Background: In Sweden, as well as in most Western countries, sickness absence is a major public health problem that has increased in recent years. This is a complex phenomenon related not only to ill health factors, but also to other factors on the levels of the individual, the family, the workplace, and the society. Most studies of sickness absence are cross sectional, which makes it difficult to investigate aetiological factors. A longitudinal study design is preferable, because sick-leave spells can have a long duration and are often due to chronic or recurrent disorders. Objectives: The aim of the present research was to conduct a pilot study to gain further information about factors associated with sickness absence and disability pension, perceptions of contacts with rehabilitation professionals, and self-rated health over time among younger persons initially on sick leave with low-back, neck, or shoulder diagnoses. Material and methods: An eleven-year prospective cohort study of all individuals who, in 1985, were aged 25–34 years, lived in the municipality of Linköping, Sweden, and had a sick-leave spell ≥ 28 days with low-back, neck, or shoulder diagnoses (n = 213, 61% women). The following information was obtained from registers: number of sick-leave days and spells in 1982–1984; diagnosis and demographical data in 1985 (age, sex, occupation, citizenship, marital status, and income); data on each sick-leave period (date, full/part time), disability pension (date, diagnoses, temporary/permanent, full/part time); emigration (date), and death (date, cause) from 1985 to 1 September 1996. In 1996, a questionnaire was sent to members of the cohort (response rate 73%). Different measures were used to analyse sickness absence and disability pension over the eleven-year period, possible risk factors for disability pension were tested by Cox regression, and possible factors predicting future low levels of sickness absence were tested by logistic regression. Based on the questionnaire perceptions of encounters with rehabilitation professionals were analysed with factor analyses and linear regression, and the so called health-line (a method to collect data on self-rated health over time) was tested, and the results were compared with data on sickness absence and disability ension. Results: The members of the cohort turned out to be a high-risk group for disability pension. After 11 years, 26% of the women and 14% of the men had been granted such benefits, mainly due to musculoskeletal diagnoses, but also with psychiatric diagnoses for half of the men and 17% of the women. Full-time pension was granted more often to men than to women. The women had higher levels of sickness absence. An extended Cox regression model proved suitable for prediction of disability pension. Taking citizenship and long-term sickness absence into consideration, the women had a 1.9 times higher risk of being granted disability pension than the men. Predictors for future low levels of sickness absence were a history of low sickness absence, having a white-collar job, and being married. These associations were not discerned when a pathogenic approach was used, which implies that factors other than the opposite risk factor for disability pension are associated with future low sickness absence. Three dimensions of the individuals’ contacts with professionals were identified: supportive treatment, distant treatment, and empowering treatment. Women perceived both social insurance officers and health care professionals as more supportive than the men did. Contact with social insurance officers was experienced as more supportive and empowering by persons on disability pension than by those not receiving such benefits. Data collected using the health-line (i.e., self-rated health from 1985 to 1995) was correlated with data on annual mean number of sick-leave days and days on disability pension. No tendency to recall bias was noted. Conclusions: Additional research is needed to elucidate the situation of women on sick leave with low-back, neck, and shoulder diagnoses. Further testing and practical application of statistical and epidemiological models for analysing sickness absence and disability pension data should be carried out to ascertain the validity and usefulness of such models. / On the day of the public defence the status of the article I was: Submitted; article III was: Accepted; article IV was: Submitted and article V was: In press.

