Systematic reviews of the effect of foster care on mental-health outcomes have consistently indicated a zero-sum game, which makes it unclear whether the intervention is suitable for children in need of out-of-home placements. This thesis took on a meta-analytical approach to examine sources of heterogeneity between studies evaluating the effect of foster care on adaptive functioning, cognitive functioning, externalizing behavior, internalizing behavior, and total problems behavior. The bulk of studies came from two recently published systematic reviews. The searches were replicated to cover studies published until March 31, 2018. From 2943 studies assessed for eligibility, 240 were selected for the analysis covering 25 085 children. A choice of study-related covariates was abstracted, and potential sources of heterogeneity were hypothesized and tested by means of meta-regression. The findings indicated that both the choice of study design and measurement instrument were significantly associated with the variation in effect sizes. These associations were even stronger in child protection-oriented welfare regimes while insignificant in family service-oriented regimes, which instead showed significant associations for outcome type and publication year. The results imply a need to standardize effect studies of foster care, and to further research on sources of heterogeneity in different child welfare regimes.

Background: Zambia has one of the highest rates of intimate partner violence (IPV) in the world. While the focus has been put on the prevalence and the consequences of physical, sexual and psychological violence, economic abuse has been a neglected area in research. Studies have shown that accepting attitudes toward IPV are the most prominent predictor of the occurrence of IPV while men’s attitudes toward IPV have not gained equal attention in research as women.  Aim: To explore women’s and men’s attitudes towards economic abuse in Livingstone, Zambia.  Methods: This study used a qualitative case study method consisting of semi-structured interviews with 17 women and men in four villages in Livingstone town. Transcripts were analyzed through a thematic analysis using the software NVivo 12 as an aid in facilitating the coding process.  Results: The husband not providing for the family was not acceptable by the respondents. As a result of this, men expressed constant feelings of societal pressure of being a good provider. Mixed and contradicting attitudes concerning preventing the wife from working or taking money without consent were shown. Preventing the wife from working or taking money were often justified as long as the husband could provide.  Conclusion: This study concludes that people’s overall attitudes towards economic abuse are strongly affected by traditional gender roles, where societal norms and expectations put on men should be questioned. Therefore, reducing the prevalence of economic abuse requires interventions targeting irresistible stereotypical norms concerning expectations on masculinities and femininities.

<p>2019-08-25</p>

Aim: To explore the causes of minority stress in trans individuals in Sweden, and how these individuals cope with such minority stress. Background: Trans individuals have markedly poor mental health compared to the general population. Meyer’s Minority Stress Model has been shown to apply to trans individuals. However, causes of minority stress and methods of coping for trans individuals have not been investigated in Sweden. Previously, social support has been highlighted as a key coping mechanism of minority stress. This thesis explores the causes of minority stress on trans individuals and how they cope with this stress. Methods: A qualitative study utilising semi-structured interviews with 18 trans individuals from across Sweden. A deductive approach was applied in analysis of the data, in order to explore the causes of minority stress, as detailed by the Minority Stress Model. Results: The main causes of minority stress were found to be the medical investigation, discrimination and internalised stigma. The trans community was a source of social support, facilitating coping with minority stress. Other facilitative coping mechanisms used by participants were the support of family. Discrimination and internalised stigma led to avoidant coping mechanisms, such as avoidance of social environments. Conclusion: This study reinforces previous findings that discrimination and internalised stigma cause minority stress for trans individuals. The structure of the medical investigation in Sweden should be reviewed, to reduce the stress it causes. The visibility of the trans community should be improved to increase the use of the community as a source of social support and facilitative coping.

<p>2019-06-04</p>

<p><strong>Background:</strong> The past three decades have seen a growth in health promotion research and practice, stimulated by the epidemiologic transition of the leading causes of death from infectious to chronic diseases. An estimated 50% of mortality from the 10 leading causes of death is due to behaviour, which suggests individuals can make important contributions to their own health by adopting some health-related behaviours and avoiding others. Motivational interviewing (MI) has emerged as a brief counselling approach for behavioural modification that builds on a patient empowerment perspective by supporting self-esteem and self-efficacy. MI has become increasingly popular in a variety of health care settings as well as non-health care settings.</p><p><strong>Aims:</strong> The overall aim of this thesis is to contribute to improved understanding of the different factors that impact on the learning and practice of MI. The aim of study I was to identify barriers and facilitators to use MI with overweight and obese children in child welfare and school health services. The aim of study II was to identify barriers, facilitators and modifiers to use MI with pharmacy clients in community pharmacies.</p><p><strong>Methods:</strong> Participants in study I were five child welfare centre nurses from the county council and six municipally-employed school health service nurses, all from Östergötland, Sweden. Participants in study II were 15 community pharmacy pharmacists in Östergötland Sweden. Data for both studies were obtained through focus group interviews with the participants, using interview guides containing open-ended questions related to the aims of the studies. Study II also included five individual interviews. Interview data were interpreted from a phenomenological perspective.</p><p><strong>Results:</strong> In study I, important barriers were nurses’ lack of recognition that overweight and obesity among children constitutes a health problem, problem ambivalence among nurses who felt that children’s weight might be a problem although there was no immediate motivation to do anything, and parents who the nurses believed were unmotivated to deal with their children’s weight problem. Facilitators included nurses’ recognition of the advantages of MI, parents who were cooperative and aware of the health problem, and working with obese children rather than those who were overweight. In study II, pharmacists who had previously participated in education that included elements similar to MI felt this facilitated their use of MI. The opportunity to decide on appropriate clients and/or healthrelated behaviours for counselling was also an important facilitator. The pharmacists believed the physical environment of the pharmacies was favourable for MI use, but they experienced time limitations when there were many clients on the premises. They also experienced many difficulties associated with the practical application of MI, including initiating and concluding client conversations.</p><p><strong>Conclusions:</strong> Learning and practicing MI effectively is difficult for many practitioners as it requires a new way of thinking and acting. Practitioners’ use of MI is not effective unless there is recognition that there is an important health-related problem to be solved. Practitioners feel more confident using MI with clients who have health-compromising behaviours and/or risks in which the practitioners feel they have expertise. Possessing considerable MI counselling skills does not compensate for insufficient knowledge about a targeted health-related behaviour and/or risk. Feedback from clients plays an important role for the quality and quantity of practitioners’ MI use.</p>

