Focusing on the 1851 International Sanitary Conference, this dissertation analyses an important episode in the international regulation of health, trade, passengers, and cargo in a period of epidemic crisis. It argues that a group of diplomats and physicians appointed to represent 12 European nations instituted a new international forum that extended – and occasionally rivalled – national and local agencies for epidemic governance. Together, delegates endeavoured to establish a common sanitary policy in Europe and in the Orient. By creating shared surveillance and judicial mechanisms – while standardising definitions and practices – delegates aimed to engineer the flow of people, vessels, cargo, and diseases in the Mediterranean region. As a transnational forum, the Conference was a platform where doctors and diplomats reinterpreted models of public health and sanitary administration while creating institutions that challenged conventional concepts of borders, national policy, and state sovereignty. As a multinational event, the Conference marked the unprecedented transition from local, national and, bilateral public health policies into a coherent transnational project for the governance of epidemics. The dissertation is based on extensive research conducted in hitherto largely unexplored medical, diplomatic, and national collections in Britain, France, Italy, Portugal, Spain, and the United States of America. Sources ranging from diplomatic correspondence to medical publications and personal diaries, tie together multiple national and professional perspectives while untangling a diversity of personal and state agendas that fundamentally shaped the foundation of international public health mechanisms and contributed towards the crystallisation of medical concepts. Chapter one demonstrates how economic and political concerns about the impact of quarantine on international trade led to calls for international regulation and the standardization of quarantine practices in the Mediterranean region. Drawing on medical reports, pamphlets and diplomatic correspondence, the chapter exposes the multitude of quarantine practices in the Mediterranean region and a growing international demand for prophylactic reform. These exchanges, it is shown, culminated with the organization of the 1851 International Sanitary Conference in Paris. Chapter two argues that the Conference challenged previous diplomatic and medical protocols by including two professional groups in the process of regulating international public health. The lack of precedent allowed diplomatic and medical delegates to establish new rules for the conduct of the conference, which gave them a relatively high level of autonomy from the states they represented. Chapter three focuses on the problems of constructing a shared aetiological classification and regulating quarantine practices. It shows that, although doctors gained progressive control over the Conference, ultimately diplomatic agendas shaped the final outcome. In addition, it demonstrates that, rather than defending the elimination of quarantines, liberal states supported the continuation of quarantine practice in the Mediterranean; albeit that they managed to severely limit its operation in practice. Finally, chapter four examines how European and Oriental sanitary institutions were uniformly redesigned and new international judicial mechanisms created. These measures variously affected the sovereignty of the participating states by limiting their independent capacity to set national epidemic policies. However, the chapter argues that these negotiations took the shape of sovereignty bargains: by loosening control over specific elements of their sovereignty, states managed to advance their political, economic and sanitary agendas. By looking at the International Sanitary Conference of 1851, this dissertation shows how the foundations of international public health had consequences not only for the control of epidemic diseases and the circulation of goods and people in the Mediterranean region, but also for the authority and status of the nation states. By doing so, it reveals that international public health governance resulted from the amalgamation of a particular configuration of expert and diplomatic struggles and compromises. Moreover, the dissertation shifts the traditional local and national focus in the history of medicine to a wider and international context where local and national traditions struggled to produce coherent discourses and practices.