This thesis reports on the effects of stress management on long-term pain patients and on a healthy sample from IT and media companies; two groups that are commonly exposed to high stress levels. Even if there are important differences between these two groups, there are similarities such as the necessity for effective stress management. Stress-related and musculoskeletal disorders are major public health issues in most industrialized countries and are expected to become increasingly common during the coming decades. The pathogenic plastic changes in the CNS and immune system caused by long-term stress pose severe burdens to individuals, organizations as well as society in general. Thus, stress management may be essential to maintain and improve long-term health and wellbeing and to proactively counteract stress-related ill-health. This thesis is based on four papers: Paper I assessed the effects of massage as compared to relaxation tapes in long-term pain patients. Paper II validated some of the Visual Analogue Scale questions that were to be used in paper III and IV. Paper III assessed the effects on mental and physical wellbeing and biological stress markers from a web-based stress management and health promotion tool. Paper IV aimed at mapping out predictors for trends (improvement vs. worsening) in self-rated health (SRH) over a period of one year. The overall results indicate that individually focused stress management interventions in long-term pain patients as well as on a healthy, working population may have short-term beneficial effects on psychological and physiological stress, health and wellbeing. On a long-term basis the beneficial changes seem to revert. In paper four, it is indicated that the stress management intervention is not a significant predictor of long-term changes in SRH. Rather, other factors such as health perception, sleep quality and sense of coherence predicted improvement in SRH over time.

In 2003, the Swedish Parliament adopted a national public health policy that included the domain - “A more health-promoting health service”. Strategies and tools are needed in the work to reorient health services. Personal health documents are documents concerning a person’s health, and are owned by the individual. Several studies that have evaluated such documents indicate that they could be of interest in health-promotion work. However, there is insufficient knowledge concerning personal health documents that target adolescents, and little is known about the feasibility of such documents in a Swedish cultural context. The concept of empowerment is gaining increased interest for health services, but the associations between empowerment, self-rated health and health behaviour are sparsely studied. The overall aim of the thesis is to explore a strategy - empowerment - and a tool - personal health documents - that might facilitate the work of the public health goal of a health-promoting health service. Specific aims are to examine the feasibility of using personal health documents in health promotion; to examine professionals’ experiences of working with health promotion and personal health documents; to examine the association between personal health documents and self-reported health behaviour change; and to examine the perception of empowerment in relation to self-rated health and health behaviour among adolescents. Two personal health documents that targeted adults and adolescents were developed and evaluated. Distribution to adults in different settings was compared in a cross-sectional study (n = 1 306). Adolescents received the document in school, and surveys were performed at baseline and after one year (n = 339). Practical use and attitudes by document owners were studied by questionnaires. Teachers (n = 69) answered a questionnaire, and community health nurses were interviewed (n = 12). The interviews also explored nurses’ experiences of working with health promotion in general, and were analysed by qualitative methodology. Adolescents’ empowerment was examined by a questionnaire (n = 1 046). Most participants reported reading in the documents; writing in the documents varied between 16% (distribution in occupational health) and 87% (adolescents). The health document was perceived as useful by 35% of the adolescents. Factors significantly related to personal usefulness were being born outside Sweden, experiencing fair treatment by teachers, being a non-smoker and having a positive school experience. Community health nurses were striving for a balance of being a doer of practical, disease-oriented tasks and a health-promotion communicator. The structural organisation in health care centres was important for their work with health promotion and the health document. Teachers were generally in favour of continued work with the document. In different settings, between 10% and 26% of adults reported changes in their health situations as a result of reading the booklet. Self-reported changes in health situations were less likely using postal distribution, and there were no significant differences between the other types of distribution. Adolescents with low empowerment scores reported poorer self-rated health and more risk-taking behaviours such as smoking and binge drinking. To conclude, personal health documents are feasible to use in different settings. Health promotion in health services needs active support from leaders as well as adequate support systems. Findings suggest that personal health documents can be tools for promoting self-reported lifestyle changes among adults in different settings. There is a close relation among adolescents between low empowerment in the domain of health, low self-rated health and health behaviours such as binge drinking and smoking.

