Disciplined into good conduct: Gender constructions of users in a municipal psychiatric context in Sweden.

AIMS AND OBJECTIVES: To examine how gendered discursive norms and notions of masculinity and femininity were (re)produced in professional conversations about users of long-term municipality psychiatric care. Focus is on the staff's use of language in relation to gender constructions. BACKGROUND: Psychiatric care in Sweden has undergone tremendous changes in recent decades from custodian care in large hospitals to a care mainly located in a municipal context. People who need psychiatric care services often live in supporting houses. In municipal psychiatric care, staff conduct weekly professional meetings to discuss daily matters and the users' needs. Official reports of the Swedish government have shown that staff in municipal care services treat disabled women and men differently. Studies exploring gender in relation to users of long-term psychiatric care in municipalities have problematised the care and how staff, through language, construct users' gender. Therefore, language used by staff is a central tool for ascribing different gender identities of users. DESIGN: The content of speech derived from audio recordings was analysed using Foucauldian discourse analysis. The COREQ checklist was used in this article. RESULTS: The results indicate that by relying on gender discourses, staff create a conditional care related to how the users should demonstrate good conduct. In line with that, an overall discourse was created: Disciplined into good conduct. It was underpinned by three discourses inherent therein: The unreliable drinker and the confession, Threatened dignity, and Doing different femininities. CONCLUSION: The community psychiatric context generates a discourse of conduct in which staff via spoken language (re)produces gendered patterns and power imbalances as a means to manage daily work routines. Such practices of care, in which constant, nearly panoptic, control despite the intention to promote autonomy, urgently require problematising current definitions of good conduct and normality.

Subordinated masculinities: A critical inquiry into reproduction of gender norms in handovers and rounds in a forensic psychiatric care.

AIMS AND OBJECTIVES: To examine how gendered discursive norms and notions of masculinity are (re)produced in professional conversations about men cared for as patients in forensic psychiatric care, with a particular focus on the centrality of language and gender. BACKGROUND: During verbal handovers and ward rounds, care staff converse to share information about patients and make decisions about their mental status. Spoken language is thus a pivotal tool in verbal handovers and ward rounds, one able to reproduce discourses and gender norms. DESIGN: Qualitative. Data collected from audio recordings of verbal handovers and ward rounds in a forensic psychiatric clinic were subjected to discourse analysis. The COREQ checklist was used. RESULTS: While discussing patients, staff subordinated them by reproducing a discourse typical of heteronormative, family-oriented care. The overarching discourse, which we labelled subordinated masculinities, was supported by three other discourses: being unable to take responsibility, being drug-addicted and performing masculinity. Such discourse was identified as a disciplining practice that subordinate's patients as a means to maintain order, rules and gender norms. CONCLUSION: The study reveals a caring practice that position male patients as children or disabled individuals and, in that way, as subordinated other men within a context were staff reproduces a heteronormative family structured care. The process also reveals a practice were downplaying aggressive and deviant behaviour could disempower and reduce patients´ responsibility for personal actions and their possibilities to participate in their care. That finding especially seems to contradict previous findings that patients want to be able to act responsibly and, to that end, want care staff to help them. RELEVANCE TO CLINICAL PRACTICE: Nurses need to deepen their understanding of how language (re)produces discursive norms of gender and masculinity in forensic care and that process's consequences for such care.

The Importance of Being Acceptable - Psychiatric Staffs' Talk about Women Patients in Forensic Care.

Currently, women comprise about ten percent of those sentenced to psychiatric forensic clinics in Sweden. Those who are sentenced to forensic care because of offending and violent behaviour have already taken a step away from the usually expected female behaviour. On the other hand, there are many women in forensic care who have not committed crimes, but who instead self-harm. Studies have identified a gender bias in diagnosing and care in psychiatric settings, but there are few studies conducted on women in forensic care. The present study therefore examined how the situation of women patients and female norms are expressed in the staff's talk about these women during verbal handovers and ward rounds at a forensic clinic in Sweden. The aim was to explore how psychiatric staff, in a context of verbal handovers and ward rounds, talk about women who have been committed to forensic psychiatric care, and what consequences this might have for the care of the patients. The content of speech was examined using audio recordings and a method of analysis that was inspired by thematic analysis. The analysis identified that the staff talked about the women in a way that indicates that they expected the women to follow the rules and take responsibility for their bodies in order to be regarded as acceptable patients.

