'No time for health:' exploring couples' health promotion in Indian slums.

Joint involvement of couples is an effective strategy to increase contraceptive use and improve reproductive health of women. However, engaging couples to understand how their gender attitudes affect their personal and family health is an idea in search of practice. This mixed-methods study explores opportunities and barriers to couples' participation in health promotion in three slums of Delhi. For each couple, surveys and semi-structured interviews were conducted with husbands and wives individually to contrast self and spousal work, time, interest in health, sources of information related to health and depth of knowledge (n = 62). Urban poverty forces men to work long hours and women to enter part-time work in the informal sector. Paid work induces lack of availability at home, lack of interest in health information and in performing household chores and a self-perception of being healthy among men. These factors inhibit men's' participation in community-based health promotion activities. Women's unpaid work in the household remains unnoticed. Women were expected to be interested in and to make time to attend community-based health-related activities. Men recalled significantly less sources of health information than their spouse. Men and their wives showed similar depth of health-related knowledge, likely due to their spousal communication, with women acting as gatekeepers. Health promotion planners must recognize time constraints, reliance on informal interpersonal communication as a source of health information and the need to portray positive masculinities that address asymmetric gender relations. Innovative, continuous and collaborative approaches may support couples to proactively care about health in low-resource settings.

Online sexual victimization in youth: predictors and cross-sectional associations with depressive symptoms.

Aim: The aim was to analyze (i) the prevalence of online unwanted sexual solicitation (USS) victimization, (ii) predictors of online USS and (iii) the associations between online USS and depressive symptoms in Swedish pupils in grades 7-9. Methods: An electronic questionnaire was disseminated in 2011 in schools in a municipality in the northern part of Sweden. Total n = 1193 (boys n = 566; girls n = 627). Logistic regression models were fitted to test the cross-sectional associations between predictors of online USS and depressive symptoms, respectively. Results: One third of girls and every fifth boy reported online USS victimization. In boys, predictors associated with online USS were offline bullying and sexual harassment victimization. Only offline sexual harassment victimization was associated with online USS in girls. Girls victimized by online USS had about twice the likelihood to report depressive symptoms compared to non-victimized girls. There were no associations between online USS and depressive symptoms in boys. While offline bullying was associated with depressive symptoms in both genders, offline sexual harassment victimization increased the likelihood to report depressive symptoms in girls only. Conclusions: Online USS was common among Swedish youth, particularly among girls. Schools, parents and internet safety educators should look at co-occurrence of different forms of victimization as offline victimization was a predictor of online USS. Online USS was associated with depressive symptoms in girls and may hence be a factor driving gender inequity in mental health in youth.

Case fatality of myocardial infarction among shift workers.

PURPOSE: Shift work has been associated with an excess risk of cardiovascular disease (CVD) and more specifically myocardial infarction (MI). The majority of the studies that found a positive association between shift work and CVD have been based on incidence data. The results from studies on cardiovascular-related mortality among shift workers have shown little or no elevated mortality associated with shift work. None of the previous studies have analysed short-term mortality (case fatality) after MI. Therefore, we investigated whether shift work is associated with increased case fatality after MI compared with day workers. METHODS: Data on incident cases with first MI were obtained from case-control study conducted in two geographical sites in Sweden (Stockholm Heart Epidemiology Program and Västernorrland Heart Epidemiology Program), including 1,542 cases (1,147 men and 395 women) of MI with complete working time information and 65 years or younger. Case fatality was defined as death within 28 days of onset of MI. Risk estimates were calculated using logistic regression. RESULTS: The crude odds ratios for case fatality among male shift workers were 1.63 [95 % confidence interval (CI) 1.12, 2.38] and 0.56 (95 % CI 0.26, 1.18) for female shift workers compared with day workers. Adjustments for established cardiovascular risk factors such as diabetes type II and socio-economic status did not alter the results. CONCLUSION: Shift work was associated with increased risk of case fatality among male shift workers after the first MI.

Photovoice: an opportunity and challenge for students' genuine participation.