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

This thesis focused on factors contributing to improved work environment in small-scale enterprises and sustainable health for the entrepreneurs. In Study I, implementation of the provision of Systematic Work Environment Management (SWEM) with and without support was investigated. Two implementation methods were used, supervised and network method. The effect of the project reached the employees faster in the enterprises with the supervised method. In general, the work environment improved in all enterprises. However, extensive support to small-scale enterprises in terms of advice and networking aimed at fulfilling SWEM regulations had limited effect – especially considering the cost of applying these methods. Studies II, III, and IV focused on entrepreneurs’ health, work conditions, strategies for maintaining good health, and utilisation of Occupational Health Service (OHS). A closed cohort of entrepreneurs in ten different trades responded to two self-administered questionnaires on health and work conditions, with five years between the surveys: at baseline, 496 entrepreneurs responded, and 251 entrepreneurs responded at follow-up. Differences were tested by Chi2-test, and associations estimated with logistic regression analyses. Qualitative interviews on entrepreneurs’ strategies for maintaining good health were included. In Study II, the most frequently reported complaints, musculoskeletal pain and mental health problems, were associated with poor job satisfaction and poor physical work environment. In Study III, consistent self-reported good health, i.e. good health both at baseline and at follow up, was associated with self-valued good social life when adjusted for physical work conditions and job satisfaction. Entrepreneurs’ strategies for maintaining good health included good planning and control over work, flexibility at work, good social contact with family, friends and other entrepreneurs, and regular physical exercise. Study IV concerned entrepreneur’s utilisation of OHS. Entrepreneurs affiliated to OHS had either better or more adverse work conditions than non-affiliated entrepreneurs. Medical care and health check-ups were the services most utilised. Affiliation to OHS correlated with use of specific information sources and active work environment management. The entrepreneurs were not consistently affiliated to OHS over the five-year-period.

Many people use the train both as a daily means of transport as well as a working place to carry out activities such as reading or writing. There are, however, several important factors in this environment that will hamper good performance of such activities. Some of the main sources of disturbance, apart form other train passengers, are noise and vibrations generated from the train itself. Although there are standards available for evaluation of ride comfort in vehicles none of them consider the effects that vibrations have on particular passengers' activities. To address these issues, three different studies were conducted to investigate how low frequency lateral vibrations influence the passengers' ability to read and write onboard trains. The first study was conducted on three types of Inter-Regional trains during normal service and included both a questionnaire survey and vibration measurements. Two proceeding laboratory studies were conducted in a train mock-up where the perceived difficulty of reading and writing was evaluated for different frequencies and amplitudes. To model and clarify how vibrations influence the processes of reading and writing the fundamentals of Human Activity Theory was used as a framework in this thesis. In the field study about 80% of the passengers were found to be reading at some point during the journey, 25% were writing by hand, and 14% worked with portable computers. The passengers applied a wide range of seated postures for their different activities. According to the standardised measurements, even the trains running on poor tracks showed acceptable levels of vibration. However, when the passengers performed a short written test, over 60 % reported to be disturbed or affected by vibrations and noise in the train. In the laboratory studies it was found that the difficulty in reading and writing is strongly influenced by both vibration frequency and acceleration amplitude. The vibration spectra of real trains were found to correspond well to the frequency characteristics of the rated difficulty. It was also observed that moderate levels of difficulty begin at fairly low vibration levels. Contextual parameters like sitting posture and type of activity also showed strong influence on how vibrations cause difficulty.

