<p>This cross-sectional study investigated the use of health benefits in relation to the self-rated health of employees at two medium-sized industrial enterprises in Hälsingland. The method used to investigate this was through a self-designed questionnaire consisting 19 questions about health, lifestyle and health benefits at the workplace. A total of 100 questionnaires were distributed in the two companies, hence 50 surveys at each workplace. The response rate was measured to 88 % and 74 %, which means a loss of 6 persons and 13 persons. The results showed that Company nr 1 offers its employees a health benefits consisting of free access to gym in the company premises after working hours and financial contributions to training-cards. These benefits are used regularly by 29% of respondents. Company nr 2 currently offered no health benefits for their employees. The results also showed that 66% of the respondents at Company nr 1 rated their physical health as <em>Excellent</em> or <em>Good</em> and 79% consider their mental health as <em>Excellent</em> or <em>Good</em>. At Company nr 2, 65 % of the participants responded that they consider their physical health as Excellent or Good and 84% consider their mental health as <em>Excellent</em> or <em>Good</em>. The study also found that more than half of the participants in the two companies had a BMI (Body Mass Index) greater than 26. The conclusion from this is that the health benefits offered at Company nr 1 is used sparingly and that more than half of the participants at both companies consider their physical and mental health as <em>Excellent</em> or <em>Good</em>.</p>

<p>The number of persons who are not employed has increased in Sweden since the early 1990s. Unemployment has been found to influence health, especially when unemployment rates are low. The extent to which unemployment affects health when unemployment is high is less clear, and this needs to be further studied. To improve health in the population, the health care system should offer equal access to health care according to need. It is important to study whether the employment status hinders the fulfilment of this goal. </p><p>This thesis is based on four papers: Paper I and II aimed at analysing self-rated health versus mortality risk in relation to employment status, during one period of low unemployment and one period of high unemployment. Paper III and IV assessed the use of medical health care services and unmet care needs among persons who were unemployed or otherwise not employed. The goal was to analyse what health problems lead people to either seek or abstain from seeking care, and what factors encumber or facilitate this process. </p><p>The overall results indicate that being unemployed or outside the labour force was associated with an excess risk of poor self-rated health, symptoms of depression, mental and physical exhaustion and mortality. The differences in self-rated health between the unemployed and employed were larger when unemployment levels were high, than when they were low. More groups of the unemployed were also afflicted with poor health when unemployment was high. Thus, poor health among the unemployed seems to be a public health problem during high levels of unemployment. Lack of employment was related to abstaining from seeking care, despite perceiving a need for care, and this was related to psychological symptoms. To deal with the needs of the unemployed and others who are outside the labour force it would be useful to develop and implement interventions within the health care system. These should focus on psychological and psychosocial problems. Future research should analyse how to facilitate health-promoting interventions among persons who are not anchored in the labour market. </p>

Background: Self-rated health (SRH) is among the most frequently assessed health perceptions in epidemiological research. While the predominant focus has been the predictive relevance of SRH, there is increasing interest in understanding the nature of SRH. Recently a conceptual interpretation of SRH was proposed. Purpose: To assess the tenability of the recently proposed distinctions of self-rated health, as a spontaneous assessment of overall health, or as an enduring self-concept, or both, and to determine the significance of mental well-being, physical and social health for SRH. Methods: A cohort of individuals undergoing total joint replacement (TJR) for hip or knee osteoarthritis (OA) was followed over 6 months of recovery. Participants (n=449) completed (pre-surgery, 3 and 6 months post-surgery) measures associated with physical health: pain, physical function, sports/recreation, fatigue; mental well-being: anxiety, depression; and social health: social participation, passive/active recreation, community access. Using structural equation modeling, confirmatory factor analyses (CFA) investigated 3 latent health variables, and the responsiveness of SRH to current and changing health status, as well as its predictive significance for future health status was investigated. Results: CFA analyses confirmed relationships between observed health measures and hypothesized latent health dimensions. SRH was responsive to current and changing mental well-being. The effects of physical and social health were mediated through mental well-being. SRH was a strong predictor of future SRH and future health status. Conclusion: SRH displayed features of both an enduring self-concept and spontaneous assessment of health status; evidence is provided that both operate simultaneously. While aspects of physical health have always been perceived as the major determinants of SRH, these findings indicate that mental and social health explain much of the relationship between physical health and SRH. These results are particularly unexpected since this is a sample of individuals undergoing TJR surgery, for which pain and restricted physical function are primary indicators. Since SRH is a significant predictor of health status, TJR outcomes, health care utilization and mortality, this study suggests that health research and care, treatment and management modalities should consider a broad range of health dimensions, not only physical aspects of health, and SRH.

