| 1. |
- Eid Rodríguez, Daniel V., 1980-
(författare)
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The rough journey to access health care : the case of leishmaniasis in the Bolivian rainforest
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Leishmaniasis is a parasitic infectious disease transmitted by vectors that cause three main clinical syndromes: cutaneous (CL), mucosal (ML), and visceral (VL). Since VL is not relevant to this thesis, only CL and ML will be further discussed. Leishmaniasis is present in 98 countries, with more than 350 million people at risk of infection. Leishmaniasis disproportionately affects poor countries and, in particular, remote areas where health services are weaker. Bolivia, a lower-middle-income country, is the fifth country with more cases in Latin America, and case detection and management is the main control strategy of the National Leishmaniasis Control Programme (NLCP). The NLCP provides free treatment to patients, which consists of systemic pentavalent antimonials (SPA) for 20 days. This treatment is highly toxic for patients and costly for the government, resulting in long periods of shortage of the drug. A good alternative to SPA is the use of intralesional pentavalent antimonials (ILPA), which are safer and have similar efficacy to SPA in treating CL. Case detection and management depend on a well-structured health-care system, and the primary level of care is responsible for this task in Bolivian endemic areas. It is well known that health-care access for leishmaniasis patients is limited but the extent and the determinant factors of this problem are unknown. The aim of this thesis is to assess health-care access among patients with leishmaniasis in a Bolivian rainforest rural area, addressing four specific questions: Who is most vulnerable to CL?; What is the extent of their lack of access to health care?; How do the dimensions of access and the quality of care influence health-care utilization in a context of vulnerability?; and how can a change in NLCP policy related to the treatment of CL improve the level of access to health care?Methods: This thesis is based on four studies that use quantitative and qualitative methods. Data collection was conducted through surveys, in-depth interviews and revision of official documents. Sub-study 1 was based on a cross-sectional study conducted in two communities of Cochabamba and assessed risk factors for CL using multivariate analysis. Sub-study 2 used the method of capture−recapture to assess the level of under-reporting of the national register for the period of 2013−2014, using Chapman’s formula. Sub-study 3 was conducted through in-depth interviews applied to 14 participants, using thematic analysis. Sub-study 4 was an economic evaluation that used data from surveys with physicians, official documents and key informants and compared the costs of systemic pentavalent antimonials (SPA) and intralesional pentavalent antimonials (ILPA) from the perspective of the Ministry of Health (MoH) and society. Additionally, a budget impact analysis of the implementation of ILPA in hypothetical scenarios of increasing level of demand was carried out.Main findings: Sub-study 1 showed that gender/sex was the only statistically significant factor associated with CL, with men being the most affected group. Other classical factors, such as animal ownership, house materials and protective measures were, however, not related to CL. Sub-study 2 revealed a high level of under-reporting (73%) of CL in the study area, and this under-reporting was higher among men compared to women. Sub-study 3 showed that the lack of availability, accessibility, affordability and quality of care were the main factors that limited the access to care of CL and ML patients. In sub-study 4, the economic analysis pointed out that the use of ILPA was cost-saving for the MoH and society, and the budget analysis confirmed that the implementation of ILPA as first-line treatment was not only cost-saving for the MoH, but it would also increase the number of patients accessing the treatment.Conclusions: The predominance of a sylvatic pattern of transmission, with men as the most affected group, demands new approaches to prevention related to occupational activities. The NLCP policy related to case management has been essential to reducing economic barriers for patients with leishmaniasis; however, there are still a considerable amount of cases who do not have access to the treatment. Lacko f health services, equipment and drugs, as well as difficulties in reaching health services, the high costs of seeking health care and the low quality of care are important factors that must be addressed to fulfil the right to health care for these patients. Finally, new therapeutic alternatives, such as ILPA, must be considered to reduce problems of affordability, adherence, as well as side effects to the treatment. This information can be used to develop targeted interventions aimed at increasing the access to health care of people with leishmaniasis in the rainforest of Bolivia.
