Syftet med studien är att undersöka hur enhetschefer arbetar med sjukskrivningar på grund av arbetsrelaterad psykisk ohälsa inom offentlig äldreomsorg. Utifrån syftet har fyra frågeställningar bearbetats fram för att utveckla och öka förståelsen till studiens problemområde. Studiens metodval är kvalitativa intervjuer med en hermeneutisk ansats och tematisk analys som bearbetningsmetod. De kvalitativa intervjuerna gjordes med nio stycken enhetschefer från två olika kommuner i södra Sverige. Resultatet visade att enhetschefer har handlingsutrymme att arbeta förebyggande för att reducera sjukskrivningar och att det skiljde sig åt från hur rehabilitering hanteras. Enhetschefer inom äldreomsorgen har tydliga riktlinjer när det handlar om rehabilitering medan det förebyggande arbetet inte har det. Det finns därmed handlingsutrymme för att arbeta mer förebyggande för att reducera sjukskrivningar. Alla respondenter hade förståelse om att det förebyggande arbetet är en viktig faktor för att sjukskrivningar ska reduceras men att tid och antal medarbetare kan försvåra att det förebyggande arbetet prioriteras. Nyckelord: / The purpose of the study is to investigate how unit managers work with sick leave due to work-related mental health in public elderly care. Based on the aim, four issues have been worked out to develop and increase understanding of the study's problem area. The methodology of the study is qualitative interviews with a hermeneutic approach and thematic analysis as a method of processing. The qualitative interviews were conducted with nine unit managers from two different municipalities in southern Sweden. The results showed that unit managers have latitude to work preventively to reduce sick leave and that differs from how rehabilitation is handled. Unit managers in elderly care have clear guidelines when it comes to rehabilitation while preventive work does not have it. Therefor, unit manager have latitude for working more prevention to reduce sick leave. All respondents understood that preventive work is an important factor in reducing sick leave, but that time and number of employees can make it difficult for preventive work to be prioritized.

Submitted by Luanna Matias (lua_matias@yahoo.com.br) on 2015-03-06T17:44:14Z No. of bitstreams: 2 Dissertação - Ana Lúcia de Melo Leão - 2012.pdf: 873518 bytes, checksum: 2e0b9cdd3da6e6f1df2a3f976192afcd (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luanna Matias (lua_matias@yahoo.com.br) on 2015-03-06T18:38:18Z (GMT) No. of bitstreams: 2 Dissertação - Ana Lúcia de Melo Leão - 2012.pdf: 873518 bytes, checksum: 2e0b9cdd3da6e6f1df2a3f976192afcd (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-03-06T18:38:18Z (GMT). No. of bitstreams: 2 Dissertação - Ana Lúcia de Melo Leão - 2012.pdf: 873518 bytes, checksum: 2e0b9cdd3da6e6f1df2a3f976192afcd (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2012-02-02 / Background: Sickness absence (SA), known as work disability justified by sick leave, can be an indicator of workers health status. In municipal government, like the rest of the country, the prevalence of SA and its main causes are still poorly documented, and are restricted to the analysis of some occupational groups, especially those who engage in health care or in institutions education. Estimates of the magnitude of SA vary widely and socio-demographic aspects related to nature and working conditions are among the main factors associated with the frequency and duration. Aims: To study the prevalence and the factors related to SA workers from the public sector in the municipality of Goiânia. Methods: Cross-sectional population-based study assessing prevalence and factors associated with sick leave lasting longer than three days for the health treatment from 2005 to 2010, in civil servants. Outcomes: 40.578 sick leave were assessed among 14.484 absent workers which generated 944.722 absent days. The indicators of sickness absence in that period were: prevalence of sick leave of 39.0%, higher among education professionals (47.7%) and health (41.9%), the mean duration of SA was 40 days / year per worker away and the average duration of Licenses was 23 days per episode. Predominance of female sexual workers, aged between 41 and 50 years, married, white, with high educational background, earning up to three minimal salaries, with their