| 1. |
- Nilsson, Maria, 1957-
(författare)
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Promoting health in adolescents : preventing the use of tobacco
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- There is a robust evidence base for the negative health effects from smoking. Smoking is linked to severe morbidity and to mortality, and kills up to half of its regular users. Tobacco use and production also bring other negative consequences such as economic loss for countries, poverty for individuals, child labour, deforestation and other environmental problems in tobacco growing countries. A combination of comprehensive interventions at different levels is needed to curb the tobacco epidemic. Tobacco control strategies at national levels in the western world often include components of information/education, taxation, legislative measures and influencing public opinion. Two approaches have dominated at the meso and micro levels: cessation support for tobacco users and prevention activities to support young people refraining from tobacco use. Smoking uptake is a complex process that includes factors at the societal level as well as social and individual characteristics. At national level, taxation and legislation can contribute to a societal norm opposing tobacco and creating a context for primary prevention aimed at tobacco free youth. There is no magic bullet in primary prevention. At the meso and micro levels, a continued development of knowledge on the underlying mechanisms and primary prevention methods is essential to prevent young people from starting to use tobacco. The overall aim of this thesis was to gain knowledge about factors that influence young people’s use of tobacco and of preventive mechanisms. The specific aims included to study the relation between Tobacco Free Duo, an intervention program targeting youth in Västerbotten County, and tobacco use prevalence. A specific interest was to explore the role adults can play in supporting young people to refrain from tobacco use. The thesis is based on four studies with three separate sets of data, two were quantitative and one was qualitative. The studies were conducted among adolescents (aged 13-15 yr) in Västerbotten County and on national level in Sweden (aged 13, 15 and 17 yr). Tobacco Free Duo is a school-based community intervention that started in 1993. An essential component of the intervention was to involve adults in supporting adolescents to stay tobacco free. Results showed decreased smoking in adolescents among both boys and girls in the intervention area during the study period of seven years. There was no change in a national reference group during the same time period. A bonus effect was a decrease in adult tobacco use in the intervention area. One out of four adults who supported a young person taking part in the intervention stopped using tobacco. In a qualitative assessment of young smokers, starting to smoke was described as a means of gaining control of their feelings and their situation during early adolescence. They expected adults to intervene against their smoking and claimed that close relations with caring adults could be a reason for smoking less or trying to quit smoking. In a quantitative study that used three decades of national data, over time adolescents became more positive toward parental action on children’s smoking. The adolescents strongly supported the idea of parental action, regardless of whether or not they themselves smoked. Adolescents preferred that actions from parents were dissuading their children from smoking, not smoking themselves, and not allowing their children to smoke at home. These results suggest that the Tobacco Free Duo program contributed to a reduction in adolescent smoking among both boys and girls. Using a multi-faceted intervention that includes an adolescent-adult partnership can decrease adolescent smoking uptake. Engaging adults as partners in tobacco prevention interventions that target adolescents has an important tobacco reducing bonus effect in the adults. The intervention has proven sustainable within communities. A growing majority of adolescents support parental interventions to help them refrain from tobacco. The findings dismiss the notion that adolescents ignore or even disdain parental practices concerning tobacco. A common and consequent norm against tobacco from both schools and parents using a supportive attitude can prevent tobacco use in young people.
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| 2. |
- Huong, Dao Lan, 1974-
(författare)
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Mortality in transitional Vietnam
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Understanding mortality patterns is an essential pre-requisite for guiding public health action and for supporting development of evidence-based policy. However, such information is not sufficiently available in Vietnam. Mortality statistics and causes of death are solely collected from health facilities while most deaths occur at home without the presence of health professionals. Facility-based data cannot represent what happened in the wider community. This thesis studies the patterns and burdens of mortality as well as their relationships with socio-economic status in rural Vietnam. The overall aim is to contribute to the improvement of the current system of mortality data collection in the country for the purposes of public health planning and priority setting. The study was carried out within the framework of an ongoing Demographic Surveillance System (DSS) in Bavi district, Hatay province, northern rural Vietnam. This study used a verbal autopsy (VA) approach to identify cause of death in a cohort of approximately 250,000 person- years over a five-year period from 1999 to 2003. During the five year study, a total of 1,240 deaths were recorded and VA was successfully completed for 1,220 cases. Results revealed that VA was an appropriate and useful method for ascertaining cause of death in this rural Vietnamese community where specific data were otherwise scarce. The mortality pattern reflected a transitional pattern of disease in which the leading cause of death was cardiovascular diseases (CVD), followed by neoplasms, infectious and parasitic diseases, and external causes, accounting for 28.9%, 14.5%, 11.2%, and 9.8%, respectively. In terms of premature mortality, there were 85 and 55 Years of Life Lost (YLL) per 1,000 population for males and females respectively. The largest contributions to YLL were CVDs, malignant neoplasms, unintentional injuries, and perinatal and neonatal causes. In general, men had higher mortality rates than women for all mortality categories. In adults of 20 years and above, mortality rates increased substantially with age, and showed similar age effects for all mortality categories with the strongest association for non-communicable diseases (NCD). Education was an important factor for survival in general, and high economic status seemed to benefit men more than women. Compared with cancer and other NCD causes, higher CVD rates were observed among males, the elderly, and those without formal education, using a Cox proportional hazards model. This study is an initial effort to provide information on mortality patterns in a community using longitudinal follow-up of a dynamic cohort. Continuing the study using the VA approach as part of routine data collection in the setting will help to show trends in mortality patterns for the community over time, which may be useful for priority setting and health planning purposes, not only locally but also at the national level. Further analyses are needed to understand mortality inequality across all ages to have a comprehensive picture of mortality burdens in the setting. Validation studies and further standardization of VA methods should be carried out whenever possible to improve the performance and extension of the technique.