There is a robust evidence base for the negative health effects from smoking. Smoking is linked to severe morbidity and to mortality, and kills up to half of its regular users. Tobacco use and production also bring other negative consequences such as economic loss for countries, poverty for individuals, child labour, deforestation and other environmental problems in tobacco growing countries.  A combination of comprehensive interventions at different levels is needed to curb the tobacco epidemic. Tobacco control strategies at national levels in the western world often include components of information/education, taxation, legislative measures and influencing public opinion. Two approaches have dominated at the meso and micro levels: cessation support for tobacco users and prevention activities to support young people refraining from tobacco use. Smoking uptake is a complex process that includes factors at the societal level as well as social and individual characteristics.  At national level, taxation and legislation can contribute to a societal norm opposing tobacco and creating a context for primary prevention aimed at tobacco free youth.  There is no magic bullet in primary prevention.  At the meso and micro levels, a continued development of knowledge on the underlying mechanisms and primary prevention methods is essential to prevent young people from starting to use tobacco.  The overall aim of this thesis was to gain knowledge about factors that influence young people’s use of tobacco and of preventive mechanisms.  The specific aims included to study the relation between Tobacco Free Duo, an intervention program targeting youth in Västerbotten County, and tobacco use prevalence.  A specific interest was to explore the role adults can play in supporting young people to refrain from tobacco use.  The thesis is based on four studies with three separate sets of data, two were quantitative and one was qualitative. The studies were conducted among adolescents (aged 13-15 yr) in Västerbotten County and on national level in Sweden (aged 13, 15 and 17 yr).  Tobacco Free Duo is a school-based community intervention that started in 1993. An essential component of the intervention was to involve adults in supporting adolescents to stay tobacco free. Results showed decreased smoking in adolescents among both boys and girls in the intervention area during the study period of seven years.  There was no change in a national reference group during the same time period. A bonus effect was a decrease in adult tobacco use in the intervention area. One out of four adults who supported a young person taking part in the intervention stopped using tobacco. In a qualitative assessment of young smokers, starting to smoke was described as a means of gaining control of their feelings and their situation during early adolescence. They expected adults to intervene against their smoking and claimed that close relations with caring adults could be a reason for smoking less or trying to quit smoking.  In a quantitative study that used three decades of national data, over time adolescents became more positive toward parental action on children’s smoking. The adolescents strongly supported the idea of parental action, regardless of whether or not they themselves smoked. Adolescents preferred that actions from parents were dissuading their children from smoking, not smoking themselves, and not allowing their children to smoke at home.  These results suggest that the Tobacco Free Duo program contributed to a reduction in adolescent smoking among both boys and girls.  Using a multi-faceted intervention that includes an adolescent-adult partnership can decrease adolescent smoking uptake.  Engaging adults as partners in tobacco prevention interventions that target adolescents has an important tobacco reducing bonus effect in the adults. The intervention has proven sustainable within communities.  A growing majority of adolescents support parental interventions to help them refrain from tobacco.  The findings dismiss the notion that adolescents ignore or even disdain parental practices concerning tobacco. A common and consequent norm against tobacco from both schools and parents using a supportive attitude can prevent tobacco use in young people.

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

Tuberculosis (TB) is a major public health problem in many low- and middle-income countries, including Indonesia. To accelerate TB case detection, and to improve the quality of diagnosis and treatment provided by all providers, the Public-Private Mix for implementing Directly Observed Treatment Short-course (PPM DOTS) was introduced in 2000. However, previous studies on PPM DOTS have focused on private practitioners and there has been a scarcity of research on PPM DOTS in the hospital setting. This dissertation aims to capture the potential of the PPM DOTS strategy, and identify the barriers to its implementation in hospitals in Indonesia. This dissertation is based on four separate but interrelated studies: 1. A costeffectiveness analysis, comparing incremental cost per additional number of TB cases successfully treated under three strategies of PPM DOTS in four provinces. 2. An evaluation of the access to TB services by a cross-sectional study among 62 hospitals, by estimating the proportion of TB cases receiving standardised diagnosis and treatment according to the DOTS strategy. The data were analysed using poststratification analysis. 3. The quality aspect was explored in a multiple-case study, including eight selected hospitals. The data were analysed using cross-case analysis. 4. The process of partnership was explored through a qualitative study. In-depth interviews were conducted with 33 informants, who were actors involved in PPM DOTS in hospitals in Yogyakarta province. Content analysis was applied to the qualitative data. PPM DOTS in hospitals was shown to be a cost-effective intervention in this particular context. However, the quality of the implementation was commonly suboptimal. In addition, a substantial number of TB cases did not get standardised diagnosis and treatment as per the DOTS strategy. The process of creating partnership among hospitals and National TB Programme was shown to be complex and dynamic. Process factors, such as commitment to collaboration and interaction and trust among the actors, were shown to be important. The rapid scaling-up of PPM DOTS in hospitals at the national level in Indonesia should be revisited. Indeed, considering the importance of hospitals in TB control, the implementation should be continued and expanded. However, more attention needs to be given to process, context and governance.

