https://www.mdu.se/

An email-based electronic screening and brief intervention (e-SBI) with personalized normative feedback on alcohol habits was offered to all 3,875 second term students at Linköping University, Sweden. The students received an email with a link to a computerized alcohol habit test and were offered personalized feedback directly on the computer screen. The students evaluated the test and were asked to state whether they were going to consider changing or actually change their alcohol habits. The response rate was 44%, with 742 female and 843 male students participating. The students displayed a strong gender difference in drinking pattern. A three-fold higher percentage of males than females were risky drinkers with regard to a high average weekly volume consumption. The gender differences were less pronounced regarding heavy episodic drinking that was reported by 51% of the females and 70.5% of the males. The email-based computerized normative feedback was appreciated by the students and one-third of the females and one-fifth of the males believed that they would benefit from the normative feedback; 8% of the females and 3% of the males believed that they would actually change their habits after the feedback. Students with a risky drinking pattern, previous experiences of blackouts, being dissatisfied with their current drinking and students that had considered to change their habits before the e-SBI, yielded a stronger motivation to change their drinking after having performed the intervention compared to students without such characteristics. The e-SBI with normative feedback was simple to administer and has the potential to be used repeatedly and on a large scale with minimum effort in terms of cost and time.

Är det mitt eget fel om jag blir sjuk? Har sjukdomar något syfte? Hur mäter man hälsa och livskvalitet? Hur kommer morgondagens folksjukdomar att se ut? Kan man vara fet och ändå ha hälsa?

Att lära sig formulera frågor och att problematisera är en viktig del av träningen i kritiskt tänkande och en viktig grundtanke bakom problembaserat lärande (PBL) som pedagogisk metod.

Frågorna, som boken besvarar, formulerades av studenter i Linköping och ställdes till en tvärvetenskaplig resurspanel bestående av lärare och forskare vid universitetet.

Boken ger en bred introduktion till centrala frågor om människors liv och hälsa och till olika förhållningssätt i dessa frågor. Den riktar sig till studenter både inom hälso- och sjukvårdsområdet och det folkhälsovetenskapliga fältet samt till alla som intresserar sig för hälsa, etik och livskvalitet.

OBJECTIVE: Everyday psychosocial functioning and quality of life are known to be reduced for patients with irritable bowel syndrome (IBS), but few previous studies have analyzed associations with functioning in working life. Accordingly, we examined perceptions of working conditions, functioning in the workplace, quality of life, and psychological complaints among IBS patients compared with age- and sex-matched controls. METHODS: A case-control study design was used based on 347 IBS patients from Swedish general practice who were compared with age- and sex-matched controls (N = 1,041) randomly selected from the general population. A survey was performed including validated questions concerning job strain, quality of life (SF-36 [Short Form 36]), absence because of illness, depression, anxiety, and sleeping habits. RESULTS: The IBS patients reported considerably more often that their daily performance in working life was affected by their gastrointestinal problems (OR [odds ratio] 7.14, 95% CI 5.45-9.36). Male IBS cases only reported less authority regarding decisions on their working pace (OR 5.44, 95% CI 1.28-23.18), while female IBS patients reported less decision authority regarding planning their work (OR 2.29, 95% CI 1.13-4.64), fewer learning opportunities at work (OR 2.12, 95% CI 1.26-3.57), and more long-term sick leave than their controls (OR 3.70, 95% CI 1.94-7.07). The female IBS cases also reported lower quality of life in all dimensions than their controls. CONCLUSION: In particular, female IBS patients reported lower authority over decisions at work and problems in their daily functioning in the workplace. These associations persisted after adjustments for possible confounders such as mood, sleeping problems, and perceived health.

The etiology of irritable bowel syndrome (IBS) tends to be complex and multi-factorial and there is still a lack of understanding of how different psychosocial factors are associated with the syndrome. Our aim was to examine the occurrence of psychosocial and behavioural factors among patients diagnosed with IBS in primary care. The study had an epidemiological population-based case-control design comparing 347 IBS cases to 1041 age and sex matched controls from the general population. A survey was directed to cases and controls based on validated questions asking for mood status, job strain, family history of IBS, and sleeping habits as well as education, nutritional and exercise habits and medication. In multivariate analyses, independent associations were found between IBS and lack of influence on work planning, a family history of IBS, anxiety, and sleeping disturbances. Important factors associated with IBS diagnosis among females were anxiety as well as family history of IBS and lack of co-determination at work. For males, only lack of influence on working pace and family history of IBS remained independently associated with an IBS diagnosis. The causal associations of the complex risk factor panorama for IBS warrants further study. This study indicates that there should be a special focus on investigating the psychosocial working conditions and their associations to IBS.

BACKGROUND: Lifestyle advice given by general practitioners (GPs) may be a cost-effective means of health promotion; however, it is not fully put into routine practice. The aim of this study was to explore to what extent GPs' patients expect and receive advice concerning alcohol, tobacco, exercise and diet in relation to sociodemographic characteristics, type of visit and patient satisfaction. METHODS: A postal questionnaire was sent to a representative sample (n = 9750) of patients who had consulted GPs in a county in Sweden. The response rate was 69% (n = 6734). RESULTS: Exercise was the most (16%) and alcohol the least (5%) common type of advice. The patients received advice more often than they expected in all areas except alcohol. The patients reported the highest rate of unfulfilled advice expectation and the lowest rate of unexpected advice in the case of alcohol. Male gender, poorer self-rated health and scheduled appointment were independent predictors of all types of advice. Continuity of GP contact was only favourable for exercise and diet advice. The patients who received advice were more satisfied with their visit to the doctor. CONCLUSIONS: A tertiary preventive perspective guides GPs' practice of giving advice. Male patients with advanced illnesses are given priority. Women and patients with long-term risk habits are more neglected. The GPs tend to misjudge the expectations and needs of their patients and are too restrained in their counselling practice. Alcohol is the most disregarded area of advice in proportion to the patients' expectations and needs.

