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. 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. 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.

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. 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. 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. 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. 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.

Every year many individuals became sick listed, it could be for a long time, or a short time but irrespective there will be 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 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 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 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.

This study analyses five different picture books from the last few decades. The aim of the analysis was to investigate how relations between children and adults are presented in the picture books. One way to achieve this has been to focus on the adults’ presence or absence in the narrative, and also what kind of authority the adult(s) can have in the action and how it can affect relations between children and adults. The idea is that this degree project can be adapted for practical use in school. It is hoped that teachers will receive inspiration for how they can work on the topic of relations between children and adults with the aid of picture books.A literary analysis which embraces the interplay between text and image, and with a focus on the different characters, has been used to analyse the picture books. The analysis shows that the absence and presence of the adults is depicted in different ways and can be divided into different groups: always absent, partly absent, physically present but absent in mind, and present. Another finding is that, in three of the five books, some adult character is portrayed as an authority, and this too affects how relations between the children and the adults are depicted.

Foundational to almost any Hitchcock film is the idea of the voyeur: the (un)natural inclination to want to look upon the private, obscene, and potentially grizzly instances in other peoples’ lives. Such inclinations are typically satiated in secret and subsequently denied as something we desire. The voyeuristic act may be connected to narcissism in that we are seduced by our own fears and inner hells projected onto the watched ‘other.’ This kind of projection not only perpetuates our sense of denial of what are our own inclinations, but it also precipitates the potential for de-humanization and feelings of emptiness in that we detach from ourselves. The phenomenological paradox to such detachment is that the more we insist we are safe and self-enclosed here while the ‘other’ remains at bay there, the more we are convinced that we know ourselves and are connected to ourselves, when arguably, we couldn’t be more detached from ourselves and our humanity. And by not really knowing ourselves as well as we thought – as we might infer from a kind of ‘doppelganger’ or ‘doubles’ reading of Strangers on a Train, for example – is how fear is born, both in a Hitchcock film and in life generally. How then, might we come to truly know or face our fear if estrangement would seem an inherent quality to our very experience of it?

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>

Foundational to almost any Hitchcock film is the idea of the voyeur: the (un)natural inclination to want to look upon the private, obscene, and potentially grizzly instances in other peoples’ lives. Such inclinations are typically satiated in secret and subsequently denied as something we desire. The voyeuristic act may be connected to narcissism in that we are seduced by our own fears and inner hells projected onto the watched ‘other.’ This kind of projection not only perpetuates our sense of denial of what are our own inclinations, but it also precipitates the potential for de-humanization and feelings of emptiness in that we detach from ourselves. The phenomenological paradox to such detachment is that the more we insist we are safe and self-enclosed here while the ‘other’ remains at bay there, the more we are convinced that we know ourselves and are connected to ourselves, when arguably, we couldn’t be more detached from ourselves and our humanity. And by not really knowing ourselves as well as we thought – as we might infer from a kind of ‘doppelganger’ or ‘doubles’ reading of Strangers on a Train, for example – is how fear is born, both in a Hitchcock film and in life generally. How then, might we come to truly know or face our fear if estrangement would seem an inherent quality to our very experience of it?

