<p>The overall aim was to study factors that affect behaviour related to CVD (cardiovascular diseases). Study I tested whether gender, education and so-cioeconomic status correlated to knowledge about risk factors, and Study II studied knowledge and risk behaviour from a national perspective (Sweden versus Poland). Furthermore, Study III examined whether obese people dif-fered from people of normal weight regarding knowledge about risk factors, and Study IV examined whether risk behaviour is affected by personal ex-perience of illness and family history of CVD. </p><p>The studies are population-based with cross-sectional design. Data were obtained by questionnaires and by screening results of risk factors related to CVD. The studies were carried out among 50-year old men and women in Västmanland, Sweden (n=1011) and in Wroclaw, Poland (n=1043).</p><p>The results show that women are more knowledgeable than men about the risk factors for CVD, and that low education is associated with insufficient knowledge about CVD (Study I). The discrepancy between knowledge and behaviour was greater among the Poles than it was among the Swedes (Study II). Obese individuals did not differ significantly from individuals with a normal weight regarding knowledge of cardiovascular risk factors when education was controlled for (Study III). Individuals with a personal experience of illness may be more inclined to change smoking behaviour than the average person (Study IV).</p><p>In conclusion, knowledge about risk factors for CVD varies with education, gender and, to a certain degree, nationality. However, knowledge does not only consist of the conditions of behaviour change. The results in the thesis substantiate theories suggesting that change in risk behaviour is a process over time. Predictors of risk behaviours on the individual level as well as national level are of importance, and needs to be considered in the every day practice of health care professionals.</p>

The aim the thesis was to investigate, the prevalence of Lower Urinary Tract Symptoms (LUTS). Moreover, we examine symptom severity and different levels of distress and describe how different symptoms from the lower urinary tract affect the self-assessed health, sadness, happiness and the quality of life in men. The studies are based on two data collections. In the first data collection, all men aged 40 – 80 years (n=2571) living in the Swedish community received a postal questionnaire. Twelve months later, 504 men who had earlier reported LUTS and 504 who had not reported symptoms were asked to complete the DAN-PSS and the SF-36 questionnaires. The overall prevalence of LUTS was 24%. Post-micturition dribbling (21%) was the most frequent symptom, and stress incontinence (2%) was the least frequent symptom. Urge incontinence, stress incontinence and “other” incontinence cause a high level of distress, even if the symptoms do not occur very often. Men experiencing mild, moderate or severe urge, stress or “other incontinence” had lower mean scores for all of the eight dimensions measured by the SF-36 than men without the same symptoms. Men experiencing a moderate/severe degree of weak stream or nocturia reported a poorer quality of life in all dimensions compared to men with a mild level of the same symptoms. The total burden of moderate/severe LUTS is related to self-assessed health, sadness and happiness. For each of the 12 specific LUTS, men with mild, moderate or severe symptoms had lower scores for self-assessed health and happiness, and higher scores for self-assessed sadness, than men without the same symptoms. In conclusions, one of every four men reports LUTS. Urinary incontinence causes high level of distress even to men who experience this symptom rarely. LUTS have a negative impact on quality of life, health, sadness and happiness.

The overall aim was to study factors that affect behaviour related to CVD (cardiovascular diseases). Study I tested whether gender, education and so-cioeconomic status correlated to knowledge about risk factors, and Study II studied knowledge and risk behaviour from a national perspective (Sweden versus Poland). Furthermore, Study III examined whether obese people dif-fered from people of normal weight regarding knowledge about risk factors, and Study IV examined whether risk behaviour is affected by personal ex-perience of illness and family history of CVD. The studies are population-based with cross-sectional design. Data were obtained by questionnaires and by screening results of risk factors related to CVD. The studies were carried out among 50-year old men and women in Västmanland, Sweden (n=1011) and in Wroclaw, Poland (n=1043). The results show that women are more knowledgeable than men about the risk factors for CVD, and that low education is associated with insufficient knowledge about CVD (Study I). The discrepancy between knowledge and behaviour was greater among the Poles than it was among the Swedes (Study II). Obese individuals did not differ significantly from individuals with a normal weight regarding knowledge of cardiovascular risk factors when education was controlled for (Study III). Individuals with a personal experience of illness may be more inclined to change smoking behaviour than the average person (Study IV). In conclusion, knowledge about risk factors for CVD varies with education, gender and, to a certain degree, nationality. However, knowledge does not only consist of the conditions of behaviour change. The results in the thesis substantiate theories suggesting that change in risk behaviour is a process over time. Predictors of risk behaviours on the individual level as well as national level are of importance, and needs to be considered in the every day practice of health care professionals.