"I have surly passed a limit, it is simply too much": women's and men's experiences of stress and wellbeing when living within a process of housework resignation.

BACKGROUND: Gender inequality within paid and unpaid work exposes women and men to different environments and responsibilities. These gender patterns shape living conditions for women and men, either negatively or positively, by affecting the prospect of good health. Most public health studies of gender and housework are quantitative, and knowledge about the relationship between housework experiences and health for women and men is limited. The aim of this study was to explore the housework experiences and practices of women and men and their experiences of stress and perceived wellbeing from a gender perspective. METHODS: We conducted thematic interviews with four women and four men living in Sweden, and performed an analysis using the Grounded Theory method. FINDINGS: We found that stereotypical gender practices in housework influenced experiences of stress and perceived wellbeing among women and men. Despite proposing gender equality in housework as a means of improving wellbeing, inequality was amplified by the way women and men handle the gendered division of housework. We call this recurring theme "The process of housework resignation", which also constitute the core category in our analysis. "The process of housework resignation" was theorised from the categories "Gender practices in housework", "Experiencing stress and wellbeing" and "Managing daily life". CONCLUSIONS: Stereotypical gender practices in housework can increase experiences of stress among women and men. Challenging stereotypical masculinities can be a key for breaking the process of resignation in housework and for facilitating improved health among both women and men in heterosexual couple relationships within a Swedish context.

Gendered discourses of youth sexualities--an exploration of PubMed articles on prevention of sexually transmissible infections.

OBJECTIVE: To explore how gender is addressed in medical articles on the prevention of sexually transmissible infections (STI) among adolescents. METHODS: Sixtyone articles were retrieved from a PubMed search and scrutinized by qualitative content analysis. RESULTS: Most articles were affiliated with North American research institutions, but there were also reports from Europe, Africa, South America, and Asia. Gender turned up in the following four recurrent discourses: Gendered Receptiveness for Information, Stereotyped Heterosexual Expectations, Power Imbalance in Sexual Relations, and Gendered Prevention Approaches. Young women were described as knowledgeable, communicative, and responsible, but at risk because of feminine ideals and a lack of negotiating power. Men were described as less informed, more reluctant to discuss, and more risk taking due to masculine ideals and power dominance. Prevention approaches concerned how to postpone sex and/or tailor gender-sensitive programs for specific groups of young women and men. CONCLUSION: Researchers' own gender expectations might have a substantial impact on how sex and sexual health is considered in prevention research. To avoid reconstruction of current inequalities and stereotypes regarding sexual practices of young women and men, the impact of gender, the power structures in intimate relations, and the cultural context should be considered. Medical research on STI prevention could benefit from including a wider array of gender perspectives.

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

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.

Experiences of well-being among Sami and Roma women in a Swedish context.

Our aim was to explore the experiences of well-being and lack of well-being among middle-aged and older women belonging to two national minority groups in Sweden. Interviews from nine older Sami women and four middle-aged Roma women were analyzed using grounded theory with the following categories identified: contributing to well-being (with the subcategories belonging to a healthy family, being spiritual, cultural norms as health promoting, and having had a life of one's own); and contributing to lack of well-being (with the subcategories living subordinate to the dominant society, living in a hierarchical family, and living in the shadow of tuberculosis.).

Psychometric properties of the Swedish version of the selection, optimization, compensation questionnaire.