Department of Health and Society, Social Medicine and Public Health Science, Linköping University, S-581 83 Linköping, Sweden. kjell.johansson@lio.se

OBJECTIVE: The aim of this study was to explore factors that influence general practitioners' (GPs') decisions regarding screening for high alcohol consumption. METHODS: GPs working at three primary healthcare centres in Sweden participated in focus group interviews. The interviews were recorded and transcribed verbatim, and a deductive framework approach was used for the analysis. RESULTS: The majority of the participating GPs did not believe in asking all patients about their alcohol consumption. Reported factors that influenced how many and which patients were questioned about alcohol consumption were time, age of the patient, consultation setting, patient-physician relationship, what symptoms the patient presented with, and knowledge of measures if patients appear to have a high alcohol consumption. Thus, alcohol screening and intervention were not performed in all patient groups as was originally intended, but were performed in limited groups of patients such as those with alcohol-related symptoms. CONCLUSIONS: Although the number of participants in this study was small and the conclusions cannot be generalized, the results provide some valuable insights into why GPs are hesitant to engage in screening for high alcohol consumption. Since prevention of alcohol-related health problems is an important public health issue, many different screening and intervention strategies have to be formulated and evaluated in order to reach patients with both hazardous and harmful alcohol consumption within the healthcare system. Screening all consecutive patients for a limited period or screening patient groups known to include a fairly high frequency of high alcohol consumers are two ways of limiting the time requirements and increasing role legitimacy. Still, there is a need for a broader public health strategy involving many players in the community in alcohol preventive measures, especially in more primary preventive approaches.

To improve alcohol prevention in primary health care, it has been suggested that primary care nurses are an under-utilised resource. The aim of this study was to identify under what circumstances primary care nurses in Sweden are willing to engage in alcohol prevention. All nurses at three primary health care centres in Ostergötland, Sweden were invited to participate in focus group interviews; 26 nurses participated. The nurses considered primary health care to be just one among other sectors within the community with responsibility for alcohol prevention. The role of health care in alcohol prevention was perceived to be important but mainly secondary preventive. The nurses felt justified screening all patients' alcohol habits only when they could refer to an obligation or a time-limited project. Otherwise, they mainly wanted to engage in screening patients with alcohol-related symptoms or diagnoses and other risk groups. Reasons for refraining from alcohol screening and intervention included lack of self-efficacy, time consumption and fear of harming their relationship with the patient. New strategies for alcohol prevention in primary care are discussed.

Tidigare forskning har visat på samband mellan olika arbetsorganisatoriska faktorer och anställdas hälsa. Dessutom framkommer att både individinriktade och organisatoriskt inriktade hälsoinsatser har betydelse för arbetsrelaterad hälsa. Ett annat resultat som tydliggörs i forskningsöversikter är att hälsointerventioner på arbetsplatsen bör ha en bred ansats, där individinriktade och organisatoriska insatser kombineras, för att vara som mest effektivt. Samtidigt finns det kunskapsluckor gällande vilken typ av hälsoinsatser som arbetsgivare erbjuder sina anställa och i vilken utsträckning utbudet utnyttjas. Arbetsgivares organisatoriska stöd för hälsoarbete är ett annat område som behöver belysas vidare. Avsikten med denna studie är därför att undersöka vilka hälsoinsatser som erbjuds vård- och omsorgspersonal i ett urval av svenska kommuner samt hur det överensstämmer med personalens uppfattningar om arbetsgivarens insatser samt den egna hälsan.

Mer specifikt är syftet med studien att undersöka: (1) arbetsgivarens utbud av hälsofrämjande insatser, (2) sambanden mellan olika typer av hälsofrämjande insatser och självskattad hälsa bland de anställda, (3) sambanden mellan arbetsgivarnas och arbetstagarnas uppfattningar av det hälsofrämjande arbetet. Studien genomfördes genom enkäter till förvaltningschefen respektive arbetstagarna inom vård- och omsorg i ett slumpmässigt urval av 60 av Sveriges 290 kommuner. Arbetsgivarenkäten omfattade: 1) arbetsorganisation 2) verksamhetsstyrning 3) hälso- och arbetsmiljöarbete samt 4) företagshälsovård. Dessa data analyserades sedan i förhållande till tidigare insamlade aggregerade enkätdata från 9 270 anställda beträffande hälsa, sjukfrånvaro samt uppfattningar om det hälsofrämjande arbetet i samma kommuner. Alla analyser genomfördes på kommunnivå med metoder för icke-parametrisk statistik.

Resultaten visar att individuellt inriktade hälsofrämjande insatser är mer vanligt förekommande (finns i c:a 80% av kommunerna) än organisatoriskt inriktade insatser (finns i c:a 50% av kommunerna). Båda typerna av åtgärder är dock relaterade till ett bättre hälsoläge bland personalen. Kommuner med ett bredare utbud av individinriktade hälsofrämjande åtgärder har bättre hälsa bland personalen. Det finns också en överensstämmelse mellan arbetsgivarnas och arbetstagarnas rapportering av utbudet. Av de organisatoriska insatserna så kan förekomsten av särskilt utsedda resurspersoner för hälsoarbete (hälsosamordnare, hälsoombud/ friskvårdsinspiratör) samt genomförandet av lokala hälsoprojekt relateras till de anställdas hälsa. Däremot finns det inget samband mellan detta organisatoriska stöd och hur nöjda arbetstagarna är med arbetsgivarens insatser. Vidare kunde inte chefsstöd för hälso- och arbetsmiljöarbetet relateras till de anställdas hälsa. Det samma gäller förekomsten av mer generella policys och faktorer i organisationsstrukturen.