Smoking remains a leading cause of premature, preventable death in South Africa killing 44 000 South Africans each year. Through the introduction of comprehensive tobacco control policies, the South African government has tried to reduce the death toll and a significant reduction in tobacco use has been recorded since its peak in the 1990’s. Smoking among women, however have remained unchanged, which calls for actions. Pregnant mothers are specifically vulnerable as their smoking detrimentally affects their own health as well as the health of their babies. This thesis gives an account of the role the antenatal care system could play in reducing the burden caused by cigarette smoking.   The overall aim was to contribute to an understanding of how a person-centred approach to smoking cessation among disadvantaged pregnant women with high smoking rates may influence smoking behaviour. The specific objectives were to confirm the high smoking rates of the target population, assess their readiness to quit, explore existing barriers and promoting factors towards smoking cessation efforts within the public antenatal health care system, and to qualitatively assess the attitudes and perceptions of disadvantaged pregnant women regarding a personcentred smoking cessation intervention.   The high smoking rates of the target population was confirmed based on a cross-sectional study at antenatal clinics in four main cities of South Africa. It focused on the prevalence of smoking during pregnancy and used the stages of change theory to identify their readiness to quit. Additional questions concerned pregnancy related disease experiences, socio-economic determinants of continued smoking as well as attitudes towards the existing clinic services and its possible role in smoking cessation. A qualitative interview study analyzed more in-depth barriers for two-way communication between pregnant mothers and midwives. Both these studies informed the design and development of a person-centred smoking cessation intervention delivered at four public sector antenatal clinics in Cape Town. The intervention was subjected to a comprehensive evaluation based on a combination of quantitative and qualitative measures. This thesis utilizes data from the qualitative process assessment part, comprising individual interviews and focus group discussions with pregnant women during the implementation period of the intervention.   The survey results pointed out a high prevalence of smoking of 46% amongst disadvantaged pregnant women, with varying readiness for behaviour change. Most women were in the contemplation stage of behaviour change and thus ready to quit. Many of the women felt positive about the role of the midwife as an antenatal care provider, but they did not have confidence in midwives concerning encouraging or supporting women to change addictive behaviour be it smoking, alcohol or other illegal substances. The qualitative research highlighted the need for revised curricula for health education and counselling. The analysis illustrated how the current situation created tension between clinic staff and pregnant women making women feel unworthy and thus leaving little room for changing behaviour. The in-depth interviews and the focus group discussions provided an analytical account of how the person-centred approach in this population was perceived by the women themselves. It illustrated that a multifaceted intervention programme, using peer counselors and educational material designed specifically for a given target population, can successfully bring about behaviour change. The intervention succeeded in shifting women’s perceptions of hopelessness into feelings of being empowered to face their addictions and competent to make a change. Though the intervention meant greater rapport with the midwives, involving peer counsellors was rated highly by the participating women. The women reported having used the educational material and attached a great value to the appropriateness of the material to their life situations, and the effectiveness of having it combined with counselling from a peer counsellor. This qualitative evaluation showed the importance of a multifaceted intervention approach, in helping women identify with their behaviour change.   The thesis highlights the importance of designing smoking cessation interventions that are specific to the needs of target populations. When smoking cessation efforts are included into routine antenatal services it is important that the target group inform the nature and specific components of the intervention.

