User involvement and value co-creation in well-being ecosystems.

PURPOSE: This article aims to examine how users' involvement in value co-creation influences the development and orchestration of well-being ecosystems to help tackle complex societal challenges. This research contributes to the public management literature and answers recent calls to investigate novel public service governances by discussing users' involvement and value co-creation for novel well-being solutions. DESIGN/METHODOLOGY/APPROACH: The authors empirically explore this phenomenon through a case study of a complex ecosystem addressing increased well-being, focussing on the formative evaluation stage of a longitudinal evaluation of Sweden's first support centre for people affected by cancer. Following an abductive reasoning and action research approach, the authors critically discuss the potential of user involvement for the development of well-being ecosystems and outline preconditions for the success of such approaches. FINDINGS: The empirical results indicate that resource reconfiguration of multi-actor collaborations provides a platform for value co-creation, innovative health services and availability of resources. Common themes include the need for multi-actor collaborations to reconfigure heterogeneous resources; actors' adaptive change capabilities; the role of governance mechanisms to align the diverse well-being ecosystem components, and the engagement of essential actors. RESEARCH LIMITATIONS/IMPLICATIONS: Although using a longitudinal case study approach has revealed stimulating insights, additional data collection, multiple cases and quantitative studies are prompted. Also, the authors focus on one country but the characteristics of users' involvement for value co-creation in innovative well-being ecosystems might vary between countries. PRACTICAL IMPLICATIONS: The findings of this study demonstrate the value of cancer-affected individuals, with "lived experiences", acting as sources for social innovation, and drivers of well-being ecosystem development. The findings also suggest that participating actors in the ecosystem should utilise wider knowledge and experience to tackle complex societal challenges associated with well-being. SOCIAL IMPLICATIONS: Policymakers should encourage the formation of well-being ecosystems with diverse actors and resources that can help patients navigate health challenges. The findings especially show the potential of starting from the user's needs and life situation when the ambition is to integrate and innovate in fragmented systems. ORIGINALITY/VALUE: The proposed model proposes that having a user-led focus on innovating new solutions can play an important role in the development of well-being ecosystems.

A Market of Lived Experience-User Involvement and the Commodification of Personal Experiences of Mental Illness.

Working actively to engage service users in participatory practices is both a policy expectation and a moral imperative for mental health social workers in contemporary Western mental health care. Recent research suggests that such practices of service user involvement are becoming increasingly individualised and driven by market logic. Based on an ethnographic study within a Swedish public psychiatric organisation, this article applies the concept of commodification to examine this trend. By showing how the practice of user involvement takes the form of a market where personal narratives and experiences of mental health problems are bought and sold as commodities, the analysis illuminates how market logic permeates the everyday practice of user involvement. One consequence of this commodification is that user organisations, as well as individual service users, are restricted in their role as independent actors pursuing their own agenda, and instead increasingly act on behalf of the public and as providers of personal experiences. While it is vital that service user perspectives are heard and recognised within mental health services, mental health social workers need to be aware of the risks of commodifying lived experience. When attention is directed to individual experiences and narratives, there is a risk that opportunities to advocate on behalf of the user collective as a whole and speak from a more principled and socio-political standpoint are lost. In addition, the commodification of personal experience tends to rationalise and privilege user narratives that conform to the dominant institutional logic of the mental health organisation, while excluding more uncomfortable and challenging voices, thereby undermining the ability of service users to raise critical issues that do not align with the interests of the mental health organisation.

Shiga toxin-producing Escherichia coli (STEC) and atypical enteropathogenic E. coli (aEPEC) in Swedish retail wheat flour.

