Regular physical activity reduces the risk of many chronic diseases. Consequently, the promotion of it and particular types (e.g. walking and cycling for travel), have become a priority for governments seeking to improve health and constrain rising demand on health services. Despite this many uncertainties persist. The aim of this thesis is to address two particular areas of uncertainty: a) the association of walking and cycling for travel with indices of health and well-being; b) and the extent to which increases in physical activity will reduce need for health and social care. The first part of my thesis consists of three studies that describe the health benefits associated with walking and cycling to work among working age adults. The first is a longitudinal study of the associations between maintenance of active commuting with sickness absence and well-being using the Commuting and Health in Cambridge dataset. The second, using the same dataset, describes the longitudinal associations between maintenance of active commuting and self-reported body mass index. Building on this, the third study using a large cohort study (the Fenland Study) with detailed characterisation of diet and physical activity (including objective measurement) describes the baseline associations between active commuting and objective measures of adiposity. The second part of my thesis describes the development of a combined microsimulation multi-state life table model that is used to characterise the effects of a population ‘shift’ in physical activity on the burden of six major diseases at the population-level. Specifically, it seeks to better describe the effect of increases in physical activity on healthcare need considering not just the effect of physical activity on disease incidence but also the effect on healthcare need arising from consequent survival to an older age (at which disease incidence is higher), and contrasts this with a method that does not make allowance for increased survival. The findings of this thesis provide evidence of the importance of walking or cycling to work in maintaining or improving the health and well-being of working age adults. It suggests that increases in physical activity, even after allowance for increased survival, are likely to reduce need for healthcare, although the reductions in need are less than might be assumed when allowance is not made for increased survival. Taken together this work provides a stronger empirical basis to inform public health practice. A stronger ‘health case’ for active travel can be made. The benefits of which should be communicated to individuals choosing how to travel as well as policy makers and others who can influence the determinants of active travel. It also provides a more realistic and nuanced understanding of how increases in physical activity may affect future healthcare need.

While recent publications indicate that employees in human service professions have higher risk of sickness absence and mental ill-health, little is known about the association with other health outcomes and possible mechanisms behind the differential risk. This study investigates differences in burnout, self-rated health and sickness absence between those in human service professions and other professions and examines whether differences in psychosocial and organizational work environment can explain possible variations. Data were derived from the Swedish Longitudinal Occupational Survey of Health (SLOSH), an approximately representative sample of the Swedish working population (n=4486). Results from binary logistic regressions suggested that those in human service professions had higher odds of burnout and sickness absence those in other professions. Differences in burnout were explained by background variables while differences in sickness absence were explained by psychosocial and organizational work factors. Employees in human service professions had lower odds of suboptimal self-rated health than others in the fully adjusted model. Women were at higher risk of burnout, sickness absence, and all adverse psychosocial and organizational work environment factors except social support. Future studies should investigate the most crucial psychosocial and organizational work factors in human service professions with the objective to improve employee health.