own house, with from 3 to 10 years of public service, having a professional bond and basically in operational tasks registered in the Municipal Secretariat of Education and Health. The main cause of sickness was mental and behavioral disorder followed by musculoskeletal diseases. The Multivariate analysis showed an association between sickness absence and the female subjects (OR 1,54 IC95%1,41-1,68), being older (OR 1,86 IC95% 1,48-2,32), married (OR 1,51 IC95% 1,13-2,02), having elementary school degree (OR 12,35 IC95% 10,39-14,69), income of up to three minimal salaries (OR 1,37 IC95% 1,21-1,55), having more working experience concerning the time(OR 3,39 IC95% 2,50-4,59), being professional in the health and educational area (OR 2,96 IC95% 2,60-3,38 and OR 2,90 IC95% 2,51- 3,36), as well as being part of the staff in the Municipal Secretariat of Education and Health (OR 1,69 IC95% 1,30-2,21 e OR 1,60 IC95% 1,23-2,09 ). Conclusions: The indicators of SA express the magnitude of this phenomenon in public service and can assist in the planning of health worker prioritizing the most vulnerable occupational groups whose socio-demographic characteristics and work organization influence on absenteeism due to illness. / Introdução: O absenteísmo-doença (AD), entendido como ausência ao trabalho por motivo de doença, é um importante indicador das condições de saúde dos trabalhadores. Na administração pública municipal, a exemplo do restante do país, a prevalência de AD e as suas principais causas ainda estão insuficientemente documentadas, e restringem-se a analise de alguns grupos ocupacionais, sobretudo daqueles que desenvolvem atividades nos serviços de saúde ou em instituições de ensino. Estimativas da magnitude do AD variam amplamente e características sóciodemográficas, aspectos ligados à natureza e às condições de trabalho situam-se entre os principais fatores associados à sua frequência e duração. Objetivos: Estudar a prevalência e os fatores associados ao absenteísmo-doença entre os servidores públicos estatutários do Município de Goiânia. Métodos: Estudo populacional de corte transversal, com análise de todas as licenças para tratamento de saúde (LTS), com duração superiores a três dias, cerificadas pela junta médica municipal no período janeiro de 2005 a dezembro de 2010. Resultados: Foram analisadas 40.578 LTS concedidas a 14.484 servidores que geraram 944.722 dias de ausências. Os indicadores de AD demonstraram uma prevalência média anual de 23,0% de servidores ausentes em decorrência de problemas de saúde; prevalência de licenças de 39,0%, sendo maior entre os profissionais de educação (47,7%) e saúde (41,9%); a duração média do AD foi de 40 dias/ano por servidor licenciado e a duração média das Licenças foi de 23 dias por episódio. Considerando os episódios de LTS houve Predomínio dos seguintes grupos: mulheres, faixa etária entre 41 a 50 anos, casados, brancos, com ensino superior, renda de até três salários mínimos, com até 10 anos de serviço público, lotados nas secretarias de educação e de saúde. A análise de regressão de Poisson demonstrou, no período, tendência de estabilidade dos indicadores entre as mulheres, e de aumento da prevalência de licenças entre os homens. A principal causa de AD foi por transtornos mentais e comportamentais seguidas pelas doenças do sistema osteomuscular e Lesões/causas externas. A análise Multivariada demonstrou associação estatisticamente significativa entre os afastamentos e ser do sexo feminino (OR 1,54 IC95%1,41-1,68), ter mais que 60 anos (OR 1,86 IC95% 1,48-2,32), ser casado (OR 1,51 IC95% 1,13-2,02), possuir até o ensino fundamental (OR 12,35 IC95% 10,39- 14,69), receber de até três salários mínimos (OR 1,37 IC95% 1,21-1,55), ter maior tempo de serviço (OR 3,39 IC95% 2,50-4,59), ser profissional de saúde e educação (OR 2,96 IC95% 2,60-3,38 e OR 2,90 IC95% 2,51-3,36 respectivamente), bem como estar lotado nas Secretarias Municipais de Saúde e Educação (OR 1,69 IC95% 1,30- 2,21 e OR 1,60 IC95% 1,23-2,09 respectivamente). Conclusões: Os indicadores de AD expressam a magnitude desse fenômeno no serviço público e podem auxiliar no planejamento das ações de saúde do trabalhador priorizando os grupos ocupacionais mais vulneráveis, cujas características sócio-demográficas e de organização do trabalho influenciaram nos afastamentos por motivos de doença.