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| 3. |
- Shayesteh Afshar, Alexander, 1975-
(författare)
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Primary hyperhidrosis : prevalence and impacts for the individual
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Primary hyperhidrosis, excessive sweating, is a condition with unknown prevalence in many parts of the world. The disease debuts in adolescence and it affects men and women in equal proportions. A genetic background exists and the most common localisation on the body for excessive sweating is the axillary region. It is known that primary hyperhidrosis reduces quality of life and interferes with daily activities. Affected individuals often hide their sweating problems and the disease may lead to social withdrawal and isolation. Although botulinum toxin is an effective and available treatment, relatively few persons with primary hyperhidrosis seek medical healthcare and a minority of those are men.We investigated the prevalence of primary hyperhidrosis in Sweden and how the disease impairs quality of life, changes in daily activities, signs of depression and anxiety and alcohol consumption before and after treatment with botulinum toxin. The severity of hyperhidrosis according to the affected body sites was also investigated. Further on we explored mens experiences living with primary hyperhidrosis by interviews and content analysis.Our results showed that primary hyperhidrosis occurs in 5.5% of the Swedish population. The disease reduces quality of life and affects mainly the psychological health of the individuals. Persons with palmar and axillary hyperhidrosis rated their symptoms more severe and with much higher impact on their quality of life compared to persons suffering from hyperhidrosis elswhere on the body. Individuals with axillary hyperhidrosis more often reported a later debut and signs of peripheral vasoconstrictions were more common in this group compared to individuals with palmar hyperhidrosis. This made us believe that factors other than genetics seem to play a role in triggering axillary hyperhidrosis. Treatment with botulinum toxin A had a significant effect in reducing the symptoms and their interferences on daily life while increasing the overall quality of life. Signs of depression, stress and anxiety were also significantly reduced by treatment. This treatment was safe and no serious side-effects were noted. Qualitative content analysis of interviews with 15 men suffering from primary hyperhidrosis resulted in the theme: To be captured in a filthy body. The experiences of men with excessive sweating were thus interpreted as stigmatising. Stigma has a negative effect on mental health which reinforces our findings in quantitative studies when investigating quality of life. It is our assumption that the symptoms act as a vicious circle reducing quality of life, stigmatising the individual and limiting daily interactions. Addressing hyperhidrosis with information when the disease debuts in young people could reduce the stigma and enable early intervention via healthcare which may have a significant effect on the life of those affected.
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| 4. |
- Waldau, Susanne, 1954-
(författare)
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Creating organisational capacity for priority setting in health care : using a bottom-up approach to implement a top-down policy decision
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In this thesis, priority setting to the form of the Swedish parliamental decision on priority setting, 1997, is considered an innovation for implementation in health care. The features of this innovation are investigated. The practical implications of implementation are identified by investigating the user organisation, ie, Swedish health care organisations and management systems. Also, a case of a three-stage process for macro-level priority setting that engaged the entire organisation in the Västerbotten County Council (VCC) is presented. This is done against a background of preceding implementation efforts in the VCC. Four specific research efforts and papers are presented. In Paper I, priority setting is operationalised into a multi-dimensional resource allocation task. On that basis, with the help of interviews (1998) and surveys (2002 and 2005) primarily of VCC health care managers, the impact of implementation is measured by prioritisation structures, processes and decisions. Survey response rates were low. Results were used as qualitative data, internally compared, and interpreted as: a) responses reflected mainly “early adopters’” opinions; b) priority setting is an ambiguous concept; c) indicating limited overall implementation; d) reinterpretation of the prioritisation task occurred over time among respondents; and, e) this group took increasingly personal responsibility as stakeholders in priority setting. Paper II reports a case study intervention of explicit, departmental level priority setting with the aim of improving cost-effectiveness in in vitro fertilization resource use and a rationing of services perceived legitimate by all stakeholders. The intervention combined priority setting and structured quality improvement techniques. Results were: a) improved operational efficiency of diagnostic procedures that allowed resources to be reallocated to treatment; and b) patients were prioritized and treatment resources were rationed based on evidence of treatment effect among subgroups. Evaluation showed that the procedure met stated criteria for legitimacy. In Paper III, a full-format test of the macro level prioritisation process is described and evaluated by participants with the help of surveys after each completed stage. Participants report the need for improvement of elements in the overall process and of procedural specifics. However, overall there was a strong commitment to the initiative and satisfaction with the process and the resulting decisions. In Paper IV, procedural specifics of the prioritisation process are evaluated. They are also compared to the Program Budgeting and Marginal Analysis (PBMA) framework when used for macro level purposes. Procedures provided intended results such as vertical and horizontal priority setting and a consistent process. However, economic targets were not fully achieved in any of the stages. Conclusions include that health care management systems are not prepared for priority setting and need profound restructuring and that the prioritisation process described in Papers III and IV was successful because: a) the process satisfied politicians’ directives; b) participants were satisfied with the procedures and perceived the subsequent reallocation decisions as legitimate; and, c) methods resulted in the intended outcome. Factors suggested as the basis of success include: long-term overall preparations; broad and deep participation; a readiness for change among participants; a stage for horizontal priority setting that added to the quality, feasibility and perceived validity of the knowledge base; a strong process leadership; and politicians determined to protect the process from opportunistic disturbances.