Denna studie bidrar med kunskap om utbudet av hälsofrämjande insatser samt olika kommunala arbetsgivares sätt att organisera hälso- och arbetsmiljöarbete. Resultaten om att individinriktade insatser är mer vanligt förekommande än organisatoriska insatser överensstämmer med tidigare forskning. Samtidigt kan både individinriktade insatser och organisatoriska insatser relateras till de anställdas hälsa. Dessutom har arbetsgivare med ett mer ambitiöst utbud av insatser ett bättre hälsoläge bland de anställda. Resultaten visar att det finns anledning för arbetsgivare att implementera såväl individinriktade som organisatoriskt inriktade insatser. Resultaten är i linje med teorier om hälsofrämjande arbetsplatser, men har tidigare inte belysts i någon större utsträckning bland ett större antal arbetsgivare i offentlig sektor.

Aim

The aim of this explorative study was to investigate the employers’ management characteristics, their provision of workplace health promotion (WHP) measures, and employee satisfaction with WHP in relation to employee health in Swedish municipal social care organizations.

Subjects and methods

A cross-sectional design was used, and questionnaires were sent to top managers (representing the employer) and employees in a nationwide random sample of 60 of the 290 municipal organizations for the social care of elderly and disabled people in Sweden. The questionnaire data from the 60 managers were linked to aggregated employee data concerning self-rated health and satisfaction with WHP from a representative sample of 8,082 employees in the same organizations. All analyses were performed at the organizational level using independent t-test, Spearman’s rank correlation and multiple linear regression analysis.

Results

In the multivariate analysis, the organizational WHP index (i.e. local WHP projects and WHP coordinators), individual WHP index (i.e. health profile assessment, fitness activities and medical check-up), and the level of employees’ satisfied with WHP were associated with employee health (F = 9.64, p < 0.001, adjusted R² = 0.48). General organizational and management characteristics were, however, not statistically related to employee health.

Conclusion

The results suggest that the provision of individual-directed and organizational-directed health-specific measures were related to employee health in Swedish municipal social care organizations and, therefore, can be part of a comprehensive approach to address WHP.

The aim of this study was to analyze how line and middle managers experience and describe barriers and enablers in the implementation of a health-promoting leadership program in municipal organizations. A qualitative case study design was applied to examine the leadership program in a case involving implementation of an organizational health intervention. Data were mainly collected using semi-structured interviews with line and middle managers participating in the leadership program. Interviews with senior managers, notes from meetings/workshops, and written action plans were used as complementary data. The interview data were analyzed using a thematic analysis, and the complementary data using a summative content analysis. The findings show that the interviewed line and middle managers experienced this leadership program as a new approach in leadership training because it is based primarily on employee participation. Involvement and commitment of the employees was considered a crucial enabler in the implementation of the leadership program. Other enablers identified include action plans with specific goals, earlier experiences of organizational change, and integration of the program content into regular routines and structures. The line and middle managers described several barriers in the implementation process, and they described various organizational conditions, such as high workload, lack of senior management support, politically initiated projects, and organizational change, as challenges that limited the opportunities to be drivers of change. Taken together, these barriers interfered with the leadership program and its implementation. The study contributes to the understanding of how organizational-level health interventions are implemented in public sector workplaces.

BACKGROUND: Previous research indicates that companies manage workplace health in various ways, but more in-depth empirical knowledge of how workplace health promotion (WHP) is managed in public sector organisations is needed.

OBJECTIVE: The aim of this study was to explore how WHP is managed and incorporated into the general management system in two large Swedish municipal organisations.

METHODS: A qualitative descriptive approach was used. Fourteen senior managers were purposefully selected and interviewed using semi-structured interviews. Documents were used as supplementary data. All data were analysed using qualitative content analysis.

RESULTS: The management of WHP was described as a set of components that together contribute to the organisation’s capacity for WHP. The informants described WHP as dominated by fitness programmes and as following a problem-solving cycle, in which the annual employee survey emerged as an important managerial tool. Achieving feasible WHP measures and appropriate follow-ups were described as challenges. The provision of leadership competence for WHP and use of supportive resources were described as additional components.

CONCLUSIONS: The WHP management approach needs to be broadened to include work environment and organisational factors. Further integration with occupational health and safety and the general management system in the organisations is also needed. 

Keywords: integration, management, occupational health and safety, public sector organisation, workplace health

There is abundant documentation in research about the significant relationship between physical activity and mental health, but there is still more to be learned about what can enhance motivation to become more physically active. Fourteen persons with psychiatric disabilities were interviewed about their experiences of being physically active, and data was analyzed using a phenomenologicalhermeneutic method. Five themes emerged: Capability for Living, Liberation from a Heavy Mind, Companionship in Being in Motion, Longing for Living One’s Life, and Struggling with Limitations. The interpreted meaning of being physically active was to be moving toward reclaiming one’s life.