Abstract The potential health effects of employee control over working times are poorly known in the field of work stress research. In this study, worktime control was hypothesized to buffer against stress by promoting successful combination of a full-time job with non-work demands and by enabling the work to be done at times of optimal resources. The participants were from the 10-Town Study, an ongoing longitudinal cohort study exploring employee health in ten Finnish towns. The survey responses on worktime control and health (baseline survey in 1997: n = 6442, 67%; follow-up survey in 2000–01: n = 32299, 67%) were linked to registered sickness absences from the employers' records. Employee worktime control covered the perceived possibilities to influence the starting and ending times of a workday, the breaks, handling private matters during the workday, the scheduling of shifts, vacations and days off, and the taking of unpaid leaves, each of which was rated on a 1–5 scale. In the follow-up survey, influence on the length of the workday was also assessed. After a factor analysis, the subdimensions of control over daily working hours and control over days off were focused. It turned out that low worktime control predicted poor subjective health, psychological distress, and medically certified sickness absences for women. For men, low worktime control was not associated with subjective health, but predicted medically certified sickness absences for those with dependent children or employed in manual occupations. With respect to work stress, the men and women suffering from job strain or effort-reward imbalance had less medically certified sickness absences if they at least had control over their working times. The men and women with long domestic and total working hours and long commuting hours gained most from high worktime control in that their medically certified sickness absences were reduced. Vulnerability to long domestic and total working hours in terms of such absences was seen among both men and women, but there were few men working long domestic hours. Long paid working hours as such were not associated with sickness absences. In sum, high worktime control appeared to buffer against health problems and to promote a successful integration of domestic responsibilities with a full-time job. The findings expand the focus of work stress research and emphasize the importance of taking conditions at home into account when analysing employee health. / Tiivistelmä Työaikojen hallinnan merkitys terveydelle tunnetaan työstressitutkimuksen alalla huonosti. Tässä väitöskirjatyössä oletettiin, että työaikojen hallinta voisi vähentää stressiä ja edistää terveyttä helpottamalla kokopäivätyön ja kotona tehtävän työn yhteensovittamista sekä mahdollistamalla työn tekemisen parhaiden voimavarojen vallitessa. Tutkimus toteutui osana Työterveyslaitoksen Kunta10 -tutkimusta, joka seuraa kymmenen suomalaisen kaupungin henkilöstön työolojen ja terveyden kehittymistä. Koettua työaikojen hallintaa ja terveyttä koskevat kyselyvastaukset (alkukysely v. 1997: n = 6442, 67 %; seurantakysely vv. 2000–01: n = 32299, 67 %) linkitettiin palkanmaksurekistereistä saatuihin sairauspoissaolotietoihin. Työaikojen hallinnan mittari sisälsi alkukyselyssä 5-luokkaisella asteikolla vastaajien kokemat vaikutusmahdollisuudet työpäivän alkamis- ja päättymisajankohtiin, taukoihin, yksityisasioiden hoitamiseen työpäivän kuluessa, työvuoroihin, lomien ja vapaapäivien ajankohtiin sekä palkattomien vapaiden pitämiseen. Seurantakyselyssä kartoitettiin myös vaikutusmahdollisuudet työpäivän pituuteen. Summamuuttujan faktorianalyysin jälkeen arvioitiin erikseen päivittäisten työaikojen hallintaa sekä loma-aikojen hallintaa. Tuloksissa huono työaikojen hallinta ennusti naisilla huonoksi koettua terveyttä, psyykkistä rasittuneisuutta