Background: Vietnam suffers consequences of global warming. There is limited data of the relationship between weather, extreme heat and potential mental health problems. It is therefore crucial to study heat-related mental illnesses and to establish good solutions with relevant adaptations to global warming. The adaptation measures should give attention to people that live in areas facing annual extreme weather, and protecting health in general and more specifically mental health of citizens. The study aimed to examine relationships between weather patterns, extreme heat or heatwaves, and mental disorders, and to investigate factors contributing to increased vulnerability and susceptibility. Methods: The thesis includes a systematic review and a hospital-based study using data from the Hanoi Mental Hospital for five years (2008 – 2012), with mental disorders diagnosed by ICD10 (F00-99) to estimate the effects of weather variation, seasonality, increased temperatures, and heatwaves on hospital admissions for depression and other mental disorders. A negative binomial regression model accounting for yearly study period, time trends, and day of the week was used to analyze the relationship between seasonality, heatwaves, and monthly and daily mental disorder hospitalizations. Results: Our findings showed (i) a general tendency for more admissions between May and December, with a seasonal bi-annual high between May-June and November-December, and elevated ambient temperature was significantly related to increasing admissions for depressive disorders; (ii) the number of hospital cases for mental disorders increased in the summer seasone specially in June, and two percent of cases emerged during elevated temperature of one degree Celsius; and (iii) when compared with non-heatwave periods, heatwaves amounted to increasing risks for admission for the whole group of mental disorders (F00-79), and admissions for mental disorders among residents in rural communities and in the elderly population increased significantly during heatwaves. Conclusion: There were associations between hospital admissions for depression and other mental disorders and seasonality, weather patterns, elevated temperatures, and heatwaves. The associations grew stronger with the length of the heatwaves and particularly the elderly appeared more sensitive to seasonality, hot weather and heatwaves.

Background Cardiovascular diseases, including myocardial infarction and stroke, are the main reason of death in Sweden and Western Europe. High iron stores are believed to produce oxygen radicals, which is the presumed putative mechanism behind lipid peroxidation, atherosclerosis and subsequent cardiovascular disease. Iron levels are associated with the hemochromatosis associated HFE single nucleotide polymorphisms C282Y and H63D. Bilirubin is an antioxidant present in relatively high levels in the human body. Several previous studies have found an association between high bilirubin levels and a lower risk for cardiovascular disease. Bilirubin levels are highly influenced by the common promoter polymorphism TA-insertion UGT1A1*28, the main reason for benign hyperbilirubinemia in Caucasians. There is a lack of prospective studies on both the association of iron and bilirubin levels, and the risk for myocardial infarction and ischemic stroke. Material and methods Iron, transferrin iron saturation, TIBC, ferritin and bilirubin were analyzed and HFE C282Y, HFE H63D and UGT1A1*28 were determined in myocardial infarction and stroke cases, and their double matched referents within the Northern Sweden Health and Disease Study Cohort. Results There were no associations between iron levels in the upper normal range and risk for myocardial infarction or stroke. No associations were seen for HFE-genotypes, except for a near fivefold increase in risk for myocardial infarction in HFE H63D homozygous women. Plasma bilirubin was lower in cases vs. referents both in the myocardial infarction and the stroke cohort. Despite a strong gene-dosage effect on bilirubin levels in both cases and referents, the UGT1A1*28 polymorphism did not influence the risk for myocardial infarction or stroke. Conclusion High iron stores are not associated with increased risk for neither myocardial infarction, nor stroke. There was no association between UGT1A1*28 and the risk for myocardial infarction or stroke. Consequently data suggests that other factors, which also may lower bilirubin, are responsible for the elevated risk observed in conjunction with lower bilirubin levels.

