Mind the Blues Swedish Police Officers’ Mental Health and

Forced Deportation of Unaccompanied Refugee Children

Jonas Hansson

Department of Public Health and Clinical Medicine Epidemiology and Global Health

Basic Training Programme for Police Officers Umeå 2017

Responsible publisher under Swedish law: the Dean of the Medical Faculty This work is protected by the Swedish Copyright Legislation (Act 1960:729) Dissertation for PhD ISBN: 978-91-7601-754-8 ISSN: 0346-6612 New Series Number 1909 Cover painted by Olivia Hansson Layout Olivia Hansson & Gabriella Dekombis inspired by music album Nebraska Electronic version available at: http://umu.diva-portal.org/ Printed by: UmU Print Service Umeå, Sweden 2017

“This book is for you, Dad. I miss you! You always cared for vulnerable people. As you look down from heaven, I know you’re

proud of your little boy.”

i

Table of Contents

Abstract ...................................................................................... iiiSammanfattning på svenska ........................................................ vThesis in a Glance ...................................................................... viiAbbreviations ........................................................................... viiiOriginal articles .......................................................................... ixPreface ......................................................................................... 1Introduction ................................................................................ 2

Policing is a public health issue ................................................................................ 2Police officers’ discretion and mental state ............................................................. 2Police officers and UARC ......................................................................................... 3Efficiency and dignity - seemingly contradictory demands .................................... 4Efficiency and New Public Management ................................................................. 5Deportations of UARC – a demanding work task .................................................... 5

Aims ............................................................................................ 7Background ................................................................................. 8

The refugee stream as a public health issue ............................................................. 8Deportations of UARC in Sweden ............................................................................ 9

Theoretical frameworks and concepts ........................................ 11Street-level bureaucracy .......................................................................................... 11Psychosocial job characteristics .............................................................................. 12

Job demand and job control ............................................................................. 13Work-related social support ............................................................................. 14

Coping ...................................................................................................................... 14Mental health ........................................................................................................... 16Summarizing the theories ....................................................................................... 16

Materials and methods .............................................................. 18The study context ..................................................................................................... 18Overall research design ........................................................................................... 18Qualitative component ............................................................................................ 19

Analysis (article I) ............................................................................................ 20Quantitative component ......................................................................................... 20

Questionnaires ................................................................................................... 21Statistical analyses (articles II-IV) .................................................................. 23

Ethical approval ...................................................................................................... 25Results ....................................................................................... 26

Police officers' use of discretion in forced repatriations of unaccompanied, asylum-seeking refugee children - Balancing efficiency and dignity (article I) ................. 26Unaccompanied Asylum-Seeking Refugee Children's Forced Repatriation: Social Workers' and Police Officers' Health and Job Characteristics (article II) ............ 27

ii

Swedish Police Officers’ Job Strain, Work-Related Social Support and General Mental Health (article III) ...................................................................................... 28The Swedish Police Service’s deportations of unaccompanied, asylum-seeking refugee children: The role of coping and general mental health (article IV) ........ 28

Discussion ................................................................................. 30Discussion of the results ......................................................................................... 30

No tensions between efficiency and dignity .................................................... 30The decision has been made – police officers make policy .............................. 31Do these children belong to the public? ........................................................... 32The government does not allow police officers the conditions to consider the child’s best ......................................................................................................... 33Deportations of UARC do not affect police officers’ mental health ................ 33Experience with deportations of UARC associated with low work-related social support ................................................................................................... 34Psychosocial job characteristics and sociodemographic variables in relation to mental health ................................................................................................ 34Active jobs category associated with poor mental health .............................. 35Coping and deportations of UARC .................................................................. 36

General Conclusion ................................................................................................. 37The missing link ...................................................................................................... 39Methodological reflections ..................................................................................... 40

Trustworthiness ................................................................................................ 41Causality and generalization ........................................................................... 42Reliability and validity .................................................................................... 43Ethical considerations ...................................................................................... 44

Recommendations ..................................................................... 46Acknowledgement ...................................................................... 48References .................................................................................. 51

iii

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

iv

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.

v

Sammanfattning på svenska Introduktion: Polisarbete är i mångt och mycket en folkhälsofråga, något som inte minst blir tydligt i polisers möte med utsatta människor. Poliser har ett stort handlingsutrymme, vilket kan påverka hur de bemöter utsatta människor. I mötet med dessa människor behöver poliserna vara professionella; att ta hand om sin psykiska hälsa när man möts av utmaningar är en del av professionalismen. Att möta utsatta människor kan påverka polisernas psykiska hälsa, som i sin tur kan påverka hur de använder sitt handlingsutrymme när de fattar beslut.

Bakgrund: Sverige tar emot fler ensamkommande asylsökande flyktingbarn än något annat land i Europa. Antalet asylansökningar för sådana barn ökade från 400 år 2004 till 7000 år 2014 till över 35 000 år 2015. Dessa barn kommer till Sverige och ansöker om asyl utan sina föräldrar eller annan vårdnadshavare. Somliga av dem nekas asyl. Om de inte återvänder till sitt ursprungsland frivilligt är polisen ansvariga för utvisningen. Den svenska regeringen kräver ett ökande antal verkställigheter av av- och utvisningar samt fastlår att verkställigheterna ska genomföras med respekt för människors värdighet. Denna avhandling handlar om polisers uppfattningar och tolkningar av de till synes motsägelsefulla kraven på att verkställa fler av- och utvisningar, det vill säga effektivitet; och hur man hanterar de mänskliga rättigheterna under utvisningsprocessen, det vill säga värdighet. Detta beskrivs och analyseras med hjälp av tre teoretiska ramverk: a) gräsrotsbyråkrati, b) jobb-krav-kontroll-socialt stödmodellen och c) coping. Dessa teoretiska ramverk visar på arbetsuppgiftens komplexitet och fungerar som utgångspunkt för att skapa förståelse för polisernas uppfattningar av arbetet med att verkställa av- och utvisningar av ensamkommande asylsökande flyktingbarn och hur sådant arbete är associerat med polisernas psykiska hälsa.

Syfte: Denna avhandling syftar till att undersöka och analysera svenska polisers psykiska hälsa i relation till av- och utvisningar av ensamkommande asylsökande flyktingbarn.

Metod: Både kvalitativ och kvantitativ metod användes i denna avhandling. Det kvalitativa tillvägagångssättet innefattade intervjuer för att uppnå en djupare förståelse för hur poliser uppfattar av- och utvisningar av ensamkommande asylsökande flyktingbarn. Den kvantitativa metoden innebar tillämpning av validerade frågeformulär för att undersöka sambandet mellan polisernas psykiska hälsa och psykosociala jobbkarakteristika samt coping. Detta tillvägagångssätt gjorde det möjligt att studera en komplex fråga

vi

i en komplex miljö och att presentera relevanta rekommendationer. Totalt intervjuades 14 gränspoliser och 714 poliser svarade på en enkätundersökning.

