Under lång tid har hälsoarbetet bestått av insatser inom det patogena området som fokuserar på orsaker till ohälsa och sjukdom. Utifrån ett salutogent perspektiv söks istället hälsans ursprung. Perspektivet utgår från vilka faktorer som gör att människor mår bra och vidmakthåller hälsan trots omständigheter som bidrar till att de är eller har varit utsatta för potentiellt sjukdomsframkallande biologiska eller psykosociala faktorer. Syftet med studien var att studera lantbrukares upplevelse av hälsa, med avsikt att beskriva salutogena faktorer för hälsa som kan vara användbara i hälsofrämjande arbete. Datainsamlingen har skett genom en postenkät till 300 lantbrukare i Skåne. Frågeformuläret innehöll frågor om arbetsförhållanden, stress, ekonomi, sociala kontakter, samt hälsa. Studien framhäver vikten av en positiv arbetsupplevelse som en signifikant påverkansfaktor för den salutogena hälsan. Det som framförallt bidrar till en positiv arbetsupplevelse är god social kontakt och en bra ekonomi. Sådana faktorer bör uppmärksammas för framtida hälsofrämjande insatser riktade till lantbrukare. / The health related work has included patogenesis interventions during a long term with focus on poor health and illness. Salutogenesis is a different perspective which emanates from factors that contribute to health and well-being. Salutogenesis explains why people stay well and even are able to improve their health in stressful situations. The aim of the study was to explore farmers´ health with intentions to describe salutogenic factors for health, that can be used in health promotion work. In a cross-sectional survey 300 farmers in Scania received a questionnaire with questions on work situation, stress, economy, social support and health. The study indicates how essential it is to have a positive work experience which has a significant impact on the salutogenic health experience. Good social contacts and good economy are factors that improve the positive work experience. These factors are important in future work with health promotion among farmers.

Långtidsarbetslösa i Sverige har sämre hälsa och välbefinnande än andra grupper och befinner sig i en utsatt position i samhället. Arbetslösa i allmänhet har en lägre känsla av sammanhang i livet, KASAM. Syftet med studien var att beskriva långtidsarbetslösas livskvalitet samt deras upplevelser och önskemål om stödjande insatser för människor i denna situation. Data samlades in genom semistrukturerade intervjuer med åtta långtidsarbetslösa som var inskrivna i ett projekt i sydvästra Sverige. Resultatet visade att socialt stöd, frihet och kreativitet i vardagen ansågs öka livskvaliteten. Hinder för en god livskvalitet uppgavs vara arbetslösheten, diskriminering, språksvårigheter samt ekonomiska svårigheter. Främjande aktiviteter som praktik, studiebesök, språkträning och hälsoaktiviteter upplevdes positiva och ett ökat utbud önskades. Detta ansågs kunna uppnås genom ökat samarbete med andra delar av samhället som företag, högskolor, föreningar och organisationer. Förslag till vidare arbete inom detta folkhälsovetenskapliga problemområde: Utvärdering av politiska mål kring arbetslösas situation, ökat språkstöd i svenska samt en kvalitativ studie av uppfattningen om stödjande insatser hos de personer som arbetar med långtidsarbetslösa. / The long-term unemployed people in Sweden are feeling unsatisfied than any other population groups and they are in a more vulnerable situation in society in comparison to others. Lowered health status and sense of coherence are often the situation for unemployed people. The purpose of this study was to describe how long-term unemployed people with economic support experience their quality of life and their experience and thoughts of supportive interventions. Data was collected through semi-structured interviews with eight long-term unemployed people who were listed in a project in south-west Sweden. The results showed social support, freedom and creativity in everyday life appears to increase quality of life. Obstacles for quality of life were the unemployment, discrimination, language problems and economic difficulties. Encouraging activities like practical experience, study tours, Swedish language courses and health activities were experienced as positive and an increased selection of some selection was wished for. This could be reached through interventions and local authorities increased cooperation and networking with other parts in society such as companies, universities and non-profit organizations. An evaluation of political implementations and goals for the unemployed, an increased language support in Swedish and a qualitative study with people who work with the long-term unemployed, to get their point of view of supportive interventions, are recommendations for further studies within this health science field.