BACKGROUND: The model of selection, optimization and compensation has been proposed as a model of adaptive management strategies throughout the lifespan. AIM: The aim of this study was to test the psychometric properties of a translated Swedish version of the 12-item selection, optimization, and compensation (SOC) questionnaire. METHOD: The 12-item SOC questionnaire is composed of four subscales: elective selection (ES), loss-based selection, optimization and compensation. A convenience sample of 122 Swedish-speaking people, aged 19-85, participated in a study of the validity and reliability of the SOC questionnaire. Cronbach's alpha coefficient, corrected item-total correlation and Cronbach's alpha if item deleted were used for reliability testing. Two other scales, the ways of coping questionnaire and Rosenberg's self-esteem scale, were used to test convergent validity, and the geriatric depression scale was used to test discriminant validity. Stability over time was evaluated using a test-retest model with a 2-week interval. RESULTS: The 12-item SOC questionnaire showed a Cronbach's alpha value of 0.50, and the subscales ranged from α = 0.16 to α = 0.64. Two items in the ES subscale had negative values on the corrected item-total correlation and showed substantial improvement (>0.05) in Cronbach's alpha when item deleted. When these two items that influenced internal consistency were deleted, Cronbach's alpha rose to 0.68. CONCLUSION: The Swedish version of the 12-item SOC questionnaire showed deficiencies in a test of internal consistency because of two items in the ES subscale, and these two items were deleted. A consequence of the reduction is a weakening of the ES subscale and thereby to some extent the SOC questionnaire in total. Further testing is advisable. However, the 10-item SOC questionnaire was acceptable in a test of validity and reliability.

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

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.

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

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.

Gender (in)equality among employees in elder care: implications for health.

INTRODUCTION: Gendered practices of working life create gender inequalities through horizontal and vertical gender segregation in work, which may lead to inequalities in health between women and men. Gender equality could therefore be a key element of health equity in working life. Our aim was to analyze what gender (in)equality means for the employees at a woman-dominated workplace and discuss possible implications for health experiences. METHODS: All caregiving staff at two workplaces in elder care within a municipality in the north of Sweden were invited to participate in the study. Forty-five employees participated, 38 women and 7 men. Seven focus group discussions were performed and led by a moderator. Qualitative content analysis was used to analyze the focus groups. RESULTS: We identified two themes. "Advocating gender equality in principle" showed how gender (in)equality was seen as a structural issue not connected to the individual health experiences. "Justifying inequality with individualism" showed how the caregivers focused on personalities and interests as a justification of gender inequalities in work division. The justification of gender inequality resulted in a gendered work division which may be related to health inequalities between women and men. Gender inequalities in work division were primarily understood in terms of personality and interests and not in terms of gender. CONCLUSION: The health experience of the participants was affected by gender (in)equality in terms of a gendered work division. However, the participants did not see the gendered work division as a gender equality issue. Gender perspectives are needed to improve the health of the employees at the workplaces through shifting from individual to structural solutions. A healthy-setting approach considering gender relations is needed to achieve gender equality and fairness in health status between women and men.

Inner strength in relation to functional status, disease, living arrangements, and social relationships among people aged 85 years and older.

Inner strength is described as an important resource that promotes well-being. We used data from a sample of 185 people in the Umeå 85+ cohort study to relate inner strength and its attributes to objective health variables. The Resilience, Sense of Coherence, Purpose in Life, and Self-Transcendence scales were used to assess aspects of inner strength, and strong correlations between the scales were found. Prevalence of heart failure, chronic obstructive pulmonary disorder, osteoporosis, or diagnosed depression was associated with low inner strength. Significant relationships were also found between high inner strength and various measures of social relationships. Participants with a higher degree of inner strength had better physical health and more satisfying social relationships. The promotion of inner strength should be a major aim of geriatric nursing.

Development and psychometric properties of the Inner Strength Scale.

