reach the Person behind the Dementia - Physical Therapists' Reflections and Strategies when Composing Physical Training.

PLoS One 2016 1;11(12):e0166686. Epub 2016 Dec 1.

Department of Community Health and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Dementia is a disease characterized by cognitive impairment and physical decline that worsens over time. Exercise is one lifestyle factor that has been identified as a potential means of reducing or delaying progression of the symptoms of dementia, maximizing function and independence. The purpose of this study was to explore physical therapists' (PTs) experiences and reflections on facilitating high-intensity functional exercise with older people living with dementia, in residential care home settings. The study used a qualitative design based on interviews, individually or in small groups, with seven PTs engaged as leaders in the training of older people with dementia. The interviews were analyzed with a modified Grounded Theory method with focus on constant comparisons. To increase trustworthiness the study used triangulation within investigators and member checking. The core category "Discover and act in the moment-learn over time" reflects how the PTs continuously developed their own learning in an iterative process. They built on previous knowledge to communicate with residents and staff and to tailor the high intensity training in relation to each individual at that time point. The category "Be on your toes" highlights how the PTs searched for sufficient information about each individual, before and during training, by eliciting the person's current status from staff and by interpreting the person's body language. The category "Build a bond with a palette of strategies" describes the importance of confirmation to build up trust and the use of group members and the room to create an interplay between exercise and social interaction. These findings highlight the continuous iterative process of building on existing knowledge, sharing and reflecting, being alert to any alterations needed for individuals that day, communication skills (both with residents and staff) and building a relationship and trust with residents in the effective delivery of high intensity functional exercise to older people living with dementia in care settings.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166686PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5132255PMC
June 2017

Laboratory- and field-based testing as predictors of skating performance in competitive-level female ice hockey.

Open Access J Sports Med 2016 18;7:81-8. Epub 2016 Aug 18.

Sport Medicine Unit, Department of Community Medicine and Rehabilitation.

Objectives: The purpose of this study was to examine whether field-based and/or laboratory-based assessments are valid tools for predicting key performance characteristics of skating in competitive-level female hockey players.

Design: Cross-sectional study.

Methods: Twenty-three female ice hockey players aged 15-25 years (body mass: 66.1±6.3 kg; height: 169.5±5.5 cm), with 10.6±3.2 years playing experience volunteered to participate in the study. The field-based assessments included 20 m sprint, squat jump, countermovement jump, 30-second repeated jump test, standing long jump, single-leg standing long jump, 20 m shuttle run test, isometric leg pull, one-repetition maximum bench press, and one-repetition maximum squats. The laboratory-based assessments included body composition (dual energy X-ray absorptiometry), maximal aerobic power, and isokinetic strength (Biodex). The on-ice tests included agility cornering s-turn, cone agility skate, transition agility skate, and modified repeat skate sprint. Data were analyzed using stepwise multivariate linear regression analysis. Linear regression analysis was used to establish the relationship between key performance characteristics of skating and the predictor variables.

Results: Regression models (adj R (2)) for the on-ice variables ranged from 0.244 to 0.663 for the field-based assessments and from 0.136 to 0.420 for the laboratory-based assessments. Single-leg tests were the strongest predictors for key performance characteristics of skating. Single leg standing long jump alone explained 57.1%, 38.1%, and 29.1% of the variance in skating time during transition agility skate, agility cornering s-turn, and modified repeat skate sprint, respectively. Isokinetic peak torque in the quadriceps at 90° explained 42.0% and 32.2% of the variance in skating time during agility cornering s-turn and modified repeat skate sprint, respectively.

Conclusion: Field-based assessments, particularly single-leg tests, are an adequate substitute to more expensive and time-consuming laboratory assessments if the purpose is to gain knowledge about key performance characteristics of skating.
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http://dx.doi.org/10.2147/OAJSM.S109124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994876PMC
August 2016

Access to rehabilitation: patient perceptions of inequalities in access to specialty pain rehabilitation from a gender and intersectional perspective.

Glob Health Action 2016;9:31542. Epub 2016 Aug 26.

Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden.

Background: Long-term musculoskeletal pain is common, particularly among women. Pain conditions are a concern in primary health care, and people with severe and complex pain are referred to specialty health care. There is gender bias in access, counselling, assessment, and treatment of long-term pain.

