Bakgrund: Unga kvinnor som skadar sig med sin sexualitet har uppmärksammats på senare år. De som tidigare i livet varit utsatta sexuellt är överrepresenterade bland dessa kvinnor som skadar sig själva med sexualitet.Syfte: Syftet med studien var att beskriva unga kvinnors upplevelser av sexualitet som självskadebeteende.Metod: En kvalitativ studie med fenomenologisk ansats av egna skrivna berättelser. Datamaterialet analyserades med hjälp av innebördsanalys.Resultat: Unga kvinnor som skadar sig genom sexualitet söker bekräftelse bland annat genom att publicera bilder på internet för att få positiv feedback om det egna utseendet. Vidare använder de sin sexualitet till att uppnå en kick och få en känsla av att duga till och på sätt dämpa den ångest de bär på. Dessa unga kvinnor behöver mycket stöd från omgivningen för att kunna förstå och bearbeta sitt självskadebeteende.Slutsats: Skolsköterskor behöver uppmärksamma att sexualitet som självskadebeteende existerar och finns i alla samhällsklasser. Skolsköterskor kan genom kontinuitet och förtroendegivande bemötande skapa en god relation som bygger på ett genuint intresse att vilja förstå dessa unga kvinnor utifrån ett livsvärldsperspektiv. För att kunna erbjuda det stöd som dessa unga kvinnor behöver är det viktigt att hen vågar finnas där, lyssna och ställa frågan. / Background: Young girls that self-harm themselves have recent years been in focus. Thosewho earlier in life have been sexually abused are overrepresented among these women thatself-harm themselves through their sexuality.Aim: The aim of this study was to illustrate young women’s experiences of sexuality as aself-harm behavior.Method: A qualitative study with a phenomenological approach of own written stories.Result: Young women that harm themselves with their sexuality seek acknowledgement forinstance by publishing pictures on the internet to receive positive feedback on theirappearance. Further they use their sexuality to achieve a rush and a sense of suffice and bythat mitigate their anxiety. These women need a lot of support from their surroundings inorder to understand and process their self-harm behavior.Conclusion: School nurses need to pay attention that sexuality as a self-harm behavior existsin all social classes. The school nurse can through continuity and a trustworthy attitude createa good relation that is based on a genuine interest of wanting to understand these youngwomen from a life-world perspective. To be able to offer these young women the supportthey are in need of it is important that the school nurse dare to be present, listen and ask the question.

As the percentage of school children with chronic conditions such as diabetes continues to rise, funding for school nurses to keep those students healthy and safe is decreasing. This dissertation includes three studies: (1) a systematic review of the literature on the role and impact of American elementary school nurses, (2) a focus group study that further examined the role of Kentucky school nurses and described their reaction to a new regulation that necessitates delegation of diabetes-related nursing tasks to unlicensed assistive personnel (UAP), and (3) a quantitative study that examined Kentucky school nurses’ past behaviors and future intentions regarding the delegation of diabetes-related tasks. A systematic review of the literature revealed that activities of school nurses can be conceptualized into four major areas: (a) health promotion and disease prevention; (b) triage and treatment of acute issues (e.g., injuries and infectious diseases); (c) management of chronic conditions; and (d) psychosocial support. School nursing activities are associated with increased attendance, higher quality schools, and cost savings. Focus groups in three regions of Kentucky found that Kentucky school nurses fulfill the same major roles as their counterparts across the nation, and face similar challenges such as lack of time, limited resources, language barriers, and communication issues with families. School nurse participants described their biggest impact on students as identifying and addressing students’ physical and psychosocial barriers to learning. While recent legislation was passed in Kentucky necessitating the delegation of insulin administration to UAP, school nurses had not experienced many changes at the time of the focus groups. However, some nurses said that their districts were not planning to delegate insulin administration and intended to keep a nurse in every school. Others appreciated the prospect of having more trained staff in schools to recognize signs of distress in chronically ill students. A statewide survey of 111 Kentucky school nurses indicated that nurses’ past delegation behaviors and future intentions related to delegation are rooted in the level of skilled decision-making that must occur and the risk to the student if the wrong decision is made. Unfortunately, school nurses’ intentions to delegate higher-stakes tasks (e.g. carbohydrate counting, insulin dose verification, and insulin administration) were significantly stronger than their support for (attitude related to) delegation of those tasks, which is disconcerting both for the safety of students as well as for the liability retained by delegating nurses. This disparity between support and intentions indicated that school nurses anticipate that they will have to delegate certain tasks to UAP despite their discomfort with delegating them, most likely due to high workload and lack of resources. Additional studies should be undertaken to determine the impact of legislative changes on the delivery of school health services in Kentucky and other states, particularly once school districts and nurses have had adequate time to adjust to new laws. Such studies should investigate to whom nurses are delegating health services, what tasks are being delegated, and the extent and process of training that UAP receive. Future surveys should utilize perceived behavioral control items that assess situational control (e.g. policy, workload) over delegation rather than, or in addition to, efficacy of individual skills required for delegation of nursing tasks. Researchers must further explore the discrepancies between attitude and intentions; that is, why are nurses planning to delegate tasks to UAP if they do not support the delegation of those tasks? Kentucky school nurses are champions of health promotion for children, not only in their provision of health services and health education, but also in the area of school health policy. School nurses should train UAP so that more school staff can recognize signs of distress in students with diabetes, but at the same time should continue to advocate and seek funding for a nurse in every school with the help of the Every Student Succeeds Act.