Resultat: Resultatet visar att poliserna utnyttjar sitt stora handlingsutrymme och uppfattar att de gör det som är bäst i situationen, att de försöker lyssna på barnet och vara medvetna om barnets behov. Poliser med erfarenhet av av- och utvisningar av ensamkommande asylsökande flyktingbarn har inte visat sig ha en sämre psykisk hälsa än poliser utan sådan erfarenhet. Vidare är höga krav och lågt beslutsutrymme på arbetet, låga nivåer av arbetsrelaterat socialt stöd, skiftarbete och singelliv associerat med dålig psykisk hälsa. Coping mildrar effekten på den psykiska hälsan hos de som har erfarenhet av att utföra av- och utvisningar av ensamkommande asylsökande flyktingbarn. Poliserna verkar utnyttja både emotionell och problemlösande coping under en och samma komplexa utvisningsprocess.

Slutsats: Den viktigaste slutsatsen i denna avhandling är att om poliser utsätts för rimliga krav, har stort beslutsutrymme, tillgång till arbetsrelaterat socialt stöd och använder sig av anpassningsbar coping, verkar det som att arbetet med av- och utvisningar inte påverkar deras psykiska hälsa. När poliser möter utsatta människor utnyttjar de sitt handlingsutrymme för att hantera de till synes motsägelsefulla kraven, det vill säga effektivitet och värdighet. Den verkställande rollen i av- och utvisningar av ensamkommande asylsökande flyktingbarn och medvetenheten om att hantera ett barn som hotas av utvisning kan ge upphov till en aktivering av känslan att ge skydd, trygghet och säkerhet. Handlingsutrymmet kan göra det möjligt att agera på denna känsla av skydd, trygghet och säkerhet samt att kunna kombinera effektivitet och värdighet. Ytterligare studier, som integrerar kognitivt och känslomässigt handlingsutrymme med coping, behöver emellertid genomföras.

vii

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viii

Abbreviations CFA Confirmatory factor analysis

CRC Convention on the Rights of the Child

JDCS Job Demand-Control-Support Model

JDCSQ Job Demand-Control-Support Questionnaire

EFA Exploratory factor analysis

EU European Union

GHQ-12 General Health Questionnaire-12

LAPD Los Angeles Police Department

NPM New Public Management

SFS Swedish Statute Book (Svensk författningssamling)

SMB Swedish Migration Board

UARC Unaccompanied, asylum-seeking refugee children

UN United Nations

UNHCR United Nations High Commissioner for Refugees

WOCQ Ways of Coping Questionnaire

WHO World Health Organization

ix

Original articles The thesis is based on the following articles, referred to as studies or articles I-IV:

I. Hansson, J., Ghazinour, M., & Wimelius, M. (2015). Police officers' use of discretion in forced repatriations of unaccompanied, asylum-seeking refugee children - Balancing efficiency and dignity. International Journal of Social Work and Human Services Practice, 3(3), 101-108.

II. Sundqvist, J., Hansson, J., Ghazinour, M., Ogren, K., & Padyab, M. (2015). Unaccompanied Asylum-Seeking Refugee Children's Forced Repatriation: Social Workers' and Police Officers' Health and Job Characteristics. Global Journal of Health Science, 7(6), 44953. doi:10.5539/gjhs.v7n6p215

III. Hansson, J., Hurtig, A.-K., Lauritz, L.-E., & Padyab, M. (2016). Swedish Police Officers’ Job Strain, Work-Related Social Support and General Mental Health. Journal of Police and Criminal Psychology, 1-10. doi:10.1007/s11896-016-9202-0

IV. Hansson, J., Ghazinour, M., & Padyab, M. (2017). The Swedish Police Service’s deportations of unaccompanied, asylum-seeking refugee children: The role of coping and general mental health. Cogent Psychology, 4(1), 1355629. doi:10.1080/23311908.2017.1355629

The original articles are reprinted with permission from the publishers.

i

1

Preface

“blind faith in your leaders, or in anything, will get you killed” (Springsteen, 1985)

Since I started my basic police training in 1993 I have been interested in the motives behind the execution of police work. I am aware that this interest has not always been a successful strategy for me personally within the police organization. Sometimes this is because the police organization requires action-oriented individuals, but sometimes also because the police organization is not willing to question the norm. In my opinion police work needs reflection in addition to action. One example is that the demands the police officers are required to meet are often quantified. The most important thing seems to be whether it is possible to count what the police officers are doing. Regardless of other factors, such as credibility or trust, it is the numbers that count. It is like counting the shots in a hockey game but not being concerned about the number of goals scored. Of course, it may be interesting to count the shots, but then this must be related to a higher purpose and to the motives behind why the shots are important. Indeed, some shots may even be counter-productive. This was something I really wanted to go into.

As a serving police officer, I often encountered vulnerable individuals. This required a professional approach. To be professional, a police officer needs to have the ability to take a step back and not react in accordance with his or her own assumptions. The Swedish Police Regulations (SFS 2014:1104) require a police officer to act as considerately as possible, show restraint and behave in a manner that inspires trust. The actions of police officers should be based on evidence and not be merely a reaction in response to stimuli. Nevertheless, police officers are human beings and their actions might be affected by their emotions, values and norms. My current knowledge has shed another light on my experiences as a serving officer. Deeper theoretical knowledge and ensuing new perspectives have contributed to increased self-awareness, responsiveness and flexibility.

These characteristics are important for policing, and police officers who just do their jobs must, in my opinion, learn to be more analytical. It is police officers who encounter the citizens and they need to be aware of when things are wrong. They need to reflect and think and be aware of the big picture. What is the role of the police in society? Awareness of this role is fundamental if a police officer is to be professional. “To protect and serve” (LAPD, 1955) and “The police are the public and the public are the police” (Peel, 1829) are notions that are being challenged by a changing society. “The times they are a-changin’” (Dylan, 1964), again, and to be a police officer is more demanding than ever.

2

Introduction The section below describes the rationale behind the thesis and the significance of the topic.

Policing is a public health issue “Both public health and policing are, in part, front-line organisations which intervene directly in the lives of people, with goals and missions that could sit well together but are expressed in a radically different language.” (van Dijk & Crofts, 2017, p. 265)

This quotation functions as entry into an understanding of the importance of my thesis. Policing is a public health issue; however, this does not mean that “police work is ‘like’ public health work” (Anderson & Burris, 2017, p. 300). Public health focuses on the population as a whole and concerns measures that prevent disease, promote health and prolong life (WHO, 2002). Additionally, Punch and James (2017); van Dijk and Crofts (2017); Wood et al. (2017) argue in favour of increasing attention being paid to vulnerable populations from a public health perspective. The police often encounter vulnerable populations. This work requires skills, knowledge and health if the police officer is to be able to be simultaneously analytical, flexible and objective. van Dijk and Crofts (2017) propose a research area covering health-related matters for professionals working in Law Enforcement and Public Health (LEPH), among the many other existing and potential research areas related to LEPH. I would like to emphasize that the mental state of police officers matters in their daily work, especially when they encounter vulnerable populations.

