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Abstract: Social Determinants of Health in Belize Free Clinic Introduction: To determine the most appropriate ways to serve patients in rural Belize through medical mission work, it is important to assess social determinants of health (SDOH). It has long been agreed that a variety of factors affect health, including environment, community and social context, access to healthcare, stress, income, mental health, education, and transportation. Many people in Roaring Creek, Belize, a village with a population of approximately 2,000, use Body and Soul Ministries, a nonprofit that invites medical teams from all over to deliver medical care, as their primary source of healthcare. During one of these trips, a medical team from East Tennessee State University (ETSU) provided medical care and employed the TeamCare survey, already used in several clinics in east Tennessee to assess the SDOH needs of the patient population in Roaring Creek. The purpose of this study was to use a survey that assesses several SDOH to determine better ways to address health needs in the community of Roaring Creek as well as connect patients with resources to meet those needs. Methods: A team of ETSU medical students, a resident, and five physicians served in a free clinic in Roaring Creek, Belize in October 2017. The team saw approximately 500 patients. Some patients were randomly selected to take the TeamCare survey to assess for six SDOH, including literacy, financial needs, drug use, abuse, transportation, and mental health. Based on the results of the survey, patients were connected with their local community health worker to assist in locating resources for patients. Using SPSS, results from the survey were arranged for frequencies and measures of central tendency. Results: Overall, a total of 106 patients responded to the TeamCare survey. Based on the survey results, 83.2% of patients responded “yes” to at least one question regarding needs related to SDOH. In fact, 7.9% of patients answered “yes” to five questions. Of note, 53.5% of patients responded positively for financial need, 46.5% positive for mental health needs, 37.6% positive for environmental alcohol or drug abuse, and 32.7% positive for transportation needs. More women stated positively for physical or verbal abuse compared to men (-1.48, p=0.001). Discussion and Conclusion: Roaring Creek, Belize is a rural community that illustrates how SDOH can impact health outcomes. There has been a recent effort for clinicians to address SDOH, especially in rural areas, but perhaps not enough globally. One way this can be done is by surveying for SDOH at clinic visits and then linking patients with relevant community resources. However, resources are not always readily available in Roaring Creek, Belize. Many patients are positive for SDOH, but with an overall lack of resources, it is important to do more research to determine how global health efforts can best serve these populations. Perhaps the best way for SDOH needs to be addressed is for Body and Soul to collaborate with community health workers and mission teams to establish ongoing programs and longstanding resources for the community.

Introduction Anthrax is a disease caused by the spores of Bacillus anthracis and can have a high fatality rate. It is a zoonosis and mostly affecting animals. In this study I want to find out risk factors on population scale for anthrax cases and deaths in humans and animals, and look at the relation of anthrax with weather patterns. Methods I searched for anthrax outbreaks in different countries, mainly yearly reports. I looked at human cases, human deaths, livestock deaths and wildlife deaths. Different risk factors were considered: country size, population characteristics, Human Development Index (HDI), total cattle number, cattle per human ratio, mean annual temperature, mean temperature of the warmest 1 and 3 months, annual precipitation and minimum and maximum precipitation in 1 month and 3 months. Linear regression was used. Statistics were repeated without China because it was often the single outlier in the figures. Statistics were also repeated with the countries aggregated in continents because of the modifiable area unit problem. Results Data was found for 28 countries resulting in 36 data points. There was a significant relation between human cases and cattle number, human deaths, country size and population size. There were also significant relations between wildlife deaths and population size, country size and mean temperature of the warmest month. Without China relations between human cases and maximum precipitation in 1 and 3 months, and between livestock deaths and country size were significant. For continents a significant relation between human cases and cattle ratio, cattle deaths and HDI. Conclusion This study mainly shows that high cattle numbers and cattle deaths due to anthrax are risk factors for human cases. Also seasonal precipitation is a risk factor. Bigger country size and population size may be indirect risk factors as these usually accompany higher cattle numbers.