Background: Self-rated health (SRH) is among the most frequently assessed health perceptions in epidemiological research. While the predominant focus has been the predictive relevance of SRH, there is increasing interest in understanding the nature of SRH. Recently a conceptual interpretation of SRH was proposed. Purpose: To assess the tenability of the recently proposed distinctions of self-rated health, as a spontaneous assessment of overall health, or as an enduring self-concept, or both, and to determine the significance of mental well-being, physical and social health for SRH. Methods: A cohort of individuals undergoing total joint replacement (TJR) for hip or knee osteoarthritis (OA) was followed over 6 months of recovery. Participants (n=449) completed (pre-surgery, 3 and 6 months post-surgery) measures associated with physical health: pain, physical function, sports/recreation, fatigue; mental well-being: anxiety, depression; and social health: social participation, passive/active recreation, community access. Using structural equation modeling, confirmatory factor analyses (CFA) investigated 3 latent health variables, and the responsiveness of SRH to current and changing health status, as well as its predictive significance for future health status was investigated. Results: CFA analyses confirmed relationships between observed health measures and hypothesized latent health dimensions. SRH was responsive to current and changing mental well-being. The effects of physical and social health were mediated through mental well-being. SRH was a strong predictor of future SRH and future health status. Conclusion: SRH displayed features of both an enduring self-concept and spontaneous assessment of health status; evidence is provided that both operate simultaneously. While aspects of physical health have always been perceived as the major determinants of SRH, these findings indicate that mental and social health explain much of the relationship between physical health and SRH. These results are particularly unexpected since this is a sample of individuals undergoing TJR surgery, for which pain and restricted physical function are primary indicators. Since SRH is a significant predictor of health status, TJR outcomes, health care utilization and mortality, this study suggests that health research and care, treatment and management modalities should consider a broad range of health dimensions, not only physical aspects of health, and SRH.

Background: It is debated whether temporary employment compared to permanent employment entails an elevated risk of illness or not, as the empirical studies have not shown a unified picture. Since a significant part of the Swedish workforce is currently working under temporary employment contracts, it is important for public health research to pay close attention to what the implications in terms of illness might be. Therefore the aim of this thesis was to explore the relationship between temporary employment and illness. Methods: This thesis was based on data from the Northern Swedish Cohort, consisting of all pupils in grade 9 in Luleå in 1981 (n=1083). The cohort was followed with extensive questionnaires. The latest follow-up was performed in year 2007, when 94% participated. To analyse the quantitative questionnaire data, logistic regression and trajectory analysis were used. A qualitative method, Grounded Theory, was also applied in this thesis to analyse interviews performed in 2011, with a strategic selection of 12 participants from the cohort. Results: Quantitative data showed that temporary employees had overall higher odds ratios for illness in terms of psychological distress and non-optimal self-rated health compared to permanent employees. This general difference in odds ratios was evident irrespective of how temporary employment was measured as well as after control for earlier health status and confounders. The qualitative analysis gained insight into temporary employment as social processes of: underling the driving force for employment; working hard for a job. The structural conditions emerged in terms of, being used and exploited on the labour market and these conditions were related to the individual strategies of adaptation and coping. In the intersection of agency, structural conditions and adaption, emotional and bodily reactions emerged, such as being worn out, worried and wrathful. Conclusion: Illness is unevenly distributed between temporary and permanent employees, with temporary employees being the unfavourable group. Striving for good and evenly distributed health conditions in the population, policy makers should aim at reducing the number of employees working in temporary contracts. In addition, there is a need to improve surveillance of the health situation among temporary employees and to reduce unfavourable conditions, such as job and financial insecurity and unemployment, among temporary employees.

