Background: Russia has undergone tremendous socioeconomic transformations. Particularly detrimental was the period of 1990-s that evidenced hazardous trends in public health. Alcohol consumption was suggested to be responsible for the negative health trends in the society. Male alcohol consumption attracted disproportional attention leaving female alcohol consumption, its predictors and influence on women’s health disregarded and uninvestigated. Aim: To describe the practices of female alcohol consumption and socio-demographic predictors of drinking, to explore the impact that drinking might have on the self-rated health of Russian women. Method: Cross-sectional analysis of data drawn from the Russia Longitudinal Monitoring Survey, round 20th. The association tests between the measures of alcohol consumption and covariates were run. Ordinal regression model tested the predictors of self-rated health.      Results: A Russian female drinker is middle-aged, high-educated, married/ cohabiting or divorced, resides from the urban area and is infrequent drinker. The frequency of drinking increases when she is young, high-educated, married/ cohabiting, resides from urban area. U-shaped relation between drinking and self-rated health was demonstrated: never drinkers and regular drinkers report poorer health than seldom-drinkers.  Conclusion: Predictors of female drinking in Russia are poorly investigated due to overrepresentation of research focused on men’s drinking. More studies are needed in order to explore the impact of drinking on self-rated health of  Russian women.

The health of adolescent boys is complex and surprisingly little is known about how adolescent boys perceive, conceptualise and experience their health. Thus, the overall aim of this thesis was to explore adolescent boys’ perceptions and experiences of health, emotions, masculinity and subjective social status (SSS). This thesis consists of a qualitative, a quantitative and a mixed methods study. The qualitative study aimed to explore how adolescent boys understand the concept of health and what they find important for its achievement. Furthermore, the adolescent boys’ views of masculinity, emotion management and their potential effects on wellbeing were explored. For this purpose, individual interviews were conducted with 33 adolescent boys aged 16-17 years. The quantitative study aimed to investigate the associations between pride, shame and health in adolescence. Data were collected through a cross-sectional postal survey with 705 adolescents. The purpose of the mixed methods study was to investigate associations between SSS in school, socioeconomic status (SES) and self-rated health (SRH), and to explore the concept of SSS in school. Cross-sectional data were combined with interview data in which the meaning of SSS was further explored. Individual interviews with 35 adolescents aged 17-18 years were conducted. In the qualitative study, data were analysed using Grounded Theory. In the quantitative study, statistical analyses (e.g., chi-square test and uni- and multivariable logistic regression analyses) were performed. In the mixed method study, a combination of statistical analyses and thematic network analysis was applied. The results showed that there was a complexity in how the adolescent boys viewed, experienced, dealt with and valued health. On a conceptual level, they perceived health as holistic but when dealing with difficult emotions, they were prone to separate the body from the mind. Thus, the adolescent boys experienced a difference between health as a concept and health as an experience (paper I). Concerning emotional orientation in masculinity, two main categories of masculine conceptions were identified: a gender-normative masculinity and a non-gender-normative masculinity (paper II). Gender-normative masculinity comprised two seemingly opposite emotional masculinity orientations, one towards toughness and the other towards sensitivity, both of which were highly influenced by contextual and situational group norms and demands, despite that their expressions are in contrast to each other. Non-gender-normative masculinity included an orientation towards sincerity, emphasising the personal values of the boys. Emotions were expressed more independently of peer group norms. The findings suggest that different masculinities and the expression of emotions are intricately intertwined and that managing emotions is vital for wellbeing. The present findings also showed that both shame and pride were significantly associated with SRH, and furthermore, that there seems to be a protective effect of experiencing pride for health (paper III). The results also demonstrated that SSS is strongly related to SRH, and high SRH is related to high SSS, and further that the positioning was done in a gendered space (paper IV). Results from all studies suggest that the emotional and relational aspects, as well as perceived SSS, were strongly related to SRH. Positive emotions, trustful relationships and having a sense of belonging were important factors for health and pride was an important emotion protecting health. Physical health, on the other hand, had a more subordinated value, but the body was experienced as an important tool to achieve health. Even though health was mainly perceived in a holistic manner by the boys, there were boys who were prone to dichotomise the health experience into a mind-body dualism when having to deal with difficult