Facing a moral dilemma--introducing a dental care insurance within the public dental service.

Through the reform entitled "Dental care insurance-dental care at a fixed price", patients are offered a dental insurance, a capitation plan, that ensures that they can visit the dentist regularly during a period of three years at a fixed price per month (Frisktandvård).This insurance may be offered to all patients. The aim of this study was to generate a theory explaining the main concern for the staff at the public dental service when they have to introduce and advocate dental care insurance to patients. Interview data from 17 persons, representing different professions within the public dental service, were collected and analyzed simultaneously in line with guidelines for grounded theory. The results indicated that dentists/dental hygienists experienced several difficult standpoints concerning the implementation of the dental insurance, somewhat of a moral dilemma. The staff generally had a "cautiously positive attitude" to the forthcoming dental care insurance, but had perceptions how and when the patients should be offered the insurance and what that may mean to the clinic.The respondents reflected about the economic aspects for the clinic and how the oral health may be affected over time for the patients.

'Making dental care possible: a mutual affair': a grounded theory relating to adult patients with dental fear and regular dental treatment.

Dental fear is a common and widespread problem, which can cause severe stress. Even so, most patients with dental fear undergo regular dental treatment in spite of their fear and many enjoy good oral health. The aim of this study was to obtain a deeper understanding of how patients with dental fear manage to undergo dental treatment. Fourteen patients with dental fear, who undergo regular dental care, were interviewed. Qualitative analysis of the transcribed interviews was performed according to the principles of grounded theory. A conceptual framework was generated, and the main concern was identified as 'making dental care possible - a mutual affair'. Four additional categories explained how patients handled their dental fear and how dental care became possible. The strategies were labelled 'taking part in a mental wrestling match', 'trust-filled interaction with dental staff', 'striving for control' and 'seeking and/or receiving social support'. The results showed that making dental care possible for patients with dental fear is a mutual challenge that requires interplay between dental staff and patients, involving verbal and non-verbal communication reflecting respect, attention, and empathy. Moreover, a balance between nearness and distance and between professional and personal treatment is required.

A qualitative study of the influence of poor dental aesthetics on the lives of young adults.

OBJECTIVE: Although many countries offer some publicly funded orthodontic treatment for children, not all conditions receive treatment and some adolescents enter adulthood with persisting poor dental aesthetics or malocclusions. The aim of this study was to generate a theory highlighting the main concerns of young adults, either native-born or of immigrant background, with poor dental aesthetics and the measures they adopt to manage their condition in everyday life. MATERIAL AND METHODS: A qualitative method, classic grounded theory, was applied in order to generate a substantive theory highlighting the main concerns and managing mechanisms of 13 strategically selected 19- and 20-year-olds with poor dental aesthetics. Open interviews were conducted with each participant, the topics covering different aspects of social and dental conditions. RESULTS: A core category and three conceptual categories were generated. The core category was labelled "Being under the pressure of social norms" and was related to categories explaining three different ways in which these young adults handle their main concern: (1) avoiding showing their teeth; (2) minimizing the importance of appearance; and (3) seeking orthodontic treatment. The theory offers the potential for improved understanding of young adults who, despite poor dental aesthetics, are managing well with life, and also of those who have not adjusted well. CONCLUSIONS: In early adolescence it may be problematic to make decisions about orthodontic treatment. Undisclosed dental fear can be an important barrier. Some of the young adults in the present study would probably benefit from treatment.

Allowing for the opposite: the parents of asthmatic children cooperate by making use of each other's differences.

This article focuses on one of the interactive processes that parents use to cope with their child's asthma. The concept allowing for the opposite was developed in the course of a clinical project designed to improve consultation methods in pediatric allergy care. We examined material from 67 conversations carried out with 22 heterosexual couples held with two family therapists: one male pediatrician and one female social worker. We found that parents made use of each other's differences in personality and parenting style, allowing each other to take opposing positions on how to cope with their child's asthma. Disagreement should be added to the list of coping mechanisms used by parents in their cooperative efforts to handle their child's asthma.

Use of perioperative dialogues with children undergoing day surgery.