Objective: This study explores patient accounts and perceptions about important (social) factors for accessing specialised pain rehabilitation from gender and intersectional equality perspectives. We aimed to identify potential biases and inequalities in accessing rehabilitation resources at a specialised rehabilitation clinic.

Design: Individual semi-structured interviews were conducted with 10 adults after an assessment or completion of a specialised rehabilitation programme in northern Sweden. Qualitative content analysis was used to explore patients' perceptions of important factors for accessing rehabilitation.

Results: One main theme was formulated as Access to rehab - not a given. Three categories of perceived inequality were demonstrated: power of gender, power of social status, and power of diagnosis. Participants perceived rehabilitation as a resource that is not equally available, but dependent on factors such as gender, socio-economic status, ability to work, ethnicity, or age, and more subtle aspects of social status and habitus (e.g. appearance, fitness, and weight). The character of diagnosis received (medical versus psychiatric or social) was also noted.

Conclusions: It is crucial that professionals are aware of how potential inequalities related to gender, social status, and diagnosis, and their intersections, can be created, perceived, and have influence on the processes of assessment and treatment. Reduction of social determinants of health and biases remain important within global, national, and local contexts.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5002397PMC
http://dx.doi.org/10.3402/gha.v9.31542DOI Listing
August 2016

Developing a Tool for Increasing the Awareness about Gendered and Intersectional Processes in the Clinical Assessment of Patients--A Study of Pain Rehabilitation.

PLoS One 2016 7;11(4):e0152735. Epub 2016 Apr 7.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Objective: There is a need for tools addressing gender inequality in the everyday clinical work in health care. The aim of our paper was to develop a tool for increasing the awareness of gendered and intersectional processes in clinical assessment of patients, based on a study of pain rehabilitation.

Methods: In the overarching project named "Equal care in rehabilitation" we used multiple methods (both quantitative and qualitative) in five sub studies. With a novel approach we used Grounded Theory in order to synthesize the results from our sub studies, in order to develop the gender equality tool. The gender equality tool described and developed in this article is thus based on results from sub studies about the processes of assessment and selection of patients in pain rehabilitation. Inspired by some questions in earlier tools, we posed open ended questions and inductively searched for findings and concepts relating to gendered and social selection processes in pain rehabilitation, in each of our sub studies. Through this process, the actual gender equality tool was developed as 15 questions about the process of assessing and selecting patients to pain rehabilitation. As a more comprehensive way of understanding the tool, we performed a final step of the GT analyses. Here we synthesized the results of the tool into a comprehensive model with two dimensions in relation to several possible discrimination axes.

Results: The process of assessing and selecting patients was visualized as a funnel, a top down process governed by gendered attitudes, rules and structures. We found that the clinicians judged inner and outer characteristics and status of patients in a gendered and intersectional way in the process of clinical decision-making which thus can be regarded as (potentially) biased with regard to gender, socio-economic status, ethnicity and age.

Implications: The clinical implications of our tool are that the tool can be included in the systematic routine of clinical assessment of patients for both awareness raising and as a base for avoiding gender bias in clinical decision-making. The tool could also be used in team education for health professionals as an instrument for critical reflection on gender bias.

Conclusions: Thus, tools for clinical assessment can be developed from empirical studies in various clinical settings. However, such a micro-level approach must be understood from a broader societal perspective including gender relations on both the macro- and the meso-level.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0152735PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4824419PMC
August 2016

Walking down 'Via Dolorosa' from primary health care to the specialty pain clinic - patient and professional perceptions of inequity in rehabilitation of chronic pain.

Scand J Caring Sci 2017 Mar 25;31(1):45-53. Epub 2016 Feb 25.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.

Objective: To analyse patient and professional perceptions about (in)equity of care and rehabilitation of chronic pain patients from primary health care to assessment at a specialty rehabilitation clinic.

Setting And Methods: This qualitative study consists one focus group interview with eight general practitioners who refer patients to pain rehabilitation clinics, 10 individual interviews with patients who were assessed at a pain rehabilitation clinic and seven interviews with professionals participating in multimodal assessment teams at a pain rehabilitation clinic. Interview analysis was conducted by the grounded theory method.