The overall aim of this thesis was to gain new knowledge of factors and interventions that improve work ability and return to work (RTW) among women on long-term sick leave from human service organizations (HSOs). The specific aims of the studies were: to evaluate the associations between the self-rated Work Ability Index (WAI) and Work Ability Score (WAS), and the relationship with prospective sick leave, symptoms, and health (Paper I); to investigate whether intervention with myofeedback training or intensive muscular strength training could decrease pain and increase work ability among women with neck pain (Paper II); to examine the associations between workplace rehabilitation and the combination of supportive conditions at work with work ability and RTW over time (Paper III); and to explore experiences, views, and strategies in the rehabilitation process for RTW (Paper IV). This thesis is based on a prospective cohort study (n=324) and a randomized controlled study (RCT) (n=60, participants with neck pain). Both quantitative and qualitative methods were used. The data collection consisted of questionnaires, laboratory-observed data, register-based data, and interviews. The results showed a very strong association between WAI and WAS, and results predicted future sick leave degree, health-related quality of life, vitality, neck pain, self-rated general health, self-rated mental health, behavioral stress, and current stress (Paper I). In the RCT (Paper II), individuals in the myofeedback intervention group increased their vitality and work ability over time and individuals in the intensive musculoskeletal strength training group increased their WAI, WAS, and mental health over time. WAI, WAS, and RTW increased over time among individuals provided with workplace rehabilitation and supportive conditions at work (Paper III) such as a sense of feeling welcome back at work, influence at work, possibilities for development, degree of freedom at work, meaning of work, quality of leadership, social support, sense of community, and work satisfaction. Women described (Paper IV) how they were striving to work and how they had different views, strategies, and approaches in the rehabilitation process for RTW. They expressed a desire to work, their goals for work, and their wishes for work. In the rehabilitation process for RTW they described their interaction with stakeholders as either controlling the interaction or struggling in the interaction. They described strategies to cope with RTW in terms of yo-yo (fluctuating) working: yo-yo working as a strategy or yo-yo working as a consequence. This thesis identifies factors of importance in improving work ability and RTW among women on long-term sick leave from HSOs. For women with neck pain, the intervention study showed feasibility of the intervention and demonstrated improved work ability and decreased pain (Paper II). The intensive muscular strength training program, which is easy for the individual to learn and perform at home, was associated with increased work ability. The results regarding rehabilitation highlight the importance of integrating workplace rehabilitation with supportive conditions at work to increase work ability and improve RTW (Paper III). Women expressed that they were striving to work and that they wanted to work (Paper IV). These women were “going in and out” of work participation (yo-yo working) as a way to handle the rehabilitation process. For assessing the status and progress of work ability among women on long-term sick leave, the single-question WAS may be used as a compliment to the full WAI as a simple indicator (Paper I). / <p>Akademisk avhandling som för avläggande av medicine doktorsexamen vid Sahlgrenska akademin, Göteborgs universitet, kommer att offentligen försvaras i hörsal Hamberger, Medicinaregatan 16 A, Göteborg, måndagen den 6 oktober 2014, klockan 09.00</p>

O método Laboratório de Mudança (LM) é um conjunto de instrumentos para a aprendizagem colaborativa por meio da experimentação em ambientes de trabalho a partir da necessidade de mudar uma determinada situação. Com o objetivo de elaborar um diagnóstico e implementar mudanças na organização do trabalho de uma escola pública do ensino fundamental, professores, a equipe de gestão, técnicos de segurança do trabalho do Serviço Especializado em Engenharia de Segurança e em Medicina do Trabalho (SESMT), representante do departamento de recursos humanos e pesquisadores participaram das 30 sessões realizadas na escola, no horário de trabalho, de agosto de 2015 a setembro de 2016. Também foram conduzidas entrevistas individuais e reuniões com a equipe de gestão da instituição de educação e com outros profissionais do SESMT. Durante as sessões os participantes reformularam a necessidade inicial (absenteísmo- doença) e o que predominou foi a necessidade de falar sobre os desgastes de ser professor e das dificuldades em conciliar o trabalho com a vida pessoal e em família. Algumas das causas do absenteísmo-doença de curta duração estavam relacionadas às necessidades dos indivíduos de cuidarem de sua vida pessoal e familiar, de forma planejada ou emergencial; os participantes deram exemplos de expressões do desgaste: fadiga, cansaço físico e mental, acordar com vontade de dormir, problemas na voz, falta de tempo e disposição para atividades sociais e de lazer e ausências do trabalho. O método permitiu aos integrantes do SESMT, durante as sessões, um novo conhecimento detalhado de aspectos do trabalho e da saúde dos professores. Mais próximos da realidade de trabalho nas escolas, os profissionais do SESMT experimentaram novas formas de atuação para a melhoria da organização e ambiente de trabalho e consequentemente da saúde dos professores. Apesar das diversas limitações ocorridas na implementação do método LM houve manifestações do protagonismo e do empoderamento dos professores tais como a discussão de um novo modelo de sistema da atividade bem como propostas para melhorar a relação deles com os familiares dos alunos e com a equipe de gestão da escola. É possível que o encerramento precoce da intervenção formativa esteja relacionado à saída do gestor principal da instituição e com as dificuldades da equipe de gestão da escola em assumir os riscos de um processo de mudança desta magnitude / The Change Laboratory (CL) method is a set of tools for collaborative learning through experimentation at the workplace on carrying out changes in organizational practices. This CL was conducted in a public elementary school; the teachers, the school management team, technicians of the safety and occupational health service and representatives of the human resources department participated in the 30 sessions which took place once a week from august 2015 to september 2016. Individual interviews and meetings were also conducted with the management team of the institution and with other professionals of the safety and occupational health service. The initial demand by the management team of the Educational Institution as the main concern was the sickness absence of the teachers. Throughout the school sessions, there was an adaptation of the demand and the central issue became the exhaustion of the teacher amongst other factors related to it. As examples of the exhaustion of the teachers, the researchers identified: physical and mental fatigue, \"waking up feeling tired\", voice issues, lack of time and willingness to join in in social and leisure activities, missing work. Some of the causes of short term sickness absence were related to the needs to take care of the personal and family life of the teachers. The method allowed the of the safety service technicians, during the sessions, a new detailed knowledge of aspects of the teacherss work and health aspects. Closer to the reality of working in schools, SESMT professionals experimented new ways of working to improve the organization and workplace and consequently the teacherss health. In spite of the several limitations that occurred in the implementation of the method, Teachers co-created the common object associated with their daily activities in a comprehensive and collective way; there was manifestations of the protagonism and the empowerment of teachers such as the discussion of proposals to improve their relationship with the students\' families and with the management team from school. It is possible that the early termination of the intervention is related to the exit of the main manager of the institution and the difficulties of the school management team in assuming the risks of the change process