Background: Many of today’s young adults suffer from impaired psychological well-being and report suffering from psycho-somatic symptoms related to stress. Lifestyle factors, such as smoking, risky alcohol consumption, lack of physical activity and poor diet are known predictors of ill health and may have long lasting impacts on young people’s lives. Aim: The aim of this thesis was to 1: measure adult high school students’ social capital and 2: examine the association between their social capital and psychological well-being as well as the association between social capital and the lifestyle factors; smoking, alcohol consumption, physical activity, diet and academic achievement. Methods: Questionnaires were used to measure high school students’ social capital self- rated psychological health, lifestyle factors and academic achievement. Participants were high school students 18 years and older (n=124) enrolled in Nacka Enskilda Gymnasium and Mörby Gymnasium, two high schools in counties with similar demographic backgrounds, measured in annual salaries, on the outskirts of Stockholm, Sweden. Results: Total social capital was significantly associated with no less than 6 factors of health; self-rated mental health, self-rated stress, psycho-somatic symptoms, intensive physical exercise, consumption of fruit and membership to a club. In addition, consumption of vegetables and expected grade point average (Grade point average (GPA): final GPA’s in Sweden range from 0-20) were significantly associated with individual factors of social capital. Conclusion: The results of this study support the findings of many earlier studies; that social capital appears to be significantly associated with young peoples’ health and well-being. The findings lend weight to earlier studies and contribute to the multitude of voices that lobby for investing in the further development of policies and interventions that aim to increase young peoples’ social capital.

Syfte: Syftet med denna studie var att kartlägga långtidssjukskrivnas hälsa före och efter avslutad intervention samt studera vilka faktorer som hindrat alternativt främjat återgång i arbete hos individer med tidsbegränsad sjukersättning. Metod: Studien baseras på data från EU-projektet ”SAMKLANG” som är en longitudinell interventionsstudie. Data har samlats in på 59 långtidssjukskrivna deltagare via enkäter både före projektstart och ett år efter och dels har data samlats in kvalitativt genom semistrukturerade intervjuer med 13 deltagare efter det att projektet avslutats. Intervjudeltagarna var indelade i två grupper (de som hade återgått i arbete/studier och de som fortfarande var sjukskrivna). Interventionen bygger på både behandling och samverkan mellan organisationer som är involverade i rehabilitering av personer som har ett år kvar av sin tid i sjukersättning. Resultatet från enkäterna analyserades fram via ANOVA upprepad mätning och data från intervjuerna analyserades via innehållsanalys. Resultat: Huvudresultaten från den kvantitativa delstudien visade att det inte fanns någon skillnad mellan de som efter ett år återgått i arbete/studier, arbetsträning alternativt de som fortfarande var sjukskrivna gällande kön, ålder eller utbildningsnivå. Den självskattade depressions- och ångestnivån minskade och självskattad hälsa och inre kontroll ökade signifikant över tid för den grupp som kommit ut i arbete efter projektet jämfört med de två andra grupperna. Den kvalitativa analysen av intervjuerna identifierade följande tema som stödjande faktorer för arbetsåtergång: att besitta egen drivkraft, ha en insikt om arbetets mervärde och att hitta en balans mellan krav- kontroll-stöd. Det tema som beskriver hur myndigheter kan hjälpa och stödja långtidssjukskrivna tillbaks i arbete är: trygghet med mer vårdkompetens och att synliggöra individuella behov. Slutsats: Att återgå i arbete för en tidigare långtidssjukskriven person kopplas till bättre självrapporterad hälsa med mindre depression och ångestbesvär, en starkare känsla av inre kontroll och en högre tilltro till egen förmåga jämfört med om personer fortfarande är sjukskrivna. Framgångsfaktorer för arbetsåtergång är balans mellan krav, kontroll och stöd för individen och en egen motivation att återgå i arbete. För att underlätta arbetsåtergång hos långtidssjukskrivna bör myndigheter och inblandade parter samverka med vård, erbjuda trygghet och synliggöra varje enskild individs behov av rehabilitering. / Aim: The aim of this study was to investigate long term sickness absentees’ health status before and after an intervention. Furthermore, to gain deeper understanding of factors related to promoting and preventing return to work for people with limited sick leave compensation. Method: The study is based on data from the EU-funded project ”SAMKLANG” which is a longitudinal intervention study. Data has been collected from 59 long term absentees though questionnaires conducted before and one year after the start of the project. Data has also been collected through semi structured interviews from 13 participants after the end of the project. They were divided into two groups (those who had returned to work/studies or had an internship and those who still were sickness absent). The intervention is based on treatment as well as cooperation between organizations involved in a rehabilitation process for people with one year of sick leave compensation remaining. The results from the surveys were analyzed with ANOVA for repeated measures and data from the interviews were analyzed using content analysis. Result: The main result from the quantitative part of this study showed no significant difference in return to work between those who had returned to work or studies, been on internships and those who still were sickness absent based on sex, age and education. The amount of self-rated depression and anxiety levels were reduced and the self-rated health and internal control were significant induced over time for the group who returned to work after the project compared to the other two groups. From the qualitative analyze of the interviews following theme was identified as supporting factors for returning to work: having own motivation, realized the positive in having a job and to have balance between demand-control-support. The theme that describes how the authority can help and support people with long term sickness absence back to work is: security with more competence in healthcare and make individual needs visible. Conclusion: Return to work for a former long term sickness absence is associated with better self-rated health with less depression and anxiety, a stronger feeling of internal control and a higher self-efficacy compared to if persons still were sickness absent. Factors for success in return to work is balance between demand-control-support for the individual and an own motivation to return to work. The authority can facilitate return to work among people with long term sickness absence by interact more with health-care services, offer security and make every individuals need for rehabilitation visible.

