This systematic review examined literature spanning the last 10 years from Canada, the U.K., the U.S.A., Australia, and New Zealand. Findings highlight the significant gap in comparative literature examining (structural) racism as a determinant of South Asian healthcare access, utilization, and outcomes, and identifies areas of future research to address South Asian health equity concerns. / Background: Race, or specifically racism, has been well-established as a critical determinant of health, though current healthcare practices and policies in Western countries do not adequately address these issues. South Asians are the largest minority group in Canada, and they face disproportionate rates of chronic illnesses, mental health conditions, and barriers to care globally. However, their experiences in healthcare settings and the impact of race and racism on their health equity remain unexplored. This systematic review examined whether race affects healthcare access, utilization, and outcomes of South Asians compared to White-majority populations in Western countries. Methods: Embase, PsycInfo, Ageline, and CINAHL, were searched following PRISMA guidelines, as well as Google Scholar. Articles from 2013-2022 were included if they discussed racism, discrimination, or disparities/inequalities in South Asian physical and mental health, healthcare access, and utilization, outcomes compared to White populations in Canada, the U.K., the U.S.A., Australia, and New Zealand. The Mixed Methods Appraisal Tool (MMAT) was used to assess methodological quality. Data was synthesized narratively. Results: The review included 89 studies from Canada (n=19), the U.K. (n=51), the U.S.A. (n=17), and Australia (n=2), with most studies (n=76) utilizing cross-sectional or cohort designs and examining physical health outcomes (n=50). Study samples predominantly included Indians, Pakistanis, and Bangladeshis over other subgroups. Notably, there was no overall increase in comparative studies over the last decade; however, the U.K. observed an 85% increase compared to an 82% and 64% decrease in Canada and the U.S.A., respectively. The review also identified limited research on experiences within healthcare settings and mental health outcomes, sexual/reproductive health, and all health outcomes for children/youth. Few studies directly discussed the impacts of structural or organizational racism or discrimination on outcomes, though some commented on individual racism as well. Instead, studies relied on the social determinants of health as proxies for structural racism, such as education and income. Conclusion: This review highlights the significant lack of comparative research on the impact of structural, organizational, and individual racism on the healthcare access, utilization, and outcomes of South Asians compared to White-majority populations in Western countries. The review emphasizes the need for more primary, comparative research that quantifies and contextualizes South Asian experiences in obtaining healthcare services. Future research must employ rigorous and representative sampling methods, diverse study designs, and quantitative and qualitative measures that capture implicit, covert, and overt racism in healthcare among South Asians. Additionally, studies should measure factors such as religion, housing, language, and racialized institutional policies, in addition to the typically examined social determinants of health. Finally, this review highlights the need to collect and report disaggregated race and ethnicity health data with input from community leaders, and stratify these data by South Asian subgroups to avoid homogenization of distinct cultures and differential experiences in healthcare systems. Overall, acknowledging racism in healthcare and institutional policies is essential to effectively dismantle these issues and ensure health equity for South Asians. / Thesis / Master of Public Health (MPH)

Abstract The purpose of the study was to broaden understanding of structural racism by examining the relationships between Indigenous peoples and nation-states in the context of education and how this affects Indigenous lives. This thesis delves into understanding both the theoretical and methodological contributions that more critical analyses can have on: the role of de-colonial approaches to Indigenous health research methodologies so that the most urgent health inequities are addressed through more rigorous and Indigenous specific research processes; and to improve our understanding of the complex interactions that historical and contemporary legacies of residential schools and boarding schools have on the health and well-being of Indigenous populations in Canada and Finland. The research design was a qualitative multiple case study informed by a public health critical race praxis. The study was completed in two phases; consisting of a literature study using content analysis of Indigenous research ethics protocols and policies, in Canada and the Nordic countries; and, three case studies developed from open ended questions from structured interview research comparing discriminatory experiences and its impact on self-perceived health with participants from Six Nations of the Grand River, Canada (n = 25) and the Sámi in Inari, Finland (n = 20); and their family members. The case studies were