1.
Novak, Masuma, 1969-
(författare)
Social inequity in health : Explanation from a life course and gender perspective
2010
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
Background: A boy child born in a Gothenburg suburb has a life expectancy that is nine years shorter than that of another child just 23 km away, and among girls the difference is five years. There is no necessary biological reason to this observed difference. In fact, like life length, most diseases follow a social gradient, even in a country like Sweden where many believe there is no class inequity. This social inequity in health tells us that some of us are not achieving our potential in health or in life length compared to our more fortunate fellow citizens. Aim: This thesis attempts to explore the patterns of health inequities and the pathways by which health inequities develop from a life course and gender perspective. In particular focuses on the importance of material, behavioural, health related and psychosocial circumstances from adolescence to adulthood in explaining social inequity in musculoskeletal disorders (MSDs), obesity, smoking, and social mobility. Method: All four papers of this thesis were based on quantitative analyses of data from a 14-year follow-up study. The baseline survey was conducted in 1981 in Luleå, Sweden. The survey included all 16-year-old pupils born in 1965. A total of 1081 pupils (575 boys and 506 girls) were surveyed. They were followed up at ages 18, 21 and 30 years with comprehensive self-administered questionnaires. The response rate was 96.5% throughout the 14-year follow-up. In addition to the questionnaires data, school records, and interviews with nurse and teachers’ were used. Results: There were no class or gender differences in MSDs and in obesity during adolescence, but significantly more girls than boys were smokers. Class and gender differences had emerged when they reached adulthood with more women reporting to have MSDs but more men being overweight and obese. Women continued to be smokers at a higher rate than men through to adulthood. When an intersection between class and gender was considered, a more complex picture emerged. For example, not all women had higher prevalence of MSDs or smoked more than men, rather men with high socioeconomic position (SEP) had lower prevalences of MSDs and smoking than women with high SEP; and these high SEP women had lower prevalences than men with low SEP. The worst-off group was women with low SEP. The obesity pattern was quite the contrary, where women with high SEP had a lower prevalence of obesity than women with low SEP; and these low SEP women had a lower prevalence than men with high SEP. The worst-off group was men with low SEP. Regarding social mobility, health status (other than height in women) and ethnic background were not associated with mobility either for men or women. The results indicated that unequal distribution of material, psychosocial, health and health related behavioural factors during adolescence, young adulthood and adulthood accounted for the observed social gradients and social mobility. However, several factors from adolescence appeared to be more important for women while recent factors were more important for men. Important adolescent factors for social inequity and downward mobility were: unfavourable material circumstances defined as low SEP of parent, unemployed family member, and had no own room during upbringing; unfavourable psychosocial circumstances defined as parental divorce, poor contact with parents, being less liked in school, and low school control; and poor health related behaviour defined as smoking and physical inactivity. Among these factors, being less liked in school showed consistent association with all outcome measures of this thesis. Being less liked by the teachers and students was found to be more common among adolescents whose parents had low SEP. Men and women who were less liked in school during their adolescence were more likely as adults to be smokers, obese (only women), and downwardly mobile. The dominant adult life factor that contributed to class inequity in MSDs for men and women was physical heavy working conditions, which attributed to an estimated 46.9% (women) and 49.5% (men) of the increased risk in MSDs of the lower SEP group. High alcohol consumption among men with low SEP was an additional factor that contributed to class inequities in health and social mobility. Conclusion: Social patterning of health in this cohort was gendered and age specific depending on the outcome measures. Unfavourable school environment in early years had long lasting negative influence on later health, health behavior and SEP. The thesis supports the notion of accumulation of risk that social inequities in health occurs due to accumulation of multiple adverse circumstances among the lower SEP group throughout their life course. Schools should be used as a setting for interventions aimed at reducing socioeconomic inequities in health. The detailed policy implications for reduction of social inequities in health among men and women are discussed.
2.