Results: The core category Via Dolorosa, the way of suffering and pain, captured how gender and sociocultural context may contribute to advantages and disadvantages during patient journeys from primary health care to a pain rehabilitation clinic. Patients and professionals perceived pain as a low-ranking illness, and women and men used different gendered strategies to legitimise the pain and to be taken seriously. Being 'a proper patient ready to change' and having 'likeness' between patients and professionals were viewed as advantageous in rehabilitation of pain patients. Patients with higher educational levels were perceived as easier to interact with and had better access to health care. Professional thoughts about gender norms influenced the rehabilitation options. The rehabilitation programme was seen by several professionals to be better suited for women than men, which could lead to unequal care.

Conclusion: From an equity and gender perspective, our study highlights the complexity in rehabilitation of chronic pain patients - both from patient and professional perspectives. Awareness of gendered and the biased preconceptions and norms is crucial when professionals struggle to offer equitable health care and rehabilitation.
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http://dx.doi.org/10.1111/scs.12312DOI Listing
March 2017

The meanings given to gender in studies on multimodal rehabilitation for patients with chronic musculoskeletal pain - a literature review.

Disabil Rehabil 2016 11 5;38(23):2255-70. Epub 2016 Jan 5.

d Department of Community Medicine and Rehabilitation, Rehabilitation Medicine , Umeå University , Umeå , Sweden.

Purpose: The purpose of this study is to assess and describe the meanings given to "gender" in scientific publications that evaluate multidisciplinary, interdisciplinary or multimodal rehabilitation for patients with chronic musculoskeletal pain.

Method: A systematic literature search for papers evaluating multimodal rehabilitation was conducted. The PubMed and EBSCO databases were searched from 1995 to 2015. Two or three researchers independently read each paper, performed a quality assessment and coded meanings of gender using qualitative content analysis.

Results: Twenty-seven papers were included in the review. Gender was used very differently in the MMR studies investigated but primarily it referred to factual differences between men and women. Only one paper provided a definition of the concept of gender and how it had been used in that study. In the content analysis, the meaning of gender formed three categories: "Gender as a factual difference", "The man is the ideal" and "Gender as a result of social role expectations".

Conclusions: The meaning of the concept of gender in multimodal rehabilitation is undefined and needs to be developed further. The way the concept is used should be defined in the design and evaluation of multimodal rehabilitation in future studies. Implications for rehabilitation Healthcare professionals should reflect on gender relations in encounters with patients, selection of patients into rehabilitation programs and design of programs. In rehabilitation for chronic pain the patients' social circumstances and cultural context should be given the same consideration as biological sex and pain symptoms.
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http://dx.doi.org/10.3109/09638288.2015.1127435DOI Listing
November 2016

Engagement in New Dietary Habits-Obese Women's Experiences from Participating in a 2-Year Diet Intervention.

Int J Behav Med 2016 Feb;23(1):84-93

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, SE 901 87, Umeå, Sweden.

Background: Dietary weight loss interventions most often result in weight loss, but weight maintenance on a long-term basis is the main problem in obesity treatment. There is a need for an increased understanding of the behaviour patterns involved in adopting a new dietary behavior and to maintain the behaviour over time.

Purpose: The purpose of this paper is to explore overweight and obese middle-aged women's experiences of the dietary change processes when participating in a 2-year-long diet intervention.

Methods: Qualitative semi-structured interviews with 12 overweight and obese women (54-71 years) were made after their participation in a diet intervention programme. The programme was designed as a RCT study comparing a diet according to the Nordic nutrition recommendations (NNR diet) and a Palaeolithic diet (PD). Interviews were analysed according to Grounded Theory principles.

Results: A core category "Engagement phases in the process of a diet intervention" concluded the analysis. Four categories included the informants' experiences during different stages of the process of dietary change: "Honeymoon phase", "Everyday life phase", "It's up to you phase" and "Crossroads phase". The early part of the intervention period was called "Honeymoon phase" and was characterised by positive experiences, including perceived weight loss and extensive support. The next phases, the "Everyday life phase" and "It's up to you phase", contained the largest obstacles to change. The home environment appeared as a crucial factor, which could be decisive for maintenance of the new dietary habits or relapse into old habits in the last phase called "Crossroads phase".

Conclusion: We identified various phases of engagement in the process of a long-term dietary intervention among middle-aged women. A clear personal goal and support from family and friends seem to be of major importance for long-term maintenance of new dietary habits. Gender relations within the household must be considered as a possible obstacle for women engaging in diet intervention.
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http://dx.doi.org/10.1007/s12529-015-9495-xDOI Listing
February 2016

Is there a gender bias in recommendations for further rehabilitation in primary care of patients with chronic pain after an interdisciplinary team assessment?