Police officers’ discretion and mental state The officers’ mental state matters because the nature of policing means that they have wide discretionary powers. In other words, it is up to the individual police officers to use their discretion to implement goals and accomplish the missions that the police are tasked with (Lipsky, 2010; van Dijk, Hoogewoning, & Punch, 2016). Police officers’ individual norms and beliefs are important parts of the discretionary decision-making in policing (Buvik, 2016; Tasdoven & Kapucu, 2013). These norms and beliefs might be affected by the police officers’ mental state.

Previous studies have reported that police work in general is highly stressful (Backteman-Erlanson, 2013; Backteman-Erlanson, Padyab, & Brulin, 2013; Chopko, 2010; Duxbury & Halinski, 2017; Garbarino et al., 2011; Morash, Haarr, & Kwak, 2006; Padyab, Backteman-Erlanson, & Brulin, 2016; Stinchcomb,

3

2004). Stress is a known major problem in the profession due to the nature of the work. In the USA, police officers have an elevated risk of death relative to the general population overall. Possible reasons for shorter life expectancy among police officers include shift work, obesity, hazardous environmental work exposures and stress (Violanti et al., 2013). Encountering violent individuals and life-threatening incidents are significant stressors for police officers (Can & Hendy, 2014; Violanti & Aron, 1995). Dealing with death, conflicts with colleagues, challenges concerning police management (Russell, 2014), shift work, exposure to crime scenes, and intimate partner violence are common stressors in policing (Can & Hendy, 2014; Lucas, Weidner, & Janisse, 2012). Political steering also constitutes a stressor for police officers (Can & Hendy, 2014; Lucas et al., 2012). If stress is not managed correctly it can negatively affect the officers’ mental state (Alexopoulos, Palatsidi, Tigani, & Darviri, 2014; Darensburg et al., 2006; Kohan & O'Connor, 2002; Kula, 2017; Violanti & Paton, 1999). Stress and poor mental health can result in anger, negative reactions, or violence, which in turn might lead to maladaptive behaviours or police misconduct. Pressure caused by organizational and operational stress can lead to compassion fatigue (Figley, 1999). Compassion fatigue attacks the very core of taking care of the needs of vulnerable populations: the police officers’ empathy and compassion for others becomes eroded (Figley Institute, 2012). Deviant police behaviour and negative emotions related to stress could have an impact on how police officers treat vulnerable populations.

Mental state and stress affect cognitive functions (Gleitman, Gross, & Reisberg, 2011), for example working memory (Gutshall, Hampton, Sebetan, Stein, & Broxtermann, 2017; Morgan Iii, Doran, Steffian, Hazlett, & Southwick, 2006) and visuospatial capacity (Morgan Iii et al., 2006), which in turn have a negative impact on decision-making (Gleitman et al., 2011). In addition, there is evidence that mental state and stress are associated with a lack of reciprocity in social exchange relationships at an interpersonal level (Kop, Euwema, & Schaufeli, 1999). It is, therefore, important to explore the complex relations between psychosocial job characteristics, coping and mental health and analyse these concepts in the light of the exercise of discretion.

Police officers and UARC One example of decision-making is policy implementation in deportations of unaccompanied asylum-seeking refugee children (UARC). UARC are seen as a vulnerable population according to the United Nations (UN) and the European Union (EU) (2008/115/EC; UN General Assembly, 2016; UNHCR, 1994; UNICEF, 2017). In the context of deportations, the police are one of the actors that encounter vulnerable populations such as UARC. Encountering UARC is an

4

important societal issue and requires the police to be vigilant regarding the children’s needs and to be aware of their vulnerability.

Police officers are faced with many other very demanding situations, such as physical violence, arresting criminals and perhaps even shootings. In reflecting on the relationship between dealing with UARC versus these other, possibly, more demanding issues some arguments can be emphasized. Firstly, there is to my knowledge a lack of research regarding policing and UARC. Secondly, the police encounter UARC in many situations other than deportations. The UARC constitute a risk group for radicalization, drug abuse, suicide and criminality, and are exposed to trafficking. Thirdly, the combination of children and policy implementation from a street-level perspective makes it important to focus on the child’s best interest.

Figure 1. Illustrates Seemingly Contradictory Goals

Efficiency and dignity - seemingly contradictory demands The current stream of refugees to Europe is affecting the political climate in Sweden, and Swedish migration policy has therefore become a central issue. One direct impact on policy is the government's demands that the Police Authority and the Migration Board improve their efficiency by continuously increasing the number of forced deportations (Swedish Government, 2012a, 2012b). Simultaneously, international directives and national policies specify that the dignity of refugees must be respected when they are forcibly deported to their countries of origin (2008/115/EC; SFS 2005:716). These seemingly contradictory directives are to be interpreted and implemented by the police (Figure 1). This

EFFICIENCYAppropriation

Directions – increase the number of deportations

DIGNITYAliens Act, EU:s Return Directive,

Convention on the Rights of the Child – child’s best

5

thesis provides new insights into police officers’ experiences and perceptions of deportations of UARC, with a special focus on the two seemingly contradictory demands for efficiency and dignity.

Efficiency and New Public Management The focus on efficiency, stressed by the government, can be attributed to a global phenomenon called New Public Management (NPM) which was introduced into public sector organizations in the late 1970s. Diefenbach (2009) identifies the central idea of NPM as being to create a more ‘business-like’ and ‘market-oriented’ public sector organization. The purpose of NPM is to give public sector organizations a new orientation. The focus should be on what the market requires, that is, providing services under the slogan ‘value for money’. Two other strategic outside-orientations are the stakeholder angle, that is, meeting objectives set by external stakeholders, and customer-orientation, that is, having a customer perspective on the delivery of services (Diefenbach, 2009). However, Diefenbach (2009) – among many others – is extremely critical of NPM and refers to a number of negative consequences and implications for public sector organizations raised by NPM. He states: “NPM’s strategic orientations are simply too narrowly defined and are based on too artificially and narrowly designed concepts of measurement and accountability” (Diefenbach, 2009, p. 895), and, “the whole idea of efficiency and measurement devalues any qualitative values and aspects” (Diefenbach, 2009, p. 896). With regard to the consequences of NPM in relation to deportations, a study by Ghazinour et al. (2015) showed that UARC in Sweden were being torn between different government agencies and public actors who all strived to increase their own efficiency. It also showed that interviewed UARC all had experienced that agencies and public actors not only were suspicious of them but also often did not trust the information they provided. There was, the study concluded, a risk that efficiency overshadowed dignity. This reinforces the importance of raising questions on how quantified demands for efficiency and the more qualitative demands for respect for human rights and dignity affect police work and police officers.