Wheat flour has been identified as the source of multiple outbreaks of gastrointestinal disease caused by shiga toxin-producing Escherichia coli (STEC). We have investigated the presence and genomic characteristics of STEC and related atypical enteropathogenic E. coli (aEPEC) in 200 bags of Swedish-produced retail wheat flour, representing 87 products and 25 brands. Samples were enriched in modified tryptone soya broth (mTSB) and screened with real-time PCR targeting stx1, stx2 and eae, and the serogroups O157, O121 and O26. Isolation was performed by immunomagnetic separation (IMS) for suspected STEC/aEPEC O157, O121 and O26, and by screening pools of colonies for other STEC. Real-time PCR after enrichment revealed 12 % of samples to be positive for shiga toxin genes (stx1 and/or stx2) and 11 % to be positive for intimin (eae). Organic production, small-scale production or whole grain did not significantly influence shiga toxin gene presence or absence in a generalized linear mixed model analysis. Eight isolates of STEC were recovered, all of which were intimin-negative. Multiple serotype/sequence type/shiga toxin subtype combinations that have also been found in flour samples in other European countries were recovered. Most STEC types recovered were associated with sporadic cases of STEC among humans in Sweden, but no types known to have caused outbreaks or severe cases of disease (i.e. haemolytic uraemic syndrome) were found. The most common finding was O187:H28 ST200 with stx2g, with possible links to cervid hosts. Wildlife associated with crop damage is a plausible explanation for at least some of the surprisingly high frequency of STEC in wheat flour.

Perceived Housing in Relation to Retirement and Relocation: A Qualitative Interview Study among Older Adults.

As people age the home environment becomes increasingly important. Retirement commonly leads to spending more time in one's home, and relocating from your own home in older age could be associated with reduced health or wellbeing. The relationship between home and person is complex and perceived aspects of one's housing such as social, emotional and cognitive ties are considered important factors for health and wellbeing. However, little is known about how perceived aspects of the home change in relation to retirement and relocation. This paper used Situational Analysis to explore, via situational mapping, how community dwelling older adults (aged 60-75) perceived their housing situation in relation to retirement and relocation. The results suggest complex relations between relocation/retirement and perceived housing, and between different aspects of perceived housing. Furthermore, the results suggest that the relationship between life transitions and perceived housing can be seen as bi-directional, where different life transitions affect aspects of perceived housing, and that perceived housing affects (decisions for) relocation. The results suggest complex relations between retirement and relocation, as well as other life transitions, and perceived aspects of one's housing. It is important to consider these interactions to understand factors that affect health and wellbeing in older adults.

Exploring the meaning, role and experiences of a patient-led social innovation for people affected by cancer: a new collaborative care model complementing traditional cancer rehabilitation in Sweden.

OBJECTIVE: Kraftens Hus is the first support centre in Sweden designed by and for people affected by cancer, including patients, family, friends, staff members and local community representatives (collectively 'stakeholders'). The purpose of this study was to explore the meaning, role and experiences of Kraftens Hus stakeholders using a patient and public involved methodology. METHODS: To understand and map the experiences of visitors to Kraftens Hus, we applied concept mapping (CM), a mixed methods approach where data are collected and analysed in four structured steps designed to capture the diverse perspectives of multiple stakeholders. Qualitative interviews with relevant stakeholders supplemented the CM findings. RESULTS: The final concept map contained six clusters of ideas. Within the clusters, there was a recurring theme that cancer-affected people value accessible and long-term psychosocial support (PSS). The intended emotional, social and practical needs identified in a previous design process seem to have been addressed and appreciated by Kraftens Hus visitors. CONCLUSION: Kraftens Hus is an example of a new patient-led social innovation based on a life-event perspective and integration of resources from different sectors in society. By focusing on life, not the disease, the care continuum expands, and long-term PSS is provided alongside cancer treatment. The evaluation confirms that PSS should focus on health and well-being in the broadest sense.

Exploring power shifts as an enabler for a strengthened patient role in quality improvements: a Swedish survey study.