Background and goals: This thesis explores the experience of rehabilitaion following myocardial infarction (MI) from the perspective of people who did not attend either a cardiac rehabilitation programme (CR) or a CHD 'self-help' group and their ‘significant others’. These resources are intended to support post-MI rehabilitation and readjustment and research identifies various benefits, yet many people do not use them. Given the scale of the population affected by CHD, the issues of why people do not use the resources, their experience and that of their family members, and the kinds of support people need and want, are of public health importance. These issues formed my investigative goals. Methods: The study used a qualitative methodology, informed by ‘grounded theory’. A screening questionnaire identified non-participants from the post-MI population in Lothian, from which a sample of ‘maximum diversity’ was selected. In-depth interviews were conducted with twenty-seven post-MI people and seventeen ‘significant others’. The analysis combined identifying emergent themes and searching the data for key issues relating to study objectives. Findings: Additional to the barrier of non-invitation, a spectrum of factors relating to people’s ‘lifeworld’ circumstances, beliefs, and identity could either encourage or discourage participation. Factors were highly similar for both resources. Reasons for, and the process of non-participation could be grouped into three categories: “No need / no point”, “Not worth it”, or “Not possible”. These were based on the way the factors that influenced individuals related to three key issues. Shifts between categories were also possible. A link between non-participation and a range of rehabilitation difficulties among post-MI people and family members is also demonstrated. Conclusions and implications: The study addresses a gap in understanding post-MI non-participation and its significance, providing insight into the process by which CR and CHD Group nonuse occurs and the impacts for people who have had MI and family members. Recommendations are made, identifying realistic ways rehabilitation support might be improved, barriers and opportunities, and areas for further investigation.

Attention Deficit / Hyperactivity Disorder (ADHD) är en uppmärksamhetsstörning med hyperaktivitet som drabbar cirka 3-5 procent av barn i skolåldern. Skolan har inflytande på barns liv och det finns ett samband mellan elevers psykiska hälsa och skolresultat. Skolsköterskor har en viktig roll som hälsofrämjare, särskilt då barn med ADHD har ökad risk för ohälsa och riskbeteende.   Syfte: Syftet med studien var att beskriva skolsköterskors erfarenheter av att arbeta med åtgärder för barn med ADHD. Metod: Studien har genomförts med kvalitativ metod. Studien är baserad på åtta telefonintervjuer med skolsköterskor, vilka har analyserats med hjälp av kvalitativ innehållsanalys. Resultat: Fem kategorier framkom ur analysen, vilka beskriver skolsköterskors erfarenheter av att arbeta med åtgärder för barn med ADHD; Att samverka genom dialog, Att anpassa skolmiljö, Att vägleda och ge råd till föräldrar och barn, Att observera och genomföra kontroller samt Att arbeta specifikt hälsofrämjande. Slutsats: Skolsköterskor har erfarenheter av olika typer av åtgärder för barn med ADHD. De betonar särskilt betydelsen av att uppmärksamma barn med ADHD tidigt samt hälsosamtalet. / Attention Deficit / Hyperactivity Disorder (ADHD) is an attention deficit hyperactivity disorder that affects approximately 3-5 percent of school-age children. The school has an important influence on children's lives and there is a correlation between students' mental health and school performance. School nurses have an important role as health promoters, especially when children with ADHD are at increased risk of ill health and risky behavior.   Aim: The aim of this study was to describe the school nurses´ experiences of working with measures for children with ADHD.   Method: The study was conducted using a qualitative method. The study is based on telephone interviews with eight school nurses, which have been analyzed using qualitative content analysis.   Results: Five categories emerged from the analysis, which describes the school nurses´ experiences of working with various measures for children with ADHD; Working together through dialogue, to adapt the school environment, provide guidance and advice to parents and children, to observe and implement controls and to work specifically with health promotion.   Conclusion: School nurses have experience of different types of measures for children with ADHD. They stressed in particular the importance of paying attention to children with ADHD and regular health discussions.

