Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

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. / digitalisering@umu

Background: The recent increase in long-term sickness absence both in Sweden and many other countries has been met with various attempts to intensify the use of rehabilitation measures in order to prevent people from remaining long-term sickness absent. Several actors, among them professionals in healthcare, occupational health services, and social insurance are involved in handling issues related to the sick leave of an individual, and in providing measures to promote return to work (RTW). Identification of the factors that are related to RTW of the individual is a multifaceted task; therefore to meet the individual in this process is an essential challenge for many actors involved. Knowledge is needed about factors that might promote RTW in order to facilitate future research aimed at designing effective rehabilitation programs. Such information is of great importance to improve the work situations of the professionals, to decrease the cost for society, and to improve the situations for people on sick leave by facilitating RTW. Objectives: The overall aim of the work underlying this thesis was to ascertain whether contacts between professionals and sickness absentees might a factor that can promote RTW, and also to identify different aspects of how such positive encounters are experienced by those who are sick listed. Material and methods: Five investigations were conducted using different study designs, data, and methods of data analyses. The first two (papers I and II) concerned interviews with people on sick leave about positive experiences of their encounters with professionals. The third study (paper III) was based on four questions about encounters, which were included in a questionnaire that was administrated to people who were on sick leave. The fourth study (paper IV) used a broad questionnaire to examine experiences of positive encounters, and the final study (paper V) proposed a model of possible effects of the encounters on RTW. Results: In paper I and II different aspects of sick-listed person’s experiences of positive encounters were identified. For example, it seemed that important qualities included being treated with respect, feeling supported, establishing a personal relationship, and participating in decisions regarding RTW measures. Several of the interviewees stated that RTW might be promoted by positive encounters. Paper III showed that perceptions of interactions varied with the type of professionals, as well as with demographics. The respondents perceived their encounters with professionals within healthcare as most positive, followed by social insurance, and lastly occupational health services. In general, females, people born in Sweden, and those who were older, or had a higher education rated their encounters with professionals as more positive. The main finding reported in paper IV was that the majority of the participants had experienced being positive encountered by professionals. Three aspects of such encounters were stressed, namely being treated with ”competence”, ”personal attention”, and ”competence and trust”. The results related in paper V indicated that theories about empowerment and on social emotions could be successfully applied in this area, after they were specifically adapted to some unique features of the contacts between sickness absentees and rehabilitation professionals. Conclusions: This thesis emphasizes that being positively encountered by professionals can have a beneficial impact on RTW after a period of sickness absence. More research is required to elucidate the interaction between sick-listed persons and professionals who are involved in their cases. Further studies should focus on how methods for professionals can be provided to increase sick-listed persons’ own ability to mobilize and develop their resources. Moreover, additional knowledge is needed to extend professional treatment strategies that enhance self-confidence and empowerment of individuals during sickness absence.

Avhandlingens formål var en kompetansekartlegging av helsefremmende tilnærming i kontakten med brukere og bedrifter for ansatte i trygdeetaten i Norge. Etaten er en regelstyrt offentlig organisasjon i endring. Ved innføringen av ”Intensjonsavtalen om et mer inkluderende arbeidsliv”(IA-avtalen), fikk trygdeetaten tildelt ansvaret for å bistå virksomheter i privat og offentlig sektor med implementering av målsettingen om et inkluderende arbeidsliv. Arbeidslivssentre ble etablert og rådgivere ansatt. I studien inngikk en spørreundersøkelse besvart av 25 rådgivere. Kommentarer i åpnespørsmål ble analysert med kvalitativ metodikk. Oppgaven belyserutfordringen med åimplementere helsefremmende holdninger og metoder blant ansatte i en regelstyrt offentlig etat som trygdeetaten. Kartlegging og tolkning avdekker rådgivernes manglende kunnskaper om folkehelsearbeid. De har liten oversikt over sammenhenger mellom disse teorier/metoderog bistanden til bedrifter/brukere for å oppnå et mer inkluderende arbeidsliv. En spesiell utfordring ser ut til å være trygdefunksjonærenes holdninger til helse og sykdom. Begrensninger, årsaker og diagnoser har tradisjonelt et sterkt fokus. Det synes å væremindre bevissthet på helse som ressurs og betydningen av medvirkning/empowerment. Det ser også ut til å være etstort behov for mer kunnskaper om salutogenesis, dvs. betydning av opplevelse av sammenheng, mestring og trivsel på tross av sykdom og begrensninger / The aim of this study was to evaluate the employees of the Norwegian National Insurance Service, NIS, in their knowledge and experience on health promotion. NIS is a strictly traditional Public Organization ongoing managing change with the newly introduced reform “Tripartite agreement on a more inclusive workplace”. On behalf of the Government, theNIS has got the responsibility of assisting and supervising the Private and Public Organizations to improve and reach the aimsset in the agreement. The National Insurance Services Workplace Centres were established and advisers were employed. This study includes questionnaires answered by 25 advisers. Data, specific from comments in open ended-questions were analyzed by qualitative methods. The study shows thechallenge of implementing attitudes and methods on Health Promotion in a strictly traditional Public Organization like NIS. Analyzing the data showes a lack of knowledge in the advisers competence on Public Health theories and methods. They do not use elements of Health Promotion towards leaders and clients in private and public Enterprises in their supervising on “Inclusive Workplace”. Aspecial challenge seemed to be the advisers own attitude towards health and disease As a result of the analyses, recommendations for the employees/advisers of NIS are the needof more knowledge on Health Promotion, Empowerment and Salutogenesis. / <p>ISBN 91-7997-107-5</p>