Background Type 2 diabetes is a common chronic disease with a two-fold increased risk for cardiovascular morbidity and mortality and has an increasing prevalence worldwide. This thesis is based on a study conducted in primary health care in Östergötland and Jönköping, Sweden. The aim of the thesis was to evaluate new risk markers to identify patients with high risk of developing cardiovascular disease in middle-aged men and women with type 2 diabetes. Methods Data from the cohort study CArdiovascular Risk in type 2 DIabetes – a Prospective study in Primary care (CARDIPP) was used. In paper III data were also used from CARDIPP-Revisited where all participants in the CARDIPP study were invited four years after the baseline investigation for a re-investigation. In paper IV data were used from CAREFUL which is a control group of 185 subjects without diabetes. The investigation included a standard medical history including data on diabetes duration and on-going medication. Anthropometric data were recorded and both office and ambulatory blood pressure were measured. The patients filled out a detailed questionnaire and physical activity was measured by using waist-mounted pedometers. Pedometer-determined physical activity was classified in four groups: Group 1: <5000 steps/day (‘sedentary’); Group 2: 5000-7499 steps/day (‘low active’); Group 3: 7500-9999 steps/day (‘somewhat active’); Group 4: and ≥10 000 steps/day (‘active’). Blood samples were drawn for routine analyses and also frozen for later analyses. The investigations at the departments of physiology included echocardiography, measurements of the carotid intima-media thickness, applanation tonometry and measurements of  sagittal abdominal diameter. Results Paper 1: Patients with a non-dipping systolic blood pressure pattern showed higher left ventricular mass index and pulse wave velocity (PWV) compared with patients with ≥10% decline in nocturnal systolic blood pressure. Patients with <10% decline in nocturnal systolic blood pressure had higher BMI and sagittal abdominal diameter, lower GFR and higher albumin:creatinine ratio and also higher levels of NT-proBNP than patients with a dipping pattern of the nocturnal blood pressure. Paper 2: The number of steps/day were inversely significantly associated with BMI, waist circumference and sagittal abdominal diameter, levels of CRP, levels of interleukin-6 and PWV. Paper 3: At the 4-year follow-up the change in PWV (ΔPWV) from baseline was calculated. The group with the lowest steps/day had a significantly higher increase in ΔPWV compared with the group with the highest steps/day. The associations between baseline steps/day and ΔPWV remained after further adjustment in a multivariate linear regression statistically significant (p=0.005). 23% of the variation in the study could be explained by our model. Every 1000 extra steps at baseline reduced the change in ΔPWV by 0.103 m/s between baseline and follow-up. Paper 4: Low vitamin D levels were associated with significantly increased risk for premature mortality in men with type 2 diabetes. High levels of parathyroid hormone were associated with significantly increased risk for premature mortality in women with type 2 diabetes. These relationships were still statistically significant also when two other well-established risk markers for mortality, PWV and carotid intima-media thickness, were added to the analyses. Conclusions Ambulatory blood pressure recording can by addressing the issue of diurnal blood pressure variation, explore early cardiovascular organ damage and microvascular complications that goes beyond effects of standardised office blood pressure measurements. Pedometer-determined physical activity may serve as a surrogate marker for inflammation and subclinical organ damage in patients with type 2 diabetes. There is novel support for the durable vascular protective role of a high level of daily physical activity, which is independent of BMI and systolic blood pressure. The use of pedometers is feasible in clinical practice and provides objective information not only about physical activity but also the future risk for subclinical organ damage in middle-aged people with type 2 diabetes. Our results indicate that low vitamin D levels in men or high parathyroid hormone levels in women give independent prognostic information of an increased risk for total mortality.