Bakgrund: Digitala medier är en del av de flesta barns vardag idag. Diskussioner om huruvida detta påverkar barns fysiska och mentala hälsa framhävs emellanåt i olika medier. Samtidig som det även diskuteras om positiva effekter. Skolsköterskan träffar alla elever och har en viktig funktion i det hälsofrämjande arbetet. Skolsköterskan kan i samverka med andra professioner och föräldrar förmedla kunskap och stöd till hälsosamma levnadsvanor. Syfte: Syftet med studien var att undersöka skolsköterskors erfarenheter av barns digitala medieanvändning och skärmtid, samt hur skolsköterskan arbetar hälsofrämjande inom området. Metod: Studien har genomförts med en kvalitativ design med induktiv ansats. Nio semistrukturerade intervjuer gjordes med stöd av en intervjuguide för att samla in data. Insamlat material har analyserats genom manifest kvalitativ innehållsanalys. Resultat: Skolsköterskans erfarenheter och hälsofrämjande arbete resulterade i två domäner med fem kategorier och 16 underkategorier. Skolsköterskor samtalade med barn och föräldrar om digitala medier i hälsosamtalen och de använde sig av standardiserade hälsoverktyg. Skolsköterskor arbetade med att väcka medvetenhet och reflektion hos eleverna. Föräldrar råddes att vara delaktiga i barnens medieanvändning och ha balans och rutiner. Skolsköterskor gav information och råd om fysisk hälsa och sömn samt arbetade med utsatthet på nätet, ofta i samarbete med andra professioner. Skolsköterskor erfor att samhällets utveckling styr, att medievanor hos barn har ändrats på fritiden. Skolsköterskor tyckte att skolor har olika förutsättningar och att digitala medier har blivit en del av lärandet. De hade erfarenhet av att digitala medier ersätter personliga aktiviteter, att det ger gemenskap och vänner, men också utanförskap och konflikter. Skolsköterskor hade också erfarenhet av att barn kan fastna i spel. De hade även erfarenhet av fysiska komplikationer, som att kroppen tar stryk och att sömnen påverkas. Slutsats: Samtliga skolsköterskor lyfte frågan om barn digitala medievanor någon gång under tiden förskola till årskurs sex. Samtliga använde sig också av standardiserade hälsoformulär under hälsosamtalet med elever. Skärmtid ansågs vara ett svårt begrepp och skolsköterskor tyckte det var svårt att ge konkreta råd angående hur länge det är lämpligt för barn att sitta vid en skärm. Skolsköterskor ansåg att deras roll i samtalet var att väcka reflektion och hjälpa elever till insikt om sina vanor. Skolsköterskor arbetade hälsofrämjande på grupp- och individnivå inom området som omfattar barns medievanor, ofta i samarbete med andra professioner. Arbetet mot mobbning på nätet var framträdande i studien. / Background: Digital medias is a part of most childrens everyday life today. Discussions about weather this effects the psysical and mental health of children is emphasized from time to time in various media. At the same time there is an ongoing discussion about the benefits of using digital media. The school nurse meets all students and has an important role in health promotion. In cooperation with other professionals and parents the school nurse can supply knowledge and support students to a healthy lifestyle. Aim: The purpose of this study was to exlore the school nurses´experiences of children´s digital media use and screen time, and also to explore how the school nurse´ health promotiong in the field. Method: The study was conducted with a qualitative design/approach. To collect data, nine semi-structured interviews with school nurses were made. Interviews were conducted with the support of an interview- guide. Collected data were analysed using manifest content analysis. Results The school nurses´ experiences and health promoting work resulted in two domains, with five categories and 16 subcategories. School nurses talked to children and parents about the use of digital medias during health conversations and they also used standardized health tools in conversations. School nurses´worked with helping students reflect on, and create an understanding of their habits. Parents were advised to be involved in their childrens media use and maintain balance and routines. School nurses gave information and advice about physical health and sleep, as well as they worked with childrens vulnerability on the internet, often in collaboration with other professions. School nurses thought that society's development rule and that the media habits of children has changed in their leisure time. School nurses felt that different schools had different conditions and that digital media has become a part of learning. They had experienced that digital media replaces personal activities, it could create solidarity and friends, but also exclusion and conflict. School nurses also experienced that children can get caught in games. They also had the experience of physical complications, such as the body in affected and that sleep is affected . Conclusion All school nurses´raised the issue of childrens digital media habits sometime during the time from kindergarden to the sixth grade. All school nurses´ used standardizied health questioairies during healthconversations with children. Screen time was considered to be a difficult concept, and school nurses found it difficult to give specific advice about how long time is appropriate for children to sit by a screen. School nurses´ felt that their role in the conversation was to help students reflect on, and to create an understanding of their habits. School nurses worked both on an individual level and group level in their health promoting work on the area of digital media habits, often in collaboration with other professions. The work against bullying online was prominent in the study.