emotions. In conclusion, this thesis demonstrates that young, masculine health is largely experienced through emotions and relationships between individuals and their contexts affected by gendered practices. Health is to feel and function well in mind and body and to have trusting relationships. The results support theories on health as a social construction of interconnected processes. Having confidence in self-esteem, access to trustful relationships and the courage to resist traditional masculine norms while still reinforcing and maintaining social status are all conducive to good health. Researchers as well as professionals need to consider the complexity of adolescent boys’ health in which norms, values, relationships and gender form its social determinants. Those working with young boys should encourage them to integrate physical, social and emotional aspects of health into an interconnected and holistic experience. / Tonårspojkars hälsa är komplex och det finns förvånansvärt lite forskning gällande hur tonårspojkar uppfattar, konceptualiserar och upplever hälsa. Därför var det övergripande syftet med denna avhandling att undersöka tonårspojkars uppfattningar och upplevelser av hälsa, emotioner, maskuliniteter och subjektiv social status. Denna avhandling består av tre delstudier: en kvalitativ, en kvantitativ och en mixed metod studie. Den kvalitativa studien syftade till att undersöka hur tonårspojkar uppfattar begreppet hälsa och vad de tyckte var viktigt för att uppnå hälsa, samt deras syn på manlighet, känslohantering och potentiell påverkan på deras välbefinnande. För detta ändamål genomfördes individuella intervjuer med 33 unga pojkar i åldern 16-17 år. Den kvantitativa studien syftade till att undersöka sambandet mellan stolthet, skam och hälsa i tonåren, och data samlades in genom en postenkät där 705 ungdomar deltog. Syftet med mixed metod-studien var att undersöka sambanden mellan subjektiv social status (SSS) i skolan, socioekonomisk status (SES) och självskattad hälsa (SRH) samt att undersöka innebörden av begreppet subjektiv social status. Data från en enkät kombinerades med intervjudata av 35 ungdomar i åldern 17-18 år. I den kvalitativa studien analyserades data med hjälp av Grounded Theory metoden. I den kvantitativa studien användes statistiska analysersåsomchi-två-test samt uni- och multivariabel logistisk regressionsanalys. I mixedmetod-studien användes en kombination av statistiskaanalyser ochtematisknätverksanalys. Resultaten visade att det fanns en komplexitet i hur unga pojkar uppfattade, upplevde, hanterade och värderade hälsa. På en teoretisk nivå uppfattade de hälsa som holistisk men när det handlade om att hantera svåra känslor, var de benägna att separera kroppen från sinnet. Således upplevde de en skillnad mellan hälsa som begrepp och hälsa som upplevelse (I). Gällande den känslomässiga maskulina orienteringen, identifierades två huvudkategorier av maskulina föreställningar: könsnormativ och icke-könsnormativ maskulinitet (II). Könsnormativ maskulinitet bestod av två till synes motsatta maskulinitetsorienteringar, en mot tuffhet och den andra mot känslighet, som båda var starkt påverkad av kontextuella och situationella gruppnormer och krav, trots att deras uttryck kontrasterade varandra. Icke-könsnormativ maskulinitet inkluderade en inriktning mot uppriktighet som betonade de personliga värdena för pojkar; känslor kunde uttryckas mer oberoende av kamratgruppens normer. Resultaten tyder på att olika maskuliniteter och känslouttryck är starkt sammanflätade och att känslohantering är avgörande för välbefinnandet. Resultat visade också att upplevelser av skam och stolthet var signifikant associerade med självskattad hälsa, och att stolthet verkar ha en skyddande effekt för hälsa (III). Vidare visade resultaten att det finns ett starkt samband mellan subjektiv social status och självskattad hälsa och att mycket god självskattad hälsa är relaterad till hög subjektiv social status. Positioneringarna gjordes i en starkt genuskodad skolmiljö (IV). Resultat från allastudier visarattde känslomässiga ochrelationellaaspekternavaravgörandeförhälsa, liksomden subjektivt upplevda statussomvar starktrelaterad tillsjälvskattad hälsa. Positivakänslor och tillitsfulla relationer, och att känna tillhörighet och stolthet varviktiga faktorerförhälsa. Fysiskhälsa å andra sidan hadeettmerunderordnat värde menkroppen var ettviktigt verktyg för attuppnåhälsa. Även omhälsauppfattadespå ett holistiskt sätt av de flesta pojkarna, fanns det pojkar som varbenägna att dela upp hälsoupplevelsen i kropp och sinne när det gällde att hantera svåra känslor. Sammanfattningsvis visar denna avhandlingatt den unga, manligahälsantill stor delupplevs genomkänsloroch relationermellanindivider och derassammanhang som är starkt genuskodade. Resultaten stöderteorier omhälsasomensocial konstruktionav sammankopplade processer. Hälsa är att må och fungera bra i kropp och sinne och ha tillgång till tillitsfulla relationer. Att ha självkänsla, tillgång till förtroendefulla relationer och att våga stå emot traditionella maskulinitetsnormer utan att tappa status bidrar positivt till hälsa. Forskare samt yrkesverksamma måste ta hänsyn till komplexiteten i unga pojkars hälsa, där normer, värderingar, relationer och genus utgör dess sociala bestämningsfaktorer. De som arbetar med unga pojkar bör uppmuntra dem att integrera fysiska, sociala och känslomässiga aspekter av hälsa till en sammanlänkad helhetsupplevelse.