sekä lääkärintodistusta vaativia yli kolmen päivän mittaisia sairauspoissaoloja. Miehillä huono työaikojen hallinta ei vaikuttanut itsearvioituun terveyteen, mutta ennusti lääkärintodistusta vaativia sairauspoissaoloja, jos heillä oli lapsia kotona tai jos he tekivät ruumiillista työtä. Hyvä työaikojen hallinta vähensi työstressiin liittyviä sairauspoissaoloja. Stressiä kuvattiin työn kovien vaatimusten ja huonon hallinnan yhdistelmällä sekä koettujen ponnistelujen ja palkkioiden epäsuhdalla. Eri elämänalueilla tehtyihin työtunteihin suhteutettuna hyvä työaikojen hallinta vähensi sairauspoissaoloja erityisesti niillä naisilla ja miehillä, joilla oli paljon kotityötunteja, työmatkatunteja tai totaalityötunteja. Sairauspoissaoloilla mitattuna naiset ja miehet olivat yhtä haavoittuvia pitkille kotityö- työmatka- ja totaalityötunneille, mutta miehillä pitkät kotityötunnit olivat harvinaisia. Pitkät palkkatyötunnit sinänsä eivät lisänneet sairauslomia. Tutkimus tuo työstressikirjallisuuteen vallitsevia malleja täydentävää tietoa työn ulkopuolisten tekijöiden merkityksestä työntekijöiden terveydelle. Tulokset kannustavat edistämään työntekijöiden mahdollisuuksia työaikojensa hallintaan sekä terveyden edistämisen että kokopäivätyön ja muun elämän menestyksellisen yhdistämisen näkökulmista.

Syftet med denna studie var att förstå hur arbetstagare upplever sin återgång i arbete efter en utmattningsdiagnos och hur upplevelser, erfarenheter, tankar och känslor upplevs främja återgång i arbete. Studien var kvalitativ och datainsamlingen bestod av fenomenologiska intervjuer med en person i taget med totalt åtta deltagare. I studien konstaterades huvudsakligen en kongruens mellan det som tidigare forskning visat och det som framkommit i införskaffad empiri. En del upplevelser som visat sig vara effektiva för återgång i arbete i tidigare forskning har också av deltagarna i denna studie visat sig upplevas som särskilt effektiva och värdefulla. De interna resurserna i form av bekräftelse, insikt och coping var av stor betydelse för tillfrisknande och återgång i arbete i kombination med ett upplevt praktiskt och emotionellt stöd av framförallt vården, chef och familj. En skillnad från tidigare studier var att det upplevda stödet från familjen uttrycktes och påtalades i högre utsträckning i denna studie än i tidigare studier. Den viktigaste slutsatsen som kan dras av studien är att ett upplevt praktiskt som emotionellt stöd, såväl under sjukskrivning som vid återgången i arbete är av oerhörd vikt för både tillfrisknande och återgång i arbete. / The purpose of this study was to understand how workers experience their return to work after a job burn out and how experiences, thoughts and feelings are perceived to promote return to work. The study was qualitative and the data collection consisted of phenomenological interviews with one person at a time with a total of eight participants. The study found mainly a congruence between what has been shown in previous research and what emerged from acquired empirical evidence. Some experiences that have proven to be effective for returning to work in previous research have also been shown by participants in this study to be particularly effective and valuable. The internal resources in terms of confirmation, insight and coping were of great importance for recovery and return in work combined with experienced practical and emotional support, especially by the care, manager and family. A difference from previous studies was that the perceived support from the family was expressed and addressed to a greater extent in this study than in previous studies. The main conclusion that can be drawn from the study is that experienced support, both practical and emotional, both during sick leave and at return to work, is of crucial importance both for recovery and return to work.