BACKGROUND: Four dimensions of inner strength were previously identified in a meta-theoretical analysis: firmness, creativity, connectedness, and flexibility. OBJECTIVE: The aim of this study was to develop an Inner Strength Scale (ISS) based on those four dimensions and to evaluate its psychometric properties. METHOD: An initial version of ISS was distributed for validation purpose with the Rosenberg Self-Esteem Scale, the resilience scale, and the sense of Coherence Scale. A convenience sample of 391 adults, aged 19-90 years participated. Principal component analysis (PCA) and confirmatory factor analysis (CFA) were used in the process of exploring, evaluating, and reducing the 63-item ISS to the 20-item ISS. Cronbach's alpha and test-retest were used to measure reliability. RESULTS: CFA showed satisfactory goodness-of-fit for the 20-item ISS. The analysis supported a fourfactor solution explaining 51% of the variance. Cronbach's alpha on the 20-item ISS was 0.86, and the test-retest showed stability over time (r=0.79). CONCLUSION: The ISS was found to be a valid and reliable instrument for capturing a multifaceted understanding of inner strength. Further tests of psychometric properties of the ISS will be performed in forthcoming studies.

Purpose in life over a five-year period: a longitudinal study in a very old population.

BACKGROUND: Few studies have specifically examined purpose in life among very old people, and we know of none that has used a prospective approach. The aim of this study was to examine changes in purpose in life over five years in very old men and women and to investigate whether depressed mood, malnutrition, inactivity in daily life, or cognitive impairment increased the risk for developing low purpose in life. METHODS: The study includes data from 51 participants (42 women and 9 men) living in northern Sweden who completed the Purpose in Life (PIL) Test once at baseline and again five years later. RESULTS: Purpose in life decreased over five years and the decrease was significantly associated with being a woman (p < 0.001) and having depressed mood (p = 0.009) or depression (p = 0.002) at baseline. There were no differences in baseline PIL scores between depressed and not depressed, but those who had depression had significantly decreased PIL scores after five years (p = 0.001). CONCLUSION: A strong purpose in life does not seem to prevent very old people from developing depression, and being depressed at baseline and living with depression over five years is associated with a loss of purpose in life.

Lack of resilience among very old men and women: a qualitative gender analysis.

High degree of resilience has been described as an enduring positive view of life despite difficult circumstances during the aging process. How to become old and being old with low resilience have not been studied. The aim of this study was to illuminate experiences about becoming old and being old among very old people with low resilience. Interviews from very old women and men were analyzed using content analysis with the following themes identified: being out of it, emphasizing life experiences from the past, religious doubting, and accepting age. Except for religious doubting, the themes contained both similarities and variations between women and men. Our study showed that in spite of scoring low on the Resilience Scale (RS), very old persons can experience integration and well-being. However, the women seemed to be more vulnerable compared to men, and for them, it is important to strengthen social and relational possibilities for contributing to resilience.

Depression in relation to purpose in life among a very old population: A five-year follow-up study.

OBJECTIVES: To investigate the relationship between purpose in life and depression and, in a five-year follow-up investigate whether purpose in life, adjusted for different background characteristics, can prevent very old men and women from developing depression. METHODS: A cross-sectional study included 189 participants (120 women and 69 men) 85-103 years of age living in a county in northern Sweden. Those who had not been diagnosed as depressed at baseline were included in the five-year follow-up study (n = 78). Depression was assessed using the Geriatric Depression Scale-15, the Organic Brain Syndrome scale, the Montgomery-Asberg Depression Rating Scale, and Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Purpose in life was assessed with the Purpose in Life (PIL) scale. RESULTS: In the cross-sectional study, 40 participants out of 189 (21.2%) were depressed, and those with depression had significantly lower PIL scores (mean score 107 vs. 99, p = 0.014). In the follow-up study, 78 persons were available for the assessment of depression. Of those, 21 (26.9%) were diagnosed as depressed and their mean PIL score at baseline was 106 (SD = 17.4) versus 108 (SD = 16.0, p = 0.750) among those not depressed. Using multivariate logistic regression analysis controlling for possible confounders, we found no association between purpose in life and the risk of developing depression after five years (OR = 1.0, 95% CI 0.97-1.03). CONCLUSIONS: The results show a significant inverse relationship between purpose in life and depression in the cross-sectional study; however, a high PIL score does not seem to serve very old people as a protection against the risk of developing depression.