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Children in out-of-home care (OHC) experience poor outcomes in almost every dimension of life. However, much less attention has been given to their birth parents who also face several co-existing challenges. This study examines the association between OHC placement of a child and changes in mental health disorders (MHD) in their parents. Data from two generations of the Stockholm Birth Cohort Multigenerational (SBC Multigen) study including 11,338 parents (Generation 1; G1) and their children (Generation 2; G2) was used and associations between OHC placement in G2 and changes in MHD in G1 were examined using multinomial regression analysis. Stratified analysis by sex in G1 was performed to explore variations in patterns of associations. Results not only showed associations between OHC and worsening of MHD (RRR=6.57), but also improvement in MHD (RRR=7.71) compared to parents that did not have a child in care. Sex stratified analysis in G1 showed that OHC placement was associated with almost twice the relative risk of worsening of MHD in mothers (RRR=7.62) as compared to fathers (RRR=4.58). The study concluded that OHC placement of a child may not only be associated with worsening but may also be associated with improvement in MHD for some parents.

The aim of this study was to investigate how high school teachers in physical education (PE) apply stress management during the school sports classes to prevent stress- related illness among high school students. The purpose was also trying to clarify which factors influence if and how PE teachers include stress management in teaching, and if they experience any obstacles or difficulties in preventing the subject from being included in a operative way. In the chosen method, qualitative semi- structured interviews were conducted by purposeful sampling of six PE teachers employed at six different high schools. A content analysis was used to identify codes and categories in the transcribed data. The main findings showed that PE teachers included activities that can be related to stress management, but in a small and varied proportion. The most common practical tools incorporated in their classes were yoga and relaxation techniques, as well as theoretical lessons related to the topic. Obstacles included insufficient knowledge, lack of description in the syllabus as well as time constraints. The PE teachers perceived students’ need to handle stress, but sometimes it was difficult to determine when the need really existed. All PE teachers had a positive attitude towards including stress management in sports classes and perceived mainly advantages. However, reduction in time for physical activity was seen as a disadvantage. The clearest conclusion drawn from this study was that the PE teachers felt that there were shortcomings in both the curriculum description and the PE teacher education that could constitute an obstacle to including stress management in the lessons in a well- functioning way. More research as well as development and implementation of evidence- based stress management programs in syllabus at schools and the education program for teachers are needed.     Keywords: Health promotion, public health, stress management, physical education teachers, high school / Syftet med den här studien var att undersöka hur idrottslärare på gymnasieskolor inkluderar stresshantering i undervisningen inom kursen idrott och hälsa. Syftet var även att försöka klargöra vilka faktorer som påverkar om och hur mycket idrottslärare berör stresshantering, och om de upplever några hinder eller svårigheter med att lära ut stresshantering i undervisningen på ett välfungerande sätt. Metoden för datainsamlingen var kvalitativa semistrukturerade intervjuer. Urvalet bestod av sex yrkesverksamma idrottslärare i gymnasieskolan. En innehållsanalys genomfördes för att identifiera koder och kategorier utifrån det transkriberade materialet. Huvudresultatet visade att idrottslärarna inkluderar moment i undervisningen som kan relateras till stresshantering, men i en liten och varierad omfattning. De vanligaste aktiviteterna var yoga och avslappningsövningar, men även teoretiska moment där relaterade ämnen berördes. Faktorer som kunde utgöra hinder var bland annat otillräcklig kunskap, bristande beskrivning i kursplanen samt begränsat tidsutrymme. Idrottslärarna uppfattade att elever har behov av att lära sig att hantera stress, men samtidigt upplevdes det ibland vara svårt att avgöra när behovet verkligen fanns. Samtliga idrottslärare hade en positiv attityd till att inkludera stresshantering i undervisningen och såg främst fördelar, men en nackdel ansågs vara att det kunde minska tiden för fysisk aktivitet. Den tydligaste slutsatsen av studiens resultat var att idrottslärarna upplevde att det fanns brister i både kursplanens beskrivning och idrottslärarutbildningen vilket kunde utgöra hinder för att inkludera stresshantering i undervisningen på ett välfungerande sätt. Mer forskning samt utveckling och implementering av evidensbaserade stresshanteringsprogram i skolans kursplan och i lärarutbildningen behövs.     Nyckelord: Hälsofrämjande arbete, folkhälsa, stresshantering, idrottslärare, gymnasieskolan