analyzed using both Western and Indigenous methodologies. Results of Phase one shows how Indigenous resistance to colonial structures within academia in Canada and Finland has resulted in dialogical processes to create an ethical space for working between the differing worldviews of academia and Indigenous communities with the aim to produce ethically valid knowledge. Phase two results shows that regardless of contextual differences of the experiences in Canada and Finland, the main parallel outcomes are similar, i.e. the teachings of shame received in these educational environments. This produces both vulnerabilities and resiliencies and the negative effects of shame require an ongoing healing journey for both individuals and their families and communities at large. Conclusion: For a more in depth understanding of structural racism and its influence on Indigenous health, investigations require methodological choices by both Western and Indigenous methodologies. / Tiivistelmä Tutkimuksen päämääränä on tuottaa tietoa rakenteellisesta syrjinnästä. Tämä tapahtuu tutkimalla alkuperäiskansojen ja kansallisvaltioiden välisiä suhteita koulujärjestelmissä sekä sitä, miten rakenteellinen syrjintä vaikuttaa alkuperäiskansojen jäsenten elämään. Tutkimuksen kriittinen analyysi tuottaa dekoloniaalisia lähestymistapoja terveystutkimuksen menetelmiin, jolloin tärkeimmät terveyserot paljastuvat alkuperäiskansalähtöisten tutkimusprosessien kautta. Tutkimus pyrkii lisäämään ymmärrystä siitä, millaisia väliaikaisia sekä nykypäivään asti ulottuvia vaikutuksia sisäoppilaitoksilla ja kouluasuntoloilla on ollut Kanadan ja Suomen alkuperäiskansojen jäsenten terveyteen ja hyvinvointiin. Väitöskirjan tutkimusasetelma on laadullinen monitapaustutkimus, jossa sovelletaan Critical Health Praxis (PHCR) -menetelmän viitekehystä. Tutkimuksen ensimmäisessä osassa vertaillaan laadullisen sisällönanalyysin avulla Kanadan ja Pohjoismaiden alkuperäiskansojen tutkimuseettisiä käytäntöjä ja menettelytapoja. Toisessa osassa on kolme tapaustutkimusta, jotka perustuvat strukturoidun kyselytutkimuksen avovastausten syrjintäkokemuksiin ja niiden vaikutuksiin itsekoettuun terveyteen Kanadan ensimmäisten kansojen jäsenillä (Six Nations of the Grand River, n = 25) sekä Suomen saamelaisilla (Inarin kunta, n = 20). Tapaustutkimuksissa sovelletaan alkuperäiskansalähtöisiä ja länsimaisia tutkimusmenetelmiä. Tulokset osoittavat, että alkuperäiskansojen vastustus kolonialistisia akateemisia rakenteita kohtaan Suomessa ja Kanadassa on synnyttänyt dialogisia prosesseja, joiden avulla voidaan luoda eettistä tilaa tiede- ja alkuperäiskansayhteisöjen maailmankuvien yhteensovittamiseksi ja eettisesti hyväksyttävän tiedon tuottamiseksi. Toisen vaiheen tulokset osoittavat, että vaikka Kanadan sisäoppilaitosten ja Suomen kouluasuntoloiden yhteiskunnalliset lähtökohdat ja käytännön toteutustavat eroavat toisistaan, lopputulos on samansuuntainen: kouluympäristön aiheuttama häpeä, joka tuottaa sekä haavoittuvuutta että resilienssiä. Kielteisten kokemusten työstäminen vaatii pitkää, parantavaa prosessia, joka koskee niin yksilöitä, perheitä kuin yhteisöjäkin. Johtopäätöksenä todetaan, että tarvitaan sekä länsimaisia että alkuperäiskansalähtöisiä tutkimusmenetelmiä, jos halutaan ymmärtää syvällisesti rakenteellista syrjintää ja sen vaikutuksia alkuperäiskansojen terveyteen ja hyvinvointiin.

Maternal Mortality Rate (MMR) in Ethiopia remains one of the highest in the world due in part to very limited use of maternal health services. However, the underlying factors for limited use of the services and hence the high MMR are not well known. The purpose of this study was to identify factors associated with use of maternal health services and maternal health risks, to analyze inequity patterns between use of maternal health services and maternal health risks, and to measure the magnitude and trends in inequity. Behavioral-cultural and structural theories of health inequalities were used to frame the study. Research questions included whether there were trends of inequity in use of maternal health services, if sociodemographic characteristics were associated with use of the services, and whether inequities in use of the services were associated with maternal health risks. The study design was quantitative and used data collected through Demographic and Health Surveys (DHS) conducted in 2000, 2005, and 2011. DHS had employed stratified 2-stage cluster design; this analysis used logistic regression method, odds ratio chi-square test, and correlation measures. The findings indicated statistically significant inequities on use of antenatal care and skilled birth attendant services associated with women's residence, level of education, income, administrative region, distance to a health facility, out-of-pocket payment for health services, and involvement in decision making. Based on the findings, it is recommended to design maternal health policies and programs that improve access and use of the services, specifically for women in rural areas, with no education and with limited economic capacity. Further research is also recommended for regions where sample size was limited. Maternal health policies and programs designed to reach the most disadvantaged women could increase service use and improve maternal health, leading to positive social change.