OBJECTIVES: This study examined the relationship between professionals' perceptions of a strengthened role for the patient and of patient involvement in quality improvement (QI) and whether professionals' experiences in improvement science were a moderator on such a relationship. DESIGN: From a predominantly close-ended, 44-item questionnaire, 4 questions specifically concerning professionals' perception on patient involvement in QI were analysed. SETTING: Three Swedish regions. PARTICIPANTS: 155 healthcare professionals who had previously participated in courses in improvement science. RESULTS: The covariate patient involvement was significantly related to a perceived strengthened patient role. There was also a significant interaction effect between degree of patient involvement and professionals' experience in the area of improvement science on a strengthened patient role. The result shows that there is a relationship between the perceived level of patient involvement in improvements and professionals' perceptions of a strengthened patient role. In this study, the covariate, perceived patient involvement, was significantly related to experiences of more equal relationships between patients and healthcare professionals. There was also a significant interaction effect between the degree of patient involvement and professionals' experience in the area of improvement science, for a more equal relationship between patients and healthcare professionals. CONCLUSION: Increased patient involvement in QI is a means of strengthening the patient role and supporting a more equal relation between patients and healthcare professionals. Furthermore, empirical evidence shows that the healthcare professionals' experiences in the area of improvement science support a strengthened patient role and a more equal power relationship, but for this to happen, the mindset of professionals is key. Future research is needed to capture and investigate the experiences from patients and relatives about being involved in QI in healthcare, and to study the effects on quality in care processes.

Discrimination against the elderly in health-care services: a systematic review.

Ageism in health-care services is a cardinal public health concern in geriatric health. It is important to know the types and extent of discrimination experienced by elderly individuals while seeking health care. This systematic review aimed to explore the available research to identify discrimination of elderly individuals in health-care services. MEDLINE through PubMed, Web of Science, PsycInfo, and Cochrane Database were searched by using a comprehensive search strategy in September 2020 with no limitation in the year of publication and types of publication. Articles published in English focusing on disparities in health-care service among the elderly were included. Two independent authors screened, extracted, and assessed the quality of data using the Joanna Briggs Institute Critical Appraisal Tool. A narrative synthesis was conducted followed by qualitative content analysis to identify themes from the extracted outcomes of the included studies. Of 3117 articles retrieved from the initial search, 21 articles were included. A total of 611 608 participants from 38 countries in four geographic regions were reported. Articles were published between 2003 and 2020. Most of the studies (n = 19) were cross-sectional in design, and the remaining two studies were qualitative. Major themes of discrimination were age-related discrimination, racial discrimination, gender discrimination, wealth-related discrimination, and technology-related discrimination. This systematic review identified the major perspectives on disparities faced by the elderly in accessing health services. There is a huge research gap on this issue. Specific strategies should be incorporated to address the varying types of discrimination experienced by elderly individuals.

Microbiota of semen from stallions in Sweden identified by MALDI-TOF.

Stallion semen is known to contain environmental bacteria and normal commensals, and in some cases may contain opportunistic pathogens. These bacteria may negatively influence sperm quality during storage before artificial insemination. The bacteria isolated depend on the culture conditions and method of identification; therefore, the aim of this study was to identify as many of the bacteria present in stallion semen as possible by culturing aliquots of semen under a variety of conditions. Eleven semen samples were available: five extended semen samples from one stud together with a sample of the extender, and six raw semen samples from another stud. Aliquots of semen samples were cultured on different agars and under specialized conditions; individual bacterial colonies were identified using Matrix-assisted laser desorption ionization time of flight mass spectrometry. Approximately 55% of the bacteria could be identified, with 20 bacterial taxa being isolated from semen samples from the five stallions on the first stud and 11 taxa from the semen samples from six stallions on the second stud. Staphylococcus spp. were present in all samples, and Micrococcus spp. were present in all of the extended semen samples although they were also isolated from the extender. The number of bacteria in colony forming units per mL varied considerably among samples. Only one microbe known to be associated with equine infertility, Pseudomonas spp., was isolated from three samples, albeit in low numbers. In conclusion, bacterial culture followed by MALDI-TOF does not identify all bacteria present in stallion semen samples. In-depth knowledge of which microbes are likely to be present is useful in determining their effects on sperm quality and, where appropriate, developing protocols for effectively controlling microbial growth.