Deportations of UARC – a demanding work task The police must balance the demands of the job directives and the emotional requirements of the work task. One exacting work task is deportations of foreigners. This work can be considered demanding in general, but is particularly so when the officers have to execute deportations of UARC. Dealing with vulnerable children is commonly stressful per se (Stevens, 2005). These children are often traumatized by their earlier experiences (UNHCR, 2007, 2017). They are also worried about what will happen in the future and mentally affected by the long waiting time for the asylum decision (Kullander, Tönnes Lönnroos,

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Verständig, & Viblemo, 2016; Riddell, 2016). Self-destructive behaviour, aggression towards others or attempts to escape are often present under these circumstances (Kullander et al., 2016; Riddell, 2016). Given this situation, police officers are having to cope with a child under stress. The police officers must be vigilant concerning the safety and security of the child as well as of third parties and themselves. At the same time, the officers must manage sad and lonely children who have to leave their friends and an environment that has been a safe haven for them. In this complex situation, “the best interests of the child must be a primary consideration” (UN General Assembly, 1989, p. 3). Dealing with such responsibilities may evoke stress and mental health issues among police officers. The question is how police officers perceive and appraise the stress to which they are exposed.

Looking at deportations as a phenomenon there are several interplaying mechanisms. Police officers utilize discretion in their daily work (Buvik, 2016; Lipsky, 2010; Tasdoven & Kapucu, 2013), in which they often encounter vulnerable populations (Punch & James, 2017; van Dijk & Crofts, 2017). If police officers are to be able to support vulnerable populations they need good mental health. One of the central issues addressed in the following thesis is police officers’ mental health, which is assessed in relation to associated concepts, such as, job demands, job control and work-related social support, and coping with deportations of UARC. In addition, the thesis explores and analyses how Swedish border police officers, as street-level bureaucrats, perceive their discretion in such deportations.

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Aims The current research aims to investigate and analyse Swedish police officers’ mental health in the context of deportations of unaccompanied, asylum-seeking refugee children.

Four sub-studies were performed. The aims of these are listed below:

• To explore and analyse how Swedish police officers perceive their participation in forced repatriations of UARC.

• To compare general mental health among social workers and police officers who had and had not experienced forced UARC repatriation; to uncover the moderator effect of psychosocial job characteristics on such associations; and to explore similarities and differences between such associations in the two professions separately.

• To analyse the association between psychosocial job characteristics and general mental health among Swedish police officers and to assess the extent to which social support at work plays a role in this association.

• To investigate the associations between coping and general mental health in relation to the deportation of UARC among police officers.

The next section begins by providing the background followed by a section outlining the theoretical frameworks and concepts. The study setting, and the design and method used in the thesis are then presented, followed by a report of the results, concluding with a discussion and recommendations for future action.

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Background The background describes the refugee stream to Europe as a public health issue, and the Swedish context of UARC and deportations of UARC.

The refugee stream as a public health issue The refugee stream to Europe is a public health issue. Many refugees are exposed to difficulties and need support from the government and the authorities. There are at present an estimated 65 million people who have been forcibly displaced from their country of origin. The World Health Organization (WHO) constitution of 1948 establishes the universal right to physical and mental health. With more people on the move than ever before, many refugees lack access to health services and financial protection for health (WHO, 2017). During 2015 approximately 160 000 refugees applied for asylum in Sweden (Swedish Migration Board, 2017). Of these 35 000 were children who had been separated from their parents or other relatives before or during the escape. These unaccompanied, asylum-seeking, refugee children (UARC) are one of the most vulnerable populations among refugees (2008/115/EC; Carlson, Cacciatore, & Klimek, 2012; Ní Raghallaigh, 2013; Sourander, 1998; UN Committee on the Rights of the Child, 2005).

There are relatively few studies in the area of UARC but there are some studies which have focused on the children’s rights. For example, Fekete (2007) claims that the European Union’s (EU) asylum policy is too rigid and focuses on numbers rather than the situation of children and their rights. Shamseldin (2012) investigated implementation of the Conventions on the Rights of the Child (CRC) in relation to UARC. She identified three obstacles impeding its implementation: “indeterminacy of the best interest principle, ill-defined and implemented special protection and assistance measures, and lack of defined service objectives.” (Shamseldin, 2012, p. 90). Other studies have focused on the children’s health. Derluyn and Broekaert (2007) found, in a study in Belgium, that between 37 and 47% of the UARC exhibit severe or very severe symptoms of anxiety, depression and post-traumatic stress. On the other hand, Kohli (2011) found that UARC can be very resilient in the face of (cruel) difficulties, as a result of several factors. These factors concern the importance of establishing lasting relationships with trustworthy people; the importance of being surrounded by a protective and supportive network; staying safe; preserving old traditions and being given the opportunity to develop new ones; access to education; having predictable routines and patterns, and being offered the opportunity to take on the future with a purpose. Many UARC begin to take root in Swedish society through going to school, learning the Swedish language, and connecting with friends and host families. Hessle (2009), for example, found that a majority of UARC who were

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interviewed had adjusted well as young adults. Nevertheless, some of them feel lonely and separated from the community (Wallin & Ahlström, 2005; Wernesjö, 2015).

Deportations of UARC in Sweden The majority of UARC are allowed to stay in the receiving country, but 15 to 20 % of them are forced to return to their country of origin (Swedish Migration Board, 2016). Most of the countries in Europe provide temporary residence permits to UARC until the child’s eighteenth birthday. Once they reach the age of 18 years, they are deported, subject to the same rules as adults. In Sweden at present, UARC are deported according to special rules for unaccompanied children, which require an organized reception in the receiving country. If the child refuses to return, then the police are involved and become responsible for the deportation.

In Sweden, an unaccompanied refugee child can be granted a permanent residence permit on three grounds. Firstly, if the child is considered a refugee in accordance with the United Nations Refugee Convention (UN General Assembly, 1951/1967); secondly, if the child needs subsidiary protection in accordance with joint EU regulations (European Union Agency for Fundamental Rights, 2014); and thirdly, if the child needs protection in accordance with the Swedish National Aliens Act (SFS 2005:716).

The Swedish Migration Board is the first instance in an asylum decision process. If an UARC is denied a permanent residence permit in the first instance, he or she can appeal to two higher instances: the Migration Court and the Migration Court of Appeal. It is very rare for the higher instances to reverse a decision of the Migration Board. The child must leave the country after receiving a final refusal and if the child refuses to return to the country of origin the Migration Board assigns enforcement of the removal to the Police Authority.

When the Police Authority receive the enforced deportation assignment they begin by establishing contact with the individual to be deported. In accordance with the Return Directive and EU Guidelines, the purpose is to create a situation in which the individual agrees to voluntarily return to their country of origin, or at least cooperate in making the return possible (2008/115/EC; Council of Europe, 2005). If the police contact the UARC before the deportation the children often disappear from the care homes in which they have been accommodated during the asylum process. If the child disappears, the police designate them a missing person. To avoid such disappearances, the police will usually contact the director of the care home in advance, and inform him/her when they will show up and initiate the deportation process. Under these circumstances the police

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usually plan to go to the care home early in the morning, collect the child and begin the journey back to their country of origin.