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| 2. |
- Gangane, Nitin, 1961-
(författare)
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Breast cancer in rural India : knowledge, attitudes, practices; delays to care and quality of life
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Cancer is a major public health problem globally. The incidence of cancer is increasing rapidly in many low- and middle-income countries like India due to the epidemiological transition. At present, breast cancer is the leading cancer in females in many countries including India. In spite of all of the epidemiological evidence pointing towards a surge in breast cancer cases, the National Cancer Control Programme of India has not yet taken sufficient measures to understand the disease burden and to plan a course of action to cope with the increasing cancer burden. Aim: The aim of this thesis is to explore the knowledge, attitudes, and practices regarding breast cancer in a predominantly rural district of central India along with identifying the determinants of delays to care and quality of life (QoL) in breast cancer patients. This understanding may help to strengthen the health system by improving breast cancer control and management programmes and the delivery of care.Methods: This thesis combines findings from two cross-sectional studies in the predominantly rural district of Wardha. The first study was a population-based crosssectional survey conducted on 1000 women, in which face-to-face interviews were conducted with the help of a questionnaire covering demographic and socio-economic information, knowledge, attitudes and practices regarding breast cancer screening and breast cancer. The Chi-square test for proportions and t-test for means were used and multivariable linear regression analysis was performed to study the association between socio-demographic factors and knowledge, attitude and practices. The second study was a patient-based cross-sectional study conducted in 212 breast cancer patients. All 212 breast cancer patients were included for patient delay. However, 208 female breast cancer patients could be included for system delay, quality of life and self-efficacy, as there was some information lacking in 4 patients. Information on socio-demographic characteristics, patient and system delays and also reasons for the delays were collected. The study also utilised WHOQOL–BREF for QoL and selfefficacy measurements in breast cancer patients. Socio-demographic determinants were examined by frequencies and means and multivariable logistic and linear regression analysis to assess the relationship between exposure and outcome variables.Results: One third of the respondents had not heard about breast cancer, and more than 90% of women from both rural and semi-urban areas were not aware of breast self-examination. Patient delay of more than 3 months was observed in almost half of participants, while a system delay of more than 12 weeks was seen in 23% of the breast cancer patients. The late clinical stage of the disease was also significantly associated with patient delay. The most common reason for patient delay was painlessness of the breast lump. Incorrect initial diagnosis or late reference for diagnosis were the most common reasons for diagnostic delay while the high cost of treatment was the most common reason for treatment delay. Self-efficacy was positively associated with QoL, after adjusting for socio-demographic factors, patient delay and clinical stage of disease.Conclusions: Our research showed poor awareness and knowledge about breast cancer, its symptoms and risk factors in women in rural India. Breast self-examination was hardly practiced, although the willingness to learn was high. Although The ideal is to have no delay in diagnosis and treatment, diagnostic and treatment delays observed in the study were not much higher than those reported in the literature, even from countries with good health facilities. However, further research is needed to identify access barriers throughout the process of cancer diagnosis and treatment. The quality of life was moderately good and its strong relationship with self-efficacy makes these two dimensions of breast cancer patients relevant enough to be considered for health workers and policy makers in the future.Interventions focused on improving breast awareness in women and the breast cancer continuum of care should be implemented at a district level. The role of community social health activists in breast cancer prevention should be encouraged and the implementation of an operational national breast cancer program is urgently required.