<p>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. </p><p>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. </p><p>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. </p>

<p>One of the most vulnerable groups in Swedish society today is single parent families, a group that has increased over the last thirty years in proportion to married and cohabiting parents. The aims of this thesis are to study inequality and inequity in health and health care utilization with regard to whether parents are single or couple (married/cohabiting), to investigate whether the concept of social capital may provide us with further understanding when analyzing inequality and inequity in health and to investigate how the mental health of single parent children may differ from couple parent children and to what extent this difference may be due to parental socio-economic and socio-demographic characteristics, including social capital. The results from the papers on which this thesis is based indicate that both single mothers and single fathers have poorer health than couple mothers and fathers. Single mothers also refrain from seeking medical care to a greater extent. The financial advantage of single fathers, in comparison with single mothers, might have an impact on their medical care utilization, since they seemingly seek and consume health care to an extent that matches their poorer health. Social capital has as robust an association with self-rated health as any traditional social determinant of health. Four parental characteristics were found to be independently associated with children’s mental health; being a single parent, ‘poor parental health’, limited social support and low levels of social capital. The uneven distribution of all investigated determinants of health, including social capital, gives us reason to conclude that our findings indeed raise concerns about equity. Action taken by society to enable single parents to increase their social capital might improve their and their children’s health. It may also be clearly stated that financial status has a major impact on both health and health care utilization. This particular characteristic is also rather accessible to alteration, for example through financial transfers between groups in society. </p>

<p>Mortality statistics are much used although their accuracy is often questioned. Producers of mortality statistics check for errors in death certification but current methods only capture obvious mistakes. This thesis investigates whether non-obvious errors can be found by linking death certificates to hospital discharge data.</p><p>Data: 69,818 deaths in Sweden 1995. Paper I: Analysing differences between the underlying cause of death from the death certificate (UC) and the main discharge condition from the patient’s last hospitalization (MDC). Paper II: Testing whether differences can be explained by ICD definitions of UC and MDC. Paper III: Surveying methods in 44 current studies on the accuracy of death certificates. Paper IV: Checking death certificates against case summaries for: i) 573 deaths where UC and MDC were the same or the difference could be explained; ii) 562 deaths where the difference could not be explained.</p><p>Results: In 54% of deaths the MDC differed from the UC. Almost two-thirds of the differences were medically compatible since the MDC might have developed as a complication of the UC. Of 44 recent evaluation studies, only 8 describe the methods in such detail that the study could be replicated. Incompatibility between MDC and UC indicates a four-fold risk that the death certificate is inaccurate. For some diagnostic groups, however, death certificates are often inaccurate even when the UC and MDC are compatible.</p><p>Conclusion: Producers of official mortality statistics could reduce the number of non-obvious errors in the statistics by collecting additional information on incompatible deaths and on deaths in high-risk diagnostic groups. ICD conventions contribute to the quality problem since they presuppose that all deaths are due to a single underlying cause. However, in an ageing population an increasing number of deaths are due to an accumulation of etiologically unrelated conditions.</p>

One of the most vulnerable groups in Swedish society today is single parent families, a group that has increased over the last thirty years in proportion to married and cohabiting parents. The aims of this thesis are to study inequality and inequity in health and health care utilization with regard to whether parents are single or couple (married/cohabiting), to investigate whether the concept of social capital may provide us with further understanding when analyzing inequality and inequity in health and to investigate how the mental health of single parent children may differ from couple parent children and to what extent this difference may be due to parental socio-economic and socio-demographic characteristics, including social capital. The results from the papers on which this thesis is based indicate that both single mothers and single fathers have poorer health than couple mothers and fathers. Single mothers also refrain from seeking medical care to a greater extent. The financial advantage of single fathers, in comparison with single mothers, might have an impact on their medical care utilization, since they seemingly seek and consume health care to an extent that matches their poorer health. Social capital has as robust an association with self-rated health as any traditional social determinant of health. Four parental characteristics were found to be independently associated with children’s mental health; being a single parent, ‘poor parental health’, limited social support and low levels of social capital. The uneven distribution of all investigated determinants of health, including social capital, gives us reason to conclude that our findings indeed raise concerns about equity. Action taken by society to enable single parents to increase their social capital might improve their and their children’s health. It may also be clearly stated that financial status has a major impact on both health and health care utilization. This particular characteristic is also rather accessible to alteration, for example through financial transfers between groups in society.