A saúde é um dos principais elementos da qualidade de vida dos indivíduos. As pesquisas direcionadas às mulheres a respeito deste tema preocupavam-se quase exclusivamente com os problemas de caráter reprodutivo e doenças ginecológicas. Todavia, nos dias atuais, outros aspectos têm sido estudados em decorrência das mudanças significativas de seu papel na sociedade contemporânea. Além de grande parcela da população feminina estar no mercado de trabalho, elas continuam assumindo a responsabilidade da maternidade e do cuidado da família. Nesse contexto, a autopercepção de saúde vem sendo aplicada como uma das formas de se avaliar o estado de saúde, refletindo os diversos aspectos do estilo de vida. O objetivo deste estudo é investigar os determinantes socioeconômicos, demográfico, nutricional, de saúde e de estilo de vida que interferem na própria percepção de saúde entre mulheres freqüentadoras do Centro de Práticas Esportivas da Universidade de São Paulo (CEPEUSP). Este trabalho foi realizado no âmbito do PRINUTHA e caracterizado como um estudo transversal do tipo exploratório. A amostra foi composta por 162 mulheres adultas e, para associar a autopercepção de saúde com os fatores que poderiam influenciá-la, foi estimada uma regressão logística binária, definindo como variável dependente a autopercepção de saúde e variáveis independentes: idade, escolaridade, estado nutricional, qualidade do consumo alimentar, hábito intestinal e prática de atividade física. A média de idade foi de 31,46 (&plusmn;12,41) anos e de escolaridade 13,77 (&plusmn;2,68) anos. Observou-se que 87% das mulheres auto-avaliaram positivamente sua saúde, 33,4% estavam com excesso de peso, 41,4% apresentaram mau hábito intestinal, 78,4% precisavam melhorar sua alimentação e 69,7% faziam exercícios físicos. O estado nutricional e a atividade física mostraram-se determinantes estatisticamente significantes (p<0,001 e p=0,050, respectivamente), sendo que aquelas com peso normal apresentaram uma probabilidade de 92,7% e as praticantes de 90,1% de terem uma boa percepção de saúde. Portanto, conclui-se que os resultados corroboraram com as políticas públicas e programas estabelecidos pelas organizações mundiais e nacionais a cerca das diretrizes básicas para um estilo de vida saudável. / Health is one of the most important elements of the individuals\' life quality. The researches headed for women regarding this theme used to focus on, almost exclusively, the problems of reproductive and gynecological diseases. Though, nowadays other aspects are subject of studies, due to significant changes of women\'s role in the contemporary society. Besides great portion of the feminine population is on the labor market, they continue taking responsibilities of maternity and family care. In this context, self-rated health status has been applied as one way of evaluating health condition, reflecting several aspects of lifestyle. The aim of this study is to investigate socioeconomic, demographic, nutritional, health and lifestyle determinants that interfere in self-rated health status among women that frequent the Sport Practices Center at the University of São Paulo (CEPEUSP). This work was accomplished under PRINUTHA activities and characterized with a transversal exploring study. The sample was composed by 162 adult women and, in order to associate self-rated health status with factors that could influence it, a logistic binary regression was estimated, defining as dependent variable the self-rated health status and, as independent variables: age, education, nutritional status, quality of the food consumption, intestinal habit and physical activity. The age average was of 31,46 (&plusmn;12,41) years and the education 13,77 (&plusmn;2,68) years. It was observed that 87% of the women self-evaluated their health positively, 33,4% were overweight, 41,4% presented bad intestinal habit, 78,4% needed to improve their diets and 69,7% made physical exercises. The nutritional status and the physical activity were shown statistically significant determinants (p <0,001 and p=0,050, respectively), and those women with normal weight presented a probability of 92,7% and the physically of 90,1% of having a good perception of health. Therefore, results corroborate public policy and the programs established by world-wide and national organizations with respect to the basic guidelines for a healthy lifestyle.