Nilsson, Kerstin
(författare)
To work or not to work in an extended working life? Factors in working and retirement decisions
2013
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
In most of the industrialised world, the proportion of older and retired people in the population is continuously increasing. This will have budgetary implications for maintaining the welfare state, because the active working section of the population must fund the non-active and old population. Aim: The overall aim of this thesis was to obtain knowledge about older workers’ work and life situation in association with their planning and decision to retire from working life. Method: The thesis includes one qualitative and three quantitative studies conducted in Sweden. Result: Self-rated health was found to be a better measure than diagnosed disease of whether older workers believed they could work until 65 years or beyond. Health seems not to be a general impediment to working in old age if older workers are satisfied with their work situation and have enough time and opportunities to recover from fatigue. In one of Sweden’s most hazardous work environments, older workers were not injured significantly more often than younger workers. Good mental and physical work environment, moderate working pace and working time, and the right competence and possibility for skills development were factors determining whether older workers believed they can extend their working life. Attitude to older workers in the organisation, motivation and work satisfaction were factors determining whether older workers want to extend working life. Health, personal economic incentives, family/leisure pursuits and attitude to pension in society affected both whether people believed they can and wanted to extend their working life. In their final retirement decision, older workers considered: i) their possibility to balance and adapt functional ageing and health to a sustainable work situation; ii) their economic situation; iii) possibilities for social inclusion and coherence; and iv) possibilities for meaningful activities. Whether these requirements were best fulfilled in or outside working life determined the decision to continue working or to retire. Conclusion: If it is desirable for society that people will to extend their working life, both the “can work” and the “want to work” factors need to be met. It is important to provide a good fit inside working life. This requires a focus not only on older workers, but also on organisations and managers in order to provide incentives that keep older workers in the work force.
3.
Kjellström, Sofia
(författare)
Ansvar, hälsa och människa : en studie av idéer om individens ansvar för sin hälsa
2005
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
That people should take responsibility for their health is a prominent contemporary idea. But what does such responsibility actually entail, and what demands are being put on people? The objective of the dissertation is to describe and critically examine various ideas on personal responsibility for health. In the first step, I identify and describe a wide variation of uses of responsibility and in the second step, I problematize them. The analyzed material consists of Swedish government reports and various types of health advice literature, including medical books and alternative medicine literature. I employ a framework of philosophical, social scientific, and developmental psychology theories on responsibility to critically examine the material.The study shows that taking responsibility involves both body and mind. Common ideas are that it requires maintaining a healthy lifestyle and managing one's self-care. But it is also considered important to take responsibility for beliefs and emotions and to adopt an accepting attitude. Another idea is that spiritual insights expand the scope of responsibility. Some important abilities required to take responsibility are conscious healthy choices, self-knowledge, and critical thinking. The view of responsibility is also influenced by individual factors, cultural beliefs about health and disease, and social structures. In the literature, health responsibility is regarded both as a social duty and as a never-ending task performed by an active individual.Finally, I use Robert Kegan's theory of adult development to show that taking responsibility imposes psychological demands on people's awareness. The demands are often higher than many people can manage. Some of the stress and poor health that people experience may be the product of an inability to manage all of life's demands. The developmental perspective also asserts that people can develop the requisite capacity. One conceivable conclusion of the study is that if we want people to take more responsibility, we should not only invest resources in health information, but also in measures that generate self-knowledge, reflection, and personal development.
4.