Background: As more women of childbearing age engage in the workforceand a lot of new chemicals are available, a growing interest of diagnosing andpreventing reproductive disorders due to occupational and environmentalexposure has occurred. The source location of this thesis is the Rönnskärcopper smelter which is situated in the north of Sweden, in the municipality of Skellefteå. Emissions from the smelter, which have diminished during theperiod 1975-1990 include sulphur dioxide and heavy metals, especially lead,arsenic, cadmium, copper, mercury and zinc. Reproductive studies from the1970s in and around the smelter reported increased risks of spontaneousabortions, malformations and lower birth weight. The aim of this thesis wasto perform a broad and long-term epidemiological assessment of adversereproductive outcome in and around the smelter and to determine if theexposed population suffered from reproductive disturbances during the recentdecades. Subjects and methods: The study involve two main sources of data. Onewas a retrospective cohort formed through record linkage of populationregisters, the medical birth register (1961-90), the register of congenitalmalformations (1973-90) and the cancer register (1961-90). As another source,information on reproductive history, life-style and work related factors wasobtained from a questionnaire study in 1992. An exposed population wasdefined as smelter workers and their children, and also neighbours to thesmelter and their children. Results: In the register study, compared to the reference population, nooverall significant increased risk of malformations, childhood cancer, low birthweight or perinatal death was found in the exposed group. In thequestionnaire study, regarding infertility, no environmental effects were found.Also, no increased risk of a prolonged waiting time to pregnancy or increasedrisk of spontaneous abortions were associated with occupational or environmentalfactors. Conclusion: With the lack of a high statistical power in mind, due to smallsample sizes in some of the studies, the summary of our findings includingseveral outcomes, different epidemiological study designs and studies coveringa long period of time gives no evidence for any increased risk of reproductivehazards due to occupational or environmental exposure. / digitalisering@umu

Background Advances in medical treatment during the last 50 years have resulted in more individuals with congenital heart disease (CHD) and Marfan syndrome reaching childbearing age. The substantial physiological changes during pregnancy result in a high-risk situation, and pregnancy is a major concern in women with these conditions. Aims To describe the socio-demographic characteristics, birth characteristics and reproductive patterns of individuals with CHD and women with Marfan syndrome. To investigate obstetric and neonatal outcomes in the firstborn children of individuals with CHD and women with Marfan syndrome. To study long-term cardiovascular outcomes after childbirth in women with Marfan´syndrome. Methods The studies are population-based register studies. The study population in the first paper included all women born between 1973 and 1983 who were alive and resident in Sweden at the age of 13 (494 692 women, of whom 2 216 were women with CHD). In the second paper, the same definition of the study population was chosen, except that it involved all men born between 1973 and 1983 (522 216 men, of whom 2 689 men with CHD). The third and fourth papers involved a study population of all Swedish women born between 1973 and 1993 who were still living in Sweden at age 13. This population consisted of 1 017 538 women, 273 of whom had been diagnosed with Marfan syndrome. Results and conclusions The individuals studied were more often born preterm, and were small-for-gestational age babies. They were more likely to have been born by cesarean section. In women with CHD, these characteristics were repeated in their firstborn children. No increased risks were found in children of men with CHD or in children of women with Marfan syndrome. There was no increased risk of aortic dissection in women with Marfan syndrome during pregnancy compared to women with Marfan syndrome who did not give birth. Higher frequencies of cardiac arrhythmia and valvular heart disease were found after childbirth in women with Marfan syndrome. Pregnancy in women with CHD is a high-risk situation associated with increased risk of adverse neonatal outcomes for the expected child. Pregnancy in women without CHD, but where the father has CHD is not so associated with increased risk of adverse obstetric or neonatal outcomes. Pregnancy in women with Marfan syndrome is not associated with adverse outcomes for the expected child.

Background: Along with the austerity measures introduced in many countries, the economic crisis affecting Europe since 2008 seems to have impacted many aspects of the health of the Spanish population and has had a negative effect on the provision health services. An increasing body of knowledge has shown a clear impact of the current crisis on suicidal behaviour and mental health, and a less consistent effect on physical health and access to healthcare. However, little is known about the impact of the crisis on social inequalities in health and healthcare access, an area on which the present study seeks to shed light in the context of Spain, and specifically Andalusia, a region hit very hard by the crisis. Objective: To study the impact of the economic crisis starting in 2008 on health, health inequalities and health service utilisation in Spain and Andalusia and the roles of socio-demographic factors in these associations. Methods: Death rates were analysed to study the annual percent change in overall and cause-specific mortality in Spain between 1999 and 2011, and the Longitudinal Database of the Andalusian Population was used to study educational inequalities in overall mortality from 2002 to 2010 (study 1). To calculate suicide attempt rates, information from 2003 to 2012 on 11,494 men and 12,886 women provided by the Health Emergencies Public