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| 5. |
- Dapi N., Léonie, 1971-
(författare)
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Socioeconomic and sex differences in adolescents’ dietary intake, anthropometry and physical activity in Cameroon, Africa
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: People in Cameroon are experiencing a dietary transition characterized by changing from traditional food habits to increased intake of highly processed sweet and fatty food. The rapid change in food pattern combined with an increased sedentary lifestyle has resulted in a rather high prevalence of obesity, hypertension, cardiovascular diseases and type 2 diabetes. Nutritional intake is important during adolescence for growth spurt, health, cognitive development and performance in school. Objective: The aim of this thesis was to assess dietary intake, anthropometry and physical activity of adolescents according to sex and socioeconomic status (SES) and to investigate food perceptions of adolescents living in urban and rural areas of Cameroon. Methods: Girls and boys, 12-16 years of age, were randomly selected from schools in urban and rural areas. Food frequency questionnaire, 24-hour dietary and physical activity recalls, anthropometric measurements, qualitative interviews and a background questionnaire were used for data collection. Results: The proportion of overweight was three times higher in girls (14%) compared to boys (4%). Stunting and underweight were more common among boys (15% and 6%) than girls (5% and 1%). The prevalence of stunting was two times higher among the urban adolescents with low SES (12%) compared to those with high SES (5%). The rural adolescents had the highest proportion of stunting but more muscle that the urban adolescents. The rural adolescents ate in order to live and to maintain health. Urban adolescents with low SES ate in order to maintain health, while those with high SES ate for pleasure. More than 30% of the adolescents skipped breakfast in the urban area. Urban adolescents with high SES and girls reported a more frequent consumption of in-between meals and most food groups compared to the rural adolescents, boys and those with low SES. Over 55% of the adolescents had a protein intake below 10% of the energy (E%). Twenty-six percent of the adolescents had fat intake below 25 E%, and 25% had fat intake above 35 E%. A large proportion of the adolescents had an intake of micronutrients below the estimated average recommendation. Boys and the adolescents with low SES reported a higher energy expenditure and physical activity level than girls and the adolescents with high SES, respectively. Both under- and over-reporting of energy intake were common among the adolescents. Conclusions: The present study showed that nutrient inadequacy, stunting, underweight, as well as overweight and obesity were common among the adolescents in Cameroon. Therefore an intervention program targeting both under- and overnutrition among school adolescents is needed. Sex and socioeconomic differences also need to be considered.
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| 6. |
- Eriksson, Malin, 1969-
(författare)
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Social capital, health and community action : implications for health promotion
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background; The overwhelming increase in studies about social capital and health occurring since 1995 indicates a renewed interest in the social determinants of health and a call for a more explicit use of theory in public health and epidemiology. The links between social capital and health are still not clear and the meanings of different forms of individual and collective social capital and their implications for health promotion needs further exploration. The overall aims of this thesis are to explore the relationship between social capital and health and to contribute to the theoretical framework of the role of social capital for health and health promotion.Methods; Data from a social capital survey were used to investigate the associations between individual social capital and self-rated health for men and women and different educational groups. Survey data were also analyzed to determine the association between collective social capital and self-rated health for men and women. A qualitative case study in a small community with observed high levels of civic engagement formed the basis for exploring the role of social capital for community action. Data from the same study were utilized for a grounded theory situational analysis of the social mechanisms leading to social capital mobilization.Main findings; Access to individual social capital increases the odds for good self-rated health equally for men and women and different educational groups. However, the likelihood of having access to social capital differs between groups. The results indicate a positive association between collective social capital and self-rated health for women but not for men. Results from the qualitative case study illustrate how social capital in local communities can facilitate collective actions for public good but may also increase social inequality. Mobilizing social capital in local communities requires identification of community issues that call for action, a fighting spirit from trusted local leaders, “know-how” from creative entrepreneurs, and broad legitimacy and support in the community.Conclusions; This thesis supports the idea that individual social capital is health-enhancing and that strengthening individual social capital can be considered one important health promotion strategy. Collective social capital may have a positive effect on self-rated health for women but not for men and therefore mobilizing collective social capital might be more health-enhancing for women. Collective social capital may have indirect positive effects on health for all by facilitating the ability of communities to solve collective health problems. However, mobilizing social capital in local communities requires an awareness of the risk for increased social inequality.
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| 7. |
- Kullberg, Agneta, 1955-
(författare)
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My Home is my Castle : Residential Well being and Perceived Safety in Different Types of Housing Areas in Sweden
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Safety in the housing environment is a basic human need and may be a prerequisite for health but studies from the perspective of the residents are limited in the literature. Although historically public health research has recognized the housing environment as an important determinant of health, there is a need for more research on how housing conditions influence residential well-being.Aim: The overall aim of this thesis was to examine factors and conditions associated with residential well-being and perceived safety in different types of housing areas and to compare safety promotion intervention designs based on residents self-expressed safety needs with corresponding designs developed by local government professionals.Materials and methods: A postal survey (response rate 56%, n=2476) and 11 focus groups (57 participants) were conducted among the residents in 3 small-scale housing areas with detached houses and 3 housing areas with blocks of flats in a Swedish municipality. The areas were geographically contiguous as each of the small-scale areas bordered on an area with blocks of flats. The study municipality is a designated member of WHO Safe Community network that have signed up to work in line with the indicators developed by WHO Collaborating Centre on Community Safety Promotion. Narrative data from a postal questionnaire were used to analyze the lay perspective and identify features perceived to be necessary to feel safe by residents in areas with blocks of flats and small-scale housing areas. Quantitative data were used to examine correlates of local safety-related concerns through a factor analysis. Logistic regression analysis examined associations between high-level scores of the safetyrelated dimensions found and area-level crime rate and being a victim of crime, area reputation, gender, age, education, country of birth, household civil status and type of housing. To examine how self-assessed area reputation is associated with social trust and residential well-being, a multilevel logistic regression analysis was performed using quantitative data, controlling for the random effect of neighbourhood- and individual-level socio-demographic factors. Data from focus