Unaccompanied children are at greater risk of developing mental illness, compared with children who have migrated with guardians. Several of the unaccompanied children who came to Sweden in 2015 turned 18 before they received a decision in their cases. They therefore were considered adults and were at risk of deportation. Changes in the law by SFS 2018:755 and SFS 2018:756 was introduced to give the young adults another opportunity to stay. The main purpose of the present study was to shed light on young adult’s, previously unaccompanied children’s, experiences of mental health in general, and to discover how the law changes has affected the mental health specifically in the county of Västmanland. A sub purpose was to discover the need for support. The study had a qualitative approach and consisted of 10 interviews with young adults who came to Sweden as unaccompanied minors. A manifest content analysis resulted in four categories; life in limbo, high demands and no control, support and help, and strategies for coping with everyday life. The results indicate that the uncertainty has contributed to worsening mental health. Furthermore, the law changes and the circumstances, such as lack of housing and time pressure, seem to have contributed to even more stress and anxiety. Lack of support may have worsened the already vulnerable situation. The young adults do not request any particular support at present. However, it appears they are experiencing difficulties finding employment, which is one of the demands by the new law. / Ensamkommande barn har större risk att drabbas av psykisk ohälsa, jämfört med barn som migrerat med vårdnadshavare. Till följd av långa handläggningstider hann flera av de asylsökande barnen som kom till Sverige under 2015 fylla 18 år innan de fått beslut i sina ärenden. De betraktades därav som vuxna, varför många riskerade utvisning. Den nya gymnasielagen infördes för att ge dem chans att stanna. Lagen innebar dock svåruppnåeliga krav för de redan utsatta ungdomarna. Föreliggande studies huvudsyfte var att belysa unga vuxnas, tidigare ensamkommande barns, upplevelser och erfarenheter av psykisk ohälsa generellt, och hur den nya gymnasielagen har påverkat den psykiska hälsan hos individerna specifikt i Västmanland. Ett delsyfte var att kartlägga vilket behov av stöd de anser att de har behövt och hur behovet ser ut framgent. En kvalitativ ansats tillämpades för genomförandet. Studien utgörs av 10 intervjuer med unga ensamkommande. En manifest innehållsanalys av det insamlade materialet resulterade i fyra kategorier; liv i limbo, höga krav och ingen kontroll, stöd och hjälp samt strategier för att klara vardagen. Resultatet tyder på att ovissheten som har präglat ungdomarnas tillvaro har bidragit till försämrad psykisk hälsa. Vidare tycks den nya gymnasielagen och de bristande förutsättningarna, såsom avsaknad av bostad och orimlig tidspress, bidragit till än mer stress och oro. Bristande stöd från myndigheter med flera kan ha försvårat den redan utsatta situationen för det ensamkommande unga. De unga vuxna efterfrågar i nuläget inget specifikt stöd. Dock framkommer att de upplever svårigheter att erhålla en fast anställning, vilket är ett krav i den nya gymnasielagen.

Introduktion: Digitalisering är en pågående process i samhället som berör många aspekter relaterat till folkhälsa. Samtidigt är folkhälsovetare, folkhälsoarbetet eller folkhälsoperspektivet vaga beskrivet i policys och vetenskaplig litteratur rörande ämnet digitalisering och folkhälsa. Tidigare forskning har även belyst hur digitaliseringen främst inkluderat tekniska och ekonomiska perspektiv med brist på sociala, kulturella och politiska perspektiv.  Syfte: Studiens syfte var att beskriva folkhälsovetares uppfattningar och erfarenheter kring implementering och nyttjande av digitala verktyg i folkhälsoarbetet på kommunal och regional nivå i norra Sverige.  Metod: En kvalitativ intervjustudie med semistrukturerade intervjuer genomfördes med åtta folkhälsovetare på kommunal och regional nivå i norra Sverige. En manifest innehållsanalys med induktiv ansats användes för att analysera materialet.  Resultat: Resultatet bestod av 4 kategorier och 14 subkategorier som beskrev deltagarnas olika erfarenheter och uppfattningar. Kategorin Erfarenheter och användningsområden beskrev de varierande erfarenheterna som deltagarna besatt samt inom vilka användningsområden deltagarna nyttjade eller önskade nyttja digitala verktyg. Kategorierna Politik och resursfördelning samt Behov beskrev de förutsättningar som deltagarna betraktade som betydelsefulla för att kunna nyttja digitala verktyg i folkhälsoarbetet. Sista kategorin God och jämlik hälsa beskrev de möjligheter och utmaningar som deltagarna uppfattade med att nyttja digitala verktyg i folkhälsoarbetet för att uppnå en god och jämlik hälsa.  Slutsats: Studiens fynd tyder på att det råder varierande erfarenheter av digitala verktyg inom folkhälsoarbetet på kommunal och regional nivå. Resultaten antyder även att en ökad integrering av folkhälsoperspektivet inom digitaliserings- och e-hälsosammanhang kan vara betydelsefull för möjligheterna att bidra till en god och jämlik hälsa. / Introduction: Digitalization influences multiple aspects of public health, yet the literature and policies related to digitalization and public health tend to provide vague descriptions of public health practice or public health perspectives. Previous research has further revealed an excessive emphasis on the technical and economic dimensions of digitalization, consequently overlooking social, cultural, and political perspectives. Aim: The aim of the study was to describe public health practitioners’ perceptions and experiences of the implementation or use of digital tools in public health practice at municipal and regional level in northern Sweden. Method: A qualitative interview study with semi-structured interviews was conducted with eight public health practitioners at municipal and regional level in northern Sweden. A manifest content analysis with an inductive approach was used for analysing. Results: The result consisted of 4 categories and 14 subcategories. The category Experiences and areas of use described the participants varying experiences as well as within which areas the participants used or wished to use digital tools. The categories Policy and resource allocation and Needs described prerequisites that the participants considered important to be able to use digital tools in public health practice. The last category Good and equal health described the opportunities and challenges that the participants perceived related to using digital tools within their work to achieve better and equal public health. Conclusion: The study findings indicate varying experiences of digital tools in public health practice at municipal and regional level. It emphasizes the importance of integrating public health perspectives into digitalization and e-health contexts to enhance public health outcomes.