Resilience among women and men aged 60 years and over in Sweden and in Thailand.

The purpose of this study was to compare the level of resilience of people aged > or = 60 years in Sweden and Thailand. In a randomized sample of 422 people in Sweden and a convenience sample of 200 people in Thailand, the level of resilience was measured by using the Resilience Scale. A chi(2)-analysis was used for the differences between proportions. The relationships between the background variables and the resilience scores were analyzed by using stepwise multiple linear regression. The mean scores of resilience were 144 for the Swedish participants and 146 for the Thai participants. The two samples differed in their background characteristics. The Thai participants were more likely to be women, to be widowed, and to have more children, while among the Swedish participants, more women were married and more participants were aged > or = 80 years. Despite different background characteristics, the Swedish and the Thai participants' scores were almost the same on the Resilience Scale. More studies are necessary to address aspects of gender and ethnicity in relation to resilience.

Health against the odds: experiences of employees in elder care from a gender perspective.

Women-dominated elder care in Sweden is a low-paid, low-status job with a high prevalence of sick leave. Our aim was to analyze health experiences of employees in elder care from a gender perspective. All caregiving staff at two establishments providing care to the elderly were invited to participate in the study. A moderator led seven focus group discussions. Qualitative content analysis was used to analyze the transcribed focus groups. We identified two central themes in relation to the employees' health. "Working against the odds" describes gendered workplace stressors of a structural character, to a large extent triggered by societal processes outside the organization. "Making work matter" refers to gendered health resources with a relational character, constructed within the organization. Health-promoting programs directed toward women-dominated workplaces need to include a gender perspective, and focus on creating structural, supportive environments to avoid the negative health effects of the stressors.

Inner strength--a theoretical analysis of salutogenic concepts.

BACKGROUND: Theoretical and empirical overlaps between the concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence have earlier been described as some kind of inner strength, but no studies have been found that focus on what attributes these concepts have in common. OBJECTIVES: The objective of this study was to perform a theoretical analysis of the concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence, in order to identify their core dimensions in an attempt to get an overarching understanding of inner strength. PRINT METHOD: An analysis inspired by the procedure of meta-theory construction was performed. The main questions underlying the development of the concepts, the major paradigms and the most prominent assumptions, the critical attributes and the characteristics of the various concepts were identified. RESULTS: The analysis resulted in the identification of four core dimensions of inner strength and the understanding that inner strength relies on the interaction of these dimensions: connectedness, firmness, flexibility, and creativity. These dimensions were validated through comparison with the original descriptions of the concepts. CONCLUSION: An overarching understanding of inner strength is that it means both to stand steady, to be firm, with both feet on the ground and to be connected to; family, friends, society, nature and spiritual dimensions and to be able to transcend. Having inner strength is to be creative and stretchable, which is to believe in own possibilities to act and to make choices and influence life's trajectory in a perceived meaningful direction. Inner strength is to shoulder responsibility for oneself and others, to endure and deal with difficulties and adversities. This knowledge about inner strength will raise the awareness of the concept and, in turn, hopefully increase our potential to support people's inner strength.

Experiences of purpose in life when becoming and being a very old woman.

The aim of the study was to illuminate how very old women describe their experiences of purpose in life (PIL) in narratives about becoming and being very old. The participants comprised 30 women selected from 120 women who had answered the PIL test and had been interviewed about their experiences of being very old. The interviews were analyzed with qualitative content analysis, which revealed four themes: having a positive view of life, living in relation to God, having meaningful activities, and simply existing. Our findings show that very old women experience purpose in life both in their daily activities and in their contact with a spiritual world. It seems to be facilitated by a positive view of life. Although the results were dominated by a positive view of life, some of the participants saw their lives in terms of simply existing, and did not experience purpose in life.