J Rehabil Med 2015 Apr;47(4):365-71

Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Bldg 9A , Umeå University, SE-901 87 Umeå, Sweden.

Objective: To examine potential gender bias in recommendations of further examination and rehabilitation in primary care for patients with chronic musculoskeletal pain after an interdisciplinary team assessment.

Methods: The population consisted of consecutive patients (n = 589 women, 262 men) referred during a 3-year period from primary healthcare for assessment by interdisciplinary teams at a pain specialist rehabilitation clinic. Patient data were collected from the Swedish Quality Registry for Pain Rehabilitation. The outcome was defined as the examination or rehabilitation that was specified in the patient's record.

Results: Men had a significantly higher likelihood than women of being recommended physiotherapy and radiological examination, and the gender difference was not explained by confounding variables and covariates (age, marital status, ethnicity, education, working status, pain severity, pain interference, pain sites, anxiety and depression). There was no significant gender difference in recommendations to treatment by specialist physician, occupational therapist, psychologist or social worker.

Conclusion: Our findings indicate that the interdisciplinary teams in specialist healthcare may discriminate against women with chronic pain when physiotherapy and radiological investigation are recommended. The team's choice of recommendations might be influenced by gendered attitudes, but this field of research needs to be studied further.
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http://dx.doi.org/10.2340/16501977-1936DOI Listing
April 2015

Enhanced information regarding exercise training as treatment is needed. An interview study in patients with chronic obstructive pulmonary disease.

Disabil Rehabil 2015 22;37(16):1424-30. Epub 2014 Oct 22.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University , Umeå , Sweden.

Purpose: The purpose of this study is to describe thoughts and attitudes of patients with chronic obstructive pulmonary disease (COPD) when talking about exercise training as treatment.

Methods: Semi-structured interviews were performed and analyzed with the grounded theory method. Four men and six women were interviewed (ages 66-84 years), with moderate to severe COPD, and no experience of organized exercise training as treatment for COPD.

Results: The analysis resulted in one core category, unknown territory, and three categories, good for those who can, but not for me; fear of future; and mastering. Exercise training as treatment was perceived by the participants as something unknown. It was also described as important for others but not for them. Their perceptions were that they could not perform exercise training, and did not have the knowledge of what or how to perform exercise that was good for them.

Conclusions: Patients with COPD, with no previous experience of exercise training as treatment for their disease, describe exercise training as something unknown and unimportant for them. The results provide important knowledge for healthcare professionals regarding how to educate patients with COPD about the content and benefits of exercise training as treatment. Implications for Rehabilitation Exercise training is effective for patients with chronic obstructive pulmonary disease (COPD) with regard to dyspnea, physical capacity, health-related quality of life, and health care use. Patients with COPD perceive a lack of information regarding exercise training as treatment. The information and the presentation of exercise training as treatment might be of importance to get better adherence to this treatment.
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http://dx.doi.org/10.3109/09638288.2014.972584DOI Listing
March 2016

Patterns of reported problems in women and men with back and neck pain: similarities and differences.

J Rehabil Med 2014 Jul;46(7):668-75

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, SE-90187 Umeå, Sweden.

Objective: To examine similarities and differences in problem areas reported by women and men who seek physiotherapy for back or neck pain.

Methods: Principal component analysis (PCA) was used to analyse questionnaire data including demographics, pain, domestic work, stress, health status, physical disability, psychosocial and physical workload, kinesiophobia and self- efficacy. Most of the questions were recruited from a number of scales, e.g. EuroQol (EQ-5D), Neck Disability Index (NDI), Oswestry Disability Questionnaire (ODQ), Tampa Scale for Kinesiophobia, and Functional-Efficacy-Scale.

Results: A total of 118 patients (84 women, 34 men) completed the questionnaire. Men and women scored similarly on physical disability, functional self-efficacy and kinesiophobia, but women scored higher on stress reactions and pain intensity. PCA showed that questions about physical disability and functional self-efficacy comprised the first component and explained most of the variance in this patient group. Questions about stress and social support at work constituted the second component. Questions about domestic workload and pain comprised the third component. Gender differences were found in the second and third components.