Background: The main objective of this study was to investigate older people’s physical activity, their participation in various life situations, and their perceptions of their own health. This included an exploration of potential influences of urban versus rural residency on these outcomes, an evaluation of the measurement properties of a balance confidence scale, and an examination of the proposed usefulness of the International Classification of Functioning, Disability and Health (ICF) as a conceptual framework to facilitate analysis and understanding of selected outcomes. Methods: The study design was cross-sectional, population-based, with random selection from the national register of one urban and two rural municipalities in Northern Iceland. There were 186 participants, all community-dwelling, aged 65 to 88 years (mean = 73.8), and 48% of the group were women. The participation rate was 79%. Data was collected in 2004, in face-to-face interviews and through various standardized assessments. The main outcomes were total physical activity; leisure-time, household, and work-related physical activity; participation frequency and perceived participation restrictions; and self-rated health. Other assessments represented aspects of the ICF body functions, activities, environmental factors and personal factors. Moreover, Rasch analysis methods were applied to examine and modify the Activities-specific Balance Confidence (ABC) scale and the ICF used as a conceptual framework throughout the study. Results: The total physical activity score was the same for urban and rural people and the largest proportion of the total physical activity behavior was derived from the household domain. Rural females received the highest scores of all in household physical activity and rural males were more physically active than the others in the work-related domain. However, leisure-time physical activity was more common in urban than rural communities. A physically active lifestyle, urban living, a higher level of cognition, younger age, and fewer depressive symptoms were all associated with more frequent participation. Rural living and depressive symptoms were associated with perceived participation restrictions. Moreover, perceived participation restrictions were associated with not being employed and limitations in advanced lower extremity capacity. Both fewer depressive symptoms and advanced lower extremity capacity also increased the likelihood of better self-rated health, as did capacity in upper extremities, older age, and household physical activity. Rasch rating scale analysis indicated a need to modify the ABC to improve its psychometric properties. The modified ABC was then used to measure balance confidence which, however, was found not to play a major role in explaining participation or self-rated health. Finally, the ICF was useful as a conceptual framework for mapping various components of functioning and health and to facilitate analyses of their relationships. Conclusions: The results highlighted the commonalities and differences in factors associated with participation frequency, perceived participation restrictions, and self-rated health in old age. Some of these factors, such as advanced lower extremity capacity, depressive symptoms, and physical activity pattern should be of particular interest for geriatric physical therapy due to their potential for interventions. While the associations between depressive symptoms, participation, and self-rated health are well known, research is needed on the effects of advanced lower extremity capacity on participation and self-rated health in old age. The environment (urban versus rural) also presented itself as an important contextual variable to be aware of when working with older people’s participation and physically active life-style. Greater emphasis should be placed on using Rasch measurement methods for improving the availability of quality scientific measures to evaluate various aspects of functioning and health among older adults. Finally, a coordinated implementation of a conceptual framework such as ICF may further advance interdisciplinary and international studies on aging, functioning, and health.

En viktig faktor för människans förmåga att arbeta är hälsa. På arbetsplatsen tillbringar människan mer än en tredje del av sina liv, vilket gör arbetsplatsen till en betydande arena i skapandet av hälsa. Kommuner har som arbetsgivare i Sverige generellt en sämre hälsa samt högre sjukfrånvaro bland sina anställda än andra arbetsgivare. De som jobbar inom vård och omsorg har generellt dåliga psykosociala arbetsförhållanden. Den psykosociala arbetsmiljön i form av höga krav, bristande kontroll och dåligt socialt stöd kan påverka hälsan negativt, vilket kan öka rörligheten på arbetsmarknaden i form av att fler tenderar att byta jobb på grund av dåliga arbetsförhållanden. Syftet är att undersöka samband mellan självskattad psykosocial arbetsmiljö, självskattad hälsa och övervägandet att byta jobb bland kommunanställda inom äldre- och handikappomsorgen i Sverige. Studien har genomförts som en deduktiv tvärsnittsstudie och är en del av en störres studie.  Den baseras på 9 270 kommunanställda inom äldre- och handikappomsorgen i Sverige. Studien teoretiska referensram är krav/kontroll/stöd modellen. Analys skedde genom univariata, bivariata och multivariata metoder.    Resultatet visar att det fanns signifikanta bi- och multivariata samband mellan att kommunanställda som upplever den psykosociala arbetsmiljön som god även skattar hälsan bättre samt i mindre utsträckning överväger att byta jobb än de som upplever sämre psykosocial arbetsmiljö. Ålder och antal år på arbetsplatsen hade betydelse för övervägandet att byta jobb. Detta i form av att ju äldre de anställda är samt ju längre de arbetat på arbetsplatsen desto mindre är övervägandet att byta jobb. Slutsatsen är att den psykosociala arbetsmiljön hade betydelse för den upplevda hälsan och övervägandet att byta jobb bland kommunanställda inom äldre och handikappsomsorgen. / Health is an important prerequisite for the ability to work. In the workplace, the human being spends more than a third of their lives. This makes the workplace a major arena for health promotion. Municipalities have as employers in Sweden generally poorer health and higher rates of sick leaves among the employees than other employers. Those who work in health care have bad demanding working conditions. Psychosocial work environment in the form of high demands, lack of control and poor social support may affect health negatively. This can increase labor market mobility in the form of more tend to change jobs due to poor working conditions. The aim of this study is to investigate the relationship between self-rated psychosocial work environment, self-rated health and occupational mobility among municipal employees in the elderly and disabled care in Sweden. The study is implemented as a deductive cross sectional study and is a part of a major study. It is based on a sample of 9 270 municipal employees in the elderly and disabled care in Sweden. The theoretical frame of reference of study is the demand / control / support model. The analyses were done by univariat, bivariat - and multivariate methods. The results show that there were significant correlation between municipal employees who experience the psychosocial work environment as good rated health better and lesser extent considering changing jobs than those who experience poorer psychosocial work environment. Age and number of years in the workplace was relevant to the consideration of changing jobs. This is in the form of the older employees are and the longer they worked in the workplace, the less is the consideration of changing jobs. The conclusion is that the psychosocial work environment was important for the perceived health and the consideration to change jobs among municipal employees in the elderly and disabled.