Syftet med studien var att undersöka hur föräldrarollen och familjesituationen påverkades av utmattningssyndrom. Studien har en kvalitativ ansats med en induktiv inriktning och datainsamlingen har bestått av åtta semistrukturerade intervjuer. Studiens empiri har analyserats med hjälp av rollteorin och valda analytiska begrepp samt med stöd av modeller och tidigare forskning. Studiens resultat visar att föräldrarnas utmattningssyndrom påverkar föräldrarollen och familjesituationen på olika sätt. De fick svårt att leva upp till förväntningar och grundläggande uppgifter inom föräldrarollen, såsom att organisera vardagslivet och att orka finnas där för barnen. Den dysfunktion som de upplevde i sin föräldraroll ledde till att de kände otillräcklighet vilket gav upphov till skuld- och skamkänslor. Empirin visar att rollerna i familjen ofta kastas om och att föräldrarna upplever någon form av rollförlust. För de som var ensamstående var det särskilt svårt då de både hade familjeansvar och var ekonomiskt begränsade på grund av sjukskrivningen. Föräldrarnas försämrade förmågor gjorde att barnen fick ta mer ansvar, vilket inte bara var negativt utan också positivt eftersom de lärde sig att ta ansvar och i större utsträckning förlita sig på hjälp från den andra föräldern. De omständigheter som bidrog till föräldrarnas utmattningssyndrom var flerdimensionella och det var svårt att skilja den ena från den andra, att det är flera olika källor till stress som orsakar utmattning. Men resultatet visar att omständigheter såsom särskilda påfrestningar, dubbla lojaliteter och höga prestationskrav i kombination med en dålig självkänsla ökade sårbarheten för att drabbas. Studiens resultat pekar även på att det görs en distinktion mellan familj och arbete trots att forskning visar att en sjukskrivning orsakad av stress rymmer många olika dimensioner. / The purpose of the study was to investigate how parenting and family situations were affected by fatigue syndrome. The study has a qualitative approach with an inductive orientation. The data collection contained eight semi-structured interviews. The empirical data has been analysed with the role theory, analytical concepts, models and with previous science. The results of the study showed that the parents' fatigue syndrome influenced the parenting and family situation in different ways. They were struggling to perform basic duties in the parenting role, such as organizing everyday life and having the energy to be with the children. The result shows that the roles in the family often reversed and the parents experienced some form of role loss. For those who were single, it was particularly difficult when they both had family responsibilities and were financially limited due the sick leave. Parents' impaired abilities made the children take more responsibility, which was not only negative but also positive because they learned to take responsibility and to rely more on the help of the other parent. The circumstances that contributed to the fatigue syndrome of the parents were multi- dimensional and it was difficult to distinguish one from the other, there are several different sources of stress. But the results show that special circumstances like specific stresses, double loyalty and high performance requirements combined with poor self-esteem, increased vulnerability to suffering. The results of the study also indicate that a distinction is made between family and work, although research shows that sick leave due to stress can accommodate many different dimensions.

One out of several distinguishing features of multiple sclerosis (MS) is the epidemiological variation of geographic distribution. Population-based studies on the prevalence and incidence of MS in Sweden have previously been performed only in Göteborg. Another feature of MS is the clinical variation between individuals. To a large extent data on the clinical characteristics of MS come from studies on cases frequenting MS clinics and therefore, may be biased. Also rare are population-based studies of the consequences of MS-related incapacity on socio­economic factors. As for MS aetiology, both environment and genes are involved. Human herpesviruses are often the main suspected environmental aetiological agents. Our aim was to estimate the prevalence of MS in Västerbotten County for 1 January 1990, the incidence during a 10-year period 1988-97, and the prevalence 31 December 1997; and also to present detailed clinical data including onset symptoms and the disability distribution for the latter two MS populations. Furthermore, we wanted to estimate the prevalence of sick leave, professional assistance, and housing; and also, to study the risk factors for sick leave. In order to investigate the association between MS and human herpesviruses, samples were identified in two regional population-based serumbank registers. This linkage identified samples collected from before MS-onset in 73 MS cases and after MS onset in 161 cases The prevalence and incidence populations were identified through multiple sources. Diagnostic ascertainment, the