It has been highlighted that youth empowerment and participation are important principles for school health promotion. Despite this fact, children and youth are rarely given instruments to participate or to influence their situations and the environments in their schools. Photovoice is a method to increased empowerment and participation. Originally it was created as a community action research method based on Freire's critical pedagogy and feminist theory. The purpose of this study was to explore challenges and opportunities for applying photovoice in a school setting to support genuine participation. Together with teachers and students in an upper secondary school in Östersund's municipality in the north of Sweden, the photovoice method was field tested and modified to a classroom situation. The teachers and the students were interviewed about their experiences with the method. The results were interpreted by content analysis and showed that the teachers' capability to be facilitators and the students' possibility to make a difference for the school or the municipality were the most important factors to succeed with photovoice. The conclusions were that photovoice challenges schools and society to have a better structure for genuine participation if youth participation is seen as valuable.

Promoting an equal and healthy environment: Swedish students' views of daily life at school.

Education is an important factor in health equity, but many students still do not complete high school. A focus on the school context rather than on individual problems might help to create a supportive environment for health and learning. In this study we explored factors that promote health and learning from the perspective of vocational and low-achieving high school students in Sweden. We used grounded theory with a constructivist orientation, informed and sensitized by the concept of salutogenesis. Students from a school in a mid-sized municipality in Sweden participated, and we collected data using the photovoice method and interviews. Students identified general factors as significant to their well-being and success in school. The main theme, "promoting driving forces for health and learning," emerged from the categories "longing to be seen by teachers," "longing for support," and "longing for recuperation."

Experiences of Online Sexual Violence: Interviews With Swedish Teenage Girls in Psychiatric Care.

Research about online sexual violence (OSV) is needed to be able to better meet the needs of girls in psychiatric care. The objectives of this study are to explore experiences of online sexual violence among young female psychiatric service users. Interviews with nine girls with psychiatric care needs were analyzed with thematic analysis. The findings are summarized in four themes which contribute to the notion that online sexual violence is only one, albeit important, part of a more complex picture of violence among young girls in psychiatric care. The girls' narratives are shaped by, as well as reproducing gender norms.

Co-occurrence of online and offline bullying and sexual harassment among youth in Sweden: Implications for studies on victimization and health a short communication.

Studies of co-occurrence of online and offline victimisation of bullying and sexual harassment and its associations to mental health outcomes among youth are scarce. To inform future study designs, the aim of this brief communication was to map co-occurrence of online and offline bullying and sexual harassment victimisation among adolescents. Data were collected in 2011 in nine schools in Northern Sweden, n = 1193 (boys = 566; girls = 627). Absolute and relative frequencies were calculated to find combinations of victimisation: one, two, three, or four forms. Reflecting a picture of the early days of online victimisation, in total fifty seven percent (57%) of adolescents were victimised. Single occurrence victimisation was 21.2% (offline sexual harassment was most common irrespective of gender), showing that most youths were victimised in a co-occurrence of two or more forms. Seven percent (7%) were victimised by all four forms of victimisation. Offline sexual harassment victimisation was present in the most common co-occurrences. Directions for future studies of victimisation and its associations to mental health outcomes are discussed.

Deliberate self-harm and associated factors in 17-year-old Swedish students.

BACKGROUND: Deliberate self-harm (DSH) in young people is an important public health issue. To prevent DSH, more knowledge is needed about its prevalence and associated contextual factors in community samples of adolescents. AIMS: To determine the prevalence of deliberate self-harm in 17-year-old Swedish students and to explore the association of demographic variables, psychological distress, experiences of violence, and school-related factors with DSH. METHODS: Data were derived from a cross-sectional study in which 17-year-old students completed questionnaires during school hours (n = 1,663; 78.3%). The variables used in this analysis are as follows: deliberate self-harm, demographic variables, psychological distress, experiences of violence, and school-related factors. Data were analysed using chi-squared statistics and logistic regression. RESULTS: The lifetime prevalence of DSH was 17%, and it was more common among girls (23.3%) than boys (10.5%). There were considerable socioeconomic differences in reports of DSH. Psychological distress was strongly associated with DSH in both boys and girls, as were experiences of bullying, sexual harassment, physical violence and sexual assault. Social support, safety and academic factors in school were related to reports of DSH in both girls and boys. There were some gender differences with respect to which factors were associated with DSH. CONCLUSIONS: Deliberate self-harm is common and more frequently reported by girls than boys. Psychological distress, experiences of different types of violence, and school-related factors (academic, social and safety-related), should be considered risk factors for DSH in young people. Findings can be applied to health-promotion policy and interventions in various contexts, for example schools.