The aim of the study was to survey the self-reported health and physical activity in a sample of community mental healthcare users in a city of Sweden. The study was conducted through a cross-sectional design with participants requested to fill out a self-report questionnaire. Participants (n =103) were persons with psychiatric disabilities living in residential psychiatric settings and/or participating in daily activities provided by community mental healthcare services. The results showed that the group is affected with serious risk factors, such as high body mass index, low rated extent and frequency of physical activity and low self-estimated general state of health. Even though some difficulties associated with the answering process of this questionnaire emerged, these self-reported results clearly confirm the fact that persons with psychiatric disabilities constitute a vulnerable group in need for health-promoting caring activities and interventions.

Purpose - The purpose of this paper is to investigate general psychosocial work conditions and specific workplace health promotion (WHP) measures in relation to employee health and sickness absence in Swedish municipal social care organizations. Design/methodology/approach - In a random sample of 60 out of the 290 municipalities in Sweden, 15,871 municipal social care employees working with elderly and disabled clients were sent a questionnaire concerning psychosocial work environment, WHP, and self-rated health. The responses (response rate 58.4 per cent) were complemented by register data on sickness absence (&amp;gt;14 days). All data were aggregated to employer level. Findings - A structural equation modelling analysis using employer-level data demonstrated that employers with more favourable employee ratings of the psychosocial work conditions, as well as of specific health-promoting measures, had better self-rated health and lower sickness absence level among employees. Practical implications - The results from this representative nationwide sample of employers within one sector indicate that employers can promote employee health both by offering various health-specific programmes and activities, such as work environment education, fitness activities, and lifestyle guidance, as well as by forming a high-quality work environment in general including developmental and supportive leadership styles, prevention of role conflicts, and a supportive and comfortable social climate. Originality/value - This study with a representative nationwide sample demonstrates: results in line with earlier studies and explanations to the challenges in comparing effects from specific and general WHP interventions on health.

Background: Doctors and nurses are two natural partners in the healthcare team, but they usually differ in their perspectives on how to work for increased health. These professions may also have different beliefs about medicines, a factor important for adherence to medicines. The aim was to explore general beliefs about medicines among doctors and nurses.

Methods: Questionnaires were sent to 306 private practitioners (PPs), 298 general practitioners (GPs) and 303 nurses in the county of Västra Götaland, Sweden. The questionnaire included sociodemographic questions and the general part of the Beliefs about Medicines Questionnaire (BMQ), which measures the beliefs people have about medicines in general. General beliefs about medicines in relation to background variables were explored with independent t-tests and ANOVA analyses. Differences between occupations and influences of interaction variables were analysed with multiple linear regression models for general beliefs about medicines.

Results: The data collection resulted in 616 questionnaires (62.1% PPs; 61.6% GPs; 80.5% nurses). The majority of the PPs and 40% of the GPs were male but most of the nurses were female. The GPs' mean age was 47 years, PPs' 60 years and nurses' 52 years. Few nurses originated from non-Nordic countries while 15% of the PPs and 25% of the GPs did. Nurses saw medicines as more harmful and less beneficial than did PPs and GPs. These differences could not be explained by the included interaction variables. GPs with a Nordic background saw medicines as more beneficial and less harmful than did GPs with a non-Nordic background. 

Furthermore, GPs of non-Nordic origin were most likely to believe that medicines were  overprescribed by doctors.

Conclusion: Doctors were more positive about medicines than nurses. The differences in beliefs about medicines found between doctors and nurses could not be explained by any of the included interaction variables. These differences in beliefs may be useful in discussions among future and practising doctors and nurses to enhance understanding of each other's profession and teamwork.

OBJECTIVES: To analyse any association between general beliefs about medicines and self-reported adherence among pharmacy clients. Further, to examine general beliefs about medicines by background variables. METHODS: The data were collected by questionnaires including the general section of the Beliefs about Medicines Questionnaire (BMQ), the self-reporting Medication Adherence Report Scale (MARS) and the following background variables: gender, age, education, country of birth and medicine use. The General BMQ measures beliefs about medicines as something harmful (General-Harm), beneficial (General-Benefit) and beliefs about how doctors prescribe medicines (General-Overuse). RESULTS: Of the 324 participating pharmacy clients, 54% were considered non-adherent. An association was found between General-Harm and adherence. Adherent behaviour and higher level of education were associated respectively with more beneficial and less harmful beliefs about medicines. Those born in the Nordic countries regarded medicines as more beneficial. Current users of herbal medicines and non-users of medicines were more likely to believe that doctors overprescribed medicines. CONCLUSIONS: General-Harm was associated with adherence to medication among Swedish pharmacy clients. Country of birth, education and medicine use influenced beliefs about medicines. PRACTICE IMPLICATIONS: Increased awareness of the patient's beliefs about medicines is needed among healthcare providers. We should encourage patients to express their views about medicines in order to optimize and personalize the information process. This can stimulate concordance and adherence to medication.

 Objective: To analyze differences in general beliefs about medicines between healthcare students and to see if health education was of importance to general beliefs about medicines.

Method: The participants were students of medicine, pharmacy, pharmaceutical bioscience, dispensing pharmacy, nursing and economics (comparison group) at the University of Gothenburg. Data were collected twice in 2003 and 2005. A questionnaire was used comprising background questions and the general part of Beliefs about Medicines Questionnaire.

Results: The questionnaire was completed by 460 of 642 (71.7%) first-year and 293 of 398 (73.6%) thirdyear students. Over 70% were women and two-thirds were under 25 years of age. Medical and pharmacy students saw medicines as less harmful than nursing students did. Stage of education was also important: third-yearmedical and pharmacy students saw medicines as more beneficial and less harmful than firstyear students did. Experience of medicine use was relevant to general beliefs about medicines.