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Theoretical frameworks and concepts This chapter sets out the theoretical dimensions of the research. The theoretical frameworks for this thesis help to identify the interrelationships among concepts and constructions (Björkqvist, 2012; Patel, 2011; Sohlberg, 2013), and help an understanding not only of “the facts” but of their explanations (Krieger, 2016). Since policing and deportation are complex areas a number of theoretical approaches and concepts are required in order to understand the conditions of deportations in which police officers are active. The next section starts with a brief description and definition of street-level bureaucracy and discretion followed by other theories and concepts.

Street-level bureaucracy Street-level bureaucracy is about how public service workers execute their jobs and function as de facto policy decision-makers. Lipsky (2010) reflects on policy implementation and shows that public service workers, such as police officers, teachers and social workers, have a significant effect on policy implementation.

Figure 2. Illustration of discretion inspired by Lipsky (2010)

According to Lipsky (2010) street-level bureaucrats are the public service workers who regularly and directly interact with citizens in the carrying out their jobs. Furthermore, street-level bureaucrats lack time, information or other resources necessary to respond properly to the individual case and, therefore, the work cannot be performed according to the highest standards of decision-making. Instead, street-level bureaucrats psychologically simplify their clientele and the

BALANCING

Street-level bureaucrats

DISCRETION

to treat all citizens alike in

their claims on

government

be respon-sive to the individual case when

appropriate

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environment and develop routine practices that powerfully influence the outcome of their efforts. The street-level bureaucrats must consider both the demand to treat every individual equally as stipulated by the law, but also to treat every person individually depending on the circumstances (Figure 2) (Lipsky, 2010). Lipsky named this discretion and defined it as the space street-level bureaucrats have in which to act in different situations. Exercising discretion means that street-level bureaucrats have the possibility to establish independent priorities and interpretations, disregard rules, invent praxis and obstruct. Street-level bureaucrats must interpret the rules they are governed by and have to implement the rules in relation to the individual present in the specific situation. Consequently, discretion makes street-level bureaucrats the ones who truly “make policy”, and thus, police officers, for example, in this role are an important link (Figure 3) between the democratic society and the people in society (Lipsky, 2010). Since police officers become shock absorbers between the legislature and the individuals in society, their interpretations of their job demands and decision latitude are important.

Figure 3. Illustration of Street-level Bureaucrats as Shock-absorbers inspired by Lipsky (2010)

Psychosocial job characteristics Various psychosocial job characteristic theories exist in the literature (Hackman & Oldham, 2005; Karasek & Theorell, 1990; Siegrist, 1996). One of the leading models for evaluating the complex set of health-risk factors at work is the job demand-control-support (JDCS) model, developed by Karasek and Theorell (1990). The JDCS model is commonly used in occupational research (Aasa, Barnekow-Bergkvist, Angquist, & Brulin, 2005; Karasek et al., 1998; Karasek,

Democratic society People in society

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Choi, Ostergren, Ferrario, & De Smet, 2007; Staland-Nyman, Alexanderson, & Hensing, 2008; Theorell et al., 1988) and in studies of police work (Backteman-Erlanson et al., 2013; Garbarino, Chiorri, & Magnavita, 2013; Padyab et al., 2016).

Job demand and job control Karasek and Theorell (1990) assumed that work-related stress stems from two psychological job characteristics, job demands and job control, which may impact the employee’s health. According to Karasek and Theorell (1990), the psychological demands constitute both the volume and intensity of one’s workload and how one copes with unforeseen tasks, while job control refers to the working individual’s potential control over the pace and content of their work tasks. Job control or decision latitude is further subdivided into skill discretion and decision authority. Skill discretion is the breadth of skills workers can use on the job, while decision authority is related to control of the job, e.g. what tasks are to be performed, when, and in what order, as well as when there will be breaks. In the model, this is combined into one single measure: decision latitude. Karasek and Theorell (1990) describe how psychological demands and decision latitude affect strain, job satisfaction and learning. According to Karasek and Theorell (1990) illness and mental stress might occur when there is a disparity between perceived psychological job demands and workers’ control over the job situation.

Job demand and decision latitude can be combined into a 2-dimensional job strain model (Figure 4) which characterizes psychosocial work exposure (Karasek, 1979; Karasek & Theorell, 1990; Schnall, Landsbergis, & Baker, 1994). High-strain jobs refer to the negative physical and psychological effect that job stress has on a person when their job involves high demands and low decision latitude. When the job involves high demands and high decision latitude it is referred to as active job. Passive job refers to low demands and low decision latitude on the job, whereas low-strain job refers to low demands and high decision latitude (Ibrahim & Ohtsuka, 2012; Karasek & Theorell, 1990). The job demands and control theory was improved later by Karasek and Theorell (1990), and now focuses on the relationship between psychological job demands and control at work and social support from colleagues and managers (Karasek et al., 1998).

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Figure 4. Karasek & Theorell´s (1990) Job Strain Model

Work-related social support Social support alludes to the quality and function of social relationships, which can be as they actually are (Sarason, Levine, Basham, & Sarason, 1983) or as they are perceived (Cohen & Syme, 1985). In this thesis, we use Karasek and Theorell’s (1990, p. 69) definition: “social support at work refers to overall levels of helpful social interaction available on the job from both co-workers and supervisors”. Social support at work can be measured by the degree of trust as well as emotional and social integration (Karasek & Theorell 1990). The rationale for applying this concept in my thesis is that it includes both emotional social support and social integration and focuses on work-related social support (Beehr, Jex, Stacy, & Murray, 2000; Ducharme & Martin, 2000).

Previous research has established that social support buffers work stress (Karasek, 1979; Karasek & Theorell, 1990; Viswesvaran, Sanchez, & Fisher, 1999), and that the combination of job strain and low social support are associated with illness (Johnson & Hall, 1988; Johnson, Hall, & Theorell, 1989). The function of social support on wellbeing can be diverse. One function is the buffering effect between the current situation and the perceived psychological stressor. Another function is the buffering effect between perceived psychological stressors and adverse health outcomes (Ibrahim & Ohtsuka, 2012).

Coping Stress was conceptualized by Lazarus and Folkman (1984) as the process by which we perceive and respond to certain events, or stressors, which we view as

Low strain

Job controlDecision latitude

Job demands

High

Low

Low High

Active

Passive High strain

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challenging or threatening to our wellbeing. This interaction between a person and his or her environment is a cognitive process which is termed “coping” by Lazarus and Folkman (1984). “Cognitive appraisal” occurs in the form of two main mechanisms that contribute to responses to stress: primary and secondary appraisal. Primary appraisal constitutes the evaluation of the demands in the current situation, whereas, secondary appraisal constitutes the evaluation of resources to handle the situation (Figure 5). Lazarus and Folkman’s (1984) definition of coping is the sum of behavioural and cognitive efforts that are constantly changing and that are intended to manage internal and external demands which are viewed as demanding or taxing.

Figure 5. Lazarus and Folkman’s (1984) Coping Process

There are three features of coping. First, coping is process oriented, which means that it focuses on what the person actually does and thinks in the specific situation. Second, coping is contextual, which means that it changes from situation to situation. Third, coping is independent of the outcome of the situation, which means that it is a cognitive process to cope with the emotions and manage the situation but not to master the situation (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986).