Despite the current preventive strategies sexually transmitted infections (STIs) are rising. This thesis presents a model with the aim of improving the prevention of STIs. Chlamydia being the most common STI in Sweden serves as a model infection. The presented model is based on five performed studies. First we evaluated the feasibility of taking a urine sample at home and sending it with mail for Chlamydia analysis. Postal screening was thereafter analyzed for cost effectiveness estimating the cost per prevented sequel and the prevalence threshold. A population based study of all the 22-year old men in Umeå tested the feasibility of the Internet as a tool in facilitating Chlamydia testing and also attempted to engage men who often have low participation in Chlamydia screening programs. A questionnaire to all 18-year old youths in four northern Swedish cities was analysed concerning condom use. Finally, ordering home a Chlamydia test from the Internet was tested as method for self-selective screening. The studies showed that it was both feasible and acceptable by the population to send in urine samples with mail for Chlamydia analysis. Large-scale postal screening would be cost-effective in a female population if the C. trachomatis prevalence exceeds 5% and cost effective in a male population if the C. trachomatis prevalence exceeds 12.3%. Using the Internet as a tool in Chlamydia testing proved feasible and almost 38% of all the 22-year old men in Umeå participated. Condom usage being the most important STI preventive measure during a sexual intercourse proved to be dependent on more male factors than female factors, where the use of oral contraceptives was the strongest factor associated with non-condom use. Ordering a test on the Internet proved to be a feasible self-selective screening method. Condom use should continuously be promoted to sexually active people especially if oral contraception is used. Success and cost effectiveness in controlling STI transmission is likely to depend on achieving consistent and regular coverage of testing and partner notification among both women and men. The suggested model uses the Internet as a tool in communicating preventive STI information and allowing a self-selective screening, which may be used as an adjunct to regular recruitment in striving for improving the STI prevention. Key words: STI, prevention, Chlamydia, postal screening, cost effective, condom, Internet, self-selective screening.

The Sami people are the Natives of northern Scandinavia. The knowledge of the health and living conditions of the Swedish Sami is extremely limited which is in contrast to the large amount of detailed information on health and socioeconomic issues that is available for other circumpolar Natives. The encounter with the western society and the acculturation process has for many native populations had serious health consequences, causing a dramatic increase of lifestyle related diseases such as cancer, diabetes, stroke, obesity and hypertension as well as a dramatic increase of suicide and drug abuse. The overall objective of this thesis was to investigate the health conditions of the Sami population of Sweden using causes of death and incidences of cancer and cardiovascular diseases (CVD) as health indicators, and to evaluate their possible association with acculturative factors such as assimilation, integration, separation and marginalization. A Sami population was identified containing a total of 41 721 individuals. Specific cohorts were selected from this population for the different studies. A four times as large demographically matched non-Sami control population was used for comparisons. A study of causes of death, 1961-2000, showed small differences in overall mortality and life expectancy between the Sami and the non-Sami. However, Sami men showed significantly lower mortality risks for cancers but higher for external cause of injury and Sami women higher risks for diseases of the circulatory system (CVD) and of the respiratory system. An increased risk of dying from subarachnoid haemorrhage (SAH) was observed among both Sami men and women. The increased risk of dying from accidents among male reindeer herders is suggested to be caused by the increased socioeconomic pressure and the extensive use of terrain vehicles. It is concluded that commercial reindeer management is one of the most dangerous occupations in Sweden. In a study of the cancer risk among the reindeer herding Sami between 1961-1997, an overall lower risk to develop cancers, particularly prostate and malignant lymphoma was observed among the reindeer herding Sami. The risk for stomach cancer was significantly higher in relation to their non-Sami neighbours. The Sami and the non-Sami had similar risk factor-patterns for CVD. The main differences were related to working conditions and lifestyle factors of the reindeer herding Sami - the women showed a more unfavourable risk factor pattern than the men. Higher incidences of stroke were observed among Sami men and women compared to their non-Sami neighbours while the mortality rates of stroke were similar. The mortality ratio of AMI was increased for Sami women in spite of similar incidence ratios. A higher risk of SAH was observed among all groups of Sami. According to traditional socioeconomic risk factors, the differences in the levels of income and education observed between the Sami and the non-Sami, were poorely associated with the disparities of CVD. As has been shown, only minor differences in the health indicators were found between the Sami and their non-Sami neighbours. This is in clear contrast to several other native populations for which the health situation is largely unfavourable in comparison with that of the general population. The observed differences between the Sami and the non-Sami probably reflect differences in lifestyle, psychosocial and genetic factors. The relation between these factors and the acculturation process is dicussed, and it is suggested that separation or segregation of the reindeer herding Sami and the assimilation of the other Sami have influenced the health condition of the Sami, but with the largest impact probably prior to 1961 and the earliest start of follow-up for the studies in this thesis. Thus, the similarities in health between the Sami and the non-Sami 1961-2002, are probably a result of centuries of close interaction that has caused similarities in culture, attitudes and lifestyle, as well as equal accessibility to the health care services and the social security systems.