Background: The high levels of sickness absence and disability pensioning experienced during the 1990's and 2000's have become both socially as well as financially burdensome for society. Sickness absence implies a costly loss of production for society and large groups of individuals are risking to become marginalised on the labour market. Sickness absence is both a public health and an economic problem. Thus from both a human approach as well as from an economic perspective it is urgent to increase knowledge about what influences individual behaviour when it comes to sickness absence and return to work. Objectives: The overall aim of the thesis is to elucidate the decisive factors for explaining sickness absence. Three different aspects of sickness absence were considered, i.e. factors leading to sickness absence, factors preventing sickness absence and factors leading back to work ability and work when being sickness absent. This is done using a frame of reference involving broadly defined areas of work, health and social insurance related factors. Material and methods: Study I analyzes the outcome of unemployed sick-listed individuals. A total of 280 individuals from the county of Värmland were followed through register data between the years 2000 to 2001. Linear and logistic regression models were used to analyze the occurrence of short and long term economic incentives. Study II has a longitudinal design and explores determinants of return to work. Sick-listed individuals with a stress-related psychiatric diagnosis from the county of Värmland were analyzed over a period of three years (2000-2003) using logistic regression. The data comprised 911 individuals. Study III is a cross-sectional study using questionnaire data from the county of Värmland from year 2004. A total of 3123 persons either working or being self employed were analyzed on determinants of work presence through logistic regression. Study IV had a cross-sectional design and used questionnaire data from five counties in central Sweden. The data, from 2004, comprised 10536 individuals being employed, i.e. not self-employed, and with self reported physical and mental medical conditions. Logistic regression was mainly used in the analysis and the focus was on risk factors for long term sickness absence. Study V comprises cross-sectional data retrieved at three separate occasions between 1991 and 1994. It includes 8839 individuals from five counties in western Sweden with sickness absence spells over 60 days. The data was analysed through bi-variate probit regression with a focus on effects of vocational rehabilitation on return to work. Results: The results from study I were interpreted as that both short and long term economic incentives matter for the outcome of sickness absence through the interaction of different insurance systems. The principal findings from study II was that age, gender and factors implying less favourable health characteristics and thereby lower work capacity, reduce probabilities of returning to work after long term sickness absence. Considering study III determinants of work presence were found to vary between sexes and whether the determinants were counteracting long or short term sickness absence. Factors interpreted as job control counteracted short term absence. Sense of coherence was found to be an important determinant of work presence for women. In study IV long term sickness absence was found to be related to the level of ill-health. Moreover it was concluded that work environment factors as job strain, job satisfaction, physical work environment were important factors for explaining sickness absence in a population with impaired health. The results from study V indicated that vocational rehabilitation is a potentially effective instrument for improving the individual's work ability and chances of return to work. That no signs of prioritizing selection of rehabilitation participants to those likely to return to work with or without rehabilitation measures, i.e. "managerial creaming", were found was also considered as important results. Conclusions: This thesis shows that we need different models and approaches to improve knowledge about the various aspects of sickness absence as entry into absence, return to work or into disability retirement. It also has the implications that sickness absence behaviour can be influenced. Largely depending on what long term path is chosen for welfare policy at the political level it should be acknowledged that other means, improving working conditions and promoting rehabilitation rather than reducing benefit levels and narrowing the eligibility criteria for the insurance benefits are at hand.

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2008. / Härtill 4 uppsatser.