Enterprise Information System in Andalusia was utilised. The association between unemployment and suicide attempts was studied through linear regression models (study 2). Two waves of the Andalusian Health Survey (2007 and 2011–12) provided data for the third and fourth studies of this thesis. Educational and employment status inequalities in poor mental health in relation with the crisis were analysed through Poisson regression models (study 3). The change in inequalities (pre-crisis–crisis) in health care utilisation outcomes (general practitioner, specialist, hospitalisation and emergency attendance) was measured by the change in horizontal inequality indices. A decomposition analysis of change in inequality between periods was performed using the Oaxaca approach (study 4). Results: Study 1: Overall mortality in Spain decreased steadily during the period, with annual percent changes of -2.44% in men and -2.20% in women. An increase in educational inequality in mortality was observed in men in Andalusia. In women, the inequalities instead remained stable. Suicide mortality showed a downward trend in both sexes in Spain. Study 2: A sharp increase in suicide attempts in Andalusia was detected after the onset of the crisis in both sexes, with adults aged 35 to 54 years being the most affected. Suicide attempts were associated with unemployment rates only in men. Study 3: Poor mental health increased in working individuals with secondary and primary studies during the crisis compared to the pre-crisis period, while it decreased in the university study group. However, in unemployed individuals poor mental health increased only in the secondary studies group. Financial strain could partly explain the crisis effect on mental health among the unemployed. Study 4: Horizontal inequality in utilisation changed to a greater equality or a more pro-poor inequality in both sexes. In the decomposition analysis, socioeconomic position and health status showed greater contributions to the changes in inequalities. Conclusion: This thesis illustrates the complexity of the influences of the current economic crisis on health inequalities in a Southern European region. Specifically, no noticeable effects of the crisis on overall and suicide mortality were detected; instead, increasing educational inequalities in mortality in men and a large increase in suicide attempts in middle aged men and women were observed. The deterioration in poor mental health was mainly detected in those of intermediate educational level. Economic conditions such as unemployment and financial strain proved to be relevant. Finally, in the light of no increased inequalities in healthcare utilisation, the universal coverage health system seems to buffer the deleterious effect of the crisis and austerity policies in this context.

The purpose of this study was to describe experiences and perceptions of ongoing work with health promotion cultural inserts in four different associations in Gavle municipallity for asylum seekers and newly arrived children and adolescents. The method used was a descriptive empirical qualitative interview with a phenomenological research effort. Five interviews were conducted with four women and one man, from four associations in Gavle municipality. The interviews were transcribed verbatim and analysed with a thematic analysis. The result showed that the staff's perceptions about their work were that the work being conducted was a good method of promoting well-being and contributing to a sense of context for remedying mental ill health. Cooperation with community actors was also a key in their work and made it possible to reach the children and adolescents who were the target group for health-promoting cultural activities. The difficulties perceived were lack of economics, information and structural changes, which made it difficult to implement, follow up and continue their work. The conclusion was that the work with health promoting activities was perceived as a method of integration as well as promoting health. There was also a consensus that the work performed had a good effect in bringing children and young people's families closer to the Swedish society. The obstacles discovered were structural changes, lack of information and too little of economy. One key to success was the cooperation in the local community which made it possible to reach the group. / Studiens syfte var att beskriva erfarenheter och uppfattningar av pågående arbete med hälsofrämjande kulturinsatser i fyra olika föreningar i Gävle kommun för målgruppen asylsökande och nyanlända barn och ungdomar. Metoden i denna studie var en beskrivande empirisk kvalitativ intervjustudie med en fenomenografisk forskningsansats. Fem intervjuer genomfördes med fyra kvinnor och en man, från fyra föreningar i Gävle kommun. Intervjuerna transkriberades ordagrant och analyserades med en tematisk analys. Resultatet visar att personalens uppfattningar kring arbetet med kulturinsatser för asylsökande och nyanlända barn och ungdomar var att arbetet som bedrivs var en bra metod för att främja välbefinnande och även bidra till en känsla av sammanhang för att motverka psykisk ohälsa. Samarbete med aktörer i lokalsamhället var dessutom en nyckel i deras arbeten och möjliggjorde att nå ut till de barn och ungdomar som var målgruppen för de hälsofrämjande kulturaktiviteterna. De svårigheter som uppfattades i arbetet var brist på ekonomi, information och strukturella förändringar vilket försvårade att genomföra, följa upp och fortsätta med arbetet. Slutsatsen av denna studie var att arbetet som bedrivs kring hälsofrämjande kulturinsatser uppfattas vara både en metod för integration och för att främja hälsa och förebygga ohälsa för målgruppen asylsökande och nyanlända barn och ungdomar. Arbetet uppfattades även ha en god effekt på barnens och ungdomarnas familjer för att komma närmare det svenska samhället. De hinder som upptäcktes var strukturella förändringar, brist på information och för lite ekonomiska medel. Avslutningsvis var samverkan i lokalsamhället en nyckel för framgång som möjliggjorde att nå ut till målgruppen.

