The purpose of this thesis is to explore the institutionally shaped response to the introduction of the national guidelines on the Swedish regional health policy arena. The thesis consists of two case studies. Adapting a qualitative approach, the data is based on individual interviews and these were analysed thematically. The first paper explores the response by four Swedish regional health authorities to the introduction of the National Guidelines for Cardiac Care, while the second paper aims to broaden the understanding of how the national guidelines are used for strategic purposes among politicians. As illustrated in this thesis, organizations will respond, adjust and react to external pressure according to conditions shaped by the institutional context. Key findings here are that the national guidelines are a complex policy instrument that, beyond being able to be used in an instrumental fashion by the medical managment, can also serve a legitimizing function for political decision-makers. The goals of the national guidelines, i.e. equal and efficient care, and the uncertainty about who, among multiple stakeholders, is responsible for the guidelines in the regional health authority, is a source of ambiguity and potential conflict. Those who are potentially responsible represent different rationales – a political rationale and a scientific rationale. The dominating scientific rationale of the national guidelines can create instability, when pushing towards the use of explicit priority-setting. Priority-setting in the institutional setting of a regional health authority has strong elements of becoming “wicked problems” since the dilemma of prioritization remains regardless of ambitions to apply a “technocratic fix”. A wicked problem is characterized by high complexity and being persistently hard to solve (Williams et al. 2012). A recurring dilemma is that priority-setting still contains many wicked problems, as social values and political considerations remain important parts of the policy process. One weakness of the national guidelines, identified in this thesis, is that the guidelines discuss each service area separately, and thereby reinforce a silo mentality in the Swedish health policy arena. To sum up, the national guidelines create a multifaceted and complex response in the Swedish health policy arena where different rationalities collide, and where conflicts appear and are dealt with within the regional health authorities.

Personer med intellektuell funktionsnedsättning har svårigheter att förstå och tolka hälsoinformation, och har därmed en ökad risk för att drabbas av livsstilsrelaterade sjukdomar. Syftet med denna studie var att beskriva hur personer med intellektuell funktionsnedsättning upplevde att delta i en hälsoutbildning om fysisk aktivitet och hälsosamma matvanor, samt vilka erfarenheter de fått av utbildningen. Studien baserades på ett pilotprojekt, Hälsan spelar roll. En kvalitativ studiedesign användes och data insamlades vid nio semistrukturerade intervjuer, vilka analyserades med kvalitativ innehållsanalys med induktiv ansats. Resultatet visade att studiedeltagarna var nöjda med utbildningen Hälsan spelar roll och de hade utökat sina kunskaper inom hälsa, kost och träning. De upplevde att de hade blivit mer fysiskt aktiva än tidigare och att de förbättrat sina matvanor efter kursen. Studiedeltagarna upplevde att de hade blivit gladare och såg mer positivt på livet. Det upplevdes även stärkande att delta i grupp, vilket motiverade dem till att göra en förändring, och samtidig kunde kursledarna tillgodose deras individuella stödbehov. Att bibehålla nya vanor upplevdes ibland svårt när hälsosamma vanor inte alltid uppmärksammades hemma. Studiedeltagarna verkar uppleva att hälsoutbildningen Hälsan spelar roll kan förbättra deras levnadsvanor. Dock kan det ibland vara svårt för målgruppen att fortsätta med nya vanor efter avslutad utbildning, om stöd saknas. / People with intellectual disabilities can have difficulty to understand and interpret health information, thus having an increased risk of lifestyle related diseases. The aim of this study was to describe how people with intellectual disabilities experienced the participation in a health education program regarding physical activity and nutrition. The study is based on a pilot project, Hälsan spelar roll. A qualitative study design model was used, and data was collected through semi-structured interviews with nine participants and were analysed with content analysis. The study shows that the participants were satisfied with the program, and had increased their knowledge in health, nutrition, and exercise. During the program, they experienced an increase in physical activity levels and improved their nutritional habits. The participants exhibited a more positive outlook on life. They found it uplifting and motivating to participate in a group program, which encouraged them to change, while concurrently allowing the course leader to address their individual needs. Maintaining new habits, could prove challenging for the participants, if their healthy habits are not supported at home. The participants of the program also seemed to experience improvements in their daily habits through their participation in the health program. However, if support is lacking, the target group can have difficulties maintaining their new habits upon program completion.