AIM: This paper is a report of a study to explore what it means for children to attend hospital for day surgery. BACKGROUND: Hospitalization is a major stressor for children. Fear of separation, unfamiliar routines, anaesthetic/operation expectations/experiences and pain and needles are sources of children's negative reactions. METHOD: A grounded theory study was carried out during 2005-2006 with 15 boys and five girls (aged 6-9 years) scheduled for elective day surgery. Data were collected using tape-recorded interviews that included a perioperative dialogue, participant observations and pre- and postoperative drawings. FINDINGS: A conceptual model was generated on the basis of the core category 'enduring inflicted hospital distress', showing that the main problem for children having day surgery is that they are forced into an unpredictable and distressful situation. Pre-operatively, the children do not know what to expect, as described in the category 'facing an unknown reality'. Additional categories show that they perceive a 'breaking away from daily routines' and that they are 'trying to gain control' over the situation. During the perioperative period, the categories 'losing control' and 'co-operating despite fear and pain' are present and intertwined. Post-operatively, the categories 'breathing a sigh of relief' and 'regaining normality in life' emerged. CONCLUSION: The perioperative dialogue used in our study, if translated into clinical practice, might therefore minimize distress and prepare children for the 'unknown' stressor that hospital care often presents. Further research is needed to compare anxiety and stress levels in children undergoing day surgery involving the perioperative dialogue and those having 'traditional' anaesthetic care.

Self-reported hearing difficulties, communication strategies and psychological general well-being (quality of life) in patients with acquired hearing impairment.

PURPOSE: The aims were to (i) translate the Amsterdam Inventory for Auditory Disability and Handicap (AIADH) into Swedish and evalute its usefulness, (ii) describe hearing difficulties and psychological well-being (quality of life) and (iii) explore variables related to psychological well-being in a Swedish population. METHOD: Seventy-nine consecutive patients, referred to the hearing clinic for hearing examination and audiological rehabilitation, formed the study sample. Along with pure-tone audiometry, the AIADH, the Psychological General Well-being index and the Communication Strategies Scale were used. RESULTS: Men had significantly worse hearing on the high frequencies (2, 3, 4 and 6 kHz) than women but their quality of life was significantly higher than for women. Men scored significantly lower on 'auditory localization' and adopted non-verbal communication strategies less often than women. A stepwise regression analysis showed that 'maladaptive behaviours' and 'intelligibility in quiet' explained 48% of the variance in quality of life. CONCLUSION: Psychosocial consequences of hearing loss, such as lowered quality of life, cannot be predicted from audiometric data alone. The adverse relationship between maladaptive behaviour and quality of life emphasizes the relevance of developing training programs aiming to improve coping with the consequences of a hearing impairment. The AIADH may be useful in assessing self-reported difficulties among patients with hearing problems, but needs to be further developed in terms of psychometric evaluations and reliability testings based on a larger representative sample.

Psychometric evaluation of a Norwegian version of the Communication Strategies Scale of the Communication Profile for the Hearing Impaired.

AIM: To evaluate the Communication Strategies Scale (CSS) in an adult Norwegian sample with hearing loss. SUBJECTS AND METHODS: Of 474 invited patients, a total of 337 consecutive adults admitted to the outpatient Unit of Audiology, ENT Department of a university hospital answered the CSS of the Communication Profile for the Hearing Impaired. The inventory assesses the use of three specific coping strategies; Maladaptive Behaviour, Verbal and Nonverbal Communication Strategies. The psychometric evaluation included construct validity by corrected item-total correlation, the internal consistency reliability by coefficient alpha (Cronbach's) and standard error of the measurement (SEM). Internal structure was evaluated by factor analyses using principal factors followed by a varimax rotation. RESULTS: CSS showed good psychometric properties with acceptable and good internal consistency reliability for the subscales. The internal structure of the entire scale gave main loadings at 24 of 25 items at the same factor as the original one. CONCLUSION: CSS may well be used as a clinical tool in the routine assessment of maladaptive and adaptive communication strategies in an unselected adult population of hearing impaired outpatients.

Patients' experiences of daily living with a pacemaker: a grounded theory study.

The purpose of this study was to examine patients' experiences of daily living with a pacemaker. A total of 13 pacemaker patients (seven women) aged 22-82 (mean = 59.2) years were interviewed. The informants had had a pacemaker from 0.5 to 33 (mean 13.1) years. The grounded theory method was the basis for collection and analysis of the data. The results of the analysis of the semi-structured interviews showed that variations in 'perceived social participation' and 'emotional state', the two core categories, were related to four qualitatively different ways of experiencing daily living after pacemaker implantation.

Psychological well-being of adults with acquired hearing impairment.