Introdução. Capital social é definido como as características das associações e cooperações humanas que podem ter efeito na saúde. Estudos realizados na última década apontam para uma associação positiva entre maior capital social e melhores indicadores de saúde. Entretanto, algumas características da vizinhança de residência podem atuar como mediadores dessa associação, um tema ainda pouco analisado na literatura científica. Estudos nessa área podem ajudar a melhor entender o efeito do capital social em uma sociedade com altos índices de desigualdade e violência, como é o caso da brasileira. Objetivo. Analisar se as características da vizinhança atuam como mediadores da associação entre o capital social e a autopercepção de saúde. Metodologia. Foram usados os dados da linha de base (2008-2010) do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). O ELSA-Brasil é uma coorte multicêntrica, composta por 15.105 funcionários públicos, ativos e aposentados, de ambos os sexos e com idades entre 35-74 anos vinculados a seis diferentes instituições de ensino e pesquisa brasileiras. As variáveis independentes de interesse foram os domínios de apoio social e de prestígio e educação e de coesão social de vizinhança individual, todos analisados no nível individual. Para a análise dos efeitos da vizinhança foram considerados apenas os indivíduos residentes no mesmo endereço há pelo menos cinco anos. As características de vizinhança estudadas foram: ambiente para atividade física, disponibilidade de alimentos saudáveis, segurança, violência percebida e vitimização. Modelos regressão logísticos foram sequencialmente ajustados para cada uma das características de vizinhança de interesse. Resultados. Os modelos apontam para uma associação consistente entre indicadores mais elevados de apoio e coesão social de vizinhança e melhor autopercepção de saúde, mesmo após o ajuste pelas características do local de residência. Por outro lado, a dimensão referente a prestigio e educação não apresentou uma associação significativa com a situação de saúde em nenhum dos modelos. O apoio social apresentou, na maioria dos modelos, um odds ratio (OR) de 0,81 (95 por cento , IC: 0,69-0,95) em indivíduos com apoio social moderado e OR de 0,62 (95 por cento , IC: 0,52-0,74) em indivíduos com apoio social elevado, mesmo após o controle pelas características da vizinhança. A coesão social da vizinhança também não apresentou modificação em seus efeitos e manteve para a maioria dos modelos um OR de 0,76 (95 por cento , IC: 0,67 0,85) para os indivíduos com coesão social moderada e OR de 0,82 (95 por cento , IC: 0,72 0,93) para os indivíduos com coesão social elevada. Apesar de todas as características de vizinhança terem apresentado associação significativa com a autopercepção de saúde, nenhuma causou modificação significante na associação entre os domínios de capital social e autopercepção de saúde. Conclusão. As características de vizinhança não alteraram significativamente a associação entre capital social e autopercepção de saúde, o que aponta para um efeito do capital social na saúde independentemente das características do local de residência. Entretanto, novos estudos são necessários para que os detalhes dos mecanismos envolvidos, principalmente em relação à possibilidade de causalidade reversa e ao tempo de exposição à vizinhança, sejam plenamente elucidados / Introduction. Social capital can be defined as the characteristics of human associations and cooperation that may have an effect on people\'s health. Studies conducted in the last decade point to a positive association between higher social capital and better health indicators. However, some characteristics of the neighborhood in which people live can act as mediators of this association, an area not yet analyzed in the scientific literature. Studies that analyze this association can help to improve the understanding of the effect of social capital in a society with high levels of inequality and violence, as is the Brazilian society. Objective. The aim of this thesis is to analyze whether neighborhood characteristics act as mediators of the association between social capital and self-perception of health. Methodology. Baseline data (2008-2010) from the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil) was analyzed. ELSA-Brasil is a multi-center cohort of 15,105 active and retired civil servants of both sexes aged between 35-74 years linked to six different Brazilian teaching and research institutions. The multiple variables were the domains of social support, prestige and education and social cohesion of individual neighborhood, all analyzed at the