Background: Reviews of primary research in developed countries and policy in the UK demonstrate there is a lack of evidence from well conducted RCTs on lifestyle interventions for childhood obesity (NICE 2006, SIGN 2003, Oude Luttikhuis et al. 2009). Objectives: To develop, implement and evaluate the Y W8? family focused childhood obesity treatment programme using a randomized controlled trial. Methods: The programme was developed using Bartholomew’s Intervention Mapping framework. Using this stepped process a needs analysis was undertaken, a steering group formed, focus groups were completed in local schools and interviews took place with parents of obese children. The determinants identified by these processes were combined with relevant theories and information gathered through a literature review to develop the programme. Y W8? is a 12 week course for families with children aged 8–13 years designed to assist with weight management. The RCT was designed as an individually randomised parallel-group trial with a waiting-list control group. Children in the intervention group (n=59) had their height, weight, self-reported physical activity levels, self-reported fruit and vegetable consumption and a measure of self-esteem recorded at pre- and post-assessment, whilst only height and weight was collected from the children in the control group (n=55). Results: Twelve week (post course) results showed a significant difference in change in BMI z-score between the control and intervention group, mean difference = -0.12 (95% CI: 0.09 to 0.16, F (1, 98) = 54.04, p < 0.0005), with the control group increasing and the intervention group decreasing their BMI z-score. Analysis showed this positive effect on weight status did not adversely affect linear growth. For the intervention group 81% of children completed the programme. Implications: This RCT offers evidence to support the use of family-based treatment programmes in the treatment of childhood obesity and displays positive results in the short-term, at a lower cost than similar interventions. The thesis also demonstrates how a public health programme can be implemented and sustained in routine NHS practice.

Hälsofrämjande arbete är viktigt inom hela hälso- och sjukvården, där distriktssköterskan har ett stort ansvar. Sedan ädelreformen har de flesta kommuner övertagit ansvaret för att tillhandahålla hälso- och sjukvård, bland annat i hemmiljö. Orems omvårdnadsteori fokuserar på egenvård och menar att människan är en aktiv och fri varelse som kan uppnå välbefinnande genom egenvård. Syftet med studien var att beskriva distriktssköterskors upplevelser av hälsofrämjande arbete inom kommunal hemsjukvård. En kvalitativ metod med induktiv ansats användes och fem intervjuer med distriktssköterskor från två kommuner i nordvästra Skåne genomfördes. Intervjuerna analyserades med kvalitativ innehållsanalys. I studien framkom kategorierna: omvårdnad är hälsofrämjande, hälsofrämjande arbete saknar prioritet samt hemmet som arena. Distriktssköterskorna upplevde att hälsofrämjande arbete bygger på holistiskt synsätt och är grunden för allt omvårdnadsarbete, samtidigt som de lutade sig mot sin medicinska kompetens. Vidare upplevde de att hälsofrämjande arbete saknade prioritet genom bristande kompetens inom hälso- och sjukvårdsteamet, tidsbrist och kortsiktiga interventioner. Det hälsofrämjande arbetet försvårades genom att hemmet är arenan, som är individens revir och dennas villkor styr arbetet. Framtida studier utifrån vårdtagarens perspektiv skulle kunna vidareutveckla resultatet i denna studie och samtidigt vara ett steg i vårdutvecklingen inom kommunal hemsjukvård. / Health promotion is important in all of the health care system, where the district nurse has big responsibility. Since the “ädelreform”, most counties are taking responsibility for providing health care, including the care takers who live at home. Orem´s nursing theory focuses on self-care and believes that man is an active and free being capable of achieving wellness through self-care. The aim of the study was to describe nurses' experiences of health promotion in municipal home care. A qualitative method with inductive approach was used and five interviews were performed, with district nurses from two counties in northwest Skåne. The interviews were analyzed using qualitative content analysis. The study revealed categories: caring is health promotion, health promotion lacks priority and the home as the arena. District nurses felt that health promotion is based on a holistic approach and the foundation for all nursing work, while they leaned towards their medical expertise. Furthermore, they felt that health promotion has low priority by lack of skills in the health care team, lack of time and short-term interventions. Health promotion efforts were affected since the home was the arena, where the individual's terms and conditions governed the work. Future studies based on the resident's perspective could further develop the results of this study while being a step in the healthcare developments in municipal home care.