The aim of this thesis is to contribute to existing knowledge. If the knowledge is not useful in building society it has limited value. In order to be a tool for decision-makers, Preventive Home Visits (PHVs) are described and discussed according to a realist synthesis approach. The premise of this approach is that a single trial cannot tell the whole story and that understanding theoutcome pattern is much more important than seeking regularities in results across different trials. In order to understand the o utcome pattern, the PHV strategy in Nordmaling is examined against other trials and scientific work, and also in grey literature such as reports and workingpapers. An increasing population of seniors means that resources for health and elderly care are being scrutinised in order to achieve the best possible health for the money invested. PHVs represent one strategy that attempts to promote health among independent seniors. This thesis is a multidisciplinary study aiming to gain knowledge about the effects of PHVs and to understand the mechanisms of importance when implementing this particular strategy. The point of departure is a study conducted in Nordmaling in the north of Sweden among healthy seniors aged 75 years and over. The study, conducted as a controlled trial during 2000 and 2001, showed a decrease in mortality as well as the utilisation of care, and an improvement in indicators of perceived health. Cost analyses showed significant savings for the municipality following a reduction in the use of home help. These and other savings combined with costs of the intervention were related to saved life years and used to conduct health economic analyses. Medical and social records from the primary health centre and the municipality, along with official registers provided information for modelling health economic analyses from a lifetime perspective. Results showed that the costs of PHVs were less than 10 000 Euros per gained life year, against an acceptable level of cost effectiveness of 50 000 Euros. Using a shorter time perspective, the result was even more favourable for PHVs. It was evident that the time window used in the analyses, the normative choice of including future healthcare costs or not, and how to handle the value of the seniors’ production were important factors in determining the results. Two years after the trial, in-depth interviews were conducted with 5 seniors who had experienced PHVs, in order to gain understanding of the outcome of the PHV trial in Nordmaling. Participants were selected with respect to their health and how they responded to advice given during the PHV trial. Grounded Theory was used to analyse the interviews. Seniors who used autonomous coping strategies in everyday life gained less from PHVs than other seniors. All participants could benefit from PHVs, but in order for these to be successful it was important for the home visitor to be professional and to understand how the different coping strategies of seniors worked. Taken together, the different aspects of this study raised normative questions that are discussed in this thesis. One, whether the production of seniors has any monetary value in health economic analyses conducted from a societal perspective, was addressed in a smaller diary study where 23 seniors were asked to keep a diary in order to identify everything they did over a oneweek period. It was evident that most of the respondents “produced” a lot, however the production of seniors is rarely taken into account in health economic analyses. The concept of “senior production” includes both the market value of what seniors do, as well as the value of what society can avoid doing if the seniors are independent and healthy.

Background During the 1990s, Tanzania, like many other developing countries, adopted health sector reforms. The most common policy change under health sector reforms has been decentralisation, which involves the transfer of power and authority from the central levels to the local governments. However, while decentralisation of health care planning and priority-setting in Tanzania gained currency in the last decade, its performance has, so far, been less than satisfactory. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority-setting in district health management were studied through action research. As part of this overall project, this doctoral thesis aims to analyse the existing health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness approach to priority setting in Tanzania. Methods A qualitative case study in Mbarali district formed the basis of exploring the socio-political and institutional contexts within which health care decision-making takes place. The thesis also explores how the Accountability for Reasonableness intervention was shaped, enabled and constrained by the interaction between the contexts and mechanisms. Key informant interviews were conducted with the Council Health Management Team, local government officials, and other stakeholders, using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting processes in the district were observed. Main findings The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The findings showed that decentralisation, in whatever form, does not automatically provide space for community engagement. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. In addition, the thesis found that while the Accountability for Reasonableness approach to priority setting was perceived to be helpful in strengthening transparency, accountability, stakeholder engagement and fairness, integrating the innovation into the current district health system was challenging.   Conclusion This thesis underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context, can lead to better prediction of the effects of the innovation, pinpoint stakeholders’ concerns, and thereby illuminate areas requiring special attention in fostering sustainability. Additionally, the thesis stresses the need to recognise and deal with power asymmetries among various actors in priority-setting contexts.