In community health promotion intersectoral collaboration is essential. Important actors are the governmental health system, the civil society and Non-Governmental organisations (NGOs). The aim of this qualitative thesis was to examine what kind of cooperation existed in a rural community in Mozambique and to describe the actor’s experiences of collaboration and how it can be improved. This was done by conducting interviews. The result of the study showed that different ways of cooperation existed, intersectoral as well as side by side and intrasectoral. The extent of intersectoral collaboration was fairly loose, such as networks, alliances or partnership. All the informants were positive to collaboration, they had experienced that people had been helped and their knowledge in health issues was improved as an effect of joint efforts. The experience among the actors was that the collaboration had improved and that they had become closer together over the years. Problems to cooperation that were mentioned concerned dropouts and financial issues. The informants were unanimous that it was necessary to broaden the collaboration. They were concerned over the sustainability in the different projects as well as the sustainability in cooperation itself. / Para a promoção da saúde em comunidade a colaboração intersetorial é essencial. O sistema público de saúde, a sociedade civil e as organisações não governamentais (ONGs) são importantes agentes. O objetivo desta tese qualitativa foi examinar qual tipo de cooperação existiu em uma comunidade rural em Moçambique e descrever as experiências de colaboração dos agentes e como ela pode ser melhorada. Isto foi feito através de entrevistas. O resultado do estudo mostrou que existiram diferentes modos de colaboração: intersetorial assim como intrasetorial de forma paralela. O nível da colaboração intersetorial foi relativamente informal assim como redes de contato, alianças e parcerias. Todos os entrevistados foram positivos a colaborar e experienciaram que as pessoas tinham sido auxiliadas e que seus conhecimentos acerca de assuntos de saúde foi melhorado como resultado da união de esforços. A experiência entre os agentes foi de que a colaboração foi melhorada e que eles se tornaram mais próximos através dos anos. Problemas acerca de colaboração que foram mencionados foram devidos a desistências e questões financeiras. Os entrevistados foram unânimes sobre a necessidade de aumento do nível de colaboração. Eles estavam preocupados sobre a sustentabilidade de diferentes projetos assim como a sustentabilidade da cooperação em sí própria.

Studien var en uppföljning av en trygghetsvandring i stadsdelen Brynäs i Gävle som gjordes 2008 med medverkan av boende i stadsdelen och tjänstemän från kommunen. Syftet med denna undersökning var att ta reda på hur de boende uppfattar trygghet i stadsmiljö utifrån sig själva och med avseende på vissa i förväg formulerade punkter. Syftet var också att utvärdera hur boende i stadsdelen Brynäs uppfattar tryggheten i området efter de förändringar som Gävle kommun gjort i den byggda miljön. Resultaten visade att det viktigaste för tryggheten var generellt att ha kontroll på och överblick över vad som händer runtomkring en. Denna känsla kunde minska eller öka genom olika faktorer i den byggda miljön. Med tanke på detta kändes öppna platser tryggare än trånga och belysning ökade tryggheten till viss del. Det var också viktigt är att området kändes välskött och att det fanns mycket folk runtomkring en. Trafiksituationen på Brynäs uppfattades som väldigt otrygg. Angående oskötta miljöer kom diskussionerna ofta in på socialt utsatta miljöer och människor i sådana miljöer, som upplevdes som brottsbenägna. Människor som vistades i stadsmiljö var minst lika viktiga som miljöerna – miljöerna var ett medel för att dölja eller avslöja dessa människor.Resultaten visade också att informanterna till största delen inte märkt de förändringar som Gävle kommun genomfört. / This study was a follow up on a project on satefy in Brynäs, performed by the community of Gävle. The aim of the study was to investigate the perceptions of safety in Brynäs by the people living there, from the persons´ spontaneous points of view and from certain subjects already specified from present research. The aim of the study was also to examine how people on Brynäs percieve some interventions in the built urban environment in Brynäs that the community of Gävle made between 2008 and 2010. The results showed that the most important factors that make the environment feel safe was that it should give people an overview of the surroundings. The informants said that overview of the surroundings made them feel in control of what happens around them. The informants thought a lot about areas with low socioeconomic status and the people living there as correlated with increaesed risks of crime. The people appearing in urban environments were as important for the perceptions of safety as the environments themselves – the environment could hide or show people able to comitting crimes to other people. The informants had mostly not noticed the interventions in the built environment made by the community of Gävle.