Absenteeism in the workplace is a longstanding challenge practised by employees for various reasons. It persists despite the numerous efforts undertaken to curb it. The City of Tshwane Metropolitan Municipality is concerned with excessive employee absenteeism. Present research evaluates the City of Tshwane’s human resources policy for managing absenteeism. Causes of absenteeism are critically examined, particular attention being paid to the different leave-types that impinge on service delivery within the City of Tshwane. Within a qualitative research framework, personal semi-structured interviews were used to gather data from staff members of the Leave Capturing Office of the City of Tshwane. The targeted office is responsible for leave management, which includes capturing, recording and encashment of leave. In addition to the questionnaire, the leave management policy as well as sick-leave statistics were brought to bear on this study of absenteeism at the City of Tshwane. Study findings highlighted factors such as job dissatisfaction, unpleasant working relations, favouritism, low wages, lack of resources, stress at the workplace alongside boredom with routine unchallenging tasks as significant causes of absenteeism. The study also found sick-leave to be the form of reported absence most misused by employees. In general, employees take two days sick leave, which is the maximum an employee can take without requiring a medical certificate. Recommendations include that management should invest in a total process that can control and mitigate absenteeism related risks that may adversely affect operations at the City of Tshwane. / Public Administration / M. Admin. (Public Administration)