Lytsy, Per, 1968-
(författare)
Power of the Pill : Views about Cardiovascular Risk and the Risk-reducing Effect of Statins
2010
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
Medical treatments with statins are prescribed to patients with increased risk of cardiovascular events. The benefits from statin treatment are well documented in clinical trials, but long-term adherence in patients is low, indicating that patients have an uncertainty about the necessity and benefits of treatment. The aims of this thesis were to investigate how patients and doctors view different aspects of statin treatment. Further aims were to investigate if the cardiovascular risk level in patients affects their views about different aspects of statin treatment. Yet further aims were to compare health behaviours and views about risk factors in patients using statins to a non-treated population. Data was obtained from patients (n = 829), doctors (n = 330) and a population sample (n = 720) using postal questionnaires. Views about the effect of statin treatment were assessed in different ways for patients and doctors. Patients based their assessments on their own situation, and doctors’ treatment decisions and assessments of anticipated effect of treatment were based on two hypothetical patient cases. The results indicate that patients greatly overestimate the general effect of statins, compared to efficacy results reported from clinical trials. Patients’ previous coronary heart disease or high overall risk were factors not associated with their views and expectations of treatment effect. Statin users with an internally perceived health control and patients satisfied with their doctor’s treatment explanation reported higher beliefs in treatment necessity and benefits. Statin users reported having better health behaviours and generally rated risk factors as more important than the non-treated population. Doctors had suboptimal understanding of the number of patients expected to benefit following five years of statin treatment and had a varying understanding of statins’ ability to prolong life. Overall the results illustrate that patients and doctors have different perspectives and views of the benefits from statin treatment which puts emphasis on how statin treatment is discussed in the clinical setting.
5.
6.
Rocha, Luis E C, 1981-
(författare)
Exploring patterns of empirical networks
2011
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
We are constantly struggling to understand how nature works, trying to identify recurrent events and looking for analogies and relations between objects or individuals. Knowing patterns of behavior is powerful and fundamental for survival of any species. In this thesis, datasets of diverse systems related to transportation, economics, sexual and social contacts, are characterized by using the formalisms of time series and network theory. Part of the results consists on the collection and analyzes of original network data, the rest focuses on the simulation of dynamical processes on these networks and to study how they are affected by the particular structures. The majority of the thesis is about temporal networks, i.e. networks whose structure changes in time. The new temporal dimension reveals structural dynamical properties that help to understand the feedback mechanisms responsible to make the network structure to adapt and to understand the emergence and inhibition of diverse phenomena in dynamic systems, as epidemics in sexual and contact networks.
7.
Meili, Kaspar Walter, 1989-
(författare)
Capability for broader cost-effectiveness in public health and social welfare : developing, valuing, and applyingcapability-adjusted life years Sweden (CALY-SWE)
2024
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
Spending in social welfare areas such as healthcare, wider public health, education, and social care consumes a major part of the public budget. Cost-effective resource allocation is a moral obligation towards both taxpayers and beneficiaries: tax money should be used efficiently, and it should be transparently accounted for. After all, economical management of resources is important for sustaining future prosperity and for addressing fundamental challenges such as climate change and demographic shift. In healthcare, cost‐effectiveness using quality-adjusted life years (QALYs) is a well-established tool to inform policymakers. Using cost per QALY implies that health-related quality of life (QoL), and not money, is an end on its own. Moreover, cost per QALY allows one to compare unrelated interventions by measuring the effects on the common QALY scale. However, for actors concerned with broader social welfare, such as the Swedish municipalities, QALYs may be less useful because their measurement focus is largely limited to health. Comparable outcome measures for broader social welfare are still sparsely available and employed, and a context-specific measure for Sweden is lacking. The aim of this thesis was to develop, value, and apply capability-adjusted life years Sweden (CALY‐SWE), a QoL outcome measure conceptually based on the capability approach, for broader social welfare and specific for Sweden.Within study 1, we organized a Delphi panel to select relevant capability attributes and then developed the phrasing for the questionnaire. The resulting questionnaire contains six attributes –health, social relations, financial situation & housing, security, occupation, and political & civil rights – each with three answer levels. The phrasing