Conclusion: In general, women and men answered questions similarly, but there were differences: more women reported stress, pain and low support at work and more men reported a lower domestic workload.
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http://dx.doi.org/10.2340/16501977-1830DOI Listing
July 2014

Low-educated women with chronic pain were less often selected to multidisciplinary rehabilitation programs.

PLoS One 2014 21;9(5):e97134. Epub 2014 May 21.

Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden; Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden.

Background: There is a lack of research about a potential education-related bias in assessment of patients with chronic pain. The aim of this study was to analyze whether low-educated men and women with chronic pain were less often selected to multidisciplinary rehabilitation than those with high education.

Methods: The population consisted of consecutive patients (n = 595 women, 266 men) referred during a three-year period from mainly primary health care centers for a multidisciplinary team assessment at a pain rehabilitation clinic at a university hospital in Northern Sweden. Patient data were collected from the Swedish Quality Registry for Pain Rehabilitation National Pain Register. The outcome variable was being selected by the multidisciplinary team assessment to a multidisciplinary rehabilitation program. The independent variables were: sex, age, born outside Sweden, education, pain severity as well as the hospital, anxiety and depression scale (HADS).

Results: Low-educated women were less often selected to multidisciplinary rehabilitation programs than high-educated women (OR 0.55, CI 0.30-0.98), even after control for age, being born outside Sweden, pain intensity and HADS. No significant findings were found when comparing the results between high- and low-educated men.

Conclusion: Our findings can be interpreted as possible discrimination against low-educated women with chronic pain in hospital referrals to pain rehabilitation. There is a need for more gender-theoretical research emphasizing the importance of taking several power dimensions into account when analyzing possible bias in health care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0097134PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4029603PMC
June 2015

Experiences of barriers and facilitators to weight-loss in a diet intervention - a qualitative study of women in northern Sweden.

BMC Womens Health 2014 Apr 16;14:59. Epub 2014 Apr 16.

Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.

Background: There is a lack of research about the experiences of participating in weight-reducing interventions. The aim of this study was to explore barriers and facilitators to weight-loss experienced by participants in a diet intervention for middle-aged to older women in the general population in Northern Sweden.

Method: In the intervention the women were randomised to eat either a Palaeolithic-type diet or a diet according to Nordic Nutrition recommendations for 24 months. A strategic selection was made of women from the two intervention groups as well as from the drop-outs in relation to social class, civil status and age. Thematic structured interviews were performed with twelve women and analysed with qualitative content analyses.

Results: The results showed that the women in the dietary intervention experienced two main barriers - struggling with self (related to difficulties in changing food habits, health problems, lack of self-control and insecurity) and struggling with implementing the diet (related to social relations and project-related difficulties) - and two main facilitators- striving for self-determination (related to having clear goals) and receiving support (from family/friends as well as from the project) - for weight-loss. There was a greater emphasis on barriers than on facilitators.

Conclusion: It is important to also include drop-outs from diet interventions in order to fully understand barriers to weight-loss. A gender-relational approach can bring new insights into understanding experiences of barriers to weight-loss.

Trial Registration: ClinicalTrials gov NCT00692536.
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http://dx.doi.org/10.1186/1472-6874-14-59DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998240PMC
April 2014

Central gender theoretical concepts in health research: the state of the art.

J Epidemiol Community Health 2014 Feb 21;68(2):185-90. Epub 2013 Nov 21.

Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, , Umeå, Sweden.

Despite increasing awareness of the importance of gender perspectives in health science, there is conceptual confusion regarding the meaning and the use of central gender theoretical concepts. We argue that it is essential to clarify how central concepts are used within gender theory and how to apply them to health research. We identify six gender theoretical concepts as central and interlinked-but problematic and ambiguous in health science: sex, gender, intersectionality, embodiment, gender equity and gender equality. Our recommendations are that: the concepts sex and gender can benefit from a gender relational theoretical approach (i.e., a focus on social processes and structures) but with additional attention to the interrelations between sex and gender; intersectionality should go beyond additive analyses to study complex intersections between the major factors which potentially influence health and ensure that gendered power relations and social context are included; we need to be aware of the various meanings given to embodiment, which achieve an integration of gender and health and attend to different levels of analyses to varying degrees; and appreciate that gender equality concerns absence of discrimination between women and men while gender equity focuses on women's and men's health needs, whether similar or different. We conclude that there is a constant need to justify and clarify our use of these concepts in order to advance gender theoretical development. Our analysis is an invitation for dialogue but also a call to make more effective use of the knowledge base which has already developed among gender theorists in health sciences in the manner proposed in this paper.
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http://dx.doi.org/10.1136/jech-2013-202572DOI Listing
February 2014

'I am afraid to make the damage worse'--fear of engaging in physical activity among patients with neck or back pain--a gender perspective.