Conclusion: Different beliefs exist between healthcare professions owing to different types and stages of education, which could result in different messages being given to the patient.

Practice implications: It is important to educate future healthcare professionals about the potential effect  of beliefs on communication.

Det be­hövs mer kunskap om hur arbetshälsan på­verkas av ledarskap och organisa­to­riska åtgärder och vilka åtgärder som är mest effektiva. Vid FALF-konferensen 2010 presenterades resultat från en studie om regionala skillnader i sjukfrånvaro hos kommunanställda baserat på personalens perspektiv (Åkerlind I, Ljungblad C, Granström F: Verksamhetsstyrning, arbetsmiljö och hälsa i kommunal vård och omsorg). Dessa resultat visade att skillnaderna mellan kommuner i personalens självskattade hälsa och sjukfrånvaro var relaterad till såväl utbud och deltagande i konkreta hälsofrämjande aktiviteter som till hur nöjd man var med ledarskapet och organisationsklimatet på arbetsplatsen. I det nu aktuella projektet belyses samma förhållanden utifrån vad arbetsgivaren i dessa kommuner rapporterar. Syftet har varit att belysa om arbetsgivare med ett mer aktivt hälso- och arbetsmiljöarbete har ett bättre hälsoläge bland personalen och vilka åtgärder som i så fall har betydelse.

Ett frågeformulär (personalenkäten) med fokus bl.a. på ledarskap, organisationskultur, socialt klimat, hälsofrämjande åtgärder och självskattad hälsa, skickades ut till ett representativt urval av 15 000 anställda inom kommunal vård och omsorg om äldre och funktionshindrade i ett slumpmässigt urval av 60 av Sveriges 290 kommuner. En databas med aggregerade data från frågeformuläret samt registerdata om sjukfrånvaro hos de anställda i de 60 kommunerna konstruerades. Ett annat frågeformulär (arbetsgivarenkäten) skickades till den högsta chefen inom förvaltningen för vård och omsorg i samma kommuner. Denna enkät omfattade 1/ grundläggande fakta om organisationen, 2/ verksamhetsstyrning, 3/ hälso- och arbetsmiljöarbete samt 4/ företagshälsovård. Samband på kommunnivå mellan enkätdata och aggregerade data om personalens hälsa och sjukfrånvaro analyserades med hjälp av icke-parametrisk statistik.

Resultaten från arbetsgivarenkäten visar att varken antalet chefer och anställda eller antalet anställda per chef var relaterat till hälsa och sjukfrånvaro. Inte heller kommunernas ambitionsnivå när det gäller kvalitetsarbete och verksamhetsstyrning i allmänhet hade något samband med utfallsmåtten. Däremot fanns tydliga samband mellan personalens självskattade hälsa och vissa aspekter av kommunens insatser beträffande hälso- och arbetsmiljöarbetet. När det gäller ledningens organisatoriska stöd för personalens hälsa var genomförandet av lokala hälsoprojekt särskilt viktigt. Även förekomsten av särskilt utsedda resurspersoner för hälsoarbetet (samordnare, hälsoutvecklare, hälsoombud, friskvårdsinspiratörer) hade betydelse. Det samma gäller utbudet av konkreta hälsofrämjande åtgärder som riktar sig till individer. Det fanns dessutom en god överensstämmelse mellan arbetsgivarnas och medarbetarnas rapportering om detta utbud, vilket ytterligare understryker dess betydelse. Däremot hade inte förekomsten av skriftlig policy för hälsofrämjande arbete eller olika former av chefsstöd i hälso- och arbetsmiljöarbetet någon betydelse (med undantag för konsultstöd i det systematiska arbetsmiljöarbetet). Alla kommuner var anslutna till företagshälsovård. Förekomsten av rutiner för behovsinventering och uppföljning av företagshälsovårdens insatser var relaterad till lägre sjukfrånvaro.

Undersökningen visar alltså att en hel del av den stora variationen i personalens hälsa mellan olika kommuner kan relateras till arbetsgivarens sätt att organisera hälso- och arbetsmiljöarbete. Kommuner med ett mer aktivt hälso- och arbetsmiljöarbete har ett bättre hälsoläge bland personalen, vilket i sin tur är relaterat till lägre sjukfrånvaro. Såväl individorienterade insatser (brett utbud av hälsofrämjande aktiviteter) som organisatoriskt stöd (lokala hälsoprojekt och resurspersoner för kompetensstöd och samordning i hälsoarbetet) har betydelse. Ett mer genomtänkt och målinriktat sätt att använda företagshälsovården har dessutom ett direkt samband med lägre sjukfrånvaro. Undersökningen visar alltså att det finns starka skäl för arbetsgivarens att tillämpa en medveten och aktiv hälsofrämjande strategi. Resultaten är i linje med aktuella teorier om hälsofrämjande arbetsplatser, men dessa har tidigare inte har kunnat styrkas genom studier av skillnader mellan många olika arbetsgivare i samma bransch.

A comparative study of the social care organizations in a representative sample of 60 out the 290 municipalities in Sweden demonstrates significant associations between the employer’s way of organizing the work and the employees’ health and sickness absence. Specific workplace health promotion measures, as well as leadership styles and social climate are of importance. External structural regional factors such as sociodemography and labour market, as well as sickness absence culture have influence too, however without reducing the association to the internal factors concerning workplace health promotion, leadership and social climate. Accordingly, there are good reasons for employers to engage in health promotion activities both by individual-directed measures and by organizational support. The same is true for a more general developmental and supportive leadership style.