Introduction The human immunodeficiency virus (HIV) epidemic has led to the upsurge of tuberculosis (TB) infection globally, but most especially in areas with high HIV prevalence. In the past, there was lack of a coordinated global and national response between TB and HIV programmes to curb the devastating impacts of both infections. However, the ProTEST Initiative piloted in sub-Saharan Africa in 1997 demonstrated that TB and HIV programmes could collaborate successfully in delivering joint services. This prompted the development of the WHO interim policy on collaborative TB/HIV activities in 2004, aimed at reducing the burden of TB and HIV in populations affected by both infections. This thesis explores how collaborative activities between TB and HIV programmes have been established in Cameroon and implemented in the Northwest Region. It also highlights the achievements and constraints in delivering joint services to TB patients co-infected with HIV. Methods The study was conducted in the Northwest Region, one of the 10 regions of Cameroon with the highest HIV prevalence. The study uses health system research combining qualitative and quantitative methods to explore the research objectives. Qualitative methods were used to capture the perspectives of: i) the service providers; key informants from the central, regional and district levels concerned with the collaboration process and in delivering HIV services to TB patients, and ii) TB patients regarding HIV testing as an entry point to HIV services. Quantitative methods were used to ascertain TB patients’ access to HIV services provided for by the collaboration. Results The study demonstrated that although there were varying levels of collaboration between TB and HIV programmes from the central to operational level in the health system, delivering joint services was feasible. Furthermore, despite the challenges TB patients faced in testing for HIV, overall implementing TB/HIV collaborative activities increased TB patients’ acceptability and accessibility to HIV services. These were facilitated by the improved collaboration at the operational level, and enhanced service provider-patient alliance which was instrumental in building patients’ trust in the health system. Collaboration also led to cross-training and teamwork between staffs from both programmes, and improved networking between service providers and other actors involved in TB and HIV care. Nevertheless, there were health system constraints including inadequate leadership and management, shortage of human and infrastructural resources, frequent interruptions in the supply of essential drugs and laboratory materials Conclusion TB/HIV collaborative activities have improved service delivery and TB patients’ access to HIV services. Nonetheless, appropriate stewardship which guarantees joint planning, monitoring and evaluation of essential activities, and accountability at all levels in the health system is invaluable. Besides, the identified health system constraints which could adversely influence effective joint service delivery and a sustainable collaboration deserve due appraisal. / Introduction L’épidémie du virus de l’immunodéficience humaine (VIH) a conduit à une augmentation globale  de la tuberculose(TB), particulièrement dans les régions à forte prévalence du VIH. Il y’avait par le passé un manque de coordination tant sur le plan mondial que national, des programmes de lutte contre la TB et le VIH pour freiner les effets dévastateurs liés à la co-infection des deux pathogènes. Cependant, l’initiative pilote “ProTEST”  conduite en 1997 en Afrique sub-saharienne  a démontré que les programmes de lutte contre le VIH et la TB pouvaient collaborer avec succès en combinant leurs services. Cette étude pilote a inévitablement incité a un changement de politique du bureau intérimaire a l’Organisation Mondiale de la Santé (OMS), de lutte contre le VIH/TB  à mettre sur pieds en 2004 des objectifs pour la réduction de l’impact du VIH/TB parmi les populations atteintes des deux infections. Cette thèse explore comment la collaboration entre les activités des programmes  de lutte VIH/TB a été établie au Cameroun, et comment son application se fait  dans la région du nord ouest. Il est également mis en exergue et les réalisations les difficultés que rencontrent les services combinés lors de la dispensation des soins aux malades de TB avec une coïnfection au VIH. Méthodes L’étude a été faite dans la région du nord ouest, une des 10 régions du Cameroun, avec le taux de prévalence au VIH le plus élevé. L’étude utilise le système de recherche en santé combinant des méthodes qualitatives et quantitatives pour explorer les objectifs de la recherche. Les méthodes qualitatives ont été utilisées pour enregistrer les données suivantes: i) centre offrant les services combinés; les personnes en charge au niveau central, régional, et des districts, qui sont responsables de l’intégration au processus et qui d’autre part veillent a ce que les malades de TB bénéficient des services du VIH ; et ii) les malades de TB qui considèrent le dépistage du VIH  comme porte d’entrée dans les services VIH. Des méthodes quantitatives ont été utilisées  pour confirmer  l’accès des malades de TB aux soins de services VIH offerts par la collaboration. Résultats L’étude a démontré que bien qu’il y ait  plusieurs niveaux de collaborations entre les programmes de VIH et TB depuis