Background The point of departure in this thesis is that unemployment is a recognised determinant of health, which may vary between different ages and among men and women. Despite governmental policies to tackle unemployment and ease its effects on health, unemployment continues to bea growing public health problem. Aim The objective of the thesis was to analyse, from a gender perspective, the relationships between ill health and unemployment as well as other unstable labour market positions in the transition from youth to adulthood. The aim of each paper was: I. Does the association between ill health and unemployment differ between young people and adults? II. Is the transition from an unstable labour market position to permanent paid job health-protective? III. Is participation in labour market programmes related to mental health? IV. What is the association between ill health among men and women and how could it be analysed with a relational theory of gender? Methods The longitudinal study was carried out in Luleå - a medium-sized industrial town in the Northern Sweden. The cohort, consisting of all 1083 pupils (506 girls and 577 boys) aged 16 who attended the last year of compulsory school in 1981, was followed up at the ages of 16, 18, 21 and 30. The response rates were high e.g. 96.4% at 14 years follow-up. The cohort was followed with extensive and well-validated questionnaires. Multivariate logistic regression was used in all papers, while propensity score matchingwas used in Paper III. Results Paper I. Health effects of long-term unemployment differed between young people and adults. Long-term unemployment was more related to psychological ill health and smoking in young people than in adults. Paper II. The results indicated that after controlling for gender as well as for an indicator of health-related selection, possible confounders and mediators transition from an unstable labour market position to permanent employment could be health-promoting. Paper III. No association was found between participation in active labour market programmes and psychological symptoms. Due to methodological shortages the results have to be interpreted with caution. Adjustment for either all background selection variables or the propensity score in multivariate logistic regression showed similar associations suggesting that propensity score could be used to adjust for background selection variables. Paper IV. A strong association between unemployment and suboptimal self-rated health among women and high alcohol consumption among men was found and a theory of structural relations was used to discuss the gendered patterns for ill health. Conclusion The thesis indicated gendered patterns of relations between unemployment and the health outcomes, in the transition from youth to adulthood. The policy implications of my thesis are that full employment policies should be promoted to reduce the health inequalities associated with unemployment. / The Northern Swedish Cohort study

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.

Sudden cardiac death (SCD) in a young person is a rare but tragic event, and the potential of prevention is unknown. The aim of this thesis is to contribute to the prevention by analysing SCD in the young in Sweden during the period 1992-1999. Data of SCD in the young based on a national registry is not previously reported. The approach is broad, covering the spectrum from epidemiology to supportive needs of families confronted with SCD. The survey methods comprised analyses of national registries, questionnaires, personal interviews, forensic-, police-, medical- and military conscription records. The SCD group selected from the database of the National Board of forensic Medicine consisted of 181 persons, 15 to 35 years old, who had suffered an SCD during 1992-1999 in Sweden, 132 men (73 %) and 49 women (27 %). The mean incidence was 0.93 per 100,000 per year. The trend showed no decrease during the surveyed years, 1992-1999. The most common diagnoses were the structurally normal heart (21 %), coronary artery disease (18 %), and dilated cardiomyopathy (12 %). In a study group of 162 individuals (19 cases of aortic aneurysm, 17 men and two women, were excluded), ECGs, symptoms and lifestyle factors were analysed and related to the autopsy findings. ECGs were available in 66 individuals (59 men and seven women) and 50 % of these were pathological. The most frequent aberrations were repolarisation abnormalities and in half of the cases with more than one ECG a development in a pathological direction was seen. In four out of ten seeking medical advice because of symptoms an ECG was taken and three of these were pathological. Possibly cardiac-related alpitations were common, but also non-specific symptoms such as fatigue after an influenza- like illness. It was not possible to link a certain sign or symptom to a specific diagnosis. In 26 (16 %) there was a family history of SCD. Physical activity and body mass index (BMI) in men were the same as in a control group, whilst women had a higher BMI and a lower level of physical activity than the controls. In coronary artery disease deaths there were a high percentage of smokers and BMI was higher than in the controls in both sexes. Competing athletes more often died during physical activity than non-athletes, but were not overrepresented in the SCD group. The majority of the athletes who died during physical activity had an underlying structural cardiac disease. Death during sleep was the most common mode of death in subjects with structurally normal heart. A lack of supportive structures in the handling of bereaved relatives were disclosed in the interviews. Most participants felt that they had been left mainly to themselves to find information and support. A common reflection from the bereaved was that there is a need of the same supportive routines in cases of a single death as in accidents where there are several casualties. The bereaved had a need of getting an explanation and a need of supportive structures. The cognitive dimension of understanding and the emotional dimension of being understood were found to be significant for the complex processes of mourning and recreating one’s life as a bereaved. In summary, SCD was uncommon in the young, but the incidence was not decreasing during the study period. The most common autopsy findings were the structurally normal heart and coronary artery disease. Symptoms preceding SCD were common but often misinterpreted. The SCD group was very similar to the normal population with regard to life style factors. In certain cardiac disorders physical activity seemed to trigger sudden death, whilst in others death during sleep was the most common mode of death. There is no single test which predicts if a person is at risk of SCD. A further cardiac evaluation in cases with pathological ECGs, and in cases with a positive family history or serious unexplained symptoms such as syncope, might permit the early identification of persons at risk of SCD. ECG is an underused tool in the investigation of symptoms, and a database with old ECGs available for comparison could be useful in the prevention of SCD. There is a need of better care of the bereaved, and based on our findings we propose the introduction of a supportive program.