individual level. For the analysis of neighborhood effects, only individuals residing at the same postal address for at least five years were included. The neighborhood characteristics studied were: physical activity environment, availability of healthy foods, safety, perceived violence and victimization. Logistic regression models were sequentially adjusted for each of the neighborhood characteristics of interest. Results. The models point to a consistent association between both higher support indicators and social neighborhood cohesion with better health status, even after adjusting for neighborhood characteristics. On the other hand, the dimension of prestige and education did not present a significant association with health situation in any of the models. Social support presented an odds ratio (OR) of 0.81 (95 per cent , CI: 0.69-0.95) for individuals with moderate social support and an OR of 0.62 (95 per cent CI, CI: 0.52-0.74) for individuals with high social support, even after controlling for neighborhood characteristics. Neighborhood social cohesion also did not presented modifications in its effects and remained stable in most OR models: 0.76 (95 per cent CI 0.67-0.85) for individuals with moderate social cohesion and 0,82 (95 per cent , CI: 0.72-0.93) for individuals with high social cohesion. Although all neighborhood characteristics presented a significant association with self-perception of health, none caused a change in the association between social capital domains and self- perception of health. Conclusions. The results indicate that neighborhood characteristics did not significantly alter the association between social capital and self-perception of health, which points to an effect of social capital on health regardless of neighborhood characteristics. However, new studies are needed in order to fully elucidate the details of the mechanisms involved, especially in relation to reverse causation and exposure time within a neighborhood

A saúde é um dos principais elementos da qualidade de vida dos indivíduos. As pesquisas direcionadas às mulheres a respeito deste tema preocupavam-se quase exclusivamente com os problemas de caráter reprodutivo e doenças ginecológicas. Todavia, nos dias atuais, outros aspectos têm sido estudados em decorrência das mudanças significativas de seu papel na sociedade contemporânea. Além de grande parcela da população feminina estar no mercado de trabalho, elas continuam assumindo a responsabilidade da maternidade e do cuidado da família. Nesse contexto, a autopercepção de saúde vem sendo aplicada como uma das formas de se avaliar o estado de saúde, refletindo os diversos aspectos do estilo de vida. O objetivo deste estudo é investigar os determinantes socioeconômicos, demográfico, nutricional, de saúde e de estilo de vida que interferem na própria percepção de saúde entre mulheres freqüentadoras do Centro de Práticas Esportivas da Universidade de São Paulo (CEPEUSP). Este trabalho foi realizado no âmbito do PRINUTHA e caracterizado como um estudo transversal do tipo exploratório. A amostra foi composta por 162 mulheres adultas e, para associar a autopercepção de saúde com os fatores que poderiam influenciá-la, foi estimada uma regressão logística binária, definindo como variável dependente a autopercepção de saúde e variáveis independentes: idade, escolaridade, estado nutricional, qualidade do consumo alimentar, hábito intestinal e prática de atividade física. A média de idade foi de 31,46 (&plusmn;12,41) anos e de escolaridade 13,77 (&plusmn;2,68) anos. Observou-se que 87% das mulheres auto-avaliaram positivamente sua saúde, 33,4% estavam com excesso de peso, 41,4% apresentaram mau hábito intestinal, 78,4% precisavam melhorar sua alimentação e 69,7% faziam exercícios físicos. O estado nutricional e a atividade física mostraram-se determinantes estatisticamente significantes (p<0,001 e p=0,050, respectivamente), sendo que aquelas com peso normal apresentaram uma probabilidade de 92,7% e as praticantes de 90,1% de terem uma boa percepção de saúde. Portanto, conclui-se que os resultados corroboraram com as políticas públicas e programas estabelecidos pelas organizações mundiais e nacionais a cerca das diretrizes básicas para um estilo de vida saudável. / Health is one of the most important elements of the individuals\' life quality. The researches headed for women regarding this theme used to focus on, almost exclusively, the problems of reproductive and gynecological diseases. Though, nowadays other aspects are subject of studies, due to significant changes of women\'s role in the contemporary society. Besides great portion of the feminine