AIM: To study psychological well-being (health-related quality of life) in a population of adults 20 years and over with hearing impairment (HI) and its relation to audiological factors, consequences of the HI, sense of humour, and use of communication strategies. SUBJECTS AND METHODS: Consecutive adults (n = 343) at the outpatient Unit of Audiology of a Norwegian university hospital answered the Psychological General Well-being inventory (PGWB), Hearing Disability and Handicap Scale (HDHS), Sense of Humour Questionnaire-6 (SHQ-6), and Communication Strategies Scale (CSS) in relation to an audiological examination and medical consultation. RESULTS: Mean PGWB index for the whole sample was 81.4 (SD 14.3) and females reported a significantly lower psychological well-being. In multiple linear regression analyses well-being was negatively associated with high levels of activity limitation and participation restriction. PGWB index was positively associated with high sense of humour, but was neither explained by audiological factors nor use of communication strategies. CONCLUSIONS: Psychological well-being was associated with the outcome of a standard HI assessment of activity limitation and participation restriction, but not with degree of HI and use of communication strategies.

Activity limitation and participation restriction in adults seeking hearing aid fitting and rehabilitation.

PURPOSES: We first aimed to describe demographic and audiological characteristics of adults referred to a university hospital for hearing aid (HA) fitting and rehabilitation. Our second aim was to employ an inventory that assesses life consequences of hearing impairment (HI) in terms of perceived activity limitation and participation restriction for the first time in a Norwegian adult outpatient population. A third aim was to study life consequences by audiological and demographic characteristics. SUBJECTS AND METHODS: During one year consecutive patients (n = 343) were requested to answer the Hearing Disability and Handicap Scale (HDHS) assessing activity limitation and participation restriction in relation to an audiological examination and medical consultation. The mean threshold of hearing (MTH) was ascertained by pure tone thresholds at 0.5 - 1 - 2 - 4 kHz in the better ear. RESULTS: Activity limitation and participation restriction were both higher for HA experienced than HA naïve subjects ( p < 0.01). In a multivariable model, the explained adjusted variance of activity limitation (R2) was 43.4% with MTH, perceived duration, and severity of hearing problems as predictor variables. Correspondingly, the explained adjusted variance of participation restriction was 28.4% for a model with MTH, age, gender and perceived severity of hearing problems as predictors. CONCLUSIONS: As a standard supplement to audiometric tests, HDHS may be successfully applied as a clinical tool among similar hearing impaired outpatients in order to assess activity limitation and participation restriction as part of audiological rehabilitation.

Quality of intimate and sexual relationship in first-time parents six months after delivery.

This study aimed to describe the quality of the intimate relationship among parents six months after the birth of their first child. The Dyadic Adjustment Scale (DAS) has been modified and used on 820 responding first-time parents, of which 768 were couples. The results reveal that most parents were happy in their relationship, but both mothers and fathers were discontented with the dyadic sexuality. "Being too tired for sexual activity" was a problem, especially for the mothers, and the most common frequency of intercourse was once or twice per month. The result does not support the assumption that the couples compensate the lacking sexuality with sensuality. Good communication within the couple was associated with higher levels of several dimensions of the intimate relationship, especially dyadic consensus and satisfaction. Thus, one way to stabilize and strengthen a relationship when dyadic sexual activity is low would be to emphasize dyadic communication and sexual activity.

To Be Stricken with Acute Myocardial Infarction: A Grounded Theory Study of Symptom Perception and Care-seeking Behaviour.

The process of perceiving symptoms of illness is complex, and many patients delay seeking care when symptoms of acute myocardial infarction occur. However delayed treatment can have great consequences for the prognosis. This article reports on a grounded theory study, the aim of which was to increase our understanding of the individual's thoughts, feelings and actions at the onset of an acute heart attack. Qualitative analysis of semi-structured interviews revealed four different ways of perceiving the onset of symptoms: understanding, misinterpretation, amazement and disregard. The symptom perception categories were related to two core categories labelled health beliefs and acute reactions. Some persons were aware of risks for coronary heart disease and were ready to seek care immediately. Several others had illusions of invulnerability. Such illusions caused people to delay seeking care at the onset of symptoms of myocardial infarction.

Struggling for a new self: in-depth interviews with 21 patients with hyperacusis after an acute head trauma.