Socially engaged calves are more likely to be colonised by VTEC O157:H7 than individuals showing signs of poor welfare.

In cattle herds, the transmission and persistence of VTEC O157:H7 (a serotype of verotoxin-producing Escherichia coli - known for its life threatening complications in humans) is dependent on a small proportion of cattle who become colonised and shed high numbers of the bacteria. Reducing the proportion of these animals is considered key for decreasing the prevalence of VTEC O157:H7. In this study, observations of calf behaviour and animal-based welfare indicators were used to explore individual risk factors and underlying drivers of colonisation in Swedish dairy calves. Interdependencies between variables led to three different approaches being used to visualize and explore the associations. Combining the results of all methods revealed similar patterns and suggest that healthy animals, actively grooming and interacting with others calves in the group have a higher risk of colonisation than small dairy calves in poor condition (diarrhoea, poor ruminal fill, poor body condition score and nasal discharge). This lends no support to the hypothesis that reduced welfare is a risk factor for VTEC O157:H7, but implies that individual differences in calf behaviour affect oral exposure to the bacteria so driving the risk of colonisation. This new finding has important implications for understanding of VTEC O157:H7 transmission within farms.

Risk factors and dynamics of verotoxigenic Escherichia coli O157:H7 on cattle farms: An observational study combining information from questionnaires, spatial data and molecular analyses.

The increasing number of human cases infected with a highly virulent type of verotoxigenic Escherichia coli (VTEC) O157:H7 in Sweden is the result of domestic transmission originating in regional clusters of infected cattle farms. To control the spread of the bacteria a comprehensive picture of infection dynamics, routes of transmission between farms and risk factors for persistence is urgently needed. The aim of the study was to investigate different aspects of the epidemiology of VTEC O157:H7 on the Swedish island of Öland by combining information from environmental sampling of VTEC O157:H7 from 80 farms with information from farmer questionnaires, spatial and molecular analyses. The farms were sampled in the spring and fall of 2014 and on four of them additional samples were collected during summer and winter. The results show a high prevalence of VTEC O157:H7 and a high proportion of strains belonging to the virulent clade 8. Farms that became infected between samplings were all located in an area with high cattle density. The most important risk factors identified are generally associated with biosecurity and indicate that visitors travelling between farms may be important for transmission. In addition, whole genome sequencing of a subset of isolates from the four farms where additional sampling was performed revealed ongoing local transmission that cannot be observed with a lower resolution typing method. Our observations also show that VTEC O157:H7 may persist in the farm environment for extended periods of time, suggesting that specific on-farm measures to reduce environmental prevalence and spread between groups of animals may be required in these cases.

The effects of educational interventions on suicide: A systematic review and meta-analysis.

BACKGROUND: Suicide is a major public health problem. Educational interventions for preventing suicidal behaviour are widely used, although little is known regarding the collective effectiveness of these interventions. AIM: We evaluated the existing evidence for the effectiveness of education interventions in the prevention of suicidal behaviour. METHODS: In this systematic review and meta-analysis, we searched multiple databases using terms related to suicide prevention. The articles were reviewed by two independent reviewers, and the quality of evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data from individual studies were combined in meta-analyses. RESULTS: We identified 41 studies evaluating two different types of interventions: school-based education interventions and gatekeeper training. Education interventions showed significant gains in terms of knowledge and attitudes, though the effects seem to vary depending on subjects' personal characteristics. School-based education interventions significantly reduced suicidal ideation and suicide attempts in youths. Gatekeeper training showed no significant effect on suicide attempts or gatekeeper skills, though the quality of evidence for the estimate, according to GRADE criteria, was rated as very low. CONCLUSION: The results of this study indicate that school-based education interventions are effective in preventing suicidal ideation and suicide attempts. In clinical practice, as well as in research, the development and implementation of educational interventions should focus on participants' individual characteristics.