Bakgrund: Hypertoni är ett folkhälsoproblem och utgör en stor riskfaktor för utveckling av hjärt-kärlsjukdom. Basen för omvårdnaden utgörs av livsstilsförändringar. Distriktssköterskors centrala roll innefattar att i jämlik, ömsesidig kommunikation ge råd, motivera och stödja till förändring av levnadsvanor samt främja patientdelaktighet och autonomi. Syfte: Syftet med studien var att belysa distriktssköterskors erfarenheter av att stödja patienter med hypertoni till livsstilsförändringar. Metod: Datamaterialet analyserades med kvalitativ innehållsanalys med en induktiv ansats. Åtta distriktssköterskor med ansvar för patienter med hypertoni intervjuades. Resultat: Ur analysen av datamaterialet framträdde tre kategorier; Initierar samarbete, Bekräftar individen och Anpassar omvårdnad för patienten, med sex underkategorier. Konklusion: Distriktssköterskorna upplevde sin roll central, viktig och ansvarsfull när det handlade om att ge råd och undervisning. De upplevde sig även vara en viktig länk mellan patient och andra aktörer. De ansåg att lyhördhet för patientens livssammanhang och en samtalsstrategi i kommunikationen vid livsstilsrådgivning var viktigt för främjandet av patientdelaktighet och autonomi. Att individuellt motivera till livsstilsförändring beskrevs som en svårighet och distriktssköterskorna uttryckte en frustration över att det var bristande tid för uppföljning. / Background: Hypertension is a public health problem and a major risk factor for developing cardiovascular disease. The basis for the nursing care is lifestyle changes. District nurses´ role includes to advise, motivate and support life style changes, as well as to promote patient participation and autonomy, through an equal and mutual communication. Aim: The aim of the study was to illuminate experiences of district nurses supporting patients with hypertension to make lifestyle changes. Method: The data were analyzed by qualitative content analysis with an inductive approach. Eight district nurses responsible for hypertensive patients were interviewed. Results: Three categories emerged from the data analysis: Initiates cooperation; Confirms the individual and Adapts nursing for the patient, with six subcategories. Conclusion: The district nurses perceived their role as central, important, and responsible when providing advice and instruction. They also considered themselves as an important link between the patient and other actors. Responsiveness of the patient's life context, as well as using a communication strategy when giving counseling on lifestyle changes were considered important to promote patient participation and autonomy. To motivate lifestyle changes individually was described as a difficulty and district nurses expressed frustration with the lack of time for follow-up.

The number of persons who are not employed has increased in Sweden since the early 1990s. Unemployment has been found to influence health, especially when unemployment rates are low. The extent to which unemployment affects health when unemployment is high is less clear, and this needs to be further studied. To improve health in the population, the health care system should offer equal access to health care according to need. It is important to study whether the employment status hinders the fulfilment of this goal. This thesis is based on four papers: Paper I and II aimed at analysing self-rated health versus mortality risk in relation to employment status, during one period of low unemployment and one period of high unemployment. Paper III and IV assessed the use of medical health care services and unmet care needs among persons who were unemployed or otherwise not employed. The goal was to analyse what health problems lead people to either seek or abstain from seeking care, and what factors encumber or facilitate this process. The overall results indicate that being unemployed or outside the labour force was associated with an excess risk of poor self-rated health, symptoms of depression, mental and physical exhaustion and mortality. The differences in self-rated health between the unemployed and employed were larger when unemployment levels were high, than when they were low. More groups of the unemployed were also afflicted with poor health when unemployment was high. Thus, poor health among the unemployed seems to be a public health problem during high levels of unemployment. Lack of employment was related to abstaining from seeking care, despite perceiving a need for care, and this was related to psychological symptoms. To deal with the needs of the unemployed and others who are outside the labour force it would be useful to develop and implement interventions within the health care system. These should focus on psychological and psychosocial problems. Future research should analyse how to facilitate health-promoting interventions among persons who are not anchored in the labour market.