Bakgrund: Individers delaktighet och möjlighet att påverka sin livssituation lyfts ofta fram i hälsofrämjande arbete. Forskning stödjer att skolframgång är en skyddsfaktor för att bevara en god psykisk hälsa. Elevers möjlighet att vara delaktiga och påverka sin skolsituation är faktorer som främjar både lärande och hälsa. Barns och elevers delaktighet är en viktig del av arbetet med mänskliga rättigheter och under år 2018 förväntas Förenta nationernas konvention om barnets rättigheter antas som svensk lag.  Syfte: Syftet med denna studie var att undersöka om det fanns det ett samband mellan elevers upplevda delaktighet i skolsituationen och deras hälsa samt att belysa vilka faktorer i skolsituationen som hade betydelse för upplevd delaktighet.  Metod: Studien genomfördes som en kvantitativ tvärsnittsstudie av data från elevhälsodatabasen ELSA. Sambandsanalyser gjordes med variabeln ”delaktig och får vara med och bestämma” mot elevens skolsituation, relationer, självbild, riskbeteende och upplevd hälsa. Alla sambandsanalyser gjordes med Chi2 test, signifikant var <0.05.  Resultat: Resultatet visade att elevers upplevda delaktighet hade statistiskt signifikanta samband med skolsituation, relationer, självbild, riskbeteende och upplevd hälsa. Elever med låg delaktighet uppgav en lägre grad av arbetsro på lektionerna, de var mindre nöjda med sitt skolarbete, hade färre vänner i skolan och upplevde i en lägre grad att vuxna var vänliga. Upplevelsen av låg delaktighet hade ett starkt samband med psykisk ohälsa. Det var mer än dubbelt så många elever med upplevd låg delaktighet, bland både pojkar och flickor, som kände sig ledsna och oroliga.  Konklusion: Studien belyser hur central elevers upplevda delaktighet är för deras hälsa och livssituation, även om det kausala sambandet inte kan påvisas. Att systematiskt stärka elevers delaktighet är ett hälsofrämjande arbetssätt som också kan förbättra skolans möjlighet att fullgöra sitt kompensatoriska uppdrag. Det vill säga att skolan ska möta varje elev utifrån dess individuella förutsättningar och kompensera för det som eleven kan ha behov av för att klara sina studier. / Background: Individuals' participation and ability to influence their life situation are often highlighted in health-promotion. Research supports that school success is a protective factor for maintaining good mental health. Pupils' ability to participate and influence their school situation are factors that promote both learning and health. The participation of children and pupils are an important part of the work on human rights and in 2018 the United Nations Convention on the Rights of the Child is expected to be adopted as a Swedish law. Aim: The aim of this study was to investigate whether there was a link between pupils ' perceived participation in the school situation and their health, as well as to shed light on what factors in a school situation which had significance for perceived participation.  Method: The study was conducted as a quantitative cross-sectional study of data from the health data base, ELSA. Correlation analysis was made with " included and be allowed to decide" towards the pupil's school situation, relationships, self-image, risk behavior and perceived health. All correlation analyses were done with the chi-squared test, significant were < 0.05.  Results: The results showed that pupils ' perceived participation had a statistical significant relation with school situation, relationships, self-image, risk behavior and perceived health. Pupils with low participation indicated a lower degree of calm to study, they were less satisfied with their school work, had fewer friends in school and experienced to a lesser extent that adults were friendly. The experience of low participation had a strong correlation with mental ill health. It was more than twice as many with perceived low participation, among both boys and girls, who felt sad and worried. Conclusion: This study highlights how central pupils ' perceived participation is for their health and life situation, although the causal relationship cannot be demonstrated. To systematically strengthen pupils’ participation is a health promotion approach that also can improve the school's ability to meet its compensatory mandates. That is, the school system must meet each pupil's individual needs and compensate for what the pupil may need to complete his or her studies.