Introduction

Sickness absence is a growing problem in several European countries. It is a complex bio-psycho-social phenomenon determined by factors at the structural, organisational, group and individual levels in addition to the biomedical level. Variation in sickness absence is often studied in relation to social groups, trades and longitudinally but more seldom in a geographic context. In Sweden there are considerable regional differences in sickness absence. The municipalities are employers with an identical assignment all over the country but with large variation in organization and personnel policy as well as in level of sickness absence among their employees. Municipal employees also constitute a vulnerable group with high level of sickness absence. The aim was accordingly to study to what extent the sickness absence differences between municipalities among their employees are determined by organisational factors at the work place and demographic and socio-economic factors respectively.

Material

A random sample of 60 out of Sweden’s 290 municipalities was selected. A questionnaire with focus on perceived organizational climate, social support, supportive leadership, distributive justice, work commitment, stress, health and absence culture was sent out to a representative sample of 15,000 employees in the sector of nursing and social care of elderly and disabled. The response rate was 58.4%. A database of the 60 municipalities was constructed with aggregated questionnaire data and official register data concerning the number and income level of inhabitants, level of expenses for social care and sickness absence among the municipality employees.

Results

Bivariate analyses revealed a lot of significant covariations between perceived organizational climate, social support, supportive leadership, distributive justice, work commitment, stress and health. Absence culture was only related to health. The level of sickness absence was only related to health and absence culture. The socioeconomic and demographic characteristics of the municipalities were not related to the level of sickness absence. In a multiple regression analysis adjusted for income level and number of inhabitants of the municipalities, health and attitude to sickness absence remained as significant predictors of sickness absence level (R²_adj=.19; p=.003).

Conclusions

Although psychological and social factors at work such as organizational climate and leadership characteristics were related to the employees’ health, they did not have an independent relation to sickness absence. Aggregated data of self-rated health is a relevant indicator of organizational health. Absence culture is an important independent determinant of the level of sickness absence.

Verksamhetsstyrning, arbetsmiljö och hälsa i kommunal vård och omsorg

Ingemar Åkerlind, Cecilia Ljungblad och Fredrik Granström

Akademin för hälsa, vård och välfärd, Mälardalens högskola

Bakgrund

Sverige har en lång tradition när det gäller arbetsmiljöarbete. Genom tillämpad forsk­ning och lokalt arbetsmiljöarbete har riskerna för fysiska skador på grund av olycksfall och kemisk exponering reducerats och belast­nings­skador­na minskats. Trots dessa framsteg har den arbets­­­relaterade ohälsan, som bl.a. visar sig i sjukfrånvaro, inte minskat utan snarare tilltagit under flera perio­der under de senaste de­cen­nierna . De insatser som gjorts tycks inte ha varit till­räck­liga för att åstadkomma en hållbar utveckling av hälsan i arbetslivet. Man har därför på många håll börjat komplettera det traditionella arbetsmiljöarbetet med hälsofrämjande inter­­ventioner riktade till såväl individer, grupper som hela organisationen (Källestål, Bjurvald, Menckel et al., 2004; Åkerlind, Schunder & Frick, 2007). Det behövs dock mer kunskap om vilken betydelse sådana mer omfattande strategier har för de anställdas hälsa och sjukfrånvaro.

Forskningen om hälsa och sjukfrånvaro i arbetslivet handlar till stor del om att kartlägga och ana­ly­sera skillnader med sikte på att upptäcka åtgärdbara orsaker. Oftast studeras skill­nader mellan sociala grupper (yrke, utbildning, social klass, kön, etnicitet, ålder m.m.) samt förändringar över tid. Men det kan också finnas en påfallande varia­tion inom olika grupperingar (t.ex. branscher, företag, kommuner, regio­ner) som inte tycks kunna förklaras av kända riskfaktorer (Szücs, Hemström & Marklund, 2003). Bakgrunden till projektet är de påfallande och relativt stabila skillnaderna i sjukfrån­varo mellan Sveriges kommuner (Riksförsäkringsverket, 2003). Skillnaderna i befolkningen kan delvis förklaras av den stora variationen i näringsstruktur, socio­ekonomi och demografi. Ännu större kommunala skillnader har påvisats när det gäller långtids­frånvaron hos den egna personalen (Hemström, 2001). Dessa skillnader är mer svårförklarade eftersom det gäller en mer homogen grupp med likartade uppdrag och arbetsuppgifter över hela landet. Kom­munerna har dock stor frihet i hur de vill organisera sin verksamhet och sin personal­­politik. Därför är det särskilt intressant att undersöka om sådana skillnader kan kopplas till skillnader i hälsa och sjukfrånvaro. Studien motiveras också av att kommunerna generellt har ett sämre hälsoläge och högre sjukfrånvaro än andra arbetsgivare. Det har genom­förts ett stort antal förebyggande och hälso­främjande projekt och interventioner i olika kom­muner, men kunskapen om effekter och ”best practice” fortfarande är begränsad. Vi är särskilt intres­serade av vilken betydelse arbetsgivarens insatser i fråga om ledarskap och organi­sa­­tion har i jäm­förelse med regionala sociodemografiska och kulturella skillnader som arbets­givaren inte kan påverka.  Enligt Dellve, Karlberg och Allebeck et al. (2006) kan yttre socioekonomiska skillnader beträffande arbetsmarknad och attityder till sjukfrånvaro endast förklara en mindre del av den stora variationen i sjukfrånvaro mellan anställda i olika kommuner. De menar att mycket tyder på att interna faktorer som ledarskap, verksamhetsstyrning och organisation har minst lika stor betydelse. Sådana åtgärder kan innebära såväl individorienterade insatser (möjliggöra deltagande i hälsofrämjande aktiviteter och friskvård) som att organisera arbetet och styra verksamheten på ett mer hälsofrämjande sätt (Chu, Breucker, Harris et al., 2000; Shain & Kramer, 2004).