group interviews were analyzed to identify mechanisms of how neighbourhood reputation was established. The quality function deployment (QFD) technique was used in a case study to integrate residents’ demands into the design of safety promotion interventions in housing areas. The resulting design was then compared with the safety intervention programme designed by professionals at the municipality administrative office. The results from this comparison were then investigated to identify improvements for the indicators for Safe Homes in the Safe Community programme.Results: The residents’ narratives showed that a stable social structure in the housing area was perceived to be the central factor in a safety-supportive residential environment. Whereas maintenance of good and reassuring relations was emphasized in small-scale housing areas, support for management of poor or even fear-provoking neighbour relations was requested from areas with blocks of flats. The crime rates were lower and safety-related concerns were less in small-scale housing areas. Three composite dimensions (CD) of perceived residential safety were identified: structural indicators of social disorder (CD 1); contact with disorderly behaviour (CD 2); and existential insecurity (CD 3). Area-level crime rates and individual-level variables were associated with dimensions (CD 1) and (CD 3), but only individuallevel variables were associated with dimension (CD 2). The level of residential well-being and social trust was higher in small-scale areas. The housing area reputation was found to be strongly associated with safety-related concerns, residential well-being and social trust. The area reputation also seemed to be a determinant of position in the local social structure; residents were found to position themselves in a rank order. The QFD analysis showed that the initiation and maintenance of social integrative processes in housing areas were the most highly prioritized interventions among the residents, but the analysis did not highlight the safety needs of several vulnerable groups. The Safe Community programme designed by professionals did not address the social integrative processes, but did cover the vulnerable groups.Conclusions: Area reputation is an important and probably underestimated dimension in the development of residential well-being and perceived safety. The QFD technique can be added to the methodological toolbox for residential safety promotion. The technique is particular suitable for providing a quality orientation from the lay perspective on safety promotion in local residential areas. The current Safe Homes concept in the Safe Community programme would benefit from being widened to Safe Housing.
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| 8. |
- Nygren, Karina, 1974-
(författare)
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Adolescent self-reported health in the Umeå region : Associations with behavioral, parental and school factors
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis consists of a quantitative and a qualitative study. The quantitative study (articles I-III) aimed to examine how self-reported health in adolescence is associated with behavioral, parental, and school factors. Through a survey directed at all adolescents in grades 7-9, data were collected in 2005 in a region in northern Sweden (n=5060). Statistical methods were used to analyze the survey data: chi2tests, multivariate logistic regressions and multilevel logistic regressions. Results showed that even though most adolescents reported good health, there were also rather large proportions of adolescents who reported headaches, stomach aches and feelings of stress. Girls reported poor health to a higher extent than boys, a difference that was larger in grade 9 than in grade 7. The results also showed that being norm compliant was associated with good self-reported health. Furthermore, perceiving relations and communication with parents as poor was associated with poor self-reported health; however, this relationship could not explain gender differences in self-reported health. Continuing on, analyses showed that there exist greater variations in self-reported health between students (within a school) than between different schools. On an individual level, poor relations to teachers, bullying and truancy were associated with poor general health. The qualitative study (article IV) sought to examine barriers to and facilitators of utilization of local school survey results within a school setting. In 2011, 21 school district managers and principals within a Swedish municipality were interviewed. Analyses were performed using a qualitative content analysis. The results from the qualitative study showed that the dissemination and utilization of school survey results appeared as two interrelated phases in one process. Barriers and facilitators differed qualitatively depending on the phase, dissemination or utilization.In conclusion, professionals as well as researchers need to consider the complexity of adolescent health and its social determinants. Adolescent health is a concern for multiple sectors in society, which highlights the need for further development of collaborations between professionals in relevant fields, such as health care, school and social services.
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| 9. |
- Waller, Göran, 1954-
(författare)
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Self-rated health : from epidemiology to patient encounter
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In epidemiology self-rated health is often measured as people’s subjective answer to a question “How is your health in general?” or “How is your general health compared to persons of your own age?”. The answers have a strong association with significant medical outcomes such as death, diabetes, coronary heart disease, functional ability and depression, medical diagnoses and how these are perceived. The overarching aim of this thesis was to investigate if and how a use of the epidemiologists’ tool of self-rated health might aid GPs in practising medicine with a holistic perspective, contextually sensitive and taking into account the patients’ medical and personal histories.Methods: In Paper I, I used semantics to elucidate the meaning of self-rated health. Data came from the Northern Sweden Monica Project 1990–1999. In Paper II, with data from the MONICA Project in 1999–2009, I used ordinal regression to investigate associations between self-rated health, medical factors, psychosocial factors and emotions. In Paper III, I used data from the Västerbotten Intervention Programme 1990–2004 in Cox regression analyses to investigate the relationship between self-rated health and standard risk factors for the outcome myocardial infarction. Paper IV is a qualitative study from seven primary care health centres. Actual consultations were audio-recorded and analysed with systematic text condensation, measuring apportionment of speaking time and by taking into account GPs’ assessments of using a question about comparative self-rated health in a consultation.Results: In Paper I, I found “health” in questionnaires being understood not through definitions of health but through associations of the word “health” with “sense relations”, that are important connotations of the word “health”. Age-comparative self-rated health was semantically clearer as it pointed towards comparison with a reference group. In Paper II, emotions of anxiety or depression and discontent with personal economy were associated with lower self-rated health and were common in the population. Paper III established self-rated health as an independent risk factor for myocardial infarction when adjusted for standard risk factors. In the qualitative Paper IV, self-rated health affected consultations, increased patients’ speaking time in relation to doctors’ when discussing self-rated health and elicited reactions, sometimes with strong language. Reflections ensued that could give vivid descriptions of function, life circumstances and resources or obstacles in handling symptoms and illnesses.Conclusion: Comparative self-rated health constitutes a feasible tool in general practice, particularly in taking account of patients’ medical and personal histories. It is holistic, sensitive to psychosocial factors. It is useful to solicit information on risk and the patient’s feelings related to an illness/disease, and to encourage the patient’s active reflection on functional abilities, life situation, health and health strategies. However, self-ratings are not to be seen as a standard procedure in all consultations.