The aim of the study was to gain a better understanding of what suffering from hyperacusis means. Twenty-one out-patients referred to a hearing clinic due to persisting hypersensitivity to sounds after an acute head trauma were interviewed. Before the head trauma, they had lived an independent, active and externally oriented life. As a consequence of the trauma, the patients became psychosocially vulnerable and suffered from a variety of symptoms: hypersensitivity to sounds, difficulties with concentrating and remembering, increased anxiety and sensitivity to stress. Structuring everyday life and using a variety of coping strategies was necessary for reducing life stress and symptoms in the process of adjusting to the changed life situation.

Ambivalence in coping with dental fear and avoidance: a qualitative study.

Dental phobia is a widespread problem, which can have significant impact on the individual's health and daily life. This grounded theory study aims to explore the situation of dental phobic patients: how dental phobia interferes with their normal routines and functioning, social activities and relationships, what factors contribute to the maintenance of dental fear and how they cope with their fear. In the qualitative analysis of thematized in-depth interviews four main categories were developed: threat to self-respect and well-being, avoidance, readiness to act and ambivalence in coping. The results show that several psychological and social factors interact in determining how dental phobic individuals cope with their fear, and demonstrate in what way dental fear affects their daily lives.

Minimizing the dysfunctional interplay between activity and recovery: A grounded theory on living with fibromyalgia.

The aim of this study was to generate a substantive theory, based on interviews with women with fibromyalgia, explaining how they manage their main concerns in daily life. The study has an inductive approach in line with classic grounded theory (Glaser, 1992). Twenty-three women living in the southwest region of Sweden were interviewed in-depth about their daily living with fibromyalgia and problems related to this. Probing and follow-up questions were asked by the interviewers when relevant. The interviews were transcribed verbatim and consecutively analysed in line with guidelines for grounded theory. The results showed that the main concern for women with fibromyalgia was to reach a balance in daily life. This concern was resolved by them using different strategies aimed at minimizing the dysfunctional interplay between activity and recovery (core category). This imbalance includes that the women are forcing themselves to live a fast-paced life and thereby tax or exceed their physical and psychological abilities and limits. Generally, the fibromyalgia symptoms vary and are most often unpredictable to the women. Pain and fatigue are the most prominent symptoms. However, pain-free periods occur, often related to intense engagement in some activity, relaxation or joy, but mainly the "pain gaps" are unpredictable. To reach a balance in daily life and manage the dysfunctional interplay between activity and recovery the women use several strategies. They are avoiding unnecessary stress, utilizing good days, paying the price for allowing oneself too much activity, planning activities in advance, distracting oneself from the pain, engaging in alleviating physical activities, and ignoring pain sensations. Distracting from the pain seems to be an especially helpful strategy as it may lead to "pain gaps". This strategy, meaning to divert attention from the pain, is possible to learn, or improve, in health promoting courses based on principles of cognitive behavioural therapy (CBT). We suggest that such courses are offered in primary care for patients with fibromyalgia or other types of longstanding pain. The courses should be led by registered nurses or psychologists, who are experienced in CBT and have extensive knowledge about theories on longstanding pain, stress and coping. Such courses would increase well-being and quality of life in women suffering from fibromyalgia.

Hunting for health, well-being, and quality of life.

Health, well-being, quality of life, and lifestyle are central concepts within health science, although generally accepted definitions are still lacking. Lifestyle can either be seen as an independent variable and the cause of unhealthy behaviour or as a dependent variable, which is affected by conditions in the society. In the first case, the attention is directed on each individual case: maintaining or improving health requires changes in lifestyle and living habits. In this perspective, diet and physical activity are important features for health promotion. In the second case the attention is rather directed on structural conditions in society, for example the food industry, the lunches for children at school, and the "fast food" industry should be influenced to protect human health. The structural perspective has, so far, received restricted impact when it concerns prevention and promotion of health. Processes of individualisation in the society have to an increasing extent viewed health as an affair for the individual. The benefits of physical activity, healthy food and beverage, social support, and joy are documented scientifically. In general, the trend towards increasing responsibility for one's lifestyle and health is positive, but might reinforce the inequality in health. With an even harder climate in society there might be a risk that individual health projects undermine the solidarity and the will to accept costs for medical treatment and care for people who risk their health through an unhealthy and risk-taking lifestyle. However, we argue that peoples' well-being and quality of life presupposes a society that stands up for all people.

Health care professionals meeting with individuals with Type 2 diabetes and obesity: Balancing coaching and caution.