O método Laboratório de Mudança (LM) é um conjunto de instrumentos para a aprendizagem colaborativa por meio da experimentação em ambientes de trabalho a partir da necessidade de mudar uma determinada situação. Com o objetivo de elaborar um diagnóstico e implementar mudanças na organização do trabalho de uma escola pública do ensino fundamental, professores, a equipe de gestão, técnicos de segurança do trabalho do Serviço Especializado em Engenharia de Segurança e em Medicina do Trabalho (SESMT), representante do departamento de recursos humanos e pesquisadores participaram das 30 sessões realizadas na escola, no horário de trabalho, de agosto de 2015 a setembro de 2016. Também foram conduzidas entrevistas individuais e reuniões com a equipe de gestão da instituição de educação e com outros profissionais do SESMT. Durante as sessões os participantes reformularam a necessidade inicial (absenteísmo- doença) e o que predominou foi a necessidade de falar sobre os desgastes de ser professor e das dificuldades em conciliar o trabalho com a vida pessoal e em família. Algumas das causas do absenteísmo-doença de curta duração estavam relacionadas às necessidades dos indivíduos de cuidarem de sua vida pessoal e familiar, de forma planejada ou emergencial; os participantes deram exemplos de expressões do desgaste: fadiga, cansaço físico e mental, acordar com vontade de dormir, problemas na voz, falta de tempo e disposição para atividades sociais e de lazer e ausências do trabalho. O método permitiu aos integrantes do SESMT, durante as sessões, um novo conhecimento detalhado de aspectos do trabalho e da saúde dos professores. Mais próximos da realidade de trabalho nas escolas, os profissionais do SESMT experimentaram novas formas de atuação para a melhoria da organização e ambiente de trabalho e consequentemente da saúde dos professores. Apesar das diversas limitações ocorridas na implementação do método LM houve manifestações do protagonismo e do empoderamento dos professores tais como a discussão de um novo modelo de sistema da atividade bem como propostas para melhorar a relação deles com os familiares dos alunos e com a equipe de gestão da escola. É possível que o encerramento precoce da intervenção formativa esteja relacionado à saída do gestor principal da instituição e com as dificuldades da equipe de gestão da escola em assumir os riscos de um processo de mudança desta magnitude / The Change Laboratory (CL) method is a set of tools for collaborative learning through experimentation at the workplace on carrying out changes in organizational practices. This CL was conducted in a public elementary school; the teachers, the school management team, technicians of the safety and occupational health service and representatives of the human resources department participated in the 30 sessions which took place once a week from august 2015 to september 2016. Individual interviews and meetings were also conducted with the management team of the institution and with other professionals of the safety and occupational health service. The initial demand by the management team of the Educational Institution as the main concern was the sickness absence of the teachers. Throughout the school sessions, there was an adaptation of the demand and the central issue became the exhaustion of the teacher amongst other factors related to it. As examples of the exhaustion of the teachers, the researchers identified: physical and mental fatigue, \"waking up feeling tired\", voice issues, lack of time and willingness to join in in social and leisure activities, missing work. Some of the causes of short term sickness absence were related to the needs to take care of the personal and family life of the teachers. The method allowed the of the safety service technicians, during the sessions, a new detailed knowledge of aspects of the teacherss work and health aspects. Closer to the reality of working in schools, SESMT professionals experimented new ways of working to improve the organization and workplace and consequently the teacherss health. In spite of the several limitations that occurred in the implementation of the method, Teachers co-created the common object associated with their daily activities in a comprehensive and collective way; there was manifestations of the protagonism and the empowerment of teachers such as the discussion of proposals to improve their relationship with the students\' families and with the management team from school. It is possible that the early termination of the intervention is related to the exit of the main manager of the institution and the difficulties of the school management team in assuming the risks of the change process

<p>This thesis consists of a summary and four papers. The first two concerns health care and sickness absence, and the last two pharmaceutical costs and prices.</p><p>Paper [I] presents an economic federation model which resembles the situation in, for example, Sweden. In the model the state governments provide health care, the fed-eral government provides a sickness benefit and both levels tax labor income. The re-sults show that the states can have either an incentive to under- or over-provide health care. The federal government can, by introducing an intergovernmental transfer, in-duce the state governments to provide the socially optimal amount of health care.</p><p>In Paper [II] the effect of aggregated public health care expenditure on absence from work due to sickness or disability was estimated. The analysis was based on data from a panel of the Swedish municipalities for the period 1993-2004. Public health care expenditure was found to have no statistically significant effect on absence and the standard errors were small enough to rule out all but a minimal effect. The result held when separate estimations were conducted for women and men, and for absence due to sickness and disability.</p><p>The purpose of Paper [III] was to study the effects of the introduction of fixed pharmaceutical budgets for two health centers in Västerbotten, Sweden. Estimation results using propensity score matching methods show that there are no systematic differences for either price or quantity per prescription between health centers using fixed and open-ended budgets. The analysis was based on individual prescription data from the two health centers and a control group both before and after the introduction of fixed budgets.</p><p>In Paper [IV] the introduction of the Swedish substitution reform in October 2002 was used as a natural experiment to examine the effects of increased consumer infor-mation on pharmaceutical prices. Using monthly data on individual pharmaceutical prices, the average reduction of prices due to the reform was estimated to four percent for both brand name and generic pharmaceuticals during the first four years after the reform. The results also show that the price adjustment was not instant.</p>