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| 10. |
- Carlsson, Lars
(författare)
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Healthcare and patient factors affecting sick leave : From a primary health care perspective
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: For indeterminate reasons, there have been major variations in sick leave in Sweden, and many physicians have perceived sick leave assignments as burdensome.Aim: To gain more knowledge and understanding, from a perspective of primary health care, about factors in health care and patients that affect sick leave. Thereby help patients in the best way, facilitate the work of physicians and other health professionals involved in the rehabilitation process, and use the health care resources optimally.Methods: This thesis is based on a randomised controlled trial (RCT) in a primary health care centre with participants on short-term sick leave, due to pain and/or mental illness, who received a multidisciplinary assessment. Qualitative focus-group discussions with physicians in primary health care centres. A cohort of women on very long-term sick leave due to pain and/or mental illness, who lost sickness benefits due to a new time limit on sickness insurance, were randomised to multidisciplinary assessment and multimodal intervention (TEAM), or to Acceptance and Commitment Therapy (ACT). In an extended cohort, including some men on very long-term sick leave due to pain and/or mental illness, the importance of the motivation for return to work (RTW) was investigated.Results. Very early multidisciplinary assessment increased days on sick leave in the first three month period. Physicians at primary health care centres perceived sick leave assignments as burdensome, but clearer rules and cooperation with other professionals have made sick leave assignments less burdensome. TEAM intervention resulted in an increase in working hours per week as well as an increase in work-related engagements, compared to control in the RCT. Motivation for RTW was associated with RTW or increased employability in the rehabilitation of patientsConclusions: Continued studies are needed to find those who are at risk of long-term sick leave, the time when rehabilitation efforts should be started, and the content of rehabilitation. Collaboration in teams facilitates sick leave assignments for physicians at primary care health centres. Motivation for RTW might be a factor of importance for the effect of rehabilitation and needs to be studied further.
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| 11. |
- Granström, Fredrik
(författare)
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Inequalities in Health : the Importance of Material/Structural Factors and Psychosocial Resources
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Socioeconomic inequalities in health are well-documented in most countries. Health differences have been shown to follow a gradient, where health status in average is somewhat poorer for every lower level in the social hierarchy. Notably, the welfare state Sweden is no exception. Considerable socioeconomic inequalities in health are found, and the magnitude of e.g. educational inequalities in health has even increased over recent decades. Important contributors, or “health determinants” of observed health inequalities, include material/structural factors, behavioral factors and psychosocial factors. The inequalities arise from uneven distributions of these health determinants accumulated over the life course. Whereas earlier research has focused on independent effects of different determinants, recent research has showed that health determinants interact in complex ways when contributing to health inequalities. However, the relative importance of the independent contributions of specific types of health determinants and of the shared contributions have not been assessed. The overall aim of this thesis was to examine possible explanations of inequalities in self-reported health among groups with different educational levels in a Swedish population, in particular how material/structural factors and psychosocial resources contribute to these inequalities. This thesis is based on four population-based studies. Studies I and IV used data from the Life & health study, based on crosssectional survey questionnaires, conducted in 2000, 2004 and 2008 in five counties in the central part of Sweden. Around 35,000 respondents were included each year with response rates varying from 60% to 67%. Studies II and III used data from a sub-sample of the Swedish national public health survey (HLV) from 2012, another cross-sectional survey questionnaire. The sub-sample was carried out in four counties in the central part of Sweden. The total number of respondents in the sub-sample was 26,706, with a response rate of 53%. Outcome variables were, in studies I, II and IV, self-rated health (SRH) and, in study III, psychological distress. The magnitudes of health inequalities were examined using rate ratios and rate differences. The associations between health determinants and health out-comes were examined using logistic regression, and the analysis of independent versus shared contributions of health determinants to health inequalities was conducted using structural equation modeling (SEM). Study I showed that relative educational inequalities in SRH were two-fold among men, unchanged from 2000 to 2008, while the inequalities initially were smaller among women but increased over time, from 1.7 to 2.1. This increase was mainly due to growing inequalities in the age group 25–34 years. The distributions of all observed health determinants were more unfavorable in low education groups; most prominent for lack of a financial buffer, smoking and low optimism. These educational differences were, for most health determinants, unchanged over time. Study II examined the association of adult SRH with adverse material conditions (eco-nomic stress in the family) in childhood as well as adverse psychosocial conditions (condescending treatment) in childhood. Both economic stress and condescending treatment in childhood were strongly associated with poorer adult SRH. These associations were attenuated, but still statistically significant after adjustment for economic stress and condescending treatment in adulthood and other risk factors. Study III showed, after adjustment for age, economic difficulties, employment status and social support, a moderate association between educational level and psychological dis-tress, where low and medium educational levels were related to a lower risk of psychological distress. However, current economic difficulties showed a strong, and positive, association with psychological distress. Study IV showed that the shared pathways, including both material/structural fac-tors (e.g. financial buffer and unemployment) and psychosocial resources (e.g. optimism and social participation), explained about 40% of educational inequalities in SRH for both men and women aged 25–74 years. The pathways including only the independent effects of psychosocial resources (14% in men and 20% in women) or material/structural factors (9% and 18%, respectively) explained substantial but smaller proportions of the inequalities. In conclusion, in an adult population in the central part of Sweden, prevalence of poor SRH was, among men, twice as high in the low education group compared to the high education group during the first decade of the new millennium. Among women, educational inequalities were initially smaller, but increased over time to the same level as among men. However, when using self-reported psychological distress as health outcome, no corresponding educational inequalities were found. Instead, economic difficulties were an important determinant of psychological distress. SRH in adulthood was significantly associated with economic stress and condescending treatment during childhood, also when the same conditions in adulthood were taken into account. Material/structural factors and psychosocial resources explained more than half of the educational inequalities in SRH, and the majority of this contribution was in the form of a shared effect of material/structural factors and psychosocial resources. A shared effect means that a material/structural factor and a psychosocial resource are strongly associated, and that the combination of the two has an effect on the educational inequalities in SRH. Therefore, to reduce educational inequalities in SRH, interventions need to address both material/structural conditions and psychosocial resources. This needs to be done across educational groups, using a life course perspective, but with more intensive interventions in lower education groups.