The burden of diabetes and obesity is increasing worldwide, indicating a need to find the best standard for diabetes care. The aim of this study was to generate a theory grounded in empirical data derived from a deeper understanding of health care professionals' main concerns when they consult with individuals with diabetes and obesity and how they handle these concerns. Tape-recorded interviews were conducted with seven groups and three individual members of a diabetes team in an area of western Sweden. The grounded theory (GT) method was used to analyse the transcribed interviews. A core category, labelled Balancing coaching and caution and three categories (Coaching and supporting, Ambivalence and uncertainty, and Adjusting intentions) emerged. The core category and the three categories formed a substantive theory that explained and illuminated how health care professionals manage their main concern; their ambition to give professional individualised care; and find the right strategy for each individual with diabetes and obesity. The theory generated by this study can improve our understanding of how a lack of workable strategies limits caregivers' abilities to reach their goals. It also helps identify the factors that contribute to the complexity of meetings between caregivers and individuals with diabetes.

Calibrating and adjusting expectations in life: A grounded theory on how elderly persons with somatic health problems maintain control and balance in life and optimize well-being.

AIM: This study aims at exploring the main concern for elderly individuals with somatic health problems and what they do to manage this. METHOD: In total, 14 individuals (mean=74.2 years; range=68-86 years) of both gender including hospitalized and outpatient persons participated in the study. Open interviews were conducted and analyzed according to grounded theory, an inductive theory-generating method. RESULTS: The main concern for the elderly individuals with somatic health problems was identified as their striving to maintain control and balance in life. The analysis ended up in a substantive theory explaining how elderly individuals with somatic disease were calibrating and adjusting their expectations in life in order to adapt to their reduced energy level, health problems, and aging. By adjusting the expectations to their actual abilities, the elderly can maintain a sense of that they still have the control over their lives and create stability. The ongoing adjustment process is facilitated by different strategies and result despite lower expectations in subjective well-being. The facilitating strategies are utilizing the network of important others, enjoying cultural heritage, being occupied with interests, having a mission to fulfill, improving the situation by limiting boundaries and, finally, creating meaning in everyday life. CONCLUSION: The main concern of the elderly with somatic health problems was to maintain control and balance in life. The emerging theory explains how elderly people with somatic health problems calibrate their expectations of life in order to adjust to reduced energy, health problems, and aging. This process is facilitated by different strategies and result despite lower expectation in subjective well-being.

'Feelings of guilt due to self-inflicted disease': a grounded theory of suffering from chronic obstructive pulmonary disease (COPD).

The aim of this grounded theory study was to illuminate the main concern of people suffering from chronic obstructive pulmonary disease (COPD) and how they handle their everyday life. Data were collected through interviews with 23 people with COPD at different stages, from mild to severe. A substantive theory was generated showing that the main concern was feelings of guilt due to self-inflicted disease associated with smoking habits. This core category was related to five managing strategies termed making sense of existence, adjusting to bodily restrictions, surrendering to fate, making excuses for the smoking-related cause and creating compliance with daily medication.

Swedish women's experiences of seeking care and being admitted during the latent phase of labour: a grounded theory study.

OBJECTIVE: to gain a deeper understanding of how women who seek care at an early stage experience the latent phase of labour. DESIGN: a qualitative interview study using the grounded theory approach. SETTING: the study was conducted at a hospital in the southwestern part of Sweden with a range of 1600-1700 deliveries per year. The interviews took place in the women's homes two to six weeks after birth. PARTICIPANT: eighteen Swedish women, aged 22-36, who were admitted to the labour ward while they were still in the latent phase of labour. FINDINGS: 'Handing over responsibility' to professional caregivers emerged as the core category or the central theme in the data. The core category and five additional categories formed a conceptual model explaining what it meant to women being admitted in the early stage of labour and their experiences of the latent phase of labour. The categories, which all related to the core category, were labelled: (1) 'longing to complete the pregnancy,' (2) 'having difficulty managing the uncertainty,' (3) 'having difficulty enduring the slow progress,' (4) 'suffering from pain to no avail' and (5) 'oscillating between powerfulness and powerlessness.' CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: findings indicate that women being admitted to the labour ward in the latent phase of labour experienced a need for handing over responsibility for the labour, the well-being of the unborn baby, and for themselves. Midwives have an important role in assisting women with coping during the latent phase of labour, and in giving the women opportunity to hand over responsibility. This care should include validation of experienced pain and confirmation of the normality of the slow process, information and support.