The mental-health consequences of childlessness have been well documented and the perception is that women are more likely than men to experience lower mental well-being, including emotional distress, as a result of childlessness; despite the fact that very few studies have focused on the implications for men. Thus, employing OLS multiple regression we seek to examine: (1) the association between childlessness and emotional distress and whether the risk was greater among men or women. (2) Whether there is significant variation in emotional distress among childless individuals after controlling for socio-demographic factors. The data was derived from the Estonian Health Interview Survey, collected in 2006 and 2007. The survey was a multi-stage random sample of the Estonian Population aged 15-85. Under study was men and women aged 40 and above (N=4294).The outcome variable- emotional distress is based on the emotional state questionnaire (EST-Q), a self-rated health measure. The simple regression and multivariate OLS regressions indicated higher predicted levels of emotional distress symptoms for childless men when compared to childless women. In comparison, the interactions revealed more distress among childless women. Overall, the results garnered indicate that educational attainment and personal income ameliorates the negative mental health consequences of childlessness. However, the degree and manner in which childlessness matter differ by gender, ethnicity and relationship status, but was inconclusive for age. An unexpected finding from the interaction models was the high level of distress among women that were parents. In general, the outcomes point to other reasons for the higher levels of distress among women. The mental-health consequences of childlessness have been well documented and the perception is that women are more likely than men to experience lower mental well-being, including emotional distress, as a result of childlessness; despite the fact that very few studies have focused on the implications for men. Thus, employing OLS multiple regression we seek to examine: (1) the association between childlessness and emotional distress and whether the risk was greater among men or women. (2) Whether there is significant variation in emotional distress among childless individuals after controlling for socio-demographic factors. The data was derived from the Estonian Health Interview Survey, collected in 2006 and 2007. The survey was a multi-stage random sample of the Estonian Population aged 15-85. Under study was men and women aged 40 and above (N=4294).The outcome variable- emotional distress is based on the emotional state questionnaire (EST-Q), a self-rated health measure. The simple regression and multivariate OLS regressions indicated higher predicted levels of emotional distress symptoms for childless men when compared to childless women. In comparison, the interactions revealed more distress among childless women. Overall, the results garnered indicate that educational attainment and personal income ameliorates the negative mental health consequences of childlessness. However, the degree and manner in which childlessness matter differ by gender, ethnicity and relationship status, but was inconclusive for age. An unexpected finding from the interaction models was the high level of distress among women that were parents. In general, the outcomes point to other reasons for the higher levels of distress among women.