Syftet med detta projekt är att stu­de­ra variationen i hälsa och sjukfrånvaro mellan olika arbets­platser i re­la­tion till skill­na­der i arbets­organisation, ledarskap och verk­sam­hetsstyrning för att klarlägga om arbets­givare med ett mer aktivt hälso- och arbets­miljö­arbete har ett bättre hälso­­läge bland personalen. Här ingår t.ex. effek­ter av ett aktivt per­sonalinriktat arbete med hälso­främjande insatser i orga­ni­sa­tion­en. Det be­hövs mer kunskap om hur mycket av hälsan som kan på­verkas genom organisa­to­riska åtgärder och vilka åtgärder som är effektivast.

Metod

Ett slumpmässigt urval av 60 av Sveriges 290 kommuner genomfördes. Ett frågeformulär med fokus på ledarskap, organisationskultur och klimat, rollförväntningar, grupparbete, socialt stöd och interaktion, krav och kontroll, distributiv rättvisa, empowerment, hälsofrämjande åtgärder och självskattad hälsa skickades ut till ett representativt urval av 15 000 anställda inom kommunal vård och omsorg om äldre och funktionshindrade i de 60 kommunerna. Svarsandelen var 58,4 procent. En ny data­bas med aggregerade data från frågeformuläret samt registerdata om invånar­antal, inkomstnivå samt sjukfrånvaro hos de anställda i de 60 kommunerna konstruerades.

Bivariata korrelationer mellan de oberoende variablerna och de två beroende variablerna hälsa och sjukfrånvaro beräknades. Ett urval av variabler testades sedan som prediktorer av kommunernas hälso- och sjukfrånvaronivå i en strukturell ekvationsmodell (SEM) för att belysa såväl direkta effekter som indirekta effekter via medierande variabler. Valet av oberoende variabler baserades på signifikanta bivariata korrelationer, resultat från tidigare forskning samt egna hypoteser.

Resultat

Den slutliga modellen (se nedan) visar att den självskattade hälsan och sjuk­frånvaron i de olika kommunerna påverkas dels direkt av hur mycket man satsat på konkreta hälso­främjande åtgärder som riktar sig till individer och grupper och dels indirekt av ledarskapet och orga­nisa­­tions­­klimatet i kommunen. Om medarbetarna tycker att de har ett uppmuntrande ledarskap så upplever de också att de har ett positivare socialt klimat på arbetsenheten och att de trivs bättre i arbets­gruppen samt att de har bättre hälsa som i sin tur är kopplad till lägre sjukfrånvaro. Om de tycker att de får mer hjälp och stöd av chefen så upplever de mindre rollkonflikter (t.ex. motstridiga krav från patienter, anhöriga, chefer och media) och då också ett bättre socialt klimat osv.

Not: Kommunstorlek (antal invånare) och skattekraft (inkomstnivå i kommunen) är med i modellen för att kontrollera att inte sådana faktorer påverkar resultatet.

Slutsatser

Resultaten visar alltså att det finns tydliga samband mellan arbetsgivarfaktorer och med­arbetarnas hälsa och sjukfrånvaro. Både konkreta hälso­främjande åtgärder och ledarskap är faktorer som arbetsgivaren borde kunna påverka genom en medveten och aktiv hälso­främjande strategi. Resultaten är i linje med aktuella teorier om hälsofrämjande arbets­platser, men dessa har tidigare inte har kunnat bekräftas genom studier av skillnader mellan många olika arbets­givare. Resultaten har stor relevans för arbetsgivarens verksamhets­styrning och ledning i kommunal verksamhet.

Referenser

Chu C, Breucker G, Harris N et al. (2000). Health promoting workplaces - international settings development. Health Promotion International 15: 155-167.

Dellve L, Karlberg C, Allebeck P et al. (2006) Macro-organisational factors, the incidence of work disability and work ability among the total work force of HCWs in Sweden. Scandinavian Journal of Public Health 34: 17-25.

Hemström, Ö. (2001). Långtidssjukskrivna, förtidspensionärer, långtidsarbetslösa och långtidsfriska. Delstudie 1.1 i Handlingsplan för ökad hälsa i arbetslivet. Stockholm: SOU.

Källestål C, Bjurvald M, Menckel E et al. (Red.). Hälsofrämjande arbete på arbetsplatser. Rapport R 2004:32. Stockholm: Statens folkhälsoinstitut.

Socialdepartementet. (2002). Handlingsplan för ökad hälsa i arbetslivet. Slutbetänkande av HpH-utredningen. SOU 2002:5. Stockholm: Socialdepartementet.

Riksförsäkringsverket. (2003). Regionala skillnader i sjukskrivning - Hur ser de ut och vad beror de på? Stockholm: Riksförsäkringsverket, Enheten för analys.

Shain M & Kramer DM. (2004). Health promotion in the workplace: framing the concept; reviewing the evidence. Occupational and Environmental Medicine 61, 643-648.