integrates an implicit threshold so that the sensitivity is focused on the lower range of the scale, thus incorporating equity considerations that relate to sufficientarianism and prioritarianism. In study 2, we developed a value set consisting of all quality weights for the 729 possible CALY-SWE states. We relied on health economic outcome methodology, namely hybrid modelling of discrete choice and time trade-off data that we collected in a cross-sectional web survey with representative sampling. This value set allows to aggregate the CALY-SWE answers into a single quality weight that can be used in cost‐effectiveness analysis to calculate CALYs. In study 3, we applied the CALY-SWE questionnaire and value set to describe the capability distribution in a cross-sectional representative sample of the Swedish population. In a framework of group comparisons, we estimated capability inequalities and shortfalls for different population groups. The results showed that there are capability inequalities for *disadvantage groups* as well as for groups with discriminative inequalities – *plurality groups*, for example between lower and higher education. For study 4, we applied CALY‐SWE in a cost‐effectiveness application to model the effects of a payroll tax reduction in Sweden from 2007 to 2016 (during the financial crisis) on young people not in employment, education, or training (NEET). The intervention was likely cost-effective from a societal perspective, but only with limited probability from a fiscal perspective, although definite statements regarding cost-effectiveness are challenging because a threshold value for a CALY is still lacking. The final chapter discusses the measure’s development, including normative choices, in relation to the Swedish social welfare and policy context, the capability framework as suggested by Amartya Sen, distributive justice, and other outcome measures in cost‐effectiveness evaluations. Important work remains – for example, assessing psychometric properties, developing the conceptualization of the 0 to 1 anchor scale for capability weights, and assessing a threshold value for a CALY. In conclusion, with the questionnaire development, value set elicitation, and demonstration of applications, important steps for CALY‐SWE were accomplished. Cost‐effectiveness evaluations in wider social welfare and public health using CALY-SWE are now possible.
8.
Nordin, Maria, 1967-
(författare)
Low social support and disturbed sleep : epidemiological and psychological perspectives
2006
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
The Swedish work force underwent dramatic changes during an economic crisis in the 1990s. In the aftermath, sick leave increased at an unprecedented rate and stress-related disorders, such as burnout, depression, and sleep disturbances replaced earlier work-related diagnoses. Sleep disturbances have been demonstrated to both precede and succeed mental and physical illnesses, including burnout, depression, anxiety, and cardiovascular disease. Disturbed sleep is also a common complaint in Sweden as well as in the rest of the Western world. Sleep has been shown to easily be disturbed by cognitive, emotional, and physiological arousal (stress). However, several studies have demonstrated that social support has a protective effect against the adverse effects of stress as well as a generally beneficial effect on health. Other studies, though, suggest that lack of social support may increase the risk for mental and physical ill-health. The purpose of this thesis was therefore to investigate the association between social support and disturbed sleep; foremost in working populations.Epidemiological methods were applied to investigate the association between social support and disturbed sleep. Three studies were used; a cross-sectional (MONICA, n = 1,179), a longitudinal (WOLF, n = 2,479), and a case-referent (SHEEP and VHEEP in conjunction, n = 6,231) study. The data was obtained by questionnaires, and social support was operationalized as network and emotional support. Disturbed sleep was defined as difficulties falling asleep, difficulties maintaining sleep, repeated awakenings, and disturbed sleep. Gender was taken into consideration throughout the studies.Foremost, low network support was found to increase the risk for contracting disturbed sleep. Which source the network support was derived from did not alter the association between low network support and disturbed sleep—low network support at work increased the risk for disturbed sleep as did low network outside work. Prolonged low network support and impaired emotional support did also increase the risk for sleep disturbances in men who were under strain at work. Furthermore, open coping buffered against low network support in the association with disturbed sleep five years later in women, whereas low network support increased the risk for developing disturbed sleep at a later date when interacting with covert coping both in women and in men. Moreover, disturbed sleep was shown to mediate low network support in myocardial infarction in women.In conclusion, the association between social support and disturbed sleep is complex and includes both interactions with other personality variables and mediating associations. Previous research on negative effects of low social support was confirmed as was previously observed gender differences in social support.
9.
Jeppsson, Anders
(författare)
Decentralization and National Health Policy Implementation in Uganda - a Problematic Process.