The objectives of the thesis was to explore partner violence during pregnancy in Nicaragua – its prevalence and characteristics, how women perceive, understand and cope with it, its association with specific child outcomes such as low birth weight (LBW), small for gestational age (SGA) and preterm birth, and possible pathways. A cross-sectional community-based study was conducted with 478 pregnant women and for a sub-sample of 147 salivary cortisol was measured. A case-referent hospital-based study was organized including 303 mothers immediately after delivery. In-depth interviews were conducted with women survivors to increase understanding of partner violence during pregnancy. The prevalence of emotional, physical and sexual partner abuse during pregnancy was 32.4%, 13.4% and 6.7% respectively. Seventeen percent of the victims suffered all three types of violence and in two thirds the abuse was severe and repeated. Half of the abused women had experienced punches and kicks directed to the abdomen; however, only 14% had sought health care and very few had disclosed the abuse or contacted police or authorities. Adolescent mothers, unwanted pregnancy and late registration for antenatal care or no check-ups were more likely among victims. The access to social resources facilitated the women’s ability to cope with the abuse, but the pregnancy itself was a barrier to receiving support from family, friends or society. The ability to confront abuse was determined by a complex interplay of factors such as economic independence, severity of abuse, access to social resources, implications for important others (i.e. children), socioeconomic group and a personal ability to cope with social norms. Low social resources, high levels of emotional distress and attempted suicide were associated with violence during pregnancy. Abuse during pregnancy was also found as an independent risk factor for LBW. Sixteen percent of LBW was attributed to physical abuse by a partner during pregnancy. A significant association between abuse during the index pregnancy and SGA was found. Partner violence during the pregnancy, low social resources and emotional distress were associated with higher levels of salivary cortisol. Pregnant women with high cortisol values were significantly more likely to give birth to SGA babies. A substantial decrease of birthweight, 142 grams, was estimated to be associated with increases in cortisol due to violence exposure. Partner violence during pregnancy is a serious social problem that impacts the rights, health and wellbeing of both the woman and her unborn child. The studies call for prioritization of intervention programmes for prevention and detection of violence, treatment and rehabilitation of the victims and the perpetrators, and change of the structural causes producing violence in society.

<p>Inflammation and oxidative stress may be involved in atherogenesis. This thesis describes clinical studies of prostaglandin F_2α (PGF_2α), an inflammatory mediator, and the isoprostane 8-iso-PGF_2α, a reliable indicator of oxidative stress, and cytokine-related inflammatory mediators and indicators in healthy subjects and in a population-based cohort of Swedish men. </p><p>PGF_2α and 8-iso-PGF_2α formation in healthy subjects varied considerably between days with a mean intra-individual coefficient of variation of 41 % and 42 %, respectively. A morning urine sample reflected the basal level of 8-iso-PGF_2α formation as accurately as a 24-hour urine collection, and represents a more practical alternative to the 24-hour urine collection in clinical studies. PGF_2α formation (as measured by urinary 15-keto-dihydro-PGF_2α) was increased in patients with type 2 diabetes and in smokers independent of other cardiovascular risk factors. These results indicated an on-going cyclooxygenase (COX)-mediated inflammatory reaction related to these conditions. Further, an increased formation of isoprostanes (as measured by urinary 8-iso-PGF_2α) was found in patients with type 2 diabetes and in smokers, indicating a high level of oxidative stress in these men. The smokers had also increased levels of the cytokine interleukin-6, indicating an on-going cytokine-related inflammatory reaction. The inflammatory indicators C-reactive protein and serum amyloid A were related to overweight but not independently associated to type 2 diabetes. High levels of serum selenium in middle-aged men predicted reduced formation of PGF_2α and 8-iso-PGF_2α 27 years later.</p><p>In summary, low-grade, chronic COX-mediated and possibly cytokine-related inflammation, and oxidative stress, seem to be joint features of type 2 diabetes and smoking, two major risk factors of atherosclerosis, in elderly men. Inflammation and oxidative stress may represent a possible common pathogenetic link between established risk factors for atherosclerosis and atherogenesis.</p>