Longitudinal Associations Between Energy Drink Consumption, Health, and Norm-Breaking Behavior Among Swedish Adolescents.

Objectives: To describe the intake of energy drinks (EDs) among a sample of Swedish adolescents while considering health-related variables, and to investigate the longitudinal associations between ED consumption, health, and norm-breaking behavior. Longitudinal studies on this topic are scarce. Methods: Questionnaire data were collected in the northern part of Sweden in 2010-2011 from 1,622 adolescents in grades 6-9. Analyses were performed using a chi-squared test and logistic regression. Results: Seventy-four percent of the boys and 54% of the girls had consumed EDs (P < 0.001). ED consumption was associated with variables related to low health, low support levels, and norm-breaking behavior. The associations were generally stronger among the girls and the boys who consumed EDs at least once a week. ED consumption was a predictor of worse health and norm-breaking behavior 1 year later. Adjusted odds ratios ranged from 1.53 (95% CI: 1.07, 2.20; school-related stress) to 4.88 (95% CI: 2.28, 10.43; gaming-related truancy). Conclusions: Health promotion activities benefit from a broad approach but could focus on girls who consume EDs and those boys with the highest consumption levels.

"You are so ugly, you whore"- girls in rural Sweden discuss and address gendered violence.

Girls face gendered violence on an everyday basis, and this may have severe health consequences. Purpose: The aim of this study was to learn about gendered violence facing girls in rural Sweden in their everyday life, as it is experienced by the girls themselves. Method: Using the photovoice method, we worked with 35 girls in an upper secondary school, aged between 16 and 20, to explore how they navigated social spaces and developed strategies for increased safety. Results: Thematic analysis revealed two main themes (constant fear and strategies) and four sub themes (fear of being raped, fear of being labelled and excluded, being "appropriately" sexually active, and appearance and performance for increased feelings of safety). Conclusion: We considered how gendered violence facing girls led to fear and marginalization in a range of situations and interactions. Consequently, girls occupied significantly smaller social spaces compared to boys, and we argue that this was reproduced and upheld through everyday practices informed by hegemonic masculinity and performativity.

Understanding adolescent mental health: the influence of social processes, doing gender and gendered power relations.

Despite a well-documented gender pattern in adolescent mental health, research investigating possible explanatory factors from a gender-theoretical approach is scarce. This paper reports a grounded theory study based on 29 focus groups. The aim was to explore 16- to 19-year-old students' perceptions of what is significant for mental health, and to apply a gender analysis to the findings in order to advance understanding of the gender pattern in adolescent mental health. Significant factors were identified in three social processes categories, including both positive and negative aspects: (1) social interactions, (2) performance and (3) responsibility. Girls more often experienced negative aspects of these processes, placing them at greater risk for mental health problems. Boys' more positive mental health appeared to be associated with their low degree of responsibility-taking and beneficial positions relative to girls. Negotiating cultural norms of femininity and masculinity seemed to be more strenuous for girls, which could place them at a disadvantage with regard to mental health. Social factors and processes (particularly responsibility), gendered power relations and constructions of masculinities and femininities should be acknowledged as important for adolescent mental health.

Interaction between Shift Work and Established Coronary Risk Factors.