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| 3. |
- Hansson, Jonas, 1971-
(författare)
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Mind the blues : Swedish police officers' mental health and forced deportation of unaccompanied refugee children
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Policing is a public health issue. The police often encounter vulnerable populations. Police officers have wide discretionary powers, which could impact on how they support vulnerable populations. In encountering vulnerable populations the police officers are required to be professional; maintaining mental health in the face of challenges is part of professionalism. Their encounters with vulnerable populations might influence their mental health which in turn might influence the way they use their discretion when making decisions.Background/context: Sweden receives more unaccompanied, asylum-seeking refugee children than any other country in Europe. The number of asylum applications for such children increased from 400 in 2004 to 7000 in 2014 to over 35,000 in 2015. These children come to Sweden and apply for asylum without being under the care of their parents or other legal guardian. Some are denied asylum. If they do not return to their country of origin voluntarily the police are responsible for their deportation. The Swedish government wants an increasing number of deportations and wants them carried out with dignity. This thesis is about the police officers’ perceptions of how to interpret the seemingly contradictory demands for more deportations, that is, efficiency; and concerns for human rights during the deportation process, that is, dignity. This is conceptualized using three theoretical frameworks: a) street-level bureaucracy, b) job demand-control-social support model and c) coping. These theoretical frameworks indicate the complexity of the issue and function as constructions by means of which understanding can be brought to the police officers’ perceptions of deportation work involving unaccompanied, asylum-seeking refugee children and how such work is associated to their mental health.Aim: The current research aims to investigate and analyse Swedish police officers’ mental health in the context of deportations of unaccompanied, asylum-seeking refugee children.Methods: This thesis uses both qualitative and quantitative methodology. The qualitative approach comprised interviews conducted to achieve a deeper understanding of the phenomenon of police officers’ perceptions of deportations of unaccompanied, asylum-seeking refugee children. The quantitative method involved the use of validated questionnaires to investigate the association between police officers’ mental health and psychosocial job characteristics and coping. This approach made it possible to study a complex issue in a complex environment and to present relevant recommendations. A total of 14 border police officers were interviewed and 714 police officers responded to a survey.Results: The police officers utilize their wide discretionary powers and perceive that they are doing what is best in the situation, trying to listen to the child and to be aware of the child’s needs. Police officers with experience of deportations of unaccompanied, asylum-seeking refugee children were not found to have poorer mental health than police officers with no such experience. Furthermore, high job demand, low decision latitude, low levels of work-related social support, shift work and being single are associated with poor mental health. Coping moderates the association between mental health and the experience of carrying out deportations of unaccompanied, asylum-seeking, refugee children, and the police officers seem to utilize both emotional and problem-solving coping during the same complex deportation process.Implications / conclusions: The general conclusion reached in this thesis is that if police officers are subject to reasonable demands, have high decision latitude, access to work-related social support, and utilize adaptable coping, the deportation work does not seem to affect their mental health. When police officers meet vulnerable people, they utilize their discretionary powers to deal with seemingly contradictory demands, that is, efficiency and dignity. The executive role in the deportations of unaccompanied, asylum-seeking refugee children and the awareness of dealing with a child threatened with deportation might give rise to activation of a sense of protection, safety and security. Discretion might make it possible to act on this sense of protection, safety and security and to combine efficiency and dignity. Further studies, which integrate cognitive and emotional discretion with coping, need to be undertaken.
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| 4. |
- Jonzon, Robert, 1952-
(författare)
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Health assessments of asylum seekers within the Swedish healthcare system : a study of the interface between control and care, and how structure and procedures may influence access and coverage
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Despite lack of evidence, there is a common notion that diseases are brought along with migrants, and thus a threat to people in the host country. In Sweden asylum seekers are to be offered a health assessment (HA), but national statistics show that the coverage is less than 50%. It has been assumed that asylum seekers do not want to attend, but this research data instead indicate structural barriers.Objectives: To explore to what extent the Swedish healthcare system provides optimal conditions for asylum seekers to access the HA and how the HA could meet their own perceived health needs, as well as society’s demand on detecting contagious diseases, from a public health perspective.Methods: This research project adopted a mixed method approach. A quantitative cross-sectional design was applied where different questionnaires were used, targeting administrators and healthcare professionals as well as former asylum seekers. In addition a qualitative, interpretative and descriptive research approach was applied, guided by grounded theory. Individual interviews were carried out among former asylum seekers.Results: This research revealed that there is no coherent national system for the HAs on asylum seekers in Sweden. The structures, organizations, procedures and outcomes vary significantly between the 21 counties, and the reasons for the low coverage seemed multifold. The former asylum seekers stated feelings of ambiguity and mistrust due to lack of information on the purpose of the HA and how it might influence their asylum application. Poor communication was identified as one of several barriers to access healthcare. The attitude was positive to the HA as such, but it was considered to be just a communicable disease control, without focus on their own perceived health needs, thus an imbalance between control and care.Conclusions: Although being an important contribution, the HA does not suffice to fulfill the right to health of asylum seekers, due to shortcomings regarding accessibility and acceptability of the information, procedures and services that it includes.