Background Overweight and obesity are global health problems with several adverse health effects that threaten public health. In Sweden, almost four of ten pregnant women are overweight or obese, conditions that are associated with adverse pregnancy outcomes, including gestational diabetes mellitus (GDM), a metabolic disorder that complicates pregnancy. Globally, physical inactivity is the fourth leading risk factor for mortality. The recommendation for physical activity (i.e., ≥150 minutes/week) issued by the Professional Associations for Physical Activity and the Swedish National Board of Health and Welfare is in line with the recommendations by the WHO. Physical activity during pregnancy is generally safe and beneficial for both the pregnant woman and her fetus and can maintain or improve fitness and may further improve pregnancy outcomes. However, pregnant women tend to lower their physical activity when entering pregnancy. Midwives working in antenatal care (ANC) in Sweden play a prominent role in promoting a healthy lifestyle through counselling pregnant women on lifestyle, including physical activity during pregnancy. Individual counselling on physical activity encourages pregnant women to maintain their pre-pregnant leisure time physical activity throughout their pregnancy. Aims This thesis has three main aims. First, this thesis investigated guidelines for screening of GDM, risk factors, and pregnancy outcomes in relation to GDM. Second, it investigated physical activity during pregnancy and pregnancy outcomes. Third, it explored midwives’ and pregnant women’s experiences with counselling that addressed physical activity during pregnancy. Methods Study I and III are cross-sectional studies using data from the Maternal Health Care Register and the Salut Register. A total of 184,183 pregnant women were included in Study I (2011-2012) and 3,868 in Study III (2011-2012). Several statistical analyses were used: two-independent samples t-test, Pearson’s Chi-Square test, and univariate and multivariate logistic regression analyses. Study II and IV are qualitative studies applying qualitative content analysis. Study II included 41 midwives who were interviewed in eight focus group discussions (FGD). Study IV included 14 pregnant women who participated in individual in-depth interviews. Main findings There was no consensus in Sweden regarding clinical guidelines for screening regimes or 2-hour cut-off value for diagnosis of GDM from 2011 through 2012. Four screening regimes were applied in Sweden during this time period: A) universal screening with a 2-hour cut-off value of 10.0 mmol/L; B) selective screening with a 2-hour cut-off value of
8.9 mmol/L; C) selective screening with a 2-hour cut-off value of 10.0 mmol/L; and D) selective screening with
a 2-hour cut-off value of 12.2 mmol/L. The highest prevalence of GDM was found where selective screening was applied with a 2-hour cut-off value of 8.9 mmol/L. Unemployment, low educational level, and non-Nordic origin were all risk factors for GDM, and a BMI ≥30 kg/m2 almost four-doubled the risk for GDM compared to pregnant women with BMI &lt;30 kg/m2. Increasing OGTT-values were associated with increasing risk of adverse pregnancy outcomes (Paper I). Midwives in antenatal care perceived counselling as both challenging and as an opportunity to promote a healthy lifestyle for pregnant women. As the theme “An on-going individual adjustment” revealed, the midwives tried to adjust their counselling to each pregnant woman’s individual needs. Counselling pregnant women on physical activity was seen as complex and ambiguous with a risk of being rejected by the women if the advice was delivered too straightforward. Instead, the midwives were “tiptoeing” around the sensitive topics (Paper II). Almost half of pregnant women reported that they achieved the recommended level of physical activity during pregnancy (i.e., ≥150 minutes/week). These pregnant women were characterized by lower BMI, higher educational level, and very good or good self-rated health (SRH) compared to the pregnant women who did not achieve the recommended level (Paper III). Pregnant women reported a desire for individual counselling on physical activity during pregnancy. The theme that emerged was “Longing for fulfilment