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| 12. |
- Grönblom-Lundström, Lena, 1951-
(författare)
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Rehabilitation in light of different theories of health : Outcome for patients with low-back complaints - a theoretical discussion
- 2001
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to investigate if the outcome of rehabilitation efforts is depending on what view health care has in relation to what need of care people have and if the outcome for different groups of patients with low-back complaints (specific versus non-specific complaints) is various successful. The outcome is measured in length of sick leave, number of spells and granted sickness and disability pensions.This thesis combines a theoretical analysis of different theories of health with studies of two empirical materials. One material comprises a group of individuals with low-back complaints (specific versus non-specific complaints) from a nation-wide survey of Living Conditions conducted by Statistics Sweden in 1981. The other material comprises a sample of individuals on sick leave either due to low-back complaints or other kinds of complaints than low-back complaints. The outcome of these studies are measured as to what extent people with low-back complaints are granted a disability pension (Paper III) and which the characteristics are of those on sick leave due to low-back complaints compared to those with other kinds of complaints (Paper IV). The results from Paper III revealed a difference concerning socio-economic group and granted disability pension between those with specific, non-specific and frequent low-back complaints. Those with non-specific and frequent low-back complaints were to higher extent manual workers and disability pensioners. The results of Paper IV reveals also a socio-economic difference besides that those with low-back complaints had longer sick leave periods and more spells. What does these results indicate? Are non-specific and frequent low-back complaints not successfully treated within the health care system? Is this due to how these matters have been identified? Are these individuals truly disabled due to their low-back complaints, if so how are they assessed and treated? I believe that the notions of health and disease as well as the social context in which people act influence the outcome of rehabilitation. If people judge their health as bad (here due to low-back troubles) and in need of health care and the health care system do not recognise their need when not identified as diseased a problem arises. These individuals claim that their ability to work is hampered due to the low-back complaint and the society has an obligation and needs a legitimate solution for those individuals that cannot support themselves due to ill health. This obligation makes a demand on the health care system.If non-specific complaints are assessed as non-medical problems, from a biomedical point of view, health care lacks measures to take care of these people if they ought to be taken care of within the health care system at all. But this outcome (a disability pension) may also indicate that people suffer from a “true” illness although not defined by objective findings. If that is the state one may ask if there is a lack of sufficient diagnostic procedures and measures as well. A rehabilitation approach stemming from a humanistic social perspective might lead to a more favourable outcome for people with low-back complaints, whether or not these complaints have been identified in a biomedical sense, as this perspective take into account both the goals, the resources and the social context of that individual. This thesis has paid attention to the matter that conceptual notions, which seldom are considered within clinical praxis, are of vital importance for the outcome of rehabilitation. Health care falls short especially when it comes to non-specific and frequent low-back complaints and this may be due to the biomedical model being used too strictly within a domain where other models, here exemplified as Pörn’s Theory of Health, might result in a more favourable rehabilitation outcome for the individual.
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| 13. |
- Norrmén, Gunilla, 1944-
(författare)
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To be or not to be Sick Certified with Special Reference to Physician and Patient Related Factors
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives The aim of this thesis was to assess the importance of general practitioners (GP) and patient related factors for the GPs’ decision to sick certify or not to sick certify the patients. Study population and methods The data were obtained from a cross-sectional questionnaire study of GP-patient consultations. 65 GPs responded to one questionnaire about themselves and one questionnaire about each of the altogether 642 consultations. The patients responded to a questionnaire about themselves and the consultation, altogether 521 consultations. Various combinations of the three questionnaires were used in the four papers on which this thesis is based. Results Among GPs, long experience of family medicine and working part-time were significant determinants for issuing more sick leave certificates. Complaints perceived as clearly somatic by the physician decreased the chance of sick certifications, and complaints resulting in severe limitation of occupational work capacity, as assessed by the patient as well as the physician, increased the chance of sick certification, as did appointments for loco-motor complaints. Among work related factors, high ‘authority over decisions’ and high ‘social support’ were associated with reduced sickness certification probability. Worrying about illness or injury risks from work increased sickness certification. GPs and their patients took a fairly similar view to statements on health related and insurance system related matters. GPs’ opinions seem to have a greater impact than patients’ on the GPs’ decision to sickness certify a patient or not. Conclusions A number of patient and GP related factors were associated with the probability of getting sick certified. The patient’s own judgement of impaired work ability was important for sickness certification, but a shared judgement and decision between the GP and the patient appears probable in most cases.
