Aim: The overall aim of this thesis is to explore School health nursing through school nurses’ descriptions of schoolchildren’s health and to analyse factors influencing the recording of school-children’s health in the School Health Record (SHR). An additional aim is to evaluate fam-ily nursing interventions as a tool for the school nurses in the School Health Service (SHS). Methods: The thesis comprises four papers. A combination of qualitative and quantita-tive methods was used through individual interviews with a strategic sample of school nurses (n=12) (PI), a national survey to a representative sample of school nurses (n=129) (PII, III) and the implementation of family nursing models developed in Canada with girls in their early ad-olescence with recurrent health complaints and their families (n=4) in co-operation with their school nurses (n=2) (PIV). The Strengths and Difficulties Questionnaire (SDQ) was used as pre and post test. Evaluation interviews were conducted with the families and the nurses separate-ly. Qualitative content analyses were used to analyze the interview text with the school nurs-es and the families. Manifest content analysis was used to analyze the free text answers of the survey and the evaluation interview with the school nurses. Descriptive statistical analyses were used to describe demographic data in all four papers. The SDQ was hand-scored statistically. Findings: The findings showed that nurses judged the schoolchildren’s mental health as dete-riorated, especially in socially disadvantaged areas and more generally among girls expressed as psychosomatic symptoms. Individual factors related to lifestyle affected the schoolchildren’s physical health, and the mental health was, to a large extent, affected by the school environ-ment and family relations. The latter seemed to be the most important factor affecting school-children’s mental health. The basis for the school nurses judgement of the physical health was health check-ups and the health dialogues. Spontaneous visits were more commonly used to judge the mental health. Recording schoolchildren’s mental health was a challenge for school nurses. Difficulties were related to ethical considerations, tradition, lack of time and the im-proper structure of the SHR. Fears of marking the schoolchild for life related to the schoolchild itself, the parents or to other authorities/successive caregivers were brought up as hinders for recording mental and social health. Family sessions may be useful within the profession when handling recurrent health complaints among adolescence girls. The girls and their families ex-perienced relief, they felt confirmed and that their feelings and reactions were normal in that situation. The families became aware of their own strengths and possibilities and this was sup-ported by the SDQ which showed an increased well-being. The school nurses valued this way of working and meant that the sessions seemed to start a changing process within the families. Conclusions: The results indicate that school nurses have a deep knowledge about schoolchil-dren’s health which is not used to its full potential in a public health perspective. However, the experienced difficulties recording schoolchildren’s mental health seem obvious, which would de-mand developing the SHR for the needs of today. Family sessions in SHS with the school nurse as a collaborator with the family seemed useful and may be transferable to other health problems expressed by the schoolchildren. Bronfenbrenner’s ecological systems theory and other models for health determinants are used to illustrate the school nurse as a mediator working on the bridge over different health streams with schoolchildren’s health on an individual and a population level.

From a public health perspective pain from low back and/or pelvis was studied in relation to pregnancy. Two interventions, water gymnastics or Friskis and Svettis ́ gymnastics for pregnant women, were evaluated regarding effects on symptoms and need for sick leave due to low back or pelvic pain. In an intervention study with 390 randomised women, 266 participated in physical activity during 60 minutes once a week during just about half their pregnancies. No one was sick-listed due to low back pain in the water gymnastic group compared to 6 women in the land-based exercise group (p=0.03). Some doubts may be raised regarding recommendations to pregnant women with a history of low back pain to participate in gymnastics. On the contrary, water gymnastics seems to be beneficial regarding low back pain. Methods to prevent pelvic pain in relation to pregnancy are not known. Furthermore, a possible relation between longstanding pelvic pain after pregnancy was investigated. Such a relation has never been described before. Fifteen subjects, women with defined posterior pelvic pain during and after pregnancy and as many controls without anamnesis of such pain were tested for lactose intolerance, using the BH2-test. A correlation was found, p=0.05 but results need to be confirmed in larger studies. The possible link towards explaining such a relation goes through the fact that lactose intolerance and “irritable bowel syndrome”, IBS, often overlap and lactose intolerance test is recommended to be included in investigation of IBS. Can low back/pelvic pain in relation to pregnancy sometimes be correlated to lactose intolerance?