The function of coping is two-fold: problem-focused coping changes the troubled environment that causes distress and emotion-focused coping regulates the stressful emotions. These coping processes can be used together or separately (Lazarus & Folkman, 1984). Lazarus and Folkman (1984) claim that problem-focused coping is associated with better health, whereas emotion-focused coping is not, if the situation can be changed. In contrast, emotion-focused coping is

Potential stressor

Primary appraisal to appraise the demands

Secondary appraisal to appraise the resources

Behaviour

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associated with better health, while problem-focused coping is not, if the situation cannot be changed.

Mental health In this thesis, mental health is a central concept related to the theoretical framework. Work-related stress often has a negative effect on individual mental health, which might cause “early retirement from work, high absence rates, and low organizational productivity (WHO, 2014b). Mental health is defined by the WHO as: “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO, 2014a). An individuals’ mental health is affected by biological, social and psychological factors.

Figure 6. Model of the Interrelation between Theories and Concepts

Summarizing the theories This section sets out how the theories are interrelated with each other and with mental health (Figure 6). Lipsky’s street-level bureaucrat theory helps in the analysis of how police officers relate to, interpret and implement the laws, regulations and directives in practice and how the police officers interviewed balance the goals of increased efficiency and respect for UARC’s dignity. The police officers’ experiences and perceptions are investigated and analysed from a psychological perspective. That is, the police officers’ thoughts, emotions and behaviour in relation to each other are important for how they utilize their

The field of deportations of UARC

Police officers’ mental health

Discretion Coping

Work-related social

support

Job demand

and control

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discretionary powers in relation to the goals of efficiency and dignity. The JDCS model is utilized to investigate the patterns of work stress and coping theory is added to the theoretical framework in order to investigate the police officers’ thinking and behaviour in the specific deportation situation. Police officers as individuals can be assumed to perceive the deportation work as stressful, thus the outcome of the study is a measure of mental health. The associations between job demand and control, work-related social support, coping and mental health are important because they might affect how police officers make policy when exercising discretion and in making decisions in the deportation of UARC.

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Materials and methods In this section, the research design will be presented first in general and then in detail.

The study context The Swedish national police system is subordinated to the government authority. The Swedish Police mission is to reduce crime and increase public safety. According to Section 2 of the Police Act (SFS 1984:387) the work of the police is aimed at: preventing crime and other disturbance of public order and safety; maintaining public order and safety, hindering disturbance and take action when such disturbance occurs; carrying out surveillance and crime investigations; providing the public with protection, information and service; and performing such duties as are mandatory on the police according to special regulations. Police activities are divided into three main sections: crime prevention, crime investigation and service (Swedish National Police Board, 2012). The Border Police in Sweden are a part of the Swedish Police Service. The Border Police are responsible for border control, investigating infringements of the Aliens Act and forced deportations of foreigners to their country of origin. Most of the police authorities had a border police unit at the time of data collection.

The data for this thesis were collected from the Swedish Police Service. Until 2014, the Swedish Police Services comprised 21 county police authorities. On 1 January, 2015, these 21 sovereign police authorities were merged into one national police authority. The data collection for this thesis took place during 2014. Thus, the data used in this thesis were collected before the reorganization of the Swedish Police Service. The 21 police authorities varied in size both geographically and regarding the number of employees. In general, every police authority had units responsible for crime prevention, order and security, and criminal investigations. In addition, the police authorities carried out administrative tasks within their geographic area. Every police authority had a border police unit or a comparable unit responsible for border control, intrinsic foreign control, and enforcement of deportations of foreigners. In December 2014, the Swedish Police Services had 28,369 employees, of whom 20 051 were police officers and 8 638 civilians. Among police officers, 31% of those employed were women. The average age of police officers was 43.8 (Swedish National Police Board, 2014).

Overall research design This thesis contains two sets of empirical data. The empirical basis for article I comprises data from interviews with border police officers. The main empirical

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basis for articles II-IV consists in data from a survey directed towards police officers from the whole of Sweden. Between 2013 and 2015, my doctoral work was situated within a research project, funded by the European Return Fund (grant number R16-209-1-01). This thesis was part of that research project and article II contained data from a survey that included social workers. The reason the social workers were included is that comparison with another group of public servants dealing with UARC was important. Thus, the social workers were used as a comparison group. The current study has a mixed method approach. Mixed methods research is justified by the perceived inability of quantitative methods alone to deal with the complexity of research in healthcare (O'Cathain, Murphy, & Nicholl, 2007). Although this is not a healthcare study, the mixed method design made it possible to examine the complexity of the deportations of UARC. Creswell (2011) states that a combination of both numbers and words can provide the most complete analysis of problems. In this thesis, words from the interviews and numbers from the survey were taken together to produce a more complete story of the problem than if the data had been analysed separately. The combination of qualitative and quantitative methods influenced the formation of the aim of the thesis, choices of theories used, the construction of the thematic interview guide and the survey, as well as the final conclusions that were drawn. The studies are described in detail below separated into the qualitative and quantitative components.

Qualitative component Article I was a qualitative interview study. The study includes 14 border police officers from five different police authorities, four of which employed between 300 and 500 police officers with five to ten deployed in the border police unit. The fifth authority employed around 3,000 police officers with 50 officers deployed in the border police unit.

Eleven men and three women, aged between 35 and 65 years, with an average working experience of eighteen years were interviewed. The respondents were identified by contacting the head of the Border Police Unit in each police authority. The officers were initially informed about the project through an e-mail which included a letter of consent, explaining the ethical principles guiding the research project. Appointment times were fixed. Before the interviews, the respondents were reminded of the purpose of the study and were fully informed of their right to refuse and withdraw from the study at any time, without prejudice. Full confidentiality and anonymity regarding respondents was maintained (Research Council, 2002). Confidentiality was guaranteed by omitting the respondents’ names and identities in the recorded and transcribed interviews. I conducted five face-to-face and nine telephone interviews. The interviews were recorded and transcribed verbatim. Because of the long

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geographical distances, we decided to use telephone interviews – a method that did not affect the results and functioned just as well as face-to-face interviews. Kvale and Brinkman’s (2009) recommendation to interview as many respondents as were needed to provide all the answers to an interview question was followed, and interviews were conducted until they added no new information. A thematic, semi-structured interview guide was used. The interviews lasted between 60 and 90 minutes.

Analysis (article I) The qualitative analysis was based on the conceptual framework of street-level bureaucracy proposed by Lipsky (2010), inspired by thematic analysis (Braun & Clarke, 2006) and content analysis (Graneheim & Lundman, 2004).