Bacteria detected in the genital tract, semen or pre-ejaculatory fluid of Swedish stallions from 2007 to 2017.

BACKGROUND: Although artificial insemination (AI) was developed as a means of controlling disease transmission, pathogens can still be transmitted to females in semen used for AI. In addition, bacteria can cause deterioration in sperm quality during storage. Semen becomes contaminated by the male's normal bacterial flora as it passes out of the reproductive tract but potential pathogens may also contaminate the semen. Therefore, semen samples from stallions to be used for AI are tested before the breeding season to minimize transmission of pathogens to inseminated mares. In Sweden, semen samples are tested at the National Veterinary Institute, Uppsala (SVA). For the present study, a retrospective analysis was made of potentially pathogenic bacteria isolated from samples submitted to the SVA from 2007 to 2017. RESULTS: In our study, Taylorella equigenitalis was found infrequently (53 out of 25,512 samples), representing 11 out of 2308 stallions. If T. equigenitalis was detected, the stallions were treated with antibiotics and re-tested later in the same year. Klebsiella pneumoniae and beta haemolytic streptococci were the most commonly found potential pathogens, whereas Pseudomonas aeruginosa was also isolated occasionally. There were considerable differences in the number of species isolated each year. CONCLUSIONS: Potential pathogens were identified in relatively few of the samples submitted to SVA during this period, with T. equigenitalis not being identified since 2015. Of the other potential pathogens, K. pneumoniae and beta haemolytic streptococci were the most common. The information is relevant for determining guidelines on the testing and treatment of stallions before breeding.

Participation in a Swedish cervical cancer screening program among women with psychiatric diagnoses: a population-based cohort study.

BACKGROUND: In Sweden, organized screening programs have significantly reduced the incidence of cervical cancer. For cancers overall, however, women with psychiatric diagnoses have lower survival rates than other women. This study explores whether women with psychiatric diagnoses participate in cervical cancer screening programs to a lesser extent than women on average, and whether there are disparities between psychiatric diagnostic groups based on grades of severity. METHODS: Between 2000 and 2010, 65,292 women within screening ages of 23-60 had at least two ICD-10 (International Statistical Classification of Diseases and Related Health Problems - Tenth Revision) codes F20*-F40* registered at visits in primary care or psychiatric care in Region Västra Götaland, Sweden. Participation in the cervical cancer screening program during 2010-2014 was compared with the general female population using logistic regression adjusted for age. RESULTS: Relative risk for participation (RR) for women diagnosed within psychiatric specialist care RR was 0.94 compared with the general population, adjusted for age. RR for diagnoses outside specialist care was 0.99. RR for psychoses (F20*) was 0.81. CONCLUSIONS: Women with less-severe psychiatric diagnoses participate in the screening program to the same extent as women overall. Women who have received psychiatric specialist care participate to a lesser extent than women overall. The lowest participation rates were found among women diagnosed with psychoses.

From one-sized to over-individualized? Service logic's value creation.

Purpose There is a current trend in healthcare management away from produced and standardized one-size-fits-all processes toward co-created and individualized services. The purpose of this paper is to increase understanding of the value concept in healthcare organization and management by recognizing different levels of value (private, group and public) and the interconnectedness among these levels. Design/methodology/approach The paper uses social constructionism as a lens to problematize the individualization of service logic's value concept. Theories from consumer culture theory/transformative service research and public management add group and public levels of value to the private level. Findings An intersubjective (rather than subjective) approach to value creation entails the construction and sharing of value perceptions among groups of people. Such an approach also implies that group members may face similar barriers in their value creation efforts. Practical implications Healthcare management should be aware of the inherent individualism of service logic and, consequently, the need to balance private value with group and public levels of value. Social implications Identifying and addressing disadvantaged groups and the reasons for their disadvantaged positions is important in order to enhance the individual's value creation prerequisites as well as to address public and societal values, such as equal/equitable health(care). Originality/value It is important to complement service logic's value creation with group and public levels in order to understand the complexity and interconnectedness of value and the creation thereof.