population is on the labor market, they continue taking responsibilities of maternity and family care. In this context, self-rated health status has been applied as one way of evaluating health condition, reflecting several aspects of lifestyle. The aim of this study is to investigate socioeconomic, demographic, nutritional, health and lifestyle determinants that interfere in self-rated health status among women that frequent the Sport Practices Center at the University of São Paulo (CEPEUSP). This work was accomplished under PRINUTHA activities and characterized with a transversal exploring study. The sample was composed by 162 adult women and, in order to associate self-rated health status with factors that could influence it, a logistic binary regression was estimated, defining as dependent variable the self-rated health status and, as independent variables: age, education, nutritional status, quality of the food consumption, intestinal habit and physical activity. The age average was of 31,46 (&plusmn;12,41) years and the education 13,77 (&plusmn;2,68) years. It was observed that 87% of the women self-evaluated their health positively, 33,4% were overweight, 41,4% presented bad intestinal habit, 78,4% needed to improve their diets and 69,7% made physical exercises. The nutritional status and the physical activity were shown statistically significant determinants (p <0,001 and p=0,050, respectively), and those women with normal weight presented a probability of 92,7% and the physically of 90,1% of having a good perception of health. Therefore, results corroborate public policy and the programs established by world-wide and national organizations with respect to the basic guidelines for a healthy lifestyle.

Rowe and Kahns theory of successful aging identifies three main components of aging successfully: reducing the risk of disease and disability, maintaining high cognitive and physical function, and engagement with life. While there is compelling evidence that suggests the legitimacy of this concept in the 50-75 year old community dwelling population, three areas of expansion are necessary: 1.) programmatic research; 2.) extending the existing research samples to include older samples and those living in continuing care retirement communities (CCRCs); and 3.) the integration of data collection and analysis to move beyond investigation of just one successful aging outcome to include elements of all three components of successful aging. Longitudinal analysis utilizing hierarchical linear modeling (HLM) was conducted on a convenience sample of 136 older adults (mean age = 80.8 years at baseline) participating in a pilot community-wide successful aging program over a 26-month period. Results indicate the sample reported exercising frequently, ate recommended levels of fruits and vegetables, had healthy BMIs, had positive ratings of health, were highly involved in productive activities, and were satisfied with their ability to give and receive social support at baseline. High levels of mobility were measured in the sample. Participants maintained this picture of successful aging over time for the majority of outcome variables, though significant declines in self-reported health were observed. Participants also reported improvements in their satisfaction with receiving social support. Results support four major conclusions: 1.) The three criteria of successful aging identified by Rowe and Kahn (1997) were observed among older adults living in CCRCs who were enrolled in a successful aging program. 2.) Stability was observed on a number of the outcomes over 26 months in this convenience sample, which has implications for intervention/programmatic research. Despite the traditional improvement-oriented focus of programmatic research, stability or maintenance of well-being over time should be viewed as a positive outcome in older age, particularly when compared to national data depicting trends of decline. 3.) The interdependence of current results support the notion that successful aging programming needs to include multi-disciplinary intervention strategies, as supported by the finding that modifiers of physical, social, and intellectual well-being include constructs from each of the components of successful aging. 4.) Participants of the current study were largely in the precontemplation and contemplation stages of change. Readiness to change needs to be factored into the design of any successful aging program, as the Transtheoretical Model could be a powerful tool for the identification of readiness to change and the development of appropriate and effective successful aging programming.