Scand J Caring Sci 2014 Mar 12;28(1):146-54. Epub 2013 Apr 12.

The National Graduate School of Gender Studies, Umeå University, Umeå, Sweden.

Rationale: Neck and back pain are major public health problems in Western societies and cause considerable disability and health service use. Swedish women report more severe neck and back pain compared with Swedish men. Most studies on the aetiology of gender differences in pain deal with biological mechanisms, and less with the role of psychological and sociocultural factors. 'Pain beliefs' is a sociocultural factor and can be expressed in different ways among women and men. It is important to know what pain beliefs are held by neck and back pain patients, especially when medical guidelines recommend that back pain patients stay physically active.

Aim: Exploring pain beliefs in relation to physical activity among neck and back pain patients consulting primary health care.

Method: Twelve patients (seven women, five men) consulting primary health care for an initial episode of neck or back pain were interviewed before their first appointment with a physiotherapist or general practitioner and 3 months later. The interviews covered patient experiences of neck or back pain, consequences, strategies and treatment experiences. The interviews were analysed with qualitative content analysis from a gender perspective.

Result: One theme 'Fear of hurting the fragile body' was expressed by all neck or back pain patients. Five categories were identified 'The mechanical body', 'Messages about activity', 'Earlier experiences of pain and activity', 'To be a good citizen' and 'Support to be active' supported or undermined beliefs about pain and physical activity. Gender expressions occurred in the categories 'Messages about activity', 'To be a good citizen' and 'Support to be active'.

Conclusions: Neck or back pain patients in the study saw the body as fragile and were afraid of hurting it. Notions of gender had an impact on the given advice about activity and on how patients perceived the message about staying active.
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http://dx.doi.org/10.1111/scs.12043DOI Listing
March 2014

Being in an exchange process: experiences of patient participation in multimodal pain rehabilitation.

J Rehabil Med 2013 Jun;45(6):580-6

Dept. of Health Science, Luleå University of Technology, 97187 Luleå, Sweden.

Objective: To explore primary healthcare patients' experiences of patients participation in multimodal pain rehabilitation.

Patients And Methods: A total of 17 patients who had completed multimodal rehabilitation for persistent pain were interviewed. The interviews were analysed using qualitative content analysis.

Results: One theme, Being in an exchange process, and 4 categories emerged. The theme depicted patient participation as a continuous exchange of emotions, thoughts and knowledge. The category Fruitful encounters represented the basic prerequisites for patient participation through dialogue and platforms to meet. Patients' emotional and cognitive resources and restrictions, as well as knowledge gaps, were conditions influencing patient participation in the category Inequality in co-operation. Mutual trust and respect were crucial conditions in patient's personal relationships with the health professionals, forming the category Confidence-inspiring alliance. In the category Competent health professionals, the health professionals' expertise, empathy and personal qualities, were emphasized to favour patient participation.

Conclusion: Patient participation can be understood as complex and individualized. A confidence-inspiring alliance enables a trusting relationship to be formed between patients and health professionals. Patients emphasized that health professionals need to play an active role in building common ground in the interaction. Understanding each patient's needs in the participation process may favour patient participation.
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http://dx.doi.org/10.2340/16501977-1136DOI Listing
June 2013

Beyond a dichotomous view of the concepts of 'sex' and 'gender' focus group discussions among gender researchers at a medical faculty.

PLoS One 2012 20;7(11):e50275. Epub 2012 Nov 20.

Department of Nursing, Umeå University, Umeå, Sweden.

Introduction: The concepts of 'sex' and 'gender' are both of vital importance in medicine and health sciences. However, the meaning of these concepts has seldom been discussed in the medical literature. The aim of this study was to explore what the concepts of 'sex' and 'gender' meant for gender researchers based in a medical faculty.