Inflammation and oxidative stress may be involved in atherogenesis. This thesis describes clinical studies of prostaglandin F2α (PGF2α), an inflammatory mediator, and the isoprostane 8-iso-PGF2α, a reliable indicator of oxidative stress, and cytokine-related inflammatory mediators and indicators in healthy subjects and in a population-based cohort of Swedish men. PGF2α and 8-iso-PGF2α formation in healthy subjects varied considerably between days with a mean intra-individual coefficient of variation of 41 % and 42 %, respectively. A morning urine sample reflected the basal level of 8-iso-PGF2α formation as accurately as a 24-hour urine collection, and represents a more practical alternative to the 24-hour urine collection in clinical studies. PGF2α formation (as measured by urinary 15-keto-dihydro-PGF2α) was increased in patients with type 2 diabetes and in smokers independent of other cardiovascular risk factors. These results indicated an on-going cyclooxygenase (COX)-mediated inflammatory reaction related to these conditions. Further, an increased formation of isoprostanes (as measured by urinary 8-iso-PGF2α) was found in patients with type 2 diabetes and in smokers, indicating a high level of oxidative stress in these men. The smokers had also increased levels of the cytokine interleukin-6, indicating an on-going cytokine-related inflammatory reaction. The inflammatory indicators C-reactive protein and serum amyloid A were related to overweight but not independently associated to type 2 diabetes. High levels of serum selenium in middle-aged men predicted reduced formation of PGF2α and 8-iso-PGF2α 27 years later. In summary, low-grade, chronic COX-mediated and possibly cytokine-related inflammation, and oxidative stress, seem to be joint features of type 2 diabetes and smoking, two major risk factors of atherosclerosis, in elderly men. Inflammation and oxidative stress may represent a possible common pathogenetic link between established risk factors for atherosclerosis and atherogenesis.

Obesity prevalences are increasing in Sweden and the US. Obesity has many health consequences and health risks are associated with small increases in weight and marked obesity. Cross-sectional and panel surveys from northern Sweden and upstate NY provide the basis for furthering understanding of body mass index (BMI) development. BMI and weight change (+/-3%) were used to evaluate obesity and weight loss, maintenance, or gain. The 1989 prevalences of obesity were 9.6% and 21.3% in Sweden and the US; 1999 prevalences were 18.4% and 32.3%. Ten-year incidences (1989-1999) of overweight and obesity were 337/1000 and 120/1000 for Sweden and 336/1000 and 173/1000 for the US. Cross-sectional data suggest obesity is a problem of older age while panel data show that the young are gaining weight most rapidly. Individual changes in BMI have similar trends for Sweden and the US; the majority of adults are gaining weight. Older age, being a woman, higher BMI, and type 2 diabetes were associated with higher odds of weight non-gain. Younger age, being a man, being married and using snuff (snus) increased the odds of weight gain. The obese were 2-7 times more likely to report self-rated poor health. Healthy behaviours explain more of the person-to-person variability in BMI than do unhealthy behaviours or chronic diseases. Encouraging trends were found among Västerbotten Intervention Programme participants: a higher proportion of adults maintained weight in more recent survey years. The proportion of weight-gaining adults with identified health risk factors is smaller than those without risk factors. Frequently weight maintenance is felt to be important only for those identified as having a problem with weight or an obesity-related health condition. The largest proportion of those gaining weight are those with a normal BMI. Obesity prevention should target those usually considered low-risk (young, without cardiovascular risk factors, normal BMI).

Sleep is a basic need as important as physical fitness and good nutrition. Without enough sleep, we will create a sleep debt and experience sleepiness. Sleepiness can be defined as the inability to stay awake, a condition that has become a health problem in our 24-hour-7-day-a-week society. Estimates suggest that up to one-third of the population suffers from excessive sleepiness. Among other interactions, sleepiness affects our performance, increasing the risk of being involved in accidents. A considerable portion of work related accidents and injuries are related to sleepiness resulting in large costs for the individuals and society. Professional drivers are one example of workers who are at risk of sleepiness related accidents. Up to 40% of heavy truck accidents could be related to sleepiness. A better knowledge about reliable indicators and predictors of sleepiness is important in preventing sleepiness related accidents. This thesis investigates both objective and subjective indicators of sleepiness, how these relate to each other, and how their pattern changes over time. The indicators investigated were electroencephalography, heart rate variability, simple reaction time, head movement, and subjective ratings of sleepiness (Study I-IV). In Study V, a questionnaire study was conducted with professional drivers in northern Sweden. This study mainly deals with predictors of sleepiness. When subjects were sleep deprived both objective and subjective ratings indicated a rapid increase in sleepiness during the first hour of the test followed by a levelling off. This change in pattern was evident for all the indicators except heart rate and heart rate variability. On the other hand, HRV was correlated with the increase of EEG parameters during the post-test sleep period. The changes in pattern of the indicators included in the thesis are analysed in the perspective of temporal patterns and relationships. Of the tested indicators, a subjective rating of sleepiness with CR-10 was considered to be the most reliable indicator of sleepiness. Of the investigated predictors of sleepiness, prior sleep habits were found to be strongly associated to sleepiness and the sleepiness related symptoms while driving. The influences of driving conditions and individual characteristics on sleepiness while driving were lower. A multidisciplinary approach when investigating and implementing indicators and predictors of sleepiness is important. In addition to their actual relations to the development of sleepiness, factors such as technical and practical limitations, work, and individual and situational needs must be taken into account.