<p>Every year many individuals became sick listed, it could be for a long time, or a short time but irrespective there will be</p><p>effects on the individuals life and on the society. The aim of this study was to describe some relevant psychosocial relationships in the workplace that effect that women become sick listed. The method of the study was a literary study which was based on a number of scientific articles. The result of the study showed that many different factors effects the risk of becoming sick listed. Factors that causes sick leave where many and individual, but lack of social support, bullying, unstructured work environment and the</p><p>workplaces management, imbalance between demands and control and the women's situation were factors that had a big influence. Women had the greatest number of sick leave, and for a better answer to why it is mostly women who are sick listed more</p><p>research is needed. The answer we found was that it was not about the sex, it was more about where you work or in which profession</p><p>you are. To reduce the number of sick listed, big achievements are needed from the individual, the employer and the society. More research on how to reduce the number of people on sick leave is also needed.</p>

<p>In this study 165 Swedish parents of young children with Downs’s syndrome (DS) were investigated regarding their perception of the quality of the first information and support received after the birth of the child. The parents’ opinions were compared with clinical routines at the paediatric clinics regarding these issues. Strong clinical ambitions fell short, however, since 70 % of the parents felt insufficiently informed; 56 % felt unsupported, and the timing of the disclosure varied between 0 hour to >5 days. On the basis of a grounded theory analysis the parents’ written narratives regarding the quality of the first information and support were analysed to better understand the reasons underlying the parental dissatisfaction. Criticisms were raised by the parents concerning: the low communication skills by professionals; the lack of privacy; too much negative information; and an unmet desire to early meet other DS parents. </p><p>The implications of being DS parents regarding their daily life were examined by measuring parental health, stress, sense of coherence, employment and sick leave rates. Results were compared with those in a randomly selected group of parents of healthy age-matched children. The similarities between the DS and control parents were more pronounced than the differences regarding divorce rates, siblings in the family, time spent on child care, employment and sick leave rates, and their self-perceived health, stress, and sense of coherence. However, self-perceived health of the DS mothers was impaired and stress was increased. A small group of DS parents (5 mothers and 1 father) had an extremely high rate of sick leave and no such group was seen in the control parents. In addition, the DS mothers stayed at home because of the child’s sickness most frequently and the DS fathers stayed at home for this reason more than control mothers.</p><p>Conclusions: Existing guidelines for optimal first information and support of new parents of children with DS are not always followed in Sweden. Qualitative clinical improvements from the parents’ perspective are proposed. Most DS parents live an ordinary family life in respect to the measured parameters, but the risk for health deterioration, particularly in DS mothers, might need attention.</p>

<p>Physicians are supposed to act as sick-listing experts and they possess a role as gate-keepers to the social insurance system. Earlier studies have demonstrated variation between physicians and physician categories regarding sick-listing practice. In addition to the patient's disease and its severity, a number of other factors may be expected to influence sick-listing practice. Most earlier studies have focused on the patient's disease and his or her work place as cause for sickness absence.</p><p>The aims of this study were to analyse variation of sick-listing practice between physician categories and the influence of physician characteristics on sick-listing practice, the influence of structure, organisation and remuneration of health care on physician sick-listing practice, the influence of local structural factors in the community, and the influence of a legislative change on physician sick-listing practice.</p><p>The study was conducted as a cross-sectional epidemiological study of 57563 doctors’ certificates for sickness absence, received by 28 local social insurance offices in eight Swedish counties, during four months in 1995 and two months in 1996.</p><p>Patient age, sex, and diagnostic group, issuing physician category, presence of a hospital in the municipality, municipality population size and county were all significantly and independently correlated to number of net days of sick-listing. Physician characteristics, such as age, sex and degree of specialisation were all associated with number of net days of sick-listing. Physicians working in general practice issued significantly shorter periods of sick-listing than the other physician categories. Reimbursement of general practice and participation in financial co-operation with social insurance were significantly correlated to length of sickness episode issued by general practitioners. A legislative change performed during the study period was associated with small effects in sick-listing practice.</p><p>In conclusion, a number of factors other than disease and disease severity and other patient and physician linked factors were found to influence the variation of sick-listing practice. It appears that the closer the influencing factor was to the place were the decision was taken, i.e., the patient-physician consultation, the higher the impact on the decision appeared to be.</p>