reliability of clinical data, and additional information were assured from a questionnaire with follow-up interview and neurological examination. The onset adjusted crude prevalence of MS was 125/100,000 (95% CI: 112-140) in January 1990, and 154/100,000 (95% Cl: 139-170) in December 1997. The increase was mainly attributable to a higher incidence than mortality. The crude incidence rate 1988-97 was 5.2/100,000 (95% CI: 4.4-6.2). The disability distribution in the 1997 prevalence population in Västerbotten was compared to the disability distribution in a Canadian MS population, which has been used for publications on the natural history of MS. One difference from the Canadian studies appears to be the better recognition of cases with more benign disease. Nevertheless almost half of prevalent MS cases aged 18-64 years were fully sick-listed, and one-fourth of all prevalent cases received professional assistance. High disability level was the strongest predictor for sick leave. All MS cases showed signs of past Epstein-Barr virus (EBV) infection. High activity to EBV (EBNA-1 but not VCA) and human herpesvirus 6 (HHV-6) significantly (borderline significance for HHV-6) increased the risk to develop MS. These estimates show that Västerbotten County is a high risk area for MS. Both incidence and prevalence were significantly higher when compared to estimates from Göteborg. The comparison with the Canadian MS population shows that MS might be a slightly more benign disease than previously recognized. Still, the consequences of MS regarding socio-economic aspects are considerable. We suggest that EBV is a prerequisite for the development of MS. Individuals that will develop MS exhibit an altered immune response against the EBV virus characterised by high activities to EBNA-1 in the absence of high VCA activities, this being most pronounced in the five-year period preceding MS onset. A pathogenetic role is suggested for EBV and remains possible also for HHV-6. / digitalisering@umu

The overall aim of this thesis was to examine the relationship between self-efficacy, individually tailored vocational rehabilitation and transition to work or studies. Study I was a cross-sectional study based on questionnaire- and registry data, investigating whether factors related to sick leave predict self-efficacy in women on long-term sick leave (n= 337) due to pain and/or mental illness. General self-efficacy was low. Anxiety and depression were the strongest predictors for low self-efficacy. Study II used longitudinal data from a randomised controlled trial, comprising partly the same women (n=401) as in Study I. Participants were allocated to either 1) assessment of multidisciplinary team and multimodal intervention (TEAM), 2) acceptance and commitment therapy (ACT), or 3) control group. Self-efficacy increased in the TEAM group in comparison with the control group. Study III had a descriptive qualitative design with individual interviews, studying participants’ (n=14) experiences with an individually tailored vocational rehabilitation project, and encounters with professionals working in it. The participants, who were on long-term sick leave due to mental illness or pain reported overall positive experiences with the project. The project was based on collaboration between authorities and motivational interviewing. The positive experiences were based on four categories: Opportunities for receiving various dimensions of support, Good overall treatment by the professionals, Satisfaction with the working methods of the project, and Opportunities for personal development. Study IV was a prospective cohort study investigating perceived self-efficacy in unemployed young adults (n= 249) aged 19-29 year with disabilities, and the association between self-efficacy and transition to work or studies. The study used questionnaire- and registry data from a vocational rehabilitation project. Higher levels of self-efficacy were associated with increased odds for ‘transition to work’. General self-efficacy was low, and young adults with lower self-efficacy reported worse self-rated health compared with those with higher self-efficacy. This thesis showed that multidisciplinary assessment with a multimodal intervention had positive effects on self-efficacy. Individually tailored vocational rehabilitation, based on cooperation and motivational interviewing, may be beneficial for individuals on long-term sick leave and the interactions between participants and the professionals may affect participants’ self-efficacy positively. Mental health needs to be considered when targeting self-efficacy in vocational rehabilitation. Furthermore, research is needed to a) clarify which components in the multidisciplinary team intervention can increase self-efficacy, b) study the effects of vocational rehabilitation based on an individual design, cooperation and motivational interviewing on self-efficacy, health and transition to work, and c) develop interventions that can increase self-efficacy and support transition to work/ studies in young adults with disabilities.