2004
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
The Ugandan Government has aimed at creating a needs-based and cost-effective health care system. The means to carry out this aim have been 1) a decentralization of the health sector in order to increase lower-level responsibility, accountability, and participation, and 2) a strong national policy formulation capacity, facilitating needs assessment and cost-effective prioritization. Aim The aim of this study is to investigate the process of ascertaining goal achievement with regard to needs-based health care services and national health policy implementation in the decentralized health care system of Uganda. Population and method The health sector of Uganda is examined from the national to the district level. Focus is on the process of decentralization, which includes a more efficient mechanism for implementing policy goals throughout the decentralized system, since traditional hierarchical methods of directing institutions become obsolete. The concepts of diffusion and translation have been adopted from the theoretical framework of new institutionalism in organizational theory, and are used as tools in the analysis. Results Financial decentralization was studied under the assumption that districts would prioritize health care financially in implementing the new national health policy. It was, however, observed that this was not the case. As the Sector-Wide Approach Process (SWAP) was studied, it was observed that, while the policy formulation capacity of the Ministry of Health (MOH) (which is no longer supposed to focus on detailed health systems planning as in the past) became stronger, the central level had difficulties in maintaining efficient interaction with those responsible for implementation. This had resulted in an increasing gap between the centre and the periphery. The adoption of new policies, paradigms, and strategies, such as SWAP, the restructuring of the MOH, and the formulation of a new health policy, has strengthened ties with the global institutions. Sharing paradigms and values has probably further promoted the independence of the MOH. Also studied was the application of two normative rationalist instruments, Burden of Disease (BOD) and Cost-Effectiveness (CE), intended to implement national health policy priorities at a district level. This application was a failure. Discussion The increasing decentralization of the health care system in Uganda during the period studied has not been followed promptly by the implementation of a global national health policy necessary for a decentralized system. It appears as if the government assumed that new health policies could be implemented by means of a fairly uncomplicated process of diffusion. However, an analysis of the near total failure of the BOD/CE initiative shows that implementation of policy in the decentralized system in Uganda is complex and must be understood as a misdirected translation process whose prerequisites were lacking. The main factors that have inhibited the adoption of a new policy and have crated a gap between centre and periphery have been different values, the absence of a common frame of reference, and the lack of government support. As a result, local obligations and local accountability have been the main factors guiding the translation.
10.
Nordlöf, Hasse
(författare)
Prerequisites and Possibilities for Manufacturing Companies to Prioritize and Manage Occupational Health and Safety
2015
Doktorsavhandling (övrigt vetenskapligt/konstnärligt) abstract
Legislation demands that health and safety of humans at work must be secured. Today, far from every company has a functioning systematic management of occupational health and safety (OHS) in place to fulfill its legal obligations. Instead, other day-to-day tasks appear to have greater priority.The overall aim of this thesis was to investigate prerequisites and possibilities for manufacturing companies to prioritize and manage OHS, with focus on professional roles, company size, safety culture, and financial performance.Four papers (I–IV) are included in this thesis, based on three data collections. A questionnaire measuring the priority accorded to work environment was completed by 249 representatives of 142 manufacturing companies (I & II). Focus group interviews were conducted with 66 workers at a large steel-manufacturing company, discussing their experiences and perceptions of safety and risks at work (III). A questionnaire measuring OHS management practices, safety culture, and priority given to work environment was completed by 280 representatives of 197 manufacturing companies (IV). Information regarding the companies’ financial performance was retrieved from a credit bureau database.The main findings of the four papers demonstrated that profitability was considered as the most prioritized interest in the companies (I), and that trade-offs between productivity and safety is an obstacle to working safely (III). Managers generally perceived their companies to prioritize work environment factors more than the safety delegates did (I & IV). Perceptions of work environment priority did, however, not differ depending on company size (II & IV). Responsibility for safety was perceived to rest on the individual to the largest extent, and risk-taking was believed to originate from a combination of individual factors and external circumstances in the work environment (III). Larger company size, positive safety culture, and low risk in creditworthiness were found to be associated with better OHS management practices in companies (IV). Correspondingly, smaller company size, negative safety culture, and high risk in creditworthiness were found to be associated with worse OHS management practices.In summary, structural, social, and financial aspects seem to be important in companies’ possibilities for prioritizing and managing OHS. Recommendations for industry and future research are discussed.