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Aim The aim of this study is to investigate the relationship between sedentary-time, gaming and motivation for physical activity in Swedish adolescents. Method This study was conducted using a questionnaire based on Lena Kalling's evaluation of screening questions about physical activity by the National Board of Health and Welfare (Kallings 2019), as well as guidelines developed by Statistics Sweden (SCB 2016). The study was conducted as a cross-sectional study. A database has been constructed with the survey results with the purpose of performing a statistical analysis. Results A total of 41 people participated in this study, 29 boys and 12 girls. Sedentary time has been quantified in two ways, the individuals own estimate and a calculation based on the lower limit of given response intervals. Spearman correlations between computer gaming and total own estimated sedentary time were r = -0,28 (p = 0,13) and corrected for covariance with gender r = -0,23 (p=0,23). Similar correlations for calculated sedentary time and computer gaming were r = 0,16 (p=0,32) and corrected for covariance with gender r = 0,07 (p=0,67).  The two most frequent motivating factors for physical activity are “it’s fun” and “I feel good or know it’s good for me”. Mann-Whitney U-tests show that none of these are significant with respect to difference in computer gaming (p=0,75 and p=0,40, respectively). A motivation factor “I want to get better at something” is almost significant (p=0.07). This group are playing computer games on average 1,14 hours (median, N=25), compared to 0,00 hours (median, N=16) for those who did not select the factor. Conclusions The study shows that adolescents who play or are interested in computer games are not more sedentary than adolescents in general. Two different independent measures for sedentary time have been used and there was no association between computer gaming and sedentary behavior. There were no differences in motivational factors towards physical activity, neither moderate nor intense for adolescents playing computer games compared to adolescent in general. / Syfte Syftet med arbetet är att studera sambanden mellan stillasittande, datorspelande och motivation för fysisk aktivitet hos ungdomar. Metod Studien har genomförts som en enkätundersökning. Enkäten är utformad med hjälp av Lena Kallings utvärdering av Socialstyrelsens screeningfrågor om fysisk aktivitet (Kallings 2019) samt riktlinjer för enkät och intervjuundersökningar som tagits fram av Statistiska Centralbyrån (SCB 2016). Studien genomfördes som en tvärsnittsstudie. En databas har konstruerats med enkätsvaren för att kunna göra en statistik analys. Resultat I denna studie deltog totalt 41 ungdomar varav 29 pojkar och 12 flickor.Stillasittande tid har tagits fram på två sätt, individens egen uppskattning samt en beräkning utgående från den undre gränsen av givna svarsintervall. Spearman-korrelationer har beräknats mellan datorspelande och totalt stillasittande. Dessa är för egen skattning av stillasittande r = -0,28 (p = 0,13) och korrigerad för kön r = -0,23 (p=0,23). För beräknad skattning av stillasittande är de r = 0,16 (p=0,32) och korrigerad för kön r = 0,07 (p=0,67).De två motivationsfaktorerna för fysisk aktivitet som valdes av flest individer är ”Det är roligt” och ”Jag mår bra eller vet att det är bra för mig”. Mann-Whitney U-test visar att ingen av dessa är signifikanta när man testar skillnad för datorspelande (p=0,75 respektive p=0,40). En motivationsfaktor ”Jag vill bli bättre på någonting” ligger på gränsen till att vara signifikant (p=0,07). Datorspelandet i gruppen som valt denna faktor är 1,14 timmar (median, N=25) att jämföra med 0,00 timmar (median, N=16) för de som inte valt faktorn. Slutsats Studien visar att ungdomar som spelar datorspel inte sitter mer stilla än ungdomar i allmänhet. Två olika oberoende mått för stillasittande har använts och för inget av dessa finns samband mellan datorspelande och stillasittande. Det finns inte heller någon skillnad i motivation till fysisk aktivitet, varken måttlig eller intensiv, för datorspelande ungdomar jämfört med ungdomar i allmänhet.