Self-assessed quality of life (QoL) is analysed using a QoL questionnaire (Hörnquist’s QLcs) covering the life spheres: somatic health, mental well-being, cognitive ability, social and family life, activity, financial situation, meaning in life and a global score for ‘entire life’. In all, 487 unemployed and 2917 employed subjects aged 25-64; and 651 unemployed subjects and 2802 in work (including employment, studying and military service) in the 18-24 age group, were investigated in a population-based cross-sectional study on life and health in northern Sweden in 1997. In line with previous findings, results showed that unemployed people exhibited poorer QoL.The greatest difference between unemployed people and those in work was in the financial domain (18-24, 25-64). Unemployed women (aged 25-64) rated the final values of QoL – ‘entire life’ and meaning in life – higher than unemployed men did. In the young group (aged 18-24), unemployed women did not rate any of the domains higher. The young unemployed men rated somatic health and mental well-being higher. Interaction effects were interpreted in the following way: a) unemployed men (aged 25-64) were worst off in the global domain ‘entire life’; b) employed respondents, having a university/college education was beneficial for QoL, while for unemployed respondents (25-64) it was not; c) in the young group (aged 18-24), people in work rated their activity higher than unemployed people, and the effect was strengthened when they were regularly active during leisure. Close friends and cash reserve were important for all participants, no matter whether they were employed or not. The risk of being young and unemployed was greater if the person had a shorter education, worse economy (according to their own ratings) and was in the upper half of the age group (aged 21-24). Finally, the conclusion that QoL is poorer when in unemployment – both for the young and those who are older (aged 25-64) – is in line with earlier findings; however, in contrast to three previous studies, we conclude that psychological well-being is even poorer for young people than for those who are older. Intervention, in terms of steadily improved labour market conditions to counteract the negative effects of exclusion from the labour market, is of great importance from a public health perspective.

The thesis is a contemporary analysis of parts of the Swedish welfare system. Co-operation between agencieswithin the welfare system and provision of welfare services by organizations within the voluntary sector are two contemporary tendencies. Both studies are focusing on the rehabilitation process for individuals who have been excluded from the labour market for a longer time period. The first study describes and analyzes co-operation in a three year project as a strategy for provision of complex welfare services (the ReSam project). The second study describes and analyzes the club house model of rehabilitation (the Fountain House movement).The first study is based on a process evaluation, where different kinds of data were collected through interviews, focus groups and diaries. These data were subsequently analyzed with qualitative methods. The second study isparticipant oriented, which means that a group of members conducted the study in co-operation with the re-searcher. The study isexplorative and research data were collected in a variety of ways including detailed notes, taped interviews and cognitive maps.The results of the first study show that it was possible to co-operate across the organizational boundaries of the different agencies involved, but there were obstacles related to organizational and cultural differences between the agencies, divided loyalties of the officials involved, and limited resources available to deal with the complex needs of the clients. The most important factor was that the officials learnt more about each other and the agencies involved. The result of the second study reveals that daily work tasks forms, deepens and reinvents both relationships as well as the supportive environment. Supportive mechanisms were an explicit ideology, plain structure of the meetings, frequent held working groups and thecertification process. Furthermore, it was important that the taskswere considered as necessaryand made a dif-ference. On the other hand, the members described the clubhouse environment as restricting for some. In the discussion, trust is used as a concept which spans over individual, interpersonal and organizational levels and becomes a useful tool as a theoretical concept binding the two studies to-gether. Trust was revealed as the most important ingredient as it comes to establishing sustainable relationships on a group level. Finally, some possible future scenarios are drawn up and discussed concerning the roles and relations between the welfare system and contemporary new forms of orga-nizing welfare services.