Stressrelaterad psykisk ohälsa ökar mest och står för den längsta varaktigheten bland sjukskrivningarna. Förändringar i sjukförsäkringssystemet och beslut om att minska sjuktalen har gett konsekvenser som ökat antal avslag om sjukpenning. Syftet med studien var att undersöka erfarenheter av avslag om sjukpenning från Försäkringskassan hos personer med stressrelaterad psykisk ohälsa för att beskriva och förstå vad det får för betydelse för deras sjukdomsbild och återhämtning. Studien är kvalitativ och har genomförts genom semistrukturerade intervjuer med fem personer som drabbats av stressrelaterad psykisk ohälsa och fått avslag om sjukpenning från Försäkringskassan. Materialet som samlats genom intervjuerna har analyserats med Ulrich Becks teorin om risksamhället och Randall Collins teori om symboliska interaktionskedjor samt tidigare forskning. Resultatet i studien indikerar att avslag om sjukpenning påverkar sjukdomsbilden och möjligheten till återhämtning negativt för personer som drabbats av stressrelaterad psykisk ohälsa. Respondenterna upplevde att avslaget förlängt sjukdomstiden, genom minskad möjlighet till återhämtning och förvärrad sjukdomsbild. Resultatet visar även på en samlad bild av upplevelsen av avslaget om sjukpenning från Försäkringskassan. Personerna upplever inte att handläggare på Försäkringskassan tror dem och därmed känner de sig kränkta. / Stress-related disorders have increased and accounts for the longest duration of sick leave. Changes in the health insurance system and decisions to reduce the sick-leave have had consequences such as an increased number of rejection of sickness benefits. The aim of this study was to investigate the experience for people having a stress-related disorder and being rejected sickness benefits from the Social Insurance Fund, to describe and understand the importance for their disease image and recovery. The study is qualitative and has been conducted through semistructured interviews with five participants who suffered from stress-related disorders and received a refusal of sickness benefits from the Social Insurance Fund. The material gathered through the interviews has been analyzed with Ulrich Beck’s theory of risk society and Randall Collin’s theory of symbolic interaction-chains and previous research. The result of this study indicates that the refusal of sickness benefits affects the recovery rate negatively for the participants in the study. The participants felt that the refusal extended the disease time, and they experienced reduced opportunities to recover and a worse diseases image. The result also shows a consistent picture of the experience of receiving a refusal of sickness benefits from the Swedish Social Insurance Agency. The participants do not feel that the case officers at the Social Security Fund believe them and thus they feel offended.

A l'éveil comme au cours du sommeil, en plaine comme en haute altitude, le maintien d'une oxygénation artérielle stable et élevée est un marqueur essentiel d'une bonne réponse physiologique de l'organisme. L'intolérance à l'altitude regroupe des pathologies graves voire fatales dont le développement est en lien direct avec le taux d'oxygénation artériel des sujets. D'autre part, en plaine, la prévalence élevée du syndrome d'apnées obstructives du sommeil (SAOS) incite les chercheurs au développement de modèles d'études spécifiques, permettant d'investiguer les conséquences du principal stimulus du SAOS : l'hypoxie intermittente. La chémosensibilité pourrait avoir un impact important dans ces deux pathologies, ayant pour rôle le maintien des gaz du sang à des valeurs normales, en adaptant la ventilation aux conditions externes ou internes à l'organisme.Les objectifs de ce travail étaient de comprendre l'impact de la chémosensibilité (avec d'autres mécanismes décrits dans la littérature) sur l'oxygénation et la tolérance à l'altitude, d'étudier les effets de la résistance expiratoire sur l'amélioration de l'oxygénation, ainsi que les conséquences de l'hypoxie intermittente chronique sur la plasticité du chémoréflexe.Il en ressort que la chémosensibilité périphérique à l'hypoxie a un impact majeur sur le développement de l'intolérance à l'altitude. Cela semble en outre être un facteur prédictif de la survenue de ces pathologies. En hypoxie, une amélioration efficace de l'oxygénation a été obtenue par l'utilisation d'une résistance expiratoire calibrée à 10 cm H2O permettant l'amélioration de la diffusion alvéolo-capillaire. L'exposition à l'hypoxie intermittente chronique nocturne a provoqué une fragmentation du sommeil ainsi qu'une intensification de la chémosensibilité à l'hypoxie et à l'hypercapnie.Ainsi, une altération de la réponse des corps carotidiens à l'hypoxémie participerait au développement du mal aigu des montagnes et de ses complications, tout en facilitant sa prédiction avant ascension. L'utilisation d'une résistance expiratoire pourrait permettre de combler la désaturation exagérée retrouvée chez les sujets sensibles à l'altitude lors d'un séjour en haute montagne. Il apparaît également que la chémosensiblité périphérique et centrale (CO2 et O2) fasse preuve d'une plasticité importante en réponse à l'hypoxie intermittente nocturne chez des sujets sains. / At awakening and during sleep, at sea level or in high altitude, maintaining a high level in arterial blood oxygenation is a marker for an adaptated physiological response external and internal factors.High altitude illness encompasses pathologies, that sometimes could be fatal, and which seems to be correlated with the level of arterial oxygenation in hypoxia.Secondly, at sea level and in general population, the high prevalence of obstructive sleep apnea syndrome (OSAS) encourage scientists to develop new models for studying consequences of the main OSAS' stimulus: intermittent hypoxia.Chemosensitivity could play an important role in those two different diseases, with regulation of blood gases and homeostasis by controlling ventilation.Our objectives was to investigate (1) impact of chemosensitivity on blood oxygenation and tolerance to high altitude, comparatively to other physiological factors commonly involved, (2) effects of using positive expiratory pressure in order to improve oxygenation in hypoxia, and (3) consequences of chronic exposure to nocturnal intermittent hypoxia on chemoreflexe plasticity.We found that peripheral chemoresponse to hypoxia play a crucial role in high altitude illness development. Moreover, this variable seems to be a predictive factor for those diseases. In hypoxic conditions, using a positive expiratory pressure (10 cmH2O) lead to a significant improve in arterial oxygenation, by increasing pulmonary diffusion. Finally, nocturnal intermittent hypoxia induced significant sleep disturbances and major changes in chemoresponse to hypoxia and hypercapnia.