Diss. (sammanfattning) Umeå : Umeå universitet, 2009. / Härtill 4 uppsatser. Även tryckt utgåva.

Tyrimo tikslas – nustatyti kaip susiję paauglių prieraišumo prie tėvų stilius su interneto naudojimo intensyvumu bei subjektyviu sveikatos vertinimu. Tyrime dalyvavo 142 mokiniai (108 merginos ir 34 vaikinai), 96 mokiniai anketas pildė internetu, 46 Viešojoje įstaigoje Kauno „Vyturio“ katalikiškoje vidurinėje mokykloje. Tiriamieji pildė anketą, kurią sudarė keturios metodikos, prieraišumo stiliaus, žmonės mano gyvenime, subjektyvaus sveikatos vertinimo ir interneto naudojimo intensyvumo klausimynas. Tyrimo rezultatai parodė, kad prieraišumas prie tėvų, subjektyvus sveikatos vertinimas ir interneto naudojimo intensyvumas skiriasi atskirose sociodemografinėse grupėse: vaikinai savo sveikatą vertina geriau nei merginos, paaugliams; gyvenantiems su abiem tėvais, būdingas didesnis prieraišumas prie tėvų ir geresnis subjektyvus sveikatos vertinimas, nei gyvenantiems su vienu iš tėvų; teigiantys, jog nejaučia skausmų, savo sveikatą vertina geriau ir ne taip intensyviai naudoja internetą, nei tiriamieji, pažymėję, jog jaučia skausmus; pildžiusių anketas mokykloje subjektyvus sveikatos vertinimas geresnis, nei pildžiusių anketas internetu. Paauglių subjektyvus sveikatos vertinimas reikšmingai koreliuoja su prieraišumu prie tėvų, gautas ryšys silpnas. Aukštas, žemas paauglių subjektyvus sveikatos vertinimas skirtingose sociodemografinėse grupėse statistiškai reikšmingai skiriasi išskyrus paauglių gyvenančių su vienu iš tėvų. Paaugliams, kuriems būdingas vyraujantis nerimastingo... [toliau žr. visą tekstą] / The aim of the study was to assess connections between adolescent attachment to parents‘ style with intensity of internet use and self – rated health. The subjects of the study were 142 students (108 girls and 34 boys), 96 students questionnaires were filled out online, 46 studets questionnaires filled out in the Catholic secondary school. Students were asked to fill 4 questionnaires: Relationship Scale Questionnaire, People In My Life, Internet Addiction Test and subjective helth questionnaire. The results of the study showed that attachment to parent, self – rated health and intensity of internet use are different among sociodemographical groups: boys evaluate their health better than the girls. Adolescent who lived with their parent have more attachment to parent and their health is better, comparing with adolescent who lived with one of his parent. Adolescent who wrote that do not feel pain their health are better and they use less intensity of the internet than students, who wrote, that feel pain. Students who filled questionnaire in school have better health than students who filled questionnaire online. Adolescents‘self – rated health was correlated with attachment to parent. Anxious attached subjects have had lower health than save attached subject. Save attached subjects are more attached to parent. Anxious attached subjects are more intensity of internet use.