<p>This thesis reports on the effects of stress management on long-term pain patients and on a healthy sample from IT and media companies; two groups that are commonly exposed to high stress levels. Even if there are important differences between these two groups, there are similarities such as the necessity for effective stress management. Stress-related and musculoskeletal disorders are major public health issues in most industrialized countries and are expected to become increasingly common during the coming decades. The pathogenic plastic changes in the CNS and immune system caused by long-term stress pose severe burdens to individuals, organizations as well as society in general. Thus, stress management may be essential to maintain and improve long-term health and wellbeing and to proactively counteract stress-related ill-health.</p><p>This thesis is based on four papers: Paper I assessed the effects of massage as compared to relaxation tapes in long-term pain patients. Paper II validated some of the Visual Analogue Scale questions that were to be used in paper III and IV. Paper III assessed the effects on mental and physical wellbeing and biological stress markers from a web-based stress management and health promotion tool. Paper IV aimed at mapping out predictors for trends (improvement vs. worsening) in self-rated health (SRH) over a period of one year.</p><p>The overall results indicate that individually focused stress management interventions in long-term pain patients as well as on a healthy, working population may have short-term beneficial effects on psychological and physiological stress, health and wellbeing. On a long-term basis the beneficial changes seem to revert. In paper four, it is indicated that the stress management intervention is not a significant predictor of long-term changes in SRH. Rather, other factors such as health perception, sleep quality and sense of coherence predicted improvement in SRH over time.</p>

Background: In Sweden, as well as in most Western countries, sickness absence is a major public health problem that has increased in recent years. This is a complex phenomenon related not only to ill health factors, but also to other factors on the levels of the individual, the family, the workplace, and the society. Most studies of sickness absence are cross sectional, which makes it difficult to investigate aetiological factors. A longitudinal study design is preferable, because sick-leave spells can have a long duration and are often due to chronic or recurrent disorders. Objectives: The aim of the present research was to conduct a pilot study to gain further information about factors associated with sickness absence and disability pension, perceptions of contacts with rehabilitation professionals, and self-rated health over time among younger persons initially on sick leave with low-back, neck, or shoulder diagnoses. Material and methods: An eleven-year prospective cohort study of all individuals who, in 1985, were aged 25–34 years, lived in the municipality of Linköping, Sweden, and had a sick-leave spell ≥ 28 days with low-back, neck, or shoulder diagnoses (n = 213, 61% women). The following information was obtained from registers: number of sick-leave days and spells in 1982–1984; diagnosis and demographical data in 1985 (age, sex, occupation, citizenship, marital status, and income); data on each sick-leave period (date, full/part time), disability pension (date, diagnoses, temporary/permanent, full/part time); emigration (date), and death (date, cause) from 1985 to 1 September 1996. In 1996, a questionnaire was sent to members of the cohort (response rate 73%). Different measures were used to analyse sickness absence and disability pension over the eleven-year period, possible risk factors for disability pension were tested by Cox regression, and possible factors predicting future low levels of sickness absence were tested by logistic regression. Based on the questionnaire perceptions of encounters with rehabilitation professionals were analysed with factor analyses and linear regression, and the so called health-line (a method to collect data on self-rated health over time) was tested, and the results were compared with data on sickness absence and disability ension. Results: The members of the cohort turned out to be a high-risk group for disability pension. After 11 years, 26% of the women and 14% of the men had been granted such benefits, mainly due to musculoskeletal diagnoses, but also with psychiatric diagnoses for half of the men and 17% of the women. Full-time pension was granted more often to men than to women. The women had higher levels of sickness absence. An extended Cox regression model proved suitable for prediction of disability pension. Taking citizenship and long-term sickness absence into consideration, the women had a 1.9 times higher risk of being granted disability pension than the men. Predictors for future low levels of sickness absence were a history of low sickness absence, having a white-collar job, and being married. These associations were not discerned when a pathogenic approach was used, which implies that factors other than the opposite risk factor for disability pension are associated with future low sickness absence. Three dimensions of the individuals’ contacts with professionals were identified: supportive treatment, distant treatment, and empowering treatment. Women perceived both social insurance officers and health care professionals as more supportive than the men did. Contact with social insurance officers was experienced as more supportive and empowering by persons on disability pension than by those not receiving such benefits. Data collected using the health-line (i.e., self-rated health from 1985 to 1995) was correlated with data on annual mean number of sick-leave days and days on disability pension. No tendency to recall bias was noted. Conclusions: Additional research is needed to elucidate the situation of women on sick leave with low-back, neck, and shoulder diagnoses. Further testing and practical application of statistical and epidemiological models for analysing sickness absence and disability pension data should be carried out to ascertain the validity and usefulness of such models. / On the day of the public defence the status of the article I was: Submitted; article III was: Accepted; article IV was: Submitted and article V was: In press.