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| 14. |
- Wallman, Thorne, 1951-
(författare)
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Disability Pension with Special Reference to Sick Leave Track Record, Health Effects, Health Care Utilisation and Survival : A Population-based Study
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background. In Sweden 10 percent (550,000) of the labour force, aged 18 to 65 years are disability pensioners and about four percent are on sick leave. The knowledge of the course from healthy individual to disability pensioner is not well known and was the theme of this thesis. Objectives, Material and Methods. The aims of the thesis were to follow the study population regarding sickness absence, health care utilisation, quality of life, and survival. Population based data including 14,538 women and men from three cities in Sweden were used, of whom 1,952 were granted a disability pension at baseline or received one during follow up. Register data, including sickness spells, health care utilisation, and mortality data during 30 years of follow up, and questionnaire data including socio-economic and quality of life data were used. Results. The most powerful determinant for being granted a disability pension was cumulative annual sick leave days, more powerful than all other tested determinants together. The degree of explanation for all determinants combined was 96%. Health care utilisation among disability pensioners continued to be high also after disability pension, 2.3 times higher for hospital admissions and 8 times higher for primary health case appointments than among referents. Disability pensioners had lower quality of life than non-pensioners and old age pensioners. For those who became disability pensioners after the baseline measurements quality of life measures decreased progressively until disability pension was granted and were then stabilised on a low level. During follow up 525 (7.6%) subjects died. Compared with subjects who did not become disability pensioners the hazards ratio was 2.78 among women and 3.43 among men, even when the effect of a number of other outcome affecting variables were taken into account. The mortality differences were not explained by underlying disease. Conclusions. The risk of disability pension may be predicted but only late in the course of events. Disability pensioners continue to have a high level of health care utilisation, and have a worse quality of life development and a higher mortality rate than non-pensioners. Given the unfavourable outcome of disability pension, other means of managing the reduced work capacity might be considered.
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| 15. |
- Boman, Jens, 1957-
(författare)
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Prevention of Chlamydia trachomatis infections
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Urogenital chlamydia infection, caused by the bacterium Chlamydia trachomatis (CT), is the most common sexually transmitted bacterial infection in Sweden. In 2008 it was estimated by WHO that there were 105.7 million new cases of CT worldwide, an increase by 4.2 million cases (4.1%) compared to 2005. If untreated, CT infections can progress to serious reproductive health problems, especially in women. These complications include subfertility/infertility, ectopic pregnancy and chronic pain. The CT infection is often asymptomatic and reliable diagnostic methods and contact tracing are important tools for identifying infected individuals. CT infection is classified in the Swedish Communicable Diseases Act as a serious disease; consequently, written reporting and contact tracing are compulsory. Previous or ongoing CT infection is not uncommon in infertile couples, especially in women with tubal factor infertility (TFI). We have tested 244 infertile couples for CT antibodies, and CT IgG positive couples were tested for CT DNA in urine. The prevalence of CT antibodies was higher in infertile men and women, and ongoing CT infection was common. Our results support a role of CT in infertility and underscore the importance of prevention of CT infection. Contact tracing was studied during using questionnaires. A total of 544 questionnaires was sent to tracers in a Swedish county and 534 (98%) were completed. Centralized contact tracing performed by experienced tracers is effective; on average 65% of sexual contacts found by contact tracing are CT-infected. Our data show that it is worthwhile to extend the tracing period beyond 6 months as 30% of reported sexual contacts between months 7-12 were CT-infected. Contact tracing may be performed face-to-face at the clinic or by telephone. Because of the severe consequences of CT infection there is a need for useful methods for both primary and secondary prevention of CT and other sexually transmitted infections (STIs). An important sub-population for CT/STI-prevention is the “core group”, i.e. a subpopulation with high incidence of STIs combined with risky sexual behaviours. This subpopulation contributes particularly to the spread of STIs in the population. Therefore, we have developed and evaluated a brief standardised but flexible manual-based single-session intervention based on motivational interviewing (MI) for the reduction of high risk sexual behaviour. Women (n=105) and men (n=119) at high risk of contracting CT infection were randomly eighter offered brief MI counselling or standard care. Our findings support the effectiveness of brief MI-based counselling in reducing high-risk sexual behaviour and incident CT infection in women (p<0.01) but not in men. Our results suggest that gender aspects need to be considered and that men and women should be treated differently for achieving maximal risk-reduction. Whereas it might be sufficient to include information and motivation when performing risk-reducing counselling on women, counsellors may also add other components, such as behavioural skills and booster sessions, when counselling is performed on men.
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| 16. |
- Carré, Helena, 1979-
(författare)
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Who's at risk of catching Chlamydia trachomatis? Identifying factors associated with increased risk of infection to enable individualized care and intervention
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Chlamydia trachomatis (CT) can cause infertility and is the most common sexually transmitted infection (STI) of bacterial origin in Europe. Surveys in seven countries estimated a population prevalence of 1.4-3.0 % in people 18 to 44 years. Approximately 87% of those diagnosed in Sweden are 15-29 years. Since 1997, with the exception of 2009-2010, despite all efforts, CT has increased steadily in many European countries including Sweden. That made us investigate risk factors associated with catching STIs, especially CT. In Sweden partner notification is mandatory by law when a patient is diagnosed with CT. Centralised partner notification, performed by a few experienced counsellors, and evaluation of the sexual history for at least 12 months back in time, shows superior results compared to other studies. Phone-interviews are a good option in remote areas. “The Västerbotten model” for partner notification fulfils these criteria and our evaluation has functioned as a model for changing recommendations of partner notification in Sweden. Preventing CT by primary prevention such as information and counselling is, however, still of great importance. We investigated whether it was necessary to test for CT in the throat. We found that patients testing positive for pharyngeal CT neither had more symptoms or signs nor a sexual history that differed from others. We therefore believe that we will find most or all of these patients by conventional testing of urine and cervical/vaginal samples. We wanted to further identify risk factors among patients attending a clinic for sexually transmitted infections to enable individualized care depending on risk. None or inconsistent use of condoms with new/temporary partners in combination with having at least one new/temporary partner within the past 6 months could identify persons with risk behaviour and at increased risk of CT (re)infection. Additional information about whether the condom was used during the whole intercourse did not add any risk of infection. A drop-in reception is a good contribution to an opportunistic screening approach. The rate of CT infected is high and the clinic attracts men and individuals ≥25 years old at risk of infection, groups which usually have a reduced test rate. The mean age was 28 years and 58% of the patients were men. The figure of correct condom usage is very low indicating the need for risk reducing counselling also in this grown-population. Among adult STI patients anxiety was common and depression uncommon. Neither was linked to high risk sexual behaviour nor ongoing CT infection. Hazardous alcohol consumption, however, was common and linked to anxiety and high risk sex. We conclude that preventive work can not only focus on STI prevention, but must consider the high frequency of hazardous alcohol consumption, which probably is contributing to sexual risk behaviour.