Szücs S, Hemström Ö & Marklund S. (2003). Organisatoriska faktorers betydelse för långa sjukskrivningar i kommuner. Solna: Arbetslivsinstitutet.

Åkerlind I, Schunder S, Frick K. (2007) Health and work organization. In U Johanson, G Ahonen, R Roslender (Eds.), Work Health and Management Control. Stockholm: Thomson Fakta.

Kontaktperson: professor Ingemar Åkerlind, tfn 021-10 73 47, ingemar.akerlind@mdh.se

Workplace health promotion and absence culture are more important than structural factors as determinants of local differences in sickness absence among social care employees in Swedish municipals

Background

In Sweden there are large unexplained differences in sickness absence between regions as well as between employers within the same trade. The aim was to study sickness absence differences between municipalities in their social care staff in relation to internal workplace factors as well as external structural factors in the local society.

Method

A questionnaire with focus on perceived organizational climate, health, absence culture and workplace health promotion (WHP) was sent out to 15,871 social care employees in a random sample of 60 out of Sweden’s 290 municipalities. The response rate was 58%. A database of the 60 municipalities was constructed with aggregated data from the questionnaire and official registers.

Results

In a Structural Equation Model analysis, lower sickness absence level was related to internal factors (access to and utilization of a broader repertory of WHP measures, a more restrictive absence culture, and better self-rated health) as well as external structural factors (lower rates of sickness absence in the population). Multivariate analyses indicate that WHP measures was the most important predictor followed by absence culture which, however, was mostly determined by external structural factors such as a more favorable situation concerning prosperity, labour market, and standardized mortality rate in the local society. Better self-rated health was determined by encouraging leadership mediated by better social climate at the workplace.

Conclusions

Although the staff sickness absence level is related to local structural factors beyond the control of the manager such as the level of sickness absence in the general population and the local absence culture, the managers’ measures concerning WHP, leadership and organizational climate matter irrespective of these external circumstances.

Health should be regarded as a dynamic concept referring to the individual’s ability to be active and fulfil his or her vital goals rather than as a negative formulation of biomedical status (absence of disease or infirmity). It reflects continuous coping processes in different circumstances of life. Health is determined by a complex multi-level interplay of structural, environmental, organizational, cultural, and personal factors. According to this systems perspective, it is often more important to focus on higher-level upstream factors such as structural, organizational, and environmental conditions than on lower-level downstream factors such as individual lifestyle and biological conditions. A participative approach aiming at enabling people to increase their control over the determinants of health is essential in order to attain a sustainable improvement of health. This healthy settings approach entails that all systems and structures which govern the social and economic conditions of life should be utilized to promote health. For many people, the working life and the workplace constitute one of the most significant arenas in life. The focus of interventions should be to strengthen people’s own ability to improve their health by creating supportive environments and contexts.

In WHP, there is a need for an organizational approach, as has already been mandated in preventive OHS management. This approach calls for changes in organizational systems that improve an individual’s chance of becoming healthy. The aim is that health becomes an essential issue in the corporate strategy and policy as well as the management control system of the company. WHP ought to be an intrinsic and central part of the organizational system rather than something that is forced through legislation or is the subject of occasional programmes offered to the employees. Health must be considered in its broadest sense, with the realization that the essential parts of organizational workplace health are complex and broad-reaching. However, to accomplish this goal, many of the problems that hinder the recognition of health as a company resource have to be resolved. Our book aims to contribute to this resolution.

There is a growing recognition that health, environment and sustainable development have a crusial significance for the future of the mankind. The problems differ between the industrialized and the developing countries but the globalization process implies an increasing interchange. In some countries, lack of basic services and poverty still constitute the main problems. In other countries, the large-scale, rapid industrialization and urbanization cause new types of hazards. In the industrialized countries, the advances in science, technology, infrastructure and education have resulted in increasing life opportunities for the great majority during the past century. Accordingly, at the same time as the development process may result in considerable gains to people, they also involve new kinds of threats to people’s health and widening health gaps between and within countries.

Environmental factors are a major contributor to ill health all around the world and especially in the poorest regions. Traditional public health risks such as defective food and water, contamination of the environment and inferior sanitation are still prevalent. Moreover, new environment problems have emerged, some of which appear to threaten the entire ecosystem. An improved understanding of the complex relationships between developmental processes, environmental capacity and health is a crucial challenge.

The determinants of health should be regarded as part of an integrated whole in a broader developmental perspective. The settings, in which health is created, such as the work environment, should be considered. The impact on health of the environmental and social consequences of the globalization process (increasing inequalities within and between countries, new patterns of consumption and communication, commercialization, global environmental change, and urbanization) ought to be studied. In conlusion, the economic development, protection of the environment and promotion of public health must be addressed together in an integrated way in practice as well as in research. Sustainability, social justice, equity and human development represent important key concepts in both areas.

In the industrialized countries, the health hazards related to the living conditions and physical environment have been circumscribed by research, welfare reforms, regulations and legislations. However, new kinds of health problems seem to emerge concurrently with the ongoing change of the labour market. The globalization process involve that the traditional manufacturing industry are transferred to low-wage countries. The new jobs (information processing and service work) seem to be characterised by more work overload and job insecurity resulting in more stress symptoms. The prevalence of mental health problems are increasing while the traditional musculo-skeletal disorders remain at a constant high level. This development indicates that the traditional effort concerning occupational safety and health with the focus on individuals and the physical working environment is not sufficient to meet the new spectrum of ill health. It needs to be complemented by a wider public health perspective that integrates the level of the individual with the group, the company or organisation and the society.