Studies in countries across the globe and in Canada show that people from minority communities generally tend to be in poorer health, experience a greater burden of disease and disability than the general population. A 2008 World Health Organization (WHO) report on the Social Determinant of Health stressed that the high burden of disease and disability around the world is due to a great extent, to poor and unequal living conditions which are the consequence of deeper structural conditions such as poor social policies and programmes, inequitable economic structures, and deficient politics. In Canada, there is a growing body of evidence suggesting a negative impact of health disparities on Official Language Minority Communities (OLMCs), especially on Francophones outside of Quebec. In order to better describe and understand the situation of Official Language Minorities (OLMs), especially of Minority Francophone older adults living outside of Quebec, two national surveys were used: The 2006 Canadian post-census Survey on the Vitality of Official Language Minorities (SVOLM) and the 2007 Canadian Community Health Survey (CCHS). Descriptive, and multivariable analyses were conducted, followed by minority Francophone community members’ feedback on the findings. A qualitative analysis of provincial/territorial French-language (English in Quebec) services policies or legislations was subsequently conducted with an in-depth focus on the Government of Saskatchewan French-language Services Policy and an assessment of the potential impact of these policies on the health of OLM older adults. This study showed that minority Francophone older adults consistently rated their health more poorly than their counterparts in the general population but the study failed to demonstrate an association between OLM status and self-rated health, due to low representativity of the OLM population in the sample. However, the sense of belonging to, and vitality of minority community were constructs associated with better self-rated health for minority Francophone older adults while high concentration of minority group was associated with poorer self-rated health. Feedback from Francophone community members emphasized the detrimental role of assimilation, systemic and structural inequities, and unfavourable policies as contributing significantly to the low vitality of their communities and eventually to health disparities. Adopting new sampling approaches for OLMs, addressing minority Francophones’ contextual realities, enhancing access to health services in French, improving the linguistic environment, and developing more supporting policies, would help improve the condition of minority Francophone older adults in Canada.

Background; The overwhelming increase in studies about social capital and health occurring since 1995 indicates a renewed interest in the social determinants of health and a call for a more explicit use of theory in public health and epidemiology. The links between social capital and health are still not clear and the meanings of different forms of individual and collective social capital and their implications for health promotion needs further exploration. The overall aims of this thesis are to explore the relationship between social capital and health and to contribute to the theoretical framework of the role of social capital for health and health promotion. Methods; Data from a social capital survey were used to investigate the associations between individual social capital and self-rated health for men and women and different educational groups. Survey data were also analyzed to determine the association between collective social capital and self-rated health for men and women. A qualitative case study in a small community with observed high levels of civic engagement formed the basis for exploring the role of social capital for community action. Data from the same study were utilized for a grounded theory situational analysis of the social mechanisms leading to social capital mobilization. Main findings; Access to individual social capital increases the odds for good self-rated health equally for men and women and different educational groups. However, the likelihood of having access to social capital differs between groups. The results indicate a positive association between collective social capital and self-rated health for women but not for men. Results from the qualitative case study illustrate how social capital in local communities can facilitate collective actions for public good but may also increase social inequality. Mobilizing social capital in local communities requires identification of community issues that call for action, a fighting spirit from trusted local leaders, “know-how” from creative entrepreneurs, and broad legitimacy and support in the community. Conclusions; This thesis supports the idea that individual social capital is health-enhancing and that strengthening individual social capital can be considered one important health promotion strategy. Collective social capital may have a positive effect on self-rated health for women but not for men and therefore mobilizing collective social capital might be more health-enhancing for women. Collective social capital may have indirect positive effects on health for all by facilitating the ability of communities to solve collective health problems. However, mobilizing social capital in local communities requires an awareness of the risk for increased social inequality.