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| 17. |
- Fredriksson, Ingela, 1967-
(författare)
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Leisure-time youth-center as health-promotion settings
- 2016
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Leisure time is an important part of young people’s lives. Despite this, leisure-time settings have hitherto had only a minor role in setting-based health-promotion initiatives. Improving adolescents’ quality of leisuretime activities can reduce social differences in health, thus youth-centers can be appropriate settings for promoting health. However, young people with immigrant backgrounds participate less in organized leisure-time activities.The overall aim of this study is to explore young people’s leisure time as their health-promotion setting in two NGO-run youth-centers in multicultural, socially deprived suburbs in Sweden.This study took a practice-based approach using a mixture of methods in close collaboration with the youth-centers. Data collection was done through surveys with young people (n = 207) and interviews with young people and leaders (n = 16). Study I, about who participates in youthcenter activities, used an explanatory mixed method. Study II, about the youth-centers’ strategies, used an explorative qualitative method with an inductive content analysis.This study shows that youth-centers have great potential to be a healthpromotion setting if their strategies include some important factors, both in theory and in daily practice. To be a health-promotion setting, a youthcenter needs to be open and inclusive for its target group, foster supportive relationships, emphasize youth empowerment, and integrate family, school, and community in its strategies.Local knowledge about young people's backgrounds, needs, interests, and motivations to attend youth-center activities – as well as good contact with young people's families – is important because it can increase participation in leisure-time activities for young people in multicultural and socio- economically disadvantaged neighborhoods and can thus help to reduce social inequalities in health.
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| 18. |
- Paulsson Do, Ulrica
(författare)
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Psychosocial Vulnerability Underlying Unhealthy Behaviours in Swedish Adolescents
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim was to examine the relationship between Swedish school adolescents´ health-related behaviours and psychosocial and socio-demographic factors, with the purpose of identifying vulnerability factors for unhealthy behaviours and exploring adolescents’ own experiences and thoughts about this.Three studies were quantitative cross-sectional studies and used data from two different questionnaires. The fourth study was a qualitative study based on focus group interviews. The sample in study I consisted of 13–18-year-old adolescents (n= 10,590) and 15–16-year-old adolescents in studies II (n=492), III (n=492) and IV (n=36). The quantitative data were analysed using a number of different statistical methods. Foremost, structural equation modelling was used in studies I and II and Poisson regression analysis in study III. Study IV used qualitative content analysis by Graneheim and Lundman.The results indicated that nearly 60 per cent of 15–16-year-old adolescents have at least two unhealthy behaviours. Interrelated psychosocial and socio-demographic factors constituted vulnerability for unhealthy behaviours in general in adolescents. Good psychosocial relationships were strongly related with high well-being, whereas poor social relationships and low well-being were associated with unhealthy behaviours in general. Low socio-economic group was associated with unhealthy behaviours in general but the strength of this association varied between the adolescent age groups. Encouragement from parents to adopt healthy behaviours was associated with less unhealthy behaviours. Having adolescents who cared about what their parents said regarding health-related behaviours was also associated with a lower number of unhealthy behaviours. The school and family were important social environments for adolescents´ health-related behaviours. Similarly, friends and social media were important social contexts. Fellowship, and close social relationships, in particular, was important to healthy behaviours. Fellowship with others was also stated to influence high well-being. The experience of feeling pressure was stated to be associated with low well-being and unhealthy behaviours in adolescents.The thesis brings new knowledge to the field of psycho-social and socio-demographic factors associated with unhealthy behaviours in Swedish adolescents. Findings may be useful in supporting adolescents to reach positive health-related behaviours.
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| 19. |
- Åhs, Annika, 1971-
(författare)
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Health and Health Care Utilization among the Unemployed
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The number of persons who are not employed has increased in Sweden since the early 1990s. Unemployment has been found to influence health, especially when unemployment rates are low. The extent to which unemployment affects health when unemployment is high is less clear, and this needs to be further studied. To improve health in the population, the health care system should offer equal access to health care according to need. It is important to study whether the employment status hinders the fulfilment of this goal.This thesis is based on four papers: Paper I and II aimed at analysing self-rated health versus mortality risk in relation to employment status, during one period of low unemployment and one period of high unemployment. Paper III and IV assessed the use of medical health care services and unmet care needs among persons who were unemployed or otherwise not employed. The goal was to analyse what health problems lead people to either seek or abstain from seeking care, and what factors encumber or facilitate this process.The overall results indicate that being unemployed or outside the labour force was associated with an excess risk of poor self-rated health, symptoms of depression, mental and physical exhaustion and mortality. The differences in self-rated health between the unemployed and employed were larger when unemployment levels were high, than when they were low. More groups of the unemployed were also afflicted with poor health when unemployment was high. Thus, poor health among the unemployed seems to be a public health problem during high levels of unemployment. Lack of employment was related to abstaining from seeking care, despite perceiving a need for care, and this was related to psychological symptoms. To deal with the needs of the unemployed and others who are outside the labour force it would be useful to develop and implement interventions within the health care system. These should focus on psychological and psychosocial problems. Future research should analyse how to facilitate health-promoting interventions among persons who are not anchored in the labour market.
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