le sommet jusqu’ à la base du  système de santé, la provision de services combinés  est faisable. Malgré les difficultés rencontrées par les malades de TB pour avoir accès au dépistage du VIH, l’application en somme de la collaboration des activités entre les programmes de VIH et de TB a augmenté l’acceptation et l’accessibilité des malades de TB aux services de VIH. Ceci fut facilité par l’amélioration de la coopération au niveau des opérations des deux programmes permettant ainsi  la facilitation de l’établissement d’une alliance entre le personnel de soin et le patient, alliance qui fut primordiale dans l’élaboration du rapport de confiance que le malade doit avoir à l’endroit du system de santé. La collaboration a également conduit  à un travail d’équipe et une formation croisée entre les équipes des deux programmes, il a été également établi une amélioration du réseau d’échange entre les personnels de soins et toutes personnes actives dans le secteur du VIH et TB.    Néanmoins, il a été relevé des défis dans le système de santé telle une insuffisance dans le leadership et la gestion de fréquente interruption dans la chaine de distribution des médicaments essentiels et du matériel de laboratoire. Conclusion La collaboration des activités des programmes VIH/TB a amélioré la qualité des soins et services  avec pour résultante une meilleure accessibilité des malades de TB aux services de VIH. Néanmoins, une conduite appropriée qui garantie une planification mixte, une évaluation et un suivi des activités essentielles, ainsi qu’une gestion fiable a tous les niveaux du système de santé est indispensable. Outre, les difficultés liées au système de santé identifiées par cette étude et qui méritent une évaluation, du fait  qu’elles pourraient affecter négativement l’application effective du but recherché et la collaboration durable entre les deux services.

Background: All over the world men and women show different health patterns, and therecan be many and various reasons for these differences. This thesis therefore evaluates theimpact of gender equality on health. To do this, we must be able to measure gender equality.In this thesis, we develop two new measurements of gender equality and evaluate the relationshipbetween gender equality and health. Methods: Two cross-sectional studies, one register-based and one survey study, are used tocompare different measurements of gender equality and different measurements of health,and the relationship between them. Differences between men and women in relation to healthoutcome are also discussed in the thesis. The register study, comprising 1 097 202 individuals,is based on public registers and includes information on workplace, income, sickness absence,full-time/part-time work, level of education, parental leave and temporary parental leave.A gender equality measurement, the Organizational Gender Gap Index or OGGI, was constructedand 123 companies in two sectors were ranked using the index. Employees in 21 of the mostand least gender-equal companies were invited to participate in a survey. A second genderequality index was constructed based on respondents’ own reports regarding gender equalityin their partner relationship. The variables measured were income, full-time/part-time work,educational level, and responsibilities for and sharing of household duties and parental leave.Both indices were evaluated using the single question: How gender equal is your workplace/your relationship with your partner? The four measurements were dichotomized and testedfor a relationship to health. Health was measured by three different measurements: registerbasedsickness absence, self-reported sickness absence in the past year, and self-rated health. Results: The thesis has produced two new measurements of gender equality, described above.On gender equality in the partner relationship, we found a difference between men and women.Men perceive higher gender equality than they report, while women report more gender equalitythan they perceive. When it comes to gender equality at work, we found that employees perceivetheir company to be more gender equal than the OGGI index shows. This thesis confirms thefindings that men have better health than women regardless of measurement. However, inthis study we also found that increased gender equality decreases these differences. If employeesperceive their company to be gender equal, they have higher odds of rating their health asgood, and this is especially so for women. Conclusion: This thesis supports the hypothesis that differences in health between men andwomen can be related to a lack of gender equality. When men and women have differentpossibilities and power to shape society and their own lives, their health will be affected throughembodiment of both biological and sociological determinants in accordance with the eco-socialtheory. Increased gender equality will decrease the differences in health between men andwomen through convergence. The theory of convergence explains why men and women areaffected differently by greater gender equality. Greater gender equality will also decrease thesocial injustice between men and women and improve justice in accordance with the theoryof justice to gender.The differences found between the indices and the single question on perceived genderequality make clear the need for “hard facts” as an complement to people’s own views on gender equality.