of individual needs and expectations”, which reflected the wish that midwives’ counselling on physical activity should be based on pregnant women’s individual needs instead of merely providing general advice. Some participants reported receiving encouragement and support, but others believed they were provided insufficient counselling on physical activity and that the midwife had her own agenda focusing mostly on medical surveillance (Paper IV). Conclusions No consensus regarding clinical guidelines and diagnostic criterion for GDM existed in Sweden during 2011 to 2012. Obesity was a strong risk factor for development of GDM, and low socio-economic status and non-Nordic origin were also demonstrated as significant risk factors. Positively, almost half of the pregnant women reached the recommended level of physical activity during pregnancy. Participants fulfilling the recommendation were characterized by lower BMI, higher education, and very good or good self-rated health. Midwives strived to adjust and individualize their counselling on physical activity; however, some of the pregnant women could experience the counselling on physical activity being too general. Clearly, healthcare professionals should encourage fertile and pregnant women to be physically active, especially overweight and obese pregnant women who report low levels of physical activity, in order to improve overall health in this population. / Bakgrund Övervikt och fetma är ett stort hälsoproblem globalt med flera negativa hälsoeffekter som utgör ett hot mot folkhälsan. Nästan 40% av de gravida i Sverige har övervikt eller fetma vilket är associerat med flera negativa graviditetsutfall där graviditetsdiabetes (GDM) är en metabolisk sjukdom som komplicerar graviditeten. Fysisk inaktivitet är den fjärde ledande riskfaktorn för dödlighet i ett globalt perspektiv. Att vara fysiskt aktiv förbättrar välbefinnandet och livskvaliteten, främjar stabil vikt, insulinkänslighet och normalt blodtryck. Vidare sänker fysisk aktivitet risken för diabetes mellitus typ 2, fetma och hjärt-och kärlsjukdomar. Fysisk aktivitet under en okomplicerad graviditet är generellt att betrakta som utan risk och ökar välbefinnandet för både kvinnan och fostret. Fysisk aktivitet bidrar till att bibehålla eller förbättra fysisk kondition och kan förbättra graviditetsutfall. Trots dessa fördelar tenderar gravida att sänka sin fysiska aktivitet under graviditeten. De svenska rekommendationerna följer de internationella riktlinjerna som innebär ≥150 minuter/vecka av måttlig fysisk aktivitet alternativt 75 minuter/vecka av intensiv fysisk aktivitet eller en kombination av dessa. Svenska barnmorskor som arbetar inom mödrahälsovården i Sverige har en central, rådgivande roll gentemot gravida kvinnor när det gäller att verka för en hälsosam livsstil inkluderande fysisk aktivitet. Individuell rådgivning i fysisk aktivitet kan uppmuntra och stödja gravida kvinnor att fortsätta vara fysiskt aktiva under hela graviditeten. Syfte Att kartlägga riktlinjer för graviditetsdiabetes i Sverige samt riskfaktorer och graviditetsutfall i relation till GDM. Vidare att undersöka fysisk aktivitet under graviditeten samt associationer till graviditetsutfall och slutligen att utforska barnmorskor och gravida kvinnors upplevelser av rådgivning i fysisk aktivitet. Metod Studie I och III var tvärsnittsstudier där data från Mödrahälsovårds-registret och Salutregistret nyttjades. Totalt 184,183 gravida kvinnor inkluderades i Studie I och 3,868 inkluderades i Studie III (tidsperiod 2011-2012). Statistiska analyser som genomfördes var t-test, Pearson’s Chi-2-test och univariat samt multivariat logistisk regressionsanalys. Studie II och IV var kvalitativa studier där intervjuerna analyserades med manifest och latent kvalitativ innehållsanalys. Studie II inkluderade 41 barnmorskor i åtta fokusgrupper och 14 gravida omföderskor djupintervjuades individuellt i Studie IV. Resultat Under perioden 2011-2012 förelåg inte någon enighet gällande riktlinjer för screening och gränsvärde för diagnosen GDM i Sveriges 43 mödrahälsovårdsområden. Fyra olika screeningregimer identifierades; A) generell screening och 2-timmar gränsvärde på 10,0 mmol/L i plasmaglukos, B) selektiv screening och 2-timmar gränsvärde på 8,9 mmol/L i plasmaglukos, C) selektiv