The thesis focuses on the Risk Life Insurance of the Czech insurance market offering coverage just for serious health risks without any investment or savings component. Assessment of the Risk Life Insurance offer is based on the findings of the general and special insurance conditions as well as on the gained draft insurance contracts worked on the model setting. The aim of the thesis is the analysis of the main coverage which is in all cases the life insurance along with the offer of the complementary insurance for case of death, disability, cancer or severe diseases. The emphasis is on the scope of risks coverage and the insurance conditions which are considered to be an insurance event.

Les chocs de santé ont des conséquences contrastées sur les trajectoires d’emploi, dépendant aussi bien de facteurs tenant à l’épidémiologie des maladies qu’à des facteurs d’organisation du marché du travail. Le cancer a ainsi des effets à la fois transitoires et durables sur la situation d’activité et d’emploi des personnes qui y survivent. Notre étude approfondie du cas des travailleurs indépendants montre qu’ils sont caractérisés par des réponses à la maladie les différentiant des travailleurs salariés dans la fréquence et la durée des arrêts-maladie mais également dans le processus de maintien à l’emploi. Certains de ces résultats sont réductibles à des traits de caractère des indépendants, comme leur attitude à l’encontre des risques. Ces résultats tiennent aussi aux modalités de la participation au marché du travail des indépendants et de leurs conditions d’exercice, le plus souvent moins protégées par les dispositifs d’assurance sociale que les travailleurs salariés, car laissés à leur discrétion. Les études utilisées sont l’enquête française sur le cancer « VICAN 2 » financée par l’INCa, l’enquête emploi, et l’enquête américaine « HRS». Tout d’abord, cette thèse souligne la nécessité de faire des études qualitatives et quantitatives seulement sur les indépendants, qui différent substantiellement des travailleurs salariés. Les résultats soulignent aussi que l’aversion au risque n’est pas une caractéristique innée et stable. Les travaux empiriques, étayés par une modélisation théorique, montrent que les chocs de santé peuvent amener les individus à reconsidérer leur goût du risque, à la baisse (maladies chroniques stables) ou à la hausse (survie au cancer). / Consequences of health shocks on professional trajectories are contrasted, depending on epidemiological factors and on the organization of the labor market. In particular, cancer has both transitory and permanent effects on the activity and on the employment status of survivors. Self-employed workers are characterized by responses to the disease that differentiate them from salaried staff, with regards to the frequency and the duration of sick leave and also with regards to their employment status. These results are linked in part to the character traits of self-employed workers, such as their attitudes toward risks. They are also due to the different modalities of their participation to labor force and their unique working conditions, as they are generally less protected by social insurance than salaried employees. The surveys used by this study are two French surveys: « VICAN 2 » survey on cancer funded by INCa, and the labor force survey carried out by INSEE, and the American Health and Retirement Survey (HRS) from the University of Michigan.This thesis underlines the importance of conducting qualitative and quantitative surveys specifically on self-employed workers to evidence their unique difficulties. Results also underline that risk aversion is not an innate and immutable characteristic. Empirical studies and theoretical model developed in this thesis demonstrate that diseases can lead people to reconsider their appetite for risk, often in a downward trend (chronic diseases) and sometimes in an upward trend (survival to cancer).

This thesis examines the reforms of Sickness Insurance that have been realized in chosen countries of European Union. I've focused myself on Belgium, Netherlands, United Kingdom and Finland and every single reform step that have been taken in between 2003 -- 2005 in these countries. I've investigated how the situation in each country was before the reform came true and explored the main reasons that I believe have led to these reforms. I've also stated which impacts these reforms were supposed to have and after that I've studied the real impacts and consequences that were brought by this change in each country. You can see these in multiple graphs followed by my explanation whether and why I think the reform step was succesful. Judging by the succes that was noted in examinated countries I've decided which path is best to follow as far as the reform in Sickness Insurance is concerned. Thanks to previous examination of reforms that differs from each another I was at the end able to recommned which steps should be taken in Czech Republic since some kind of Sickness Insurance reform is needed as well. I believe comparing foreign Sickness Insurance reforms and my suggestions can help to improve Sickness Insurance system in CR and lead to the solution of various problems Czech Republic hasn't coped with yet.