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.

Smoking habits in adolescence have a strong impact on smoking habits in adulthood. Nine of ten adult smokers started smoking before the age of eighteen. Thus, efforts to prevent the use of tobacco among minors are of great interest. In 1997 a minimum-age law of 18 years for purchase of tobacco was introduced in Sweden. The purpose of the age limit was to reduce the availability of tobacco to young people and hence ultimately to reduce the consumption of tobacco. The overall purpose of the work reported in the present thesis was: to study whether the Swedish minimum-age law for the purchase of tobacco has affected young people’s possibilities of buying tobacco to study how compliance with the minimum-age law for the purchase of tobacco can be improved to develop methods for following compliance with the minimum-age law for the purchase of tobacco. The empirical basis for the work was three different types of data: Test purchases of tobacco in 1996, 1999, 2002 and 2005 in Värmland, Västernorrland and Malmö. In total there were forty-eight test purchasers that made 3,150 test purchases. Questionnaire surveys on tobacco habits and attitudes that were carried out in 1996, 2000 and 2005 among students in grades 7 and 9 of the compulsory school and in 1996 and 2000 in grade 2 of the upper-secondary school. All data was collected in the same three regions as the test purchase studies. The questionnaire was completed by a total of about 57,000 students. Structured telephone interviews in 2005 with 28 key people in tobacco prevention work in the three regions. In conclusion, the thesis shows that: the minimum-age law introduced in 1997 for the purchase of tobacco products has limited adolescents’ opportunities for purchasing tobacco. Compliance with the minimum-age law is, however, still incomplete the most important factor in whether test purchasers were able to buy tobacco was whether there was an age control (as the law prescribes) compliance with the minimum-age law differs among the three regions studied. It is reasonable to assume that the regional differences can be related partly to regional differences in the effectiveness of the measures taken to ensure compliance with the law the proportion of daily smokers among students in grade 9 in the compulsory school declined from 1996 to 2005 in Värmland and Västernorrland but there was no change in Malmö the method used for test purchase of tobacco and further developed and adapted for Swedish conditions, functioned well for following compliance with the law.

The overall aims of this thesis were to investigate psychological and behavioral effects of receiving cancer genetic counseling for breast, ovarian and colorectal cancer and/or with a family history of these cancer types and to determine whether counselees’ informational needs were met. Study I was performed 3-7 years post-counseling. Participants (n=214) reported a relatively high level of anxiety but a low level of depression compared to cancer patients in general. However, there was no indication that the distress experienced was due to the counseling. Moderate changes in life and family relations, high level of adherence to recommended controls and satisfaction was reported. Study II was a randomized control trial (RCT) intervention study which involved 147 counselees. An increase in the level of knowledge and correct estimation of personal risk was reported in both the intervention and control groups, although this increase declined at later follow-up. Enhanced information led to significantly greater satisfaction with the given information, and the way of informing relatives. Most counselees had shared information with their at-risk relatives. Study III focused on sharing information with at-risk relatives among participants in study II and their relatives (n=81). Counselees were interviewed and answered a questionnaire, whilst their relatives only answered the questionnaire. Counselees reported positive/neutral feelings about communicating genetic information and mostly interpreted their relatives’ reactions as positive/ neutral. Also, approximately 50% of relatives reported positive/neutral reactions and were generally satisfied with the received information. Study IV was conducted in Sweden and Norway based on 235 counselees. Counselees expected counselors to be skillful and thoughtful, take them seriously and provide risk estimations and medical information. Most important issues to counselees were satisfactorily addressed by the counselors. Analyzing importance rankings resulted in five categories of needs: a need for facts, caring communication and medical information, need for understanding and support in sharing genetic information, practical care and medical/practical information. In conclusion, no adverse psychological or behavioral effect on counselees was observed. Apparently, genetic counseling is managed properly and counselors successfully address counselees’ needs. Providing extended information does not seem necessary, however, tailoring information to individual counselees needs may create a more effective counseling.