Methods: Sixteen researchers took part in focus group discussions. The analysis was performed in several steps. The participating researchers read the text and discussed ideas for analysis in national and international workshops. The data were analysed using qualitative content analysis. The authors performed independent preliminary analyses, which were further developed and intensively discussed between the authors.

Results: The analysis of meanings of the concepts of 'sex' and 'gender' for gender researchers based in a medical faculty resulted in three categories; "Sex as more than biology", with the subcategories 'sex' is not simply biological, 'sex' as classification, and 'sex' as fluid and changeable; "Gender as a multiplicity of power-related constructions", with the subcategories: 'gender' as constructions, 'gender' power dimensions, and 'gender' as doing femininities and masculinities; "Sex and gender as interwoven", with the subcategories: 'sex' and 'gender' as inseparable and embodying 'sex' and 'gender'.

Conclusions: Gender researchers within medicine pointed out the importance of looking beyond a dichotomous view of the concepts of 'sex' and 'gender'. The perception of the concepts was that 'sex' and 'gender' were intertwined. Further research is needed to explore how 'sex' and 'gender' interact.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0050275PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502325PMC
May 2013

Subjective health complaints in older adolescents are related to perceived stress, anxiety and gender - a cross-sectional school study in Northern Sweden.

BMC Public Health 2012 Nov 16;12:993. Epub 2012 Nov 16.

Umeå Center for Gender Studies, Umeå University, Umeå, Sweden.

Background: Negative trends in adolescent mental and subjective health are a challenge to public health work in Sweden and worldwide. Self-reported mental and subjective health complaints such as pain, sleeping problems, anxiety, and various stress-related problems seem to have increased over time among older adolescents, especially girls. The aim of this study has therefore been to investigate perceived stress, mental and subjective health complaints among older adolescents in Northern Sweden.

Methods: Data were derived from a cross-sectional school-based survey with a sample consisting of 16-18 year olds (n = 1027), boys and girls, in the first two years of upper secondary school, from different vocational and academic programmes in three public upper secondary schools in a university town in northern Sweden. Prevalence of perceived stress, subjective health complaints, general self-rated health, anxiety, and depression were measured using a questionnaire, including the Hospital Anxiety and Depression Scale (HADS).

Results: A large proportion of both girls and boys reported health complaints and perceived stress. There was a clear gender difference: two to three times as many girls as boys reported subjective health complaints, such as headache, tiredness and sleeping difficulties and musculoskeletal pain, as well as sadness and anxiety. High pressure and demands from school were experienced by 63.6% of girls and 38.5% of boys. Perceived stress in the form of pressure and demands correlated strongly with reported health complaints (r = 0.71) and anxiety (r = 0.71).

Conclusions: The results indicate that mental and subjective health complaints are prevalent during adolescence, especially in girls, and furthermore, that perceived stress and demands may be important explanatory factors. Future studies should pay attention to the balance between gender-related demands, perceived control and social support, particularly in the school environment, in order to prevent negative strain and stress-related ill-health. The gender gap in subjective adolescent health needs to be further explored.
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http://dx.doi.org/10.1186/1471-2458-12-993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3533931PMC
November 2012

Personal resources and support when regaining the ability to work: an interview study with Exhaustion Disorder patients.

J Occup Rehabil 2013 Jun;23(2):270-9

Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, 901 87, Umeå, Sweden.

Purpose: The aim of the study was to explore experiences and thoughts in the process of returning to work in employed patients with Exhaustion Disorder.

Methods: Twelve patients with Exhaustion Disorder (burnout) who had been referred to a Stress Rehabilitation Clinic were interviewed. All patients were employed but a majority was on full or part-time sick leave. Grounded Theory was used as the qualitative method.

Results: A core category, regaining the ability to work, was developed. Alongside, two categories, internal resources and the external support system, were experienced as being important to the process. The internal resources were expressed through three key features (sub-categories), perceived validation, insights and adaptive coping abilities. The external support system was diverse and described by the sub-categories practical/structural and/or emotional support. Four external support actors were identified; the workplace, health care, the Social Insurance Agency, and the union. The supervisor was described as the most important external actor.

Conclusions: Internal and external resources are intertwined in the process of regaining the ability to work. The internal resources and external support can directly increase the probability to regain the ability to work. Moreover, these resources can affect each other and thus indirectly have an effect on the process.
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http://dx.doi.org/10.1007/s10926-012-9396-7DOI Listing
June 2013

"The balancing act"--licensed practical nurse experiences of falls and fall prevention: a qualitative study.