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| 5. |
- Mumba Zulu, Joseph, 1980-
(författare)
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Integration of national community-based health worker programmes in health systems : Lessons learned from Zambia and other low and middle income countries
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: To address the huge human resources for health (HRH) crisis that Zambia and other low and middle income countries (LMICs) are experiencing, most LMICs have engaged the services of small scale community-based health worker (CBHW) programmes. However, several challenges affect the CBHWs’ ability to deliver services. Integration of national CBHW programmes into health systems is an emerging innovative strategy for addressing the challenges. Integration is important because it facilitates recognition of CBHWs in the national primary health care system. However, the integration process has not been optimal, and a more comprehensive understanding of the factors that shape the integration process is lacking. This study aimed at addressing this gap by analysing the integration process of national CBHW programmes in health systems in LMICs, with a special emphasis on Zambia.Methodology: This was a qualitative study that used case study and systematic review study designs. The case study focused on Zambia and analysed the integration processes of Community Health Assistants (CHAs) into the health system at district level (Papers I-III). Data collected using key informant interviews, participant observation, in-depth interviews and focus group discussions were analysed using thematic analysis. The systematic review analysed, using thematic and pathways analysis, the integration process of national CBHWs into health systems in LMICs (Brazil, Ethiopia, India and Pakistan)-(Paper IV). The framework on the integration of health innovations into health systems guided the overall analysis.Results: Factors that facilitated the integration of CHAs into the health system in Zambia included the HRH crisis which triggered the willingness by the Ministry of Health to develop and support implementation of the integration strategy-the CHA strategy. In addition, the attributes of the CHA strategy, such as the perceived competence of CHAs compared to other CBHWs, enhanced the community’s confidence in the CHA services. Involvement of the community in selecting CHAs also increased the community’s sense of programme ownership. However, health system characteristics such as limited support by some support staff, supply shortages as well as limited integration of CHAs into the district governance system affected CHAs’ ability to deliver services. In other LMICs, as in Zambia, the HRH problems necessitated the development of integration strategies. In addition, the perceived relative advantage of national CBHWs with regard to delivering health services compared to the other CBHWs also facilitated the integration process. Furthermore, the involvement of community members and some politicians in programme processes enhanced the perceived legitimacy, credibility and relevance of programmes in other LMICs. Finally, the integration process within the existing health systems enhanced programme compatibility with health system elements such as financing. However, a rapid scale-up process, resistance from other health workers, ineffective incentive structures, and discrimination of CBHWs based on social, gender and economic status inhibited the integration process of national CBHWs into the health systems.Conclusion: Strengthening the integration process requires fully integrating the programme into the district health governance system; being aware of the factors that can influence the integration process such as incentives, supplies and communication systems; clear definition of tasks and work relationships; and adopting a stepwise approach to integration process.
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| 6. |
- Ragnarsson, Susanne, 1966-
(författare)
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Att klara skolan när huvudet dunkar och kroppen värker : en studie om återkommande smärta och skolprestation bland skolbarn
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Bakgrund Återkommande smärta är ett av de vanligaste folkhälsoproblemen bland skolbarn. Den höga förekomsten är ingen ny kunskap, trots det finns det lite beskrivet hur smärtan påverkar barnens funktion och då särskilt om det får konsekvenser för barnens skolprestationer.Syfte Det övergripande syftet med avhandlingen var att studera och värdera evidensen för ett samband mellan återkommande smärta och skolprestation. Detta utifrån smärtans frekvens, lokalisation och utbredning, samt utifrån både subjektiva och objektiva mått på skolprestation. Därutöver studerades möjlig modertorer och mediatorer .Metod Processen delades in i två steg. Steg 1 utgjordes av en systematisk litteraturöversikt (delstudie 1) som studerade den tillgängliga evidensen för sambandet mellan återkommande smärta och skolprestation bland skolbarn mellan 4 och 18 år. Samtliga delar med urval, dataextraktion, kvalitets- och evidensbedömningar utfördes systematisk. Några av de kunskapsluckor som upptäcktes i steg 1 blev grunden till Steg 2 som utgjordes av delstudie 2 och 3. Dessa studier baserades på en longitudinell totalpopulationsstudie från Umeå “The Study of Health in School-aged children from Umeå”. Urvalet bestod av 1524 respektive 1567 barn. Oberoende variabeln var återkommande smärta och beroende variablerna var upplevda problem med skolprestation, meritvärde och gymnasiebehörighet. I studie 2 och 3 analyserades data med hjälp av logistisk och linjär regression.Resultat Steg 1: av 6 387 identifierade studier inkluderades 21 studier varav 13 kunde verifiera samband mellan återkommande smärta och nedsatta skolprestationer. Sammantaget fann översikten begränsat