Background: Child sexual abuse is a global public health and human rights concern. Despite beinga crime in most countries, and with well-known physical and mental health consequences, the majority of sexual offences are not reported. Child sexual abuse is a maltreatment form characterized by contact or non-contact acts perpetrated by adults or older children toward younger children who have little power to resist. This thesis aims to understand the social context of child sexualabuse, and the perceived roles of parents, community, and key professionals in handling such incidents in urban Tanzania. Methods: A combination of qualitative and quantitative research designs were applied to four sub-studies performed in Temeke district, Dar es Salaam. Qualititative content analysis was conducted on 23 in-depth interviews to describe the perceptions of key professionals and their experiencesof handling cases of child sexual abuse, in addition, eight in-depth interviews with parents to capture their experiences of legal reporting of child sexual abuse incidents. Grounded theory was used to analyse 13 focus group discussions held with male and female community members to explore norm systems and community awareness related to child sexual abuse. Findings from these exploratory sub-studies paved the way for a school survey among 1359 students from 23 randomly selected secondary schools. Using descriptive statistics and multivariate regression analyses, prevalence, risk factors, and health consequences of child sexual abuse were estimated. Results: Lack of working tools and financial support were perceived as major problems among the key professionals. Corruption at community and institutional levels was seen as jeopardizing justice. Community passivity and lack of knowledge about laws regulating sexual offences were identifiedas additional challenges for conducting fair investigations. The community perspective illustrated that children’s rights were challenged by lack of agency. Community awareness about child sexual abuse was clear but there was also a lack of trust in that the healthcare and legal systems were capable of handling such cases. Myths and cultural beliefs justified abuse. Disclosure of abuse was threatened by fear of stigma and discrimination. Parental interviews identified four types of sexual abuse incidents. The type most strongly associated with a determination to seek justice was one with an innocent child. The youth who was forced into sex elicited feelings of parental betrayal. The consenting, curious youth created uncertainty in how to proceed, while the transactional sex youth evoked feelings of parental powerlessness. Shame and stigma, but also fear of perpetrator retaliation and breach of confidentiality, were seen as challenges for disclosure. The school survey showed that 28% (boys=30%, girls=26%) of the students were exposed to child sexual abuse, with boys more often affected than girls. Twenty-six per cent of boys and 19% of girls reported being forced to look at pornography. Forced sexual intercourse was experienced by 9.8% of boys and 8.7% of girls. Abuse increased with age and diminished self-rated health. Perpetrators were most often neighbours, teachers and peers. In contrast, survivor confidants were most often teachers, family members and friends. Most survivors did not want any action taken for the abuse. Proportions of students who perceived having fair/poor health increased with severity of abuse comparing the none-abused (7.0% and 6.3% of boys and girls respectively) with the ever abused (26% and 41% of boys and girls respectively) and those reporting penetrative sex (35% and 53% of boys and girls respectively). Likewise, suicidal ideation and attempts increased with severity of abuse when compared with those not abused. Conclusions and recommendations: Sexual abuse of children poses a devastating social, and public health challenge. In Tanzania neither the community nor the health or legal institutions are adequately prepared to handle these cases. Educating the community, economically empowering women and strengthening the medico-legal system are needed to increase the opportunity for human,legal and fair investigations and reactions. A national child protection system is needed to address the complexities of abuse at different levels and to safeguard the rights of children in Tanzania.