BACKGROUND: Shift work is associated with increased risk of cardiovascular disease, but the causes have not yet been fully established. It has been proposed that the coronary risk factors are more hazardous for shift workers, resulting in a potential interaction effect with shift work. OBJECTIVE: To analyse interaction effects of work schedule and established risk factors for coronary artery disease on the risk of myocardial infarction. METHODS: This analysis was conducted in SHEEP/VHEEP, a case-control study conducted in two counties in Sweden, comprising all first-time cases of myocardial infarction among men and women 45-70 years of age with controls stratified by sex, age, and hospital catchment area, totalling to 4648 participants. Synergy index (SI) was used as the main outcome analysis method for interaction analysis. RESULTS: There was an interaction effect between shift work and physical inactivity on the risk of myocardial infarction with SI of 2.05 (95% CI 1.07 to 3.92) for male shift workers. For female shift workers, interaction effects were found with high waist-hip ratio (SI 4.0, 95% CI 1.12 to 14.28) and elevated triglycerides (SI 5.69, 95% CI 1.67 to 19.38). CONCLUSION: Shift work and some established coronary risk factors have significant interactions.

Ischemic stroke and shift work.

OBJECTIVES: This study analyzed the potential association between shift work and ischemic stroke. METHODS: The analysis was carried out using a nested case-control study consisting of 138 shift workers and 469 day workers from the register of the Northern Sweden Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) study and the Västerbotten Intervention Programme. Logistic regression analysis was used to analyze the risk estimate for day workers in a comparison with shift workers and the risk of ischemic stroke. RESULTS: The crude odds ratio for shift workers' risk of experiencing an ischemic stroke was 1.0 (95% confidence interval 0.6-1.8) for both the men and the women. The risk estimates were consistent despite the introduction of several recognized risk factors for ischemic stroke in the logistic regression models. CONCLUSIONS: In the present study, none of the findings indicated a higher risk of shift workers undergoing an ischemic stroke than day workers.

Participation and support - associations with Swedish pupils' positive health.

From the perspective of salutogenesis, schools have opportunities to create supportive environments for health and well-being, but there is a need for more knowledge about positive health determinants in the school setting. The aim of this study was to analyse adolescents' self-reported positive health and its association with supportive factors in the school environment. Data was derived from a cross-sectional study in which pupils were aged 12-16 (n=1527). A positive health scale was used to examine the association of positive health with the following determinants: classroom participation; teacher support; peer support; parental support; and personal relative affluence. Data was analysed with multiple logistic regression. The results showed that positive health was associated with classroom participation and support from teachers and parents more commonly among boys than girls. All determinants were significantly associated with pupils' positive health. The conclusion is that students' positive health is strongly associated with support from the school. Classroom participation and support are major concerns for the health of pupils, and it is essential to develop these aspects of the school environment.

A non-randomised pragmatic trial of a school-based group cognitive-behavioural programme for preventing depression in girls.

The aim of this study was to investigate the effectiveness of the DISA-programme in preventing depressive symptoms (DS) in adolescent girls, as implemented in a real-world school setting, accounting for baseline socioeconomic and psychosocial factors, and to investigate whether the effects of these baseline variables on DS differed between intervention participants and non-participants. In this non-randomised pragmatic trial, an electronic questionnaire was disseminated in 2011 (baseline) and 2012 (follow-up) in schools in one municipality in northern Sweden. Pupils (total n=275; intervention participants identified in the questionnaire: n=53; non-participants: n=222) were 14-15 years old at baseline. The groups were compared by means of SEM. DISA could not predict differences in DS at follow-up in this real-life setting. In the overall sample, sexual harassment victimisation (SH) at baseline was associated with DS at follow-up and the estimate for SH increased in the DISA-participants compared to the overall sample.

Have you been sexually harassed in school? What female high school students regard as harassment.