In Sweden, sickness absence due to mental disorder is increasing for both men and women, although more among women. The psychosocial work environment is acknowledged as an important predictor for sickness absence. Employee based work-time control is beneficial for the balance between job stress and recovery and could therefore be of interest when aiming to prevent sickness absence. The aim is to investigate the association between control over daily hours (CoDH) and control over time off (CoT), respectively, and sickness absence. The study also examine whether the association differ by gender and if burnout or depression mediates the associations. Data was derived from two waves of the Swedish Longitudinal Occupational Survey of Health (SLOSH) which is an approximate representation of the Swedish working population (n=8418, of which 4936 were females). Binary logistic regression was used as method of analysis. After adjustment for possible confounders, no association between CoDH and sickness absence was found. Low CoT was significantly associated with sickness absence among men (OR=0.90 [0.84, 0.96]), but not among women. Neither burnout nor depression mediates the associations. CoT is stronger associated with sickness absence than CoDH. CoT with regard to sickness absence is of greater importance for men than women.

Esta dissertação é fruto de um estudo etnográfico de aproximadamente três anos e meio de pesquisa com lideranças indígenas kanhgág no Rio Grande do Sul, estado mais ao sul do Brasil. Baseado em análise de rede de relações sociais, nós estudamos as relações diádicas entre humanos e não humanos e clusters de rede que compõem a cosmopolítica kanhgág. Com o intuito de compreender estas relações nos apoiamos em teorias antropológicas consistentes com o estudo de corporalidades Ameríndias. Estas referências nos permitem analisar as relações políticas, alianças, guerra, parentesco, saúde e infortúnios, tomando o corpo não como uma experiência infra-sociológica. O corpo, nesta etnografia, se apresenta como um microcosmo social no qual a agência do conhecimento e das práticas xamânicas são experienciadas, sendo estas referenciadas nas noções de tempo e espaço kanhgág. No conjunto destas relações, encontramos os principais mediadores entre o cosmos, humanos e não humanos caracterizados a partir das corporalidades dos pã’i (lideranças), kujá (xamãs curadores) e pëj (guardadores dos mortos). / This dissertation is the result of a three and a half year long ethnographic study about indigenous kanhgág leaders, in Rio Grande do Sul, the southernmost state of Brazil. Based on social network analysis we looked into the dyadic relations between humans and non humans and network clusters that make up the kanhgág cosmopolitics. In order to understand these relations we rely on anthropological theories consistent with studies of Amerindian corporalities. These references allow us to analyze political relations, alliances, war, kinship, health and misfortune taking the body not as an infra-sociologic experience. The body, in this ethnography, presents itself as a social microcosm where the agency of shamanic knowledge and practices are experienced, and refer to specific notions of kanhgág time and space. Among these relations, we find leading mediators, intermediaries between the cosmos, humans and non humans, embodied in the pã’i (leaders) the shamans (spiritual healers) and the pëj (dead keepers).