Hälsoutvecklingen bland skolbarn i Sverige vittnar om att psykosomatiska besvär ökar och att barnens självskattade hälsa minskar med stigande ålder. Samtidigt minskar också andelen barn som uppnår tillräckliga nivåer av fysisk aktivitet, medan stillasittande istället ökar. Interventioner för mer fysisk aktivitet i skolan är ett sätt problematiken skulle kunna bemötas med. Fysisk aktivitet fungerar som en skyddsfaktor mot flera livsstilsrelaterade sjukdomar och mer fysisk aktivitet i skolan har bland annat visats leda till förbättrade kognitiva förmågor och ökat välbefinnande. Syftet med studien var att undersöka barns beskrivningar av välbefinnande i relation till deltagande i PULS-projektet på Degebergaskolan, en intervention för mer fysisk aktivitet i skolan. Via fokusgruppsintervjuer med elever som deltog i PULSprojektet erhölls studiens empiri, från vilken vidare induktiv kvalitativ innehållsanalys genomfördes. Resultaten från studien påvisade att det viktigaste för erhållandet av subjektivt välbefinnande var att ha roligt och att känna glädje. Vidare visade resultaten att deltagarna erhöll ökat subjektivt välbefinnande från sitt deltagande i PULS-projektet och att utövandet av fysisk aktivitet hade en betydande roll för välbefinnande, både i skolan och på fritiden. Detta är viktiga fynd då hälsointerventioner för mer fysisk aktivitet i skolan medför möjligheter att motverka den negativa hälsoutveckling som förekommer bland skolbarn i Sverige. Djupare förståelse för hur barn själva definierar välbefinnande och vilken inverkan interventioner som PULS-projektet har för deras subjektiva välbefinnande bidrar till att det skapas underlag för att också möta barnens självupplevda behov och därmed utveckla och förbättra utformandet av lika interventioner ytterligare.

Det finns vetenskapliga belägg för att män och kvinnor reagerar olika på stress men behovet av forskning kring hur det ser ut och varför samt hur vi kan åstadkomma förändring kvarstår. Syftet med vår studie var att beskriva män och kvinnors upplevelse och hantering av stress. I denna studie är det män och kvinnors egen upplevelse och hantering av stress som ligger till grund för resultaten. Datainsamling gjordes genom en enkät som lades ut på sociala media, riktad till män och kvinnor i arbetsför ålder (20 till 65 år). Det resulterade i 233 respondenter. Studien har en kvantitativ ansats. Datamaterialet fördes över till en matris i Microsoft Excel och sedan till grafer. Dataanalysens resultat består av relevanta fynd kopplat till skillnader i män och kvinnor upplevelse och hantering av stress. Resultaten visar lika hög andel oro och ångest hos män och kvinnor men fler män än kvinnor upplever att de går på högvarv av stress. Kvinnor upplever sin stress mer frekvent som en fara för egen hälsa i jämförelse med män. Hälsovägledare kan ha nytta av studien utifrån ett hälsopromotivt perspektiv för att bistå ett mer individanpassat stöd i stresshantering som tar hänsyn till män och kvinnors olika sätt att uppleva och hantera stress. / There is scientific evidence that men and women react differently to stress but the need for research into how it looks and how we can achieve change persists. The aim of our study was to describe men and women's experience and management of stress. In this study, the men and women's own experience and management of stress is the basis of the results. Data collection was done by a questionnaire on the social media, targeted to men and women of working age (20-65 years). This resulted in 233 respondents. The study has a quantitative approach. The data material was transferred to a matrix in Microsoft Excel and then to graphs. The results of data consists relevant findings linked to differences in men and women`s experience and management of stress. The results show equal high proportion of concern and anxiety among men and women but more men than women experience that they go into overdrive of stress. Women feel their stress more frequently as a danger to their own health in comparison with men. Health guides can benefit from the study on the basis of a preventive health perspective to assist more personalised support in stress management which takes account of men and women's different way to experience and manage stress.