Background: As overnutrition rises along with nutrition transition in low- and middle-income settings such as Bangladesh, evaluating metabolic risk factors using overnutrition measures in adolescents is important. Before doing such evaluation, a preliminary step should be taken to attest the independence of overnutrition measures from total height. Moreover, sitting height measures are recognized as important metabolic risk indicators. This study aims to understand the association of attained height –total and sitting– with overnutrition measures including body mass index (BMI), percent body fat (PBF), fat mass index (FMI) and fat free mass index (FFMI) and to assess modification by sex. Methods: Cross-sectional analysis of the MINIMat study’s 15-year follow-up data from October 2017 to December 2018 was undertaken. The associations of attained height –total and sitting– with each of the overnutrition measures were analysed using multiple linear regressions. Results: Overnutrition measures were non-independent of total height among male adolescents. The taller they were, the higher their BMI would be. This increase of BMI along with the height would have been contributed relatively more by the increase of fat free mass (FFM) than that of fat mass (FM). When total heights of both sexes were kept equal at the median, female adolescents had lower lean mass (FFMI) and higher fat mass (FMI) than the males although there was no difference in BMI on average between them. Sitting height was associated with all overnutrition measures with varying extents depending on the sex. Conclusion: When assessing overnutrition measures, it is important to examine beyond BMI and into FMI and FFMI. Again, when assessing the metabolic risks using overnutrition measures among adolescents, normalizing those indices for height is important to be considered to avoid inferring the implication from growth as risks.

Introduction: The attention on environmental impact on human health is rising. But, the association between particulate matter 2.5 and birth weight is still not acknowledged in the global burden of diseases, and the association has not yet been studied in the Philippines. The aim was to explore how increasing/decreasing concentrations of particulate matter 2.5 in pregnant women’s residence area was associated with the risk of having a child with low birth weight in the Philippines. Method: 1462 women pregnant in 2016 from the Demographic and Health Survey done in the Philippines in 2017 were analyzed by exposure to particulate matter 2.5 in their residence area. Particulate matter 2.5 was derived from the DIMAQ model, which estimated the annual mean exposure based on a mix of methods. A logistic regression adjusted for demographic variables and variables important for fetal growth, and the birth season was done. Results: The results of the logistic regression when adjusted for all variables showed that the non-statistically significant odds of low birth weight in the children from to the particulate matter 2.5 categories: 7-10 μg/m3, 11-14 μg/m3, and 15-18 μg/m3 were respectively 21% lower (CI: 0.42-1.50), 33% lower (CI: 0.39-1.21) and 34% lower (CI: 0.39-1.14) compared to the highest exposure category of 19-22 μg/m3. Discussion: The study had several limitations in regard to the study design, especially in dealing with seasonal changes in low birth weight. Yet, the study did not disagree with the results from similar studies done in other countries or globally.

Estimates on the prevalence of childhood sexual abuse on boys vary from 8% to 35% globally. These figures are known to be well below the actual numbers that are believed to be much higher than those found in official data. Most cases of childhood sexual abuse are never reported, boys are less likely to report sexual abuse and if they ever do, they do so up to 10-20 years later than girls with similar experiences. This metasynthesis adds to the scarce qualitative literature on coping of male victims. It brings together the types of coping strategies men with histories of childhood sexual abuse use and allows for deeper understanding on how men cope with childhood sexual abuse. Aim: To explore coping strategies used by men who have been affected by childhood sexual abuse  Method: A qualitative metasynthesis Findings: Men affected by childhood sexual abuse reported the use of several coping strategies throughout their lives. These coping strategies were adapted to changes in their social environment. Meaningful inter-personal relationships were found to influence which coping strategies victims would resort to. Not all men felt affected by their experiences of childhood sexual abuse and some reject to be labelled as victims, while others felt empowered by the recognition of their victimhood. Conclusion: Men reported using similar coping strategies in different settings, but with different outcomes. Social support and social awareness about male victimisation were found to affect coping strategies used by men who have been affected by childhood sexual abuse.

Background: Intimate partner violence is a major human rights problem, that affects all sexes of all ages in all societies. Men are the primary perpetrators, and women are more likely to get injured since the violence against women also tends to be more severe. The majority of the perpetrators of violence are in an intimate relationship and in many of the cases, alcohol is a significant contributor to the abuse. Aim: To investigate which societal factors drive and maintain the alcohol-related violence towards women and what coping strategies these women use to handle this form of violence in Livingstone, Zambia. Methods: A qualitative study using semi-structured interviews with 16 Zambian women who had experienced violence by alcohol abusive male partners was conducted. Thematic analysis was used to analyze the data. Results: The results in this study shows that poverty is the source of this form of violence. It is not only the absence of money but also the presence thereof and the way in which this challenges the traditional gender roles. These traditional gender roles are changing because men do not take their responsibilities as providers. Women used emotion-focused and problem-focused strategies to cope with these stressful situations. Conclusion: This study concludes that poverty and the challenging of traditional gender roles perpetuate violence. These women, who are exposed to this violence are reaching out for help but are not getting the help they need, which is partly due to the society’s view of the importance of marriage.