evidens för ett samband mellan återkommande smärta och objektiv skolprestation, samt otillräcklig evidens för ett samband mellan återkommande smärta och subjektiv skolprestation. Brister i de enskilda studiernas kvalitet och design bidrog till den låga evidensen. Steg 2: visade att smärta i årskurs 6 fördubblande oddsen för upplevda problem med skolprestation i årskurs 9, vilket gällde vid olika smärtfrekvenser, lokalisationer och antal smärtställen. Skolfrånvaro, koncentrations och sömnproblem kunde inte mediera sambandet mellan återkommande smärta och upplevda problem med skolprestation. Dessutom sågs ett samband mellan återkommande smärta i veckan i årskurs 6 och meritvärde i årskurs 9. Däremot fanns inget samband mellan smärta i årkurs 6 och gymnasiebehörighet, förutom bland flickor med magsmärta. Skolfrånvaro, koncentrationsproblem och upplevda skolprestation medierade delvis sambandet mellan smärta i årskurs 6 och lägre meritvärde i årskurs 9.Slutsats Resultaten indikationer att återkommande smärta kan predicerar nedsatta betyg och en upplevelse av problem med att prestera i skolan. Resultatet kan lägga till grund för prioriteringar av preventiva insatser i skolan och inom hälso-och sjukvården och kan också bidra med underlag inför utvecklandet av insatser riktade till barn med återkommande smärta.
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| 7. |
- Sirili, Nathanael, 1984-
(författare)
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Health workforce development post-1990s health sector reforms : the case of medical doctors in Tanzania
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Health systems in many low- and middle-income countries suffer from critical shortages and inequitable geographical distribution of the health workforce. Since the 1940s, many low- and middle-income countries have passed through different regimes of health sector reforms; the most recent one was in the 1990s. Tanzania is a good example of these countries. From the 1990s, Tanzania has been implementing the third generation of health sector reforms. This thesis analysed the health workforce development following the 1990s health sector reforms in Tanzania.Methods: An exploratory case study employing both quantitative and qualitative research approaches was used to analyse the training, deployment, and retention of medical doctors about two decades following the 1990s healthsector reforms. The quantitative approach involved analysis of graduation books and records from the Medical Council of Tanganyika to document the number of doctors who graduated locally and abroad, a countrywide survey of available doctors as of July 2011, and analysis of staffing levels to document the number of doctors recommended for the health sector as of 2012. The gap between the number of available and required doctors was computed by subtracting available from required in that period. The qualitative approach involved key informant interviews, focus group discussions, and a documents review. Key informants were recruited from districts, regions, government ministries, national hospitals, medical training institutions in both the public and private sectors, Christian Social Services Commission and the Association of Private Health Facilities in Tanzania. Focused group discussion participants were members of Council Health Management Teams in three selected districts. Documents reviewed included country human resources for health profiles, health sector strategic plans, human resources for health strategic plans and published and grey literature on health sector reforms, health workforce training, and deployment and retention documentation. For the training, analysis of data was done thematically with the guide of policy analysis framework. For deployment and retention, qualitative content analysis was adopted.Results: Re-introduction of the private sector in the form of public-private partnerships has boosted the number of doctors graduating annually sevenfold in 2010 compared to that in 1992. Despite the increase in the number of doctors graduating annually, their training faces some challenges, including the erosion of university autonomies prescribed by the law; coercive admission of many medical students greater than the capacity of the medical schools, thus threatening the quality of the graduates; and lack of coordination between trainers and employers. Tanzania requires a minimum of 3,326 doctors to attain the minimum threshold of 0.1 doctor per 1,000 population, as recommended by the World Health Organization. However, a countrywide survey has revealed the existence of around 1,300 doctors working in the health sector—almost the same as the number before the reforms. Failure to offer employment to all graduating doctors, uncertainties around the first appointment, failure to respect doctors’ preferences for first appointment workplaces, and the feelings of insecurity in going to districts are among the major challenges haunting the deployment of doctors in Tanzania. For those who went to the districts, the issues of unfavourable working conditions, unsupportive environment in the community, and resource scarcity have all challenged their retention.Conclusions: The development of human resources for health after the 1990s health sector reforms have to some extent been contradictory. On the one hand, Tanzania has succeeded in training more doctors than the minimum it requires, despite some challenges facing the training institutions. On the other hand, failure to deploy and retain an adequate number of doctors in its health system has left the country to continue suffering from a shortage and inequitable distribution of doctors in favour of urban areas. For health sector reforms to bring successes with minimal challenges in health workforce development, a holistic approach that targets doctors’ training, deployment, and retention is recommended.