screening och 2-timmar gränsvärde på 10,0 mmol/L i plasmaglukos och D) selektiv screening och 2-timmar gränsvärde på 12,2 mmol/L i plasmaglukos. Den högsta prevalensen av GDM återfanns i det område som hade 8,9 mmol/L som gränsvärde och den lägsta där 12,2 mmol/L var gränsvärdet för GDM. Arbetslöshet, låg utbildningsnivå och ett utom-nordiskt ursprung utgjorde alla riskfaktorer för utveckling av GDM. Fetma, BMI ≥30 kg/m2, utgjorde den riskfaktor med högst risk för att utveckla GDM under graviditet med en nästan fyrdubblad risk jämfört med en kvinna med BMI &lt;30kg/m2. Ökande 2-timmarsvärden av blodglukos var associerat med ökande negativa graviditetsutfall såsom kejsarsnitt och instrumentell vaginal förlossning (Artikel I). Barnmorskorna i mödrahälsovården upplevde rådgivningen i fysisk aktivitet som å ena sidan utmanande men å andra sidan som en möjlighet att verka för en hälsosam livsstil hos de gravida kvinnorna. Temat ”En ständigt pågående anpassning” visar barnmorskornas försök att anpassa sin rådgivning efter varje enskild gravid kvinnas behov och situation. Rådgivningen i fysisk aktivitet till gravida upplevdes som komplex och mångfacetterad. Det uttrycktes en oro för att bli avvisad av den gravida kvinnan om de givna råden förmedlades för uppriktigt. Detta ledde ibland till att barnmorskorna ”trippade på tå” och försiktigt närmade sig känsliga ämnen såsom övervikt och råd om fysisk aktivitet. Barnmorskorna försökte även finna individuella lösningar och anpassa råden utifrån varje enskild gravid kvinnas möjligheter. Detta var särskilt tydligt i mötet med kvinnor som immigrerat till Sverige, där barnmorskorna upplevde att en del av rådgivningen bestod i att slå hål på myter om fysisk aktivitet såsom något riskfyllt samt att informera om de positiva hälsoeffekterna med fysisk aktivitet under graviditeten (Artikel II). Nästan hälften av de gravida kvinnorna uppnådde Socialstyrelsens rekommendationer avseende fysisk aktivitet under graviditet och dessa kvinnor karakteriserades av lägre BMI, högre utbildningsnivå samt mycket bra/bra självskattad hälsa jämfört med de gravida som inte uppnådde rekommendationerna Artikel III). Temat som framkom i Artikel IV var ”Längtan efter tillfredsställelse av individuella behov och förväntningar” och speglar de gravidas önskan att erhålla en individuellt anpassad rådgivning i fysisk aktivitet av barnmorskorna istället för en generell rådgivning avsedd för alla. Några gravida hade erfarenheter av barnmorskan som stöttande och uppmuntrande i sin rådgivning i fysisk aktivitet. Andra kunde uppleva rådgivningen som otillräcklig, att barnmorskan exempelvis inte hade tillräckligt med kunskap i fysisk aktivitet samt att barnmorskan hade en egen agenda för deras möten som i huvudsak fokuserade på den medicinska övervakningen av graviditeten. Slutsats Under perioden 2011-2012 förelåg ingen consensus angående de nationella riktlinjerna och diagnostiska värdet för GDM i Sverige. Fetma var den riskfaktor med högst risk för utvecklande av GDM och låg socio-ekonomi, maternell ålder &gt;35 år samt utom-nordiskt ursprung utgjorde även riskfaktorer för GDM. Positivt var att nästan hälften av de gravida uppnådde Socialstyrelsens rekommendationer för fysisk aktivitet under graviditeten och dessa karakteriserades av signifikant lägre BMI, högre utbildningsnivå samt mycket god/god självskattad hälsa. Trots att barnmorskorna beskrev hur de strävade efter att anpassa rådgivningen i fysisk aktivitet till varje enskild kvinna, kunde de gravida kvinnorna uppleva att rådgivningen var otillräcklig, för generell och främst fokuserad på den medicinska övervakningen. Det är av största vikt att hälso- och sjukvårdspersonal som möter fertila och gravida kvinnor verkar för en hälsosam livsstil, särskilt avseende kvinnor med en inaktiv livsstil och de som har övervikt eller fetma för att på så sätt förbättra hälsan hos denna del av befolkningen. För att uppnå detta krävs resurser gällande personal, tidsutrymme samt fortbildning inom hälsa och rådgivning för barnmorskor och annan hälso- och sjukvårdspersonal som möter dessa kvinnor. Slutligen, för att möjliggöra rådgivning som avser att stödja fysisk aktivitet för de kvinnor som immigrerat till Sverige behövs mer kunskap och utbildning i mötet med dessa kvinnor.