The aim of the study was to explore what behaviors experienced from peers and school staff at school are acknowledged as sexual harassment, and perceived as problematic, by female high school students, and what other factors may be relevant. Analyses were performed of responses (to 540 questionnaires) in an anonymous self-report mail survey from a random sample of female Swedish high-school students (59% response rate). Exposure to relevant behaviors, of varying levels of severity, alone, does not explain the acknowledgment of harassment. Many students were subjected to many of the potentially offensive behaviors without labeling them as sexual harassment, despite the fact that they saw many of them as problematic. Further, viewing the relevant behaviors as problems in one's school did not necessarily lead to acknowledging that sexual harassment in general was a problem. However, the behaviors seen as problems were less likely to be dismissed as sexual harassment than personal experiences. This was especially true of the most common behaviors, namely verbal ones. The results demonstrate female students' reluctance to label incidents as sexual harassment, despite the fact that actual behaviors are perceived as environmental problems. Potentially offensive sex-related behaviors become normalized in the school environment and are difficult to address, when little support is provided by schools.

Struggle for time to teach: teachers' experiences of their work situation.

OBJECTIVE: The objective of this study was to from a gender perspective, explore elementary school teacher' experiences of their work situation, and identify conditions that could be health risks. PARTICIPANTS: Eighteen female teachers who work in an elementary school in Northern Sweden. METHOD: Thematic interviews were conducted using an interview guide. The interviews were tape-recorded and transcribed verbatim. Qualitative content analysis was used to analyse the transcribed text and interpretations were made within gender theory. RESULTS: Four categories emerged: "Squeezed between dream and reality", "Effort to keep up with demands", "We can make it together" and "The school needs men's qualities". The categories were linked together with the theme "A struggle for time to teach". The theme describes the conflict between the teachers' ambitions to teach and create a stimulating learning environment versus the increased need for behaviour control that took time from classroom work. Beside work at the school, the teachers carried a large burden of domestic work. CONCLUSIONS: Teachers' work includes both endless demands and great joy. Their work is structured within the schools gender system in which caring duties are subordinated despite a growing demand for behaviour control. Traditional gender roles affect their domestic work load.

Experiences of violence among adolescents: gender patterns in types, perpetrators and associated psychological distress.

PURPOSE: To explore the psychological distress associations of experiences of several types of violence and the victim-perpetrator relationship of physical violence, a gender analysis was applied. METHODS: Data were derived from a cross-sectional questionnaire study among 17-year-old upper secondary school students (N = 1,663). Variables in focus were: self-reported psychological distress, experiences of physical violence, sexual assault, bullying and sexual harassment. Logistic regressions were used to examine associations. RESULTS: Experiences of physical violence, sexual assault, bullying and sexual harassment were associated with psychological distress in boys and girls. The perpetrators of physical violence were predominately males. Whether the perpetrator was unknown or known to the victim seem to be linked to psychological distress. Victimisation by a boyfriend was strongly related to psychological distress among girls. CONCLUSIONS: Experiences of several types of violence should be highlighted as factors associated with mental health problems in adolescents. The victim-perpetrator relationships of violence are gendered and likely influence the psychological distress association. Gendered hierarchies and norms likely influence the extent to which adolescents experience violence and how they respond to it in terms of psychological distress.

Subjective health complaints among boys and girls in the Swedish HBSC study: focussing on parental foreign background.

OBJECTIVE: The general aim of this study was to explore the associations between foreign extraction and subjective health complaints (SHC) among school-aged children in Sweden. METHODS: Data were obtained from the global cross-sectional survey Health Behaviour in School-aged Children (HBSC), 1997/1998, 2001/2002, and 2005/2006. A total of 11,972 pupils in grades 5, 7 and 9 participated in the survey. Logistic regression analyses were used to estimate remaining risk of SHC among the subgroups of pupils. The analyses were adjusted for socio-demographic indicators, grade and measurement year. RESULTS: Parental background: Swedish n = 9,585, mixed n = 1,263, and foreign n = 1,124. The results showed an increased risk of SHC among girls with a foreign background OR 1.27 (95% CI 1.04-1.55) compared with girls with a Swedish background and among girls in single-adult households OR 1.42 (95% CI 1.20-1.67) compared with girls in two-adult households. No such differences were shown among boys. CONCLUSIONS: A significantly increased risk of ill health remained in girls of foreign background after adjustment for socio-demographic indicators, grade and measurement year.