Istanbul est pour Pamuk ce que Paris est pour Baudelaire : une source inépuisable d’inspiration et de spleen. Or, si le poète est davantage conscient de ses états d’âme, le romancier turc le plus lu des deux côtés du Bosphore ne sait pas toujours que tout discours sur le monde extérieur est un discours sur lui-même. Dans un premier temps, il se complait dans l’hüzün, ce sentiment collectif et généralisé de mélancolie, apparemment intrinsèque à la ville et ses ruines, traces tangibles de la décadence d’un grand empire dont les héritiers peinent à se relever. Il n’en est pourtant rien, car, au fur à mesure que Pamuk suit les traces des écrivains et artistes étrangers de passage à Istanbul, il s’aperçoit que l’apparente mélancolie des ruines n’est qu’une strate parmi d’autres, c’est-à-dire glissante, malléable et fluide, tout dépend de l’emplacement et du point de vue de l’observateur, dans une ville palimpseste qui cache dans ses entrailles toutes les altérités. En suivant les traces de l’altérité, Pamuk découvre la nature hétérogène de sa ville et de lui-même et s’aperçoit que la mélancolie collective est fabriquée de toutes pièces par un certain récit socio-politique et une certaine classe sociale. En effet, c’est en traquant les reflets de son double que le romancier prend soudainement conscience du caractère fuyant de sa propre subjectivité, mais aussi de celui du monde et des autres. Si tel est le cas, l’espace urbain qui préoccupe et obsède Pamuk n’est qu’un reflet de son esprit et l’accès à la présence pleine s’avère une illusion. Comme si, l’inquiétante étrangeté de son inconscient, en lui dévoilant le côté insaisissable du monde et du soi, l’encourageait à remettre en cause un certain nombre d’opinions acquises, non seulement à l’intérieur de sa propre culture, mais aussi dans la culture de son double européen. Car si tout est fluide et malléable, il n’y a pas raison de ne pas tout questionner, incluant la tradition et la politique, cette dernière faisant de lui, « une personne bien plus politique, sérieuse et responsable que je ne le suis et ne souhaitais l’être ». Ainsi, Istanbul, souvenir d’une ville questionne le rapport entre la subjectivité et les strates hétérogènes d’Istanbul, pour aboutir à un constat déconstructiviste : tout n’est que bricolage et substitut du sens là où il brille par son absence. S’il brille par son absence, il en est de même loin d’Istanbul, dans une maison périphérique appelée La Maison du Silence à l’intérieur de laquelle les personnages soliloques et par moments muets, se questionnent sur le rapport entre la tradition et la modernité, le centre et la périphérie, l’Occident et l’Orient, sans oublier le caractère destructeur et éphémère du temps, mais aussi de l’espace. Et enfin, Le Musée de l’Innoncence, cette oeuvre magistrale où l’amour joue (en apparence seulement) le rôle principal, n’est en fait que l’étrange aboutissement de la quête obsessessive et narcissique du personnage principal vers un autre espace-temps, quelque part entre la réalité et la fiction, entre l’Est et l’Ouest, entre la tradition et la modernité, cet entre-deux qui campe indéniablement Pamuk parmi les meilleurs romanciers postmodernes de notre époque. Or, pour y parvenir, il faut au préalable un bouc-émissaire qui, dans le cas de Pamuk, représente presque toujours la figure du féminin. / Istanbul is for Pamuk what Paris is for Baudelaire: an inexhaustible source of inspiration and spleen. But, if the French poet is more conscious of his states of mind, the most widely read contemporary Turkish novelist seems at first to deliberately disregard the fact that any discourse on the external world is also a discourse about himself. At first, in emulation of other Turkish novelists, Pamuk seems to thoroughly enjoy mapping the hüzün, the much talked about collective feeling of melancholy, reputed to be intrinsic to the city and its ruins. Nevertheless, as soon as Pamuk starts to follow in the footsteps of foreign writers and artists who have visited Istanbul, he notices that the apparent melancholy of the ruins is only one layer among many fluid layers. While following the tracks of the otherness, Pamuk discovers the heterogeneous character of his city but also of himself and notices that the collective melancholy widely accepted by most his compatriots is fabricated by a certain socio-political narrative, within a specific social class. Indeed, by tracking the reflections of his own imaginative twin, the novelist is suddenly aware of the elusiveness of his own subjectivity but also of the world and the others. If such is the case, the urban space that preoccupies and obsesses Pamuk is only a reflection of his mind and the will to fully access to the presence, is nothing but an illusion. As if the disturbing uncanny of his unconscious, by revealing the elusive side of the world and the self, encourages Pamuk to challenge a number of views and opinions taken for granted, inside his own culture but also inside the culture of the other, his European twin. For, if everything is fluid and malleable, there is no reason not to question everything, including tradition and state politics, the latter making him, "a person well more political, serious and responsible that I am and ever whished to be". Thus, Istanbul: memoires and the city questions the relationship between the subjectivity and the heterogeneous layers of Istanbul in order to come to a deconstructionist conclusion: everything is a substitute; there is a general absence of sense. If the city lacks a tangible raison d’être or sense in its history and topography, then it must be the same in places that are far from Istanbul. Thus central characters in The House of the Silence question not only the very foundation of their identity and subjectivity, but also the relationship between tradition and modernity, center and periphery, East and West, not to mention the destructive and ephemeral nature of time and space. In Pamuk’s most recent novel, The Museum of Innocence, the protagonist engages in an even more obsessive and destructive quest for another kind of space and time — an imaginary in-between space allowing for a seamless traffic between reality and fiction, East and West, and tradition and modernity. This in-between space or identity clearly anchors Pamuk among the most interesting postmodern novelists of our time. But, this in-between positionality, however, can only be attained at a price: Pamuk’s work, illuminating insight or a precarious balance is more often than not achieved through the sacrifice of the female figure.