The thematic interview guide was structured in such a way as to build on the analytical framework of the study. Consequently, the study is a theoretical, thematic analysis driven by theoretical and analytical interests (Braun & Clarke, 2006). Questions about the United Nations Convention on the Rights of the Child (CRC) (UN General Assembly, 1989), national policies and potential conflicts between efficiency and dignity were included in the interview guide. The thematic interview guide and the analytical framework facilitated interpretation of the police officers’ perceptions of the deportation process, as we focussed on their interpretations of efficiency and dignity (Braun & Clarke, 2006). Graneheim and Lundman’s (2004) approach to content analysis guided us in the analysis. The first step was to read the interview transcripts several times, to obtain a sense of the content as a whole. The text was then condensed into meaning units, in order to gain an in-depth sense of the interviews. In the third step, the authors discussed and analysed the condensed meaning units and, finally consensual theories about the units and the significance of the patterns were arrived at (Braun & Clarke, 2006).

Quantitative component The overall sample for the quantitative part of the thesis comprised 714 police officers employed at one of 18 of the 21 police authorities in Sweden. Three of the police authorities declined to participate in the study. A convenience sample was used because of secrecy rules in the Swedish police organization. Power analysis was performed to determine the necessary sample size, calculated using “sample size calculation for logistic regression analyses” (Demidenko, 2007). There is common agreement that the test used to compute the sample size should match the test used in future regression significance testing. Assuming that one out of 10 officers experiences working with unaccompanied children, we wish to be able to detect an odds ratio OR=2 with 80 per cent power and a 5 per cent significance level. From this formula (Demidenko, 2007), we computed the total number of

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participants needed to be 734 police officers. A total of 2113 survey questionnaires were posted, together with prepaid return envelopes, in a sealed envelope to the contact person in each authority. The contact person distributed them to the police officers. The police officers who agreed to participate in the survey returned the completed questionnaires in the prepaid envelopes. A total of 714 police officers responded and returned the questionnaires.

The final sample comprised predominantly men (69%) with an average age of 42 (range = 24 to 67 years), an average of 15 years of work experience with the police authority (range = 0 to 46 years, median = 9 years), and 83% of the police officers were married or cohabitating. The respondents worked as patrolling officers (45%), detectives (24%), highway patrolmen (3%), community police officers (7%), border police officers (11%) and others (10%), and 51 % of the total sample were shift workers. There were 157 police officers (22%) who had experience of deportations of UARC.

The following section of the thesis contains a description of the course of action taken with regard to the quantitative part.

Questionnaires The survey consisted of a socio-demographic questionnaire and three self-administered validated questionnaires.

Socio-demographic questionnaire This questionnaire was designed by the project research group to elicit socio-demographic background information, such as the participants’ gender, age, marital status, education, working experience, type of duty, shift work and experience of working with UARC. Gender was defined as male or female. Age was a continuous variable in years. Marital status had two categories, married (married and cohabiting) and single (single, widowed and divorced). Education was defined as a university degree or no university degree. Working experience was the total work experience as a police officer in years. Type of duty was defined as patrolling versus others. Shift work was defined as daytime work and shift work. Experience working with UARC was identified using a single-item question in the socio-demographic questionnaire (yes/no).

Job Demand Control Social Support Questionnaire (JDCSQ) The Swedish version of Karasek’s Job Demand Control Social Support Questionnaire (JDCSQ) was used to measure psychosocial job demands, decision latitude and social support at work. This instrument has been tested for reliability in the Norwegian and Swedish populations (Sanne, Torp, Mykletun, & Dahl, 2005; Theorell et al., 1988). The questionnaire consists of 3 scales: psychological

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job demand, job control or decision latitude, and work-related social support. A sample item from each domain follows: “Does your job require you to work very fast?’, ‘Do you have the possibility to decide for yourself how to carry out your work?’ and ‘My co-workers (colleagues) are there for me (support me)”.

Psychological job demands were defined using four items and decision latitude was based on six items on a four-point Likert scale 1, 2, 3 and 4. The scores were totalled giving score values of 4–16 for psychological demands and 6–24 for decision latitude. Psychological demands and decision latitude were both dichotomized by the median score consistent with previous Swedish studies (Alfredsson et al., 2002; Peter et al., 1998). Social support at work was measured using six statements. Response scores, ranging from 1 to 4 (high score=low support), were totalled, and police officers who scored above the mean of 10.4 (standard deviation=2.9) were considered to have low levels of social support at work.

A cross-classification of job demands and job decision latitude according to their gender-specific medians produced four mutually exclusive categories: low-strain job (low demands + high control), active job (high demands + high control), passive job (low demands + low control), and high-strain job (high demands + low control).

Ways of Coping Questionnaire (WOCQ) The Ways of Coping Questionnaire (WOCQ) was used to assess coping in UARC deportation work. The WOCQ has been standardized and validated in Sweden in relation to a variety of contexts, mainly health situations (Ahlström & Wenneberg, 2002; Lundqvist & Ahlström, 2006; Padyab et al., 2016). The instructions state that the respondents will be asked to answer each item in terms of how they coped with a specific scenario: “Two days ago, you enforced the deportation of a 16-year-old asylum-seeking youth, who told you about the escape to Sweden and the fear of being forced to go back and being killed”. The instrument contains 66 items with a recommended four-point response scale ranging from does not apply/not used (0) to used a great deal (3) (Folkman & Lazarus, 1988). A sample item was: escape-avoidance ”Tried to make myself feel better by eating, drinking, smoking, using drugs or medication, etc.”; planful problem solving “Tried to get the person responsible to change his or her mind.”; self-control “I went over in my mind what I would say or do.”; distancing “I tried to keep my feelings to myself.”; positive reappraisal “Looked for the silver lining, so to speak; tried to look on the bright side of things.”. The scoring of the coping sub-scales was carried out according to the WOCQ manual (Folkman & Lazarus, 1988) as the mean values of items in each sub-scale.

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General Health Questionnaire (GHQ-12) The general health questionnaire (GHQ-12) was used to assess mental health. The GHQ-12 is a 12-item questionnaire developed to detect psychiatric disorders in community settings and non-psychiatric clinical settings (Arnetz, Arble, Backman, Lynch, & Lublin, 2013; Banks et al., 1980; Goldberg & Williams, 1988). It has been extensively used in various settings and cultures (Black, McCabe, & McConnell, 2013; Mofidi, Ghazinour, Araste, Jacobsson, & Richter, 2008). A study on a Swedish sample showed an internal consistency (Cronbach’s α) between 0.80 and 0.84 for three different groups (Sconfienza, 1998). One advantage of the GHQ is that it is widely used in occupational research (Jackson, 2007; Jones, Rona, Hooper, & Wesseley, 2006; Leijon et al., 2017), which allows simple comparisons with results obtained in other studies. A sample of items follows: “Have you recently been able to concentrate on what you’re doing?’ or ‘Have you recently lost much sleep over worry?”. We used the original scoring by Goldberg with response categories scored “not at all” and “no more than usual” as “0” and “rather more than usual” and “much more than usual” as “1”, or the reverse depending on the question, giving a possible range from 0 to 12, with higher scores indicating poorer mental health. In accordance with Goldberg, Oldehinkel, and Ormel’s (1998) recommendation that “if the mean is below 1.85 then the threshold of 1/2, from 1.85 to 2.7 a threshold of 2/3, and above 2.7 a threshold of 3/4 seems to work best for the GHQ-12”. We used the appropriate cut-off scores for differentiating between individuals with and without psychological disturbances.