BMC Geriatr 2012 Oct 15;12:62. Epub 2012 Oct 15.

Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, SE-90187, Umeå, Sweden.

Background: Falls are common in old age and may have serious consequences. There are many strategies to predict and prevent falls from occurring in long-term care and hospitals. The aim of this study was to describe licensed practical nurse experiences of predicting and preventing further falls when working with patients who had experienced a fall-related fracture. Licensed practical nurses are the main caretakers that work most closely with the patients.

Methods: A qualitative study of focus groups interviews and field observations was done. 15 licensed practical nurses from a rehabilitation ward and an acute ward in a hospital in northern Sweden were interviewed. Content was analyzed using qualitative content analysis.

Results: The result of the licensed practical nurse thoughts and experiences about risk of falling and fall prevention work is represented in one theme, "the balancing act". The theme includes three categories: "the right to decide", "the constant watch", and "the ongoing negotiation" as well as nine subcategories. The analysis showed similarities and differences between rehabilitation and acute wards. At both wards it was a core strategy in the licensed practical nurse work to always be ready and to pay attention to patients' appearance and behavior. At the rehabilitation ward, it was an explicit working task to judge the patients' risk of falling and to be active to prevent falls. At the acute ward, the words "risk of falling" were not used and fall prevention were not discussed; instead the licensed practical nurses used for example "dizzy and pale". The results also indicated differences in components that facilitate workplace learning and knowledge transfer.

Conclusions: Differences between the wards are most probably rooted in organizational differences. When it is expected by the leadership, licensed practical nurses can express patient risk of falling, share their observations with others, and take actions to prevent falls. The climate and the structure of the ward are essential if licensed practical nurses are to be encouraged to routinely consider risk of falling and implement risk reduction strategies.
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http://dx.doi.org/10.1186/1471-2318-12-62DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3536659PMC
October 2012

Work ability as obscure, complex and unique: views of Swedish occupational therapists and physicians.

Work 2013 ;45(1):117-28

Department of Community Medicine and Rehabilitation, Division of Occupational Therapy, Umeå University, Umeå, Sweden.

Unlabelled: The concept of work ability is not clearly defined although it has a central place in vocational rehabilitation. Several health professions are involved in assessing work ability, physicians and occupational therapists are two of these.

Objective: The purpose of this study was to explore occupational therapist and physician views about work ability and experiences in assessing work ability.

Participants: Fourteen physicians and 23 occupational therapists participated in seven focus group discussions that were audio taped and transcribed verbatim.

Methods: Qualitative content analysis was used. Each author performed an individual preliminary analysis. These analyses were later discussed and refined in the research team and a workshop. The final categorization resulted in one theme, four categories and 13 sub-categories.

Results: The overall theme expressed work ability as an obscure, complex and unique concept. The four categories illustrate the affecting factors and confirm the complex structure of work ability: the person, the context of life, the work, and the society. Physicians expressed greater difficulty in assessing work ability than occupational therapists did, because they have fewer instruments to access this concept.

Conclusions: Assessment of work ability requires team cooperation with several different professionals. Cooperation could increase accuracy in issuing sickness certification and strengthens the ability of identifying individual requirements for rehabilitation.
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http://dx.doi.org/10.3233/WOR-2012-1416DOI Listing
December 2014

Sex and gender traps and springboards: a focus group study among gender researchers in medicine and health sciences.

Health Care Women Int 2012 ;33(8):739-55

Department of Nursing, Umeå University, Umeå, Sweden.

We explored the difficulties that gender researchers encounter in their research and the strategies they use for solving these problems. Sixteen Swedish researchers, all women, took part in focus group discussions; the data were analyzed using qualitative content analysis. The problems reported fell into four main categories: the ambiguity of the concepts of sex and gender; traps associated with dichotomization; difficulties with communication; and issues around publication. Categories of suggested problem-solving strategies were adaptation, pragmatism, addressing the complexities, and definition of terms. Here the specific views of gender researchers in medicine and health sciences-"medical insiders"-bring new challenges into focus.
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http://dx.doi.org/10.1080/07399332.2011.645970DOI Listing
October 2012
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