Abstract Background. It is relatively well established in previous research that unemployment has direct health consequences in terms of mental and physical ill health. Recently, knowledge has emerged indicating that unemployment can lead to economic consequences that remain long after re-establishment in the labour market. However, few empirical studies have been able to apply a life course perspective asking whether there are also long-term health consequences of unemployment, and, when and in which context unemployment may affect the individual health status across the life course. The aim of this thesis was to analyse the relationship between unemployment and illness across the life course, and how it relates to individual and structural factors in the geographical setting of northern Sweden. In particular, three main areas have been explored: youth unemployment and illness in adulthood (Paper I and Paper II), contextual unemployment of national unemployment rate and neighbourhood unemployment (Paper II and Paper III) and lastly, social determinants of health inequality between employment statuses (Paper IV). Methods. This thesis is positioned in Sweden between the early 1980s and the mid-2010s, following two comparable cohorts sampled from northern Sweden (26 and 19 years follow-up time respectively from youth to midlife) and a cross-sectional sample from 2014 of the four northernmost counties in Sweden. The two longitudinal cohorts comprised the Northern Swedish Cohort and the Younger Northern Swedish Cohort, consisting of all pupils in the 9th grade of compulsory school in Luleå municipality in 1981 and 1989. The participants responded to an extensive questionnaire on socioeconomic factors, work and health, in 5 and 2 waves respectively of data collections. Neighbourhood register data from Statistics Sweden was also collected for all participants in the Northern Sweden Cohort. At the latest data collection, 94.3% (n=1010) participated in the Northern Sweden Cohort and 85.6% (n=686) in the Younger Northern Sweden Cohort. The cross-sectional study Health on Equal Terms is a national study, administered by the Public Health Agency together with Statistics Sweden and county councils with the aim of mapping public health and living conditions in the country over time. In this thesis, material from 2014 has been used for northern Sweden with a response rate of around 50% (effective sample n=12769). The statistical analyses used were linear regression, multilevel analysis and difference-in-difference analysis to estimate the concurrent and long-term health consequences of unemployment, and a decomposition analysis to disentangle the inequality in health between different labour market positions. The health outcomes in focus were functional somatic symptoms (the occurrence of relatively common physical illnesses such as head, muscle and stomach ache, insomnia and palpitation) and psychological distress. Results. Among men only, as little as one month of youth unemployment was related to increased levels of functional somatic symptoms in midlife, regardless of previous ill health or unemployment later in life, although only during relatively low national unemployment (pre-recession) when comparing with youth unemployment during high national unemployment (recession). This was explained by the health promoting effect of more time spent in higher education during the recession period. Furthermore, the health impact of neighbourhood unemployment highlights the importance of the contextual setting for individuals’ health both across the life course and at specific periods of life. Lastly, employment-related mental health inequalities exist for both men and women in all life phases (youth, adulthood and midlife). Economic and social deprivation related to unemployment and illness varied across different phases in life and across genders. Conclusion. The key findings of this thesis paint a rather pessimistic vision of the future: one’s own and others’ unemployment may cause not only ill health today but also ill health later in life. Importantly, the responsibility of unemployment and the associated ill health should not be placed on the already marginalised individuals and communities. Instead, the responsibility should be directed towards the structural aspects of society and the political choices that shape these. In other words, health inequality manifested by the position in the labour market is socially produced, unfair and changeable through political decisions. The results of this study therefore cannot contribute to any simple or concrete solutions to the concurrent or long-term health consequences of individual or contextual unemployment, as the solution is beyond the areas of responsibility and abilities of research. However, if there are long-term health consequences of one’s own and other people’s unemployment, labour market and public health policies should be initiated from a young age and continue throughout the life course to reduce individual suffering and future costs of social insurance, sick-leave and unemployment benefits.