This thesis reports on the effects of stress management on long-term pain patients and on a healthy sample from IT and media companies; two groups that are commonly exposed to high stress levels. Even if there are important differences between these two groups, there are similarities such as the necessity for effective stress management. Stress-related and musculoskeletal disorders are major public health issues in most industrialized countries and are expected to become increasingly common during the coming decades. The pathogenic plastic changes in the CNS and immune system caused by long-term stress pose severe burdens to individuals, organizations as well as society in general. Thus, stress management may be essential to maintain and improve long-term health and wellbeing and to proactively counteract stress-related ill-health. This thesis is based on four papers: Paper I assessed the effects of massage as compared to relaxation tapes in long-term pain patients. Paper II validated some of the Visual Analogue Scale questions that were to be used in paper III and IV. Paper III assessed the effects on mental and physical wellbeing and biological stress markers from a web-based stress management and health promotion tool. Paper IV aimed at mapping out predictors for trends (improvement vs. worsening) in self-rated health (SRH) over a period of one year. The overall results indicate that individually focused stress management interventions in long-term pain patients as well as on a healthy, working population may have short-term beneficial effects on psychological and physiological stress, health and wellbeing. On a long-term basis the beneficial changes seem to revert. In paper four, it is indicated that the stress management intervention is not a significant predictor of long-term changes in SRH. Rather, other factors such as health perception, sleep quality and sense of coherence predicted improvement in SRH over time.

In 2003, the Swedish Parliament adopted a national public health policy that included the domain - “A more health-promoting health service”. Strategies and tools are needed in the work to reorient health services. Personal health documents are documents concerning a person’s health, and are owned by the individual. Several studies that have evaluated such documents indicate that they could be of interest in health-promotion work. However, there is insufficient knowledge concerning personal health documents that target adolescents, and little is known about the feasibility of such documents in a Swedish cultural context. The concept of empowerment is gaining increased interest for health services, but the associations between empowerment, self-rated health and health behaviour are sparsely studied. The overall aim of the thesis is to explore a strategy - empowerment - and a tool - personal health documents - that might facilitate the work of the public health goal of a health-promoting health service. Specific aims are to examine the feasibility of using personal health documents in health promotion; to examine professionals’ experiences of working with health promotion and personal health documents; to examine the association between personal health documents and self-reported health behaviour change; and to examine the perception of empowerment in relation to self-rated health and health behaviour among adolescents. Two personal health documents that targeted adults and adolescents were developed and evaluated. Distribution to adults in different settings was compared in a cross-sectional study (n = 1 306). Adolescents received the document in school, and surveys were performed at baseline and after one year (n = 339). Practical use and attitudes by document owners were studied by questionnaires. Teachers (n = 69) answered a questionnaire, and community health nurses were interviewed (n = 12). The interviews also explored nurses’ experiences of working with health promotion in general, and were analysed by qualitative methodology. Adolescents’ empowerment was examined by a questionnaire (n = 1 046). Most participants reported reading in the documents; writing in the documents varied between 16% (distribution in occupational health) and 87% (adolescents). The health document was perceived as useful by 35% of the adolescents. Factors significantly related to personal usefulness were being born outside Sweden, experiencing fair treatment by teachers, being a non-smoker and having a positive school experience. Community health nurses were striving for a balance of being a doer of practical, disease-oriented tasks and a health-promotion communicator. The structural organisation in health care centres was important for their work with health promotion and the health document. Teachers were generally in favour of continued work with the document. In different settings, between 10% and 26% of adults reported changes in their health situations as a result of reading the booklet. Self-reported changes in health situations were less likely using postal distribution, and there were no significant differences between the other types of distribution. Adolescents with low empowerment scores reported poorer self-rated health and more risk-taking behaviours such as smoking and binge drinking. To conclude, personal health documents are feasible to use in different settings. Health promotion in health services needs active support from leaders as well as adequate support systems. Findings suggest that personal health documents can be tools for promoting self-reported lifestyle changes among adults in different settings. There is a close relation among adolescents between low empowerment in the domain of health, low self-rated health and health behaviours such as binge drinking and smoking.