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| 8. |
- Sundqvist, Johanna, 1978-
(författare)
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Forced repatriation of unaccompanied asylum-seeking refugee children : towards an interagency model
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction Not all children seeking asylum without parents or other relatives are entitled to residence permits. In the last few years, more than one in four unaccompanied asylum-seeking refugee children have been forced to repatriate, either to their home country or to a transit country. Mostly the children refuse to leave the country voluntarily, and it becomes a forced repatriation. Five actors collaborate in the Swedish child forced repatriation process: social workers, staff at care homes, police officers, Swedish Migration Board officers and legal guardians. When a child is forced to repatriate, the Swedish workers involved must consider two different demands. The first demand requires dignified repatriation, which is incorporated from the European Union’s (EU’s) Return Directive into Swedish Aliens Act. The second demand requires that the repatriation process be conducted efficiently, which means that a higher number of repatriation cases must be processed. The fact that the same professionals have different and seemingly contradictory requirements places high demands on the involved collaborators. Two professionals have a legal responsibility for the children until the last minute before they leave Sweden: social workers and police officers. That makes them key actors in forced repatriation, as they carry most of the responsibility in the process. Further, they often work with children who are afraid what will happen when they return to their home country and often express their fear through powerful emotions. Being responsible and obliged to carry out the government’s decision, despite forcing children to leave a safe country, may evoke negative emotional and mental stress for the professionals involved in forced repatriation. Aim The overall aim of this study is to explore and analyse forced repatriation workers’ collaboration and perceived mental health, with special focus on social workers and police officers in the Swedish context.Materials and methods The study combines a qualitative and quantitative research design in order to shed light at both a deep and general level on forced repatriation. In qualitative substudy I, a qualitative case study methodology was used in one municipality in a middle-sized city in Sweden. The municipality had a contract regarding the reception of unaccompanied asylum-seeking refugee children iv with the Swedish Migration Board. The municipality in focus has a population of more than 100,000 inhabitants. The city in which the data were collected has developed a refugee reception system where unaccompanied asylumseeking refugee children are resettled and await a final decision regarding their permit applications. This situation made it possible to recruit participants who had worked with unaccompanied refugee children without a permit. Semi-structured interviews were conducted with a total of 20 social workers, staff at care homes, police officers, Swedish Migration Board officers and legal guardians. A thematic approach was used to analyse the data. In quantitative substudies II, III and IV, a national survey of social workers (n = 380) and police officers (n = 714), with and without experience of forced repatriation, was conducted. The questionnaires included sociodemographic characteristics, the Swedish Demand-Control Questionnaire, Interview Schedule for Social Interaction, Ways of Coping Questionnaire and the 12- item General Mental Health Questionnaire. Factor analysis, correlational analysis, and univariate and multivariable regression models were used to analyse the data.Results The qualitative results in substudy I showed low levels of collaboration among the actors (social workers, staff at care homes, police officers, Swedish Migration Board officers and legal guardians) and the use of different strategies to manage their work tasks. Some of them used a teamwork pattern, showing an understanding of the different roles in forced repatriation, and were willing to compromise for the sake of collaboration. Others tended to isolate themselves from interaction and acted on the basis of personal preference, and some tended to behave sensitively, withdraw and become passive observers rather than active partners in the forced repatriation. The quantitative results in substudy II showed that poorer mental health was associated with working with unaccompanied asylum-seeking refugee children among social workers but not among police officers. Psychological job demand was a significant predictor for mental health among social workers, while psychological job demand, decision latitude and marital status were predictors among police officers. Substudy III showed that both social workers and police officers reported relatively high access to social support. Furthermore, police officers working in forced repatriation with low levels of satisfaction with social interaction and close emotional support increased the odds of psychological disturbances. In substudy IV, social