"Brave Men" and "Emotional Women": A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain.

Background: Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity. Methods: A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach. Results: The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity. Conclusions: Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

Effect of on-farm interventions in the aftermath of an outbreak of hypervirulent verocytotoxin-producing Escherichia coli O157:H7 in Sweden.

In 2007, human infections with a hypervirulent strain of verocytotoxin-producing Escherichia coli O157:H7 increased in Sweden and especially in the Halland County. A connection between the cases and a local beef cattle farm with an on-farm abattoir and meat processing plant was established. In this observational study the control measures implemented on the infected farm and the dynamics of infection in the herd are described. In May 2008, when measures were initiated and animals put to pasture, the prevalence of positive individuals was 40 per cent and 18 carcasses out of 24 slaughtered animals were contaminated. During summer the monthly prevalence of positive carcasses varied between 8 and 41 per cent and at turning-in 22 out of 258 individually sampled animals were shedding the pathogen. After January 2009 no positive carcasses were found at slaughter and follow-up samplings of environment and individuals remained negative until the study period ended in May 2010. The results indicate that on-farm measures have potential to reduce the prevalence of the pathogen in a long-term perspective. However, as self-clearance cannot be excluded the effectiveness of the suggested measures needs to be confirmed.

Exploring complaints by female and male patients at Swedish hospitals using a probabilistic graphical model.

BACKGROUND: Patients' complaints have been highlighted as important for constructively improving healthcare services. In so doing, it may be important to identify disparities in experiences based on patients' demographics, such as sex. AIM: To explore hospital recorded complaints addressing potential sex differences and whether complaints were reported by the patient or a relative. METHODS: Quantitative study of all 835 closed patient complaints during 2013 at three mid-sized hospitals in Sweden. The complaints were categorisation based on perceived quality theory and analysed using a probabilistic graphical model. The findings were validated through qualitative interviews. FINDINGS: Female patients were more likely than male patients to report dissatisfaction with interpersonal issues, whereas male patients were more likely to report dissatisfaction with administration. If a complaint from a male patient had been reported by a relative, the matter was more likely to be interpersonal. Improvement suggestions were predominantly reported by staff. However, patients and relatives proved more likely than staff to report improvement suggestions when dissatisfied with interpersonal matters. CONCLUSION: Using a Bayesian network, this article suggests that complaints in health care should be more holistically understood and the factors should be viewed as interconnected. This article addresses complaints as an important source of identifying not only perceived healthcare deficiencies and sex disparities, but also improvement suggestions.

Dynamics of insertion sequence element IS629 inactivation of verotoxin 2 genes in Escherichia coli O157:H7.

There are several anecdotal reports of insertion sequence (IS) element inactivation of verotoxin genes among enterohaemorrhagic Escherichia coli of the serotype O157:H7, a pathogen causing severe gastrointestinal disease in infected humans. These insertions can be expected to drastically reduce the virulence of the bacteria. IS element inactivation has been shown to be reversible in model systems, suggesting the possibility of spontaneous restoration of virulence. In this study, traditional and high-throughput sequencing was used to characterise three patterns of IS629 inactivation of verotoxin 2 genes in EHEC O157:H7, caused by insertion or insertion followed by partial deletion. At least one of the patterns of inactivation appears to have persisted several years among cattle O157:H7, indicating it has no major effect on fitness in the animal reservoir. Digital PCR was used to directly quantify the reversal rates of the insertional inactivation of a selected isolate under laboratory conditions. Inserts were found to be absent from in the order of 1/105 of individual genomes, with significantly higher loss frequencies observed in cultures under nutrient-poor conditions. We conclude that strains with this type of inactivation found in food or animal samples should be considered a threat to human health, and may pose a challenge for PCR-based detection methods.