Background: Bangladesh is home to 36 million adolescents with the majority living in rural areas. Adolescence presents an additional window of opportunity to correct nutritional deficits among rural Bangladeshi adolescents. A high-quality, diverse diet is pivotal in this regard. Ultra-processed food (UPF) consumption is an emergent threat to public health. This study aimed to explore dietary diversity (DD) and UPF consumption in terms of gender and socio-economic stratification among rural adolescents in Matlab, Bangladesh. Methods: Adopting cross-sectional design 1441 adolescents were surveyed. Dietary diversity score and ultra-processed food consumption score (UFCS) were constructed through 24-hour recalls. Means and consumption proportions were compared across gender and socio-economic strata. Binary and ordinal logistic regression models were fitted to isolate socio-demographic variables associated with inadequate DD and higher UFCS respectively. Results: 43% of the adolescents had inadequate DD. Pro-boy gap in DD was evident, so was heavy reliance on rice and scant consumption of nutrient-rich foods. UPF consumption was low. Belonging to the richest and to food secure households were associated with lower odds of inadequate DD. Girls were more likely to have inadequate DD but less likely to have higher UFCS. Gender modified the effect of socio-economic status on UPF consumption. Conclusions: The diet of adolescents in Matlab lacked diversity, putting them at significant risk of nutritional deficiencies. Improving their DD requires pragmatic policies and tailored programs to tackle affordability and food insecurity issues, address social norms and intra-household dynamics that favor boys, and sensitize the adolescents to importance of consuming diverse diet. / 15-year Follow-up of MINIMat Trial

Introduction: Sexual and gender-based violence (SGBV) is a violation against human rights with severe implications for the health of women globally. Migrant women may be exposed to a heightened risk of SGBV as well as obstacles that impair their ability to respond to violence and access care. The aim of this meta-synthesis is to explore healthcare providers’ perceptions and experiences of caring for migrant women affected by SGBV in North America and Europe, in order to identify facilitating factors and strategies used to overcome existing barriers to the provision of care. Methods: Systematic searches were conducted between February and April 2019 by using the databases PubMed, Scopus, Applied Social Sciences Index & Abstracts (ASSIA) and Proquest Social Science Premium Collection. Data was analysed using thematic analysis. Results: The ten studies included illustrate perceptions and experiences of healthcare providers from multiple professional backgrounds in the United States, Great Britain and Sweden. Three themes derived from the analysis; (a) Providing a patient-centred care; (b) Knowledge and training-key factors affecting screening and response; and (c) Working under psychologically demanding conditions. Conclusion: Healthcare providers address violence screening and response by adopting a patient-centred approach to care, facilitated by trust-building strategies and external support. However, barriers grounded in a lack of knowledge and training, underline a need of context specific guidelines and screening tools. Further, emotional distress and health issues bring attention to the importance of support mechanisms when caring for migrant women affected by SGBV.

Stressrelaterad ohälsa på grund av brister i den organisatoriska och sociala arbetsmiljön har blivit allt vanligare och utgör idag var tredje sjukskrivning i Sverige. Polismyndigheten är en statlig myndighet som står inför stora utmaningar med hög personalomsättning och hög ärendebelastning. Det finns behov av en djupare kunskap om arbetssituationen för att verka för god arbetsmiljö för de anställda inom myndigheten. Studiens syfte är att undersöka hur brottsutredare upplever sin organisatoriska och sociala arbetsmiljö. En kvalitativ metod användes där datainsamling skedde genom semistrukturerade intervjuer. Urvalet var målinriktat där brottsutredare med varierad yrkeserfarenhet utgjorde deltagare i studien. Det insamlade materialet analyserades genom en manifest innehållsanalys. Resultatet visar på att utredarna upplevde att det fanns organisatoriska brister i kompetensutveckling samt delaktighet i beslut om arbetets upplägg och utförande. Organisatoriska brister upplevdes påverka arbetsklimatet främst genom hög personalomsättning vilket försvårade möjligheterna att skapa funktionella arbetsgrupper. Utredarna ansåg att bättre introduktion för nya medarbetare samt utökade möjligheter till kompetensutveckling skulle förbättra arbetssituationen.

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