workers used more escape avoidance, distancing and positive-reappraisal coping, whereas police officers used more planful problem solving and self-controlling coping. Additionally, social workers with experience in forced repatriation used more planful problem solving than those without experience.Conclusions In order to create the most dignified forced repatriation, based on human dignity, for unaccompanied asylum-seeking refugee children and with healthy actors, a forced repatriation system needs: overall statutory national guidance, interagency collaboration, actors working within a teamworking pattern, forced repatriation workers with reasonable job demands and decision latitude, with a high level of social support and adaptive coping strategies. The point of departure for an interagency model is that it is impossible to change the circumstances of the asylum process, but it is possible to make the system more functional and better adapted to both the children’s needs and those of the professionals who are set to handle the children. A centre for unaccompanied asylum-seeking refugee children, consisting of all actors involved in the children’s asylum process sitting under the same roof, at the governmental level (Swedish Migration Board, the police authority) and municipality level (social services, board of legal guardians), can meet all requirements.
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| 9. |
- Tetui, Moses, 1983-
(författare)
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Participatory approaches to strengthening district health managers' capacity : Ugandan and global experiences
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction:Residents of low in-come countries have persistently suffered poor health outcomes, modest progress made over time notwithstanding. Weak health systems are one of the key reasons for the less than optimum progress. These health systems are constrained by inadequately equipped managers who play a main role in curbing this progress. Strengthening the capacity of health managers capacity is one of the known ways to improve the performance of health systems. This study examined strategies for strengthening the capacity of health managers at the sub-national level, with a special focus on the Participatory Action Research (PAR) approach.Methods:I used an emergent qualitative design which included both primary data collection and a literature review. Primary data collection techniques included individual interviews, Focus Group Discussions (FGDs), participant observations, and a review of project documents and meeting minutes, while searching for peer-reviewed databases was used for the literature review. Several analytical tools were adopted to answer the objectives, including the grounded theory, content and thematic analysis approaches. The Critical Interpretive Synthesis (CIS) method was used to analyze the literature reviewed.Findings:Stakeholders’ perceived the approaches to strengthening health managers’ capacity as an overarching process comprised of three interconnected subprocesses namely: the professionalizing of health managers, the use of engaging approaches to learning, and the availability of a supportive work environment. PAR as an engaging approach to learning was experienced by stakeholders as a nuanced awakening approach. On the one hand, stakeholders felt engaged, valued, responsible, awakened and a sense of ownership. On the other hand, they felt conflicted, stressed and uncertain. The PAR approach enhanced health managers’ capacity to collaborate with others, be creative, attain goals, and review progress. Expanded spaces for interaction, the encouragement of flexibility, the empowerment of local managers and the promotion of reflection and accountability enabled this enhancement. Lastly, the literature reviewed revealed five interrelated elements for harnessing PAR to strengthen health managers capacity. These were: a shared purpose, skilled facilitation and social psychological safety, activity integration into organizational procedures, organizational support and supportive external monitoring.Conclusions:Health managers have a central role in strengthening health systems; hence the formalization of their role, especially within the public-sector, is needed. In addition, significant investments into developing and strengthening their capacity is required. Strengthening the capacity of health managers is an iterative process that draws synergies from different approaches. The process leans on formal trainings as well as more engaging means of learning, such as PAR. As an engaging approach to learning, PAR expands interaction spaces, provides inclusiveness and flexibility, promotes local ingenuity and shared responsibility, and allows for monitoring and learning. PAR had positive effects on the strengthening of the capacity of health managers while at the same time achieving other project outcomes. Participatory approaches are hence relevant for dealing with the complex challenges bedevilling health systems. The approach nonetheless should be applied with a more nuanced appreciation of the challenges when using it and the elements for harnessing it to strengthen health systems.
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