When they talk about motherhood: a qualitative study of three groups' perceptions in a Swedish child health service context.

BACKGROUND: In light of the growing emphasis on individualization in healthcare, it is vital to take the diversity of inhabitants and users into consideration. Thus, identifying shared perceptions among group members may be important in improving healthcare that is relevant to the particular group, but also perceptions of the staff with whom interactions take place. This study investigates how motherhood is perceived among three groups: Somali-born mothers; Swedish-born mothers; and nurses at Swedish child health centers. Inequities in terms of access and satisfaction have previously been identified at the health centers. METHODS: Participants in all three groups were asked to finalize two statements about motherhood; one statement about perfect motherhood, another about everyday motherhood. The responses were analyzed using qualitative coding and categorization to identify differences and similarities among the three groups. RESULTS: The responses to both statements by the three groups included divergences as well as convergences. Overall, biological aspects of motherhood were absent, and respondents focused almost exclusively on social matters. Working life was embedded in motherhood, but only for the Somali-born mothers. The three groups put emphasis on different aspects of motherhood: Somali-born mothers on the community; the Swedish-born mothers on the child; and the nurses on the mother herself. The nurses - and to some extent the Swedish-born mothers - expected the mother to ask for help with the children when needed. However, the Somali-born mothers responded that the mother should be independent, not asking for such help. Nurses, more than both groups of mothers, largely described everyday motherhood in positively charged words or phrases. CONCLUSION: The findings of this paper suggest that convergences and divergences in perceptions of motherhood among three groups may be important in equitable access and utilization of healthcare. Individualized healthcare requires nuance and should avoid normative or stereotypical encounters by recognizing social context and needs that are relevant to specific groups of the population.

Genomic comparison of Escherichia coli serotype O103:H2 isolates with and without verotoxin genes: implications for risk assessment of strains commonly found in ruminant reservoirs.

INTRODUCTION: Escherichia coli O103:H2 occurs as verotoxigenic E. coli (VTEC) carrying only vtx 1 or vtx 2 or both variants, but also as vtx-negative atypical enteropathogenic E. coli (aEPEC). The majority of E. coli O103:H2 identified from cases of human disease are caused by the VTEC form. If aEPEC strains frequently acquire verotoxin genes and become VTEC, they must be considered a significant public health concern. In this study, we have characterized and compared aEPEC and VTEC isolates of E. coli O103:H2 from Swedish cattle. METHODS: Fourteen isolates of E. coli O103:H2 with and without verotoxin genes were collected from samples of cattle feces taken during a nationwide cattle prevalence study 2011-2012. Isolates were sequenced with a 2×100 bp setup on a HiSeq2500 instrument producing >100× coverage per isolate. Single-nucleotide polymorphism (SNP) typing was performed using the genome analysis tool kit (GATK). Virulence genes and other regions of interest were detected. Susceptibility to transduction by two verotoxin-encoding phages was investigated for one representative aEPEC O103:H2 isolate. RESULTS AND DISCUSSION: This study shows that aEPEC O103:H2 is more commonly found (64%) than VTEC O103:H2 (36%) in the Swedish cattle reservoir. The only verotoxin gene variant identified was vtx 1a . Phylogenetic comparison by SNP analysis indicates that while certain subgroups of aEPEC and VTEC are closely related and have otherwise near identical virulence gene repertoires, they belong to separate lineages. This indicates that the uptake or loss of verotoxin genes is a rare event in the natural cattle environment of these bacteria. However, a representative of a VTEC-like aEPEC O103:H2 subgroup could be stably lysogenized by a vtx-encoding phage in vitro.