Statistical analyses (articles II-IV) Articles II-IV were based on the survey. The GHQ-12 was the outcome (dependent variable). Sociodemographic variables, psychosocial job characteristics, experience of deportations of UARC and the WOCQ were the independent variables.

The chi-square test was used to compare the nominal variables (gender, marital status, education, duty, work schedule, psychological demands and decision latitude) between males and females, as well as between those with and without experience of working with UARC. To compare continuous variables (coping scales, age and work experience) between males and females, as well as between those with and without experience of working with UARC, T-tests or the Mann-Whitney U test (depending on the Gaussian distribution) were used.

T-tests and the chi-square test were used to analyse the gender stratified associations between sociodemographic variables and work-related social support. The Mann-Whitney test (due to skewed distribution of psychological

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demands and decision latitude) was applied to compare psychosocial job characteristics and gender.

Pearson’s correlation coefficient was used to assess the associations between mental health and age, and psychological demands and decision latitude total scores. Univariate and multivariable logistic regression were applied to describe the association between demographic and psychosocial job characteristics on the likelihood of having a psychological disturbance (“yes or no”) according to GHQ cut-off scores. Depending on the normal distribution, the t-test or Mann-Whitney test were used to compare coping sub-scales, age and working experience between police officers with and without psychological disturbance. Pearson’s Chi-square test for independence was used to calculate the association between categorical variables (gender, marital status, education, duty and work schedule) and experience with forced UARC deportations and psychological disturbance.

The probability of psychological disturbance was calculated by different categories of job strain and work-related social support. The predicted probabilities were computed following two steps. First, the coefficients for the linear predictor were calculated. The linear predictor is a linear function of the coefficients and exploratory variables in the logistic regression model (Buis, 2007). Next the linear predictor was transformed to the probability metric. Logistic regression was used to calculate the univariate and the multivariable associations between job strain categories and psychological disturbance at different levels of work-related social support. To analyse the crude odds ratio univariate logistic regression was used. Multivariable logistic regression was used to analyse how the magnitude of the associations changed before and after controlling for sociodemographic variables and work-related social support.

Univariate and multivariable logistic regression described the associations between coping and psychological disturbance, “yes or no”. Hierarchical logistic regression analysis was used to assess the predictive value of coping and other sociodemographic variables for psychological disturbance.

Confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were used to investigate the construct validity of WOCQ. CFA was used to test the original eight-factor structure (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986). To extract more appropriate factors based on the given scenario among police officers EFA was used. We used parallel analysis to obtain the optimal number of factors (Hayton, Allen, & Scarpello, 2004). Modifications were performed, and CFA on the newly derived scales from EFA. We evaluated the correspondence between the WOCQ items and the coping dimensions specified by Folkman and Lazarus’s theory. In this procedure, the items in each factor were evaluated in relation to the coping dimensions and compared to Folkman and

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Lazarus’s (1988) labelling. We omitted items that did not fit into the coping dimension and had a low loading factor. We based the decisions regarding some of the items on semantic and conceptual, rather than empirical, reasons.

We followed Jöreskog’s (2004) CFAs guidelines for the analysis of ordinal data. Diagonal weighted least-squares estimation was applied to polychoric correlations that were based on the asymptotic covariance matrix. The models were evaluated by means of the Bentler–Satorra chi-square score, root mean square error of approximation (RMSEA) (Steiger, 1990), and 90% confidence interval for RMSEA. Browne and Cudeck (1993) provided a guideline stating that RMSEA values of less than .05 indicate a close fit, values in the range of .05 to .08 indicate a fair fit, and values above .10 indicate a poor fit. The goodness-of-fit index (GFI) and adjusted goodness-of-fit index (AGFI) were used. Values exceeding .90 indicate a good fit of the model to the data. The comparative fit index (CFI) (Bentler, 1990) and incremental fit index (IFI) (Bollen, 1989), were also reported, with values equal to or greater than .90 denoting an acceptable fit to the model (Bentler & Bonett, 1980; Kline, 2005).

We conducted EFA using principal component analysis (PCA) with polychoric correlation and oblique rotation. Polychoric correlation was applied because the variables consist of ordinal data, and oblique rotation was used because the factors were expected to be dependent on each other (Folkman & Lazarus, 1988). The internal consistency of the scale was measured by calculating Cronbach’s α, which ranges from 0 to 1, with values greater than .60 – .70 considered to have acceptable reliability (Tabachnick & Fidell, 2006).

We conducted EFA of the factor structure of the WOCQ and statistical analysis using STATA version 13.1 (StataCorp, College Station, TX) and we performed CFAs by means of LISREL 8.8. Significance was established at p < 0.05.

Ethical approval The research proposal was approved by the Regional Review Board at Umeå University, Dn 2014/69-31Ö. The survey included an introductory letter stating the purpose of the study and a consent form. At the start of the interviews potential participants were told about the purpose of the study, that participation in the study was voluntary and that they could withdraw at any time during the interviews, without giving a reason.

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Results An overview of main findings from articles I-IV is presented below. Detailed findings from each study are presented in the original publications appended to the thesis.

Police officers' use of discretion in forced repatriations of unaccompanied, asylum-seeking refugee children - Balancing efficiency and dignity (article I) The aim was to explore and analyse how police officers perceive and interpret increased efficiency and dignity in relation to deportations of UARC and what they think constitutes an efficient and dignified forced repatriation. All police officers argued that they are unable to do anything about the enforcement order once they have received the assignment to deport a child. One police officer stated: ‘Somewhere, someone has decided that it is acceptable to ship children here and there’. The decision has been made by the Swedish Migration Board or by a court of law. However, the officers thought that they ‘do their best for the child’ and implement the decision to deport the child ‘in the best way’. A majority of the police officers argued that efficiency is important, but also emphasized the importance of not sacrificing fundamental values, as expressed in the CRC. One of them stated that ‘efficiency does not mean one should stop thinking’. Generally, the officers stressed that not sacrificing fundamental values requires professional knowledge and that at the end of the day ‘the child’s rights must be placed first’. However, the police officers thought of the ‘child’s best interest’ from their own point of view. One of the officers interpreted ‘the child’s best interest’ in relation to the experience of ‘having my own children’. Another respondent stated that ‘the child’s best interest must come first because the CRC says so’ but also interpreted the child’s best interest with explicit reference to the Return Directive ‘meaning to be reunited with their family’.

The police officers linked dignity to ‘good and kind treatment’, which is treating the child with ‘respect’, ‘warmth and dignity’. In deportations, the police intervention needs to be ‘discreet and nice’, ‘peaceful’, ‘smooth and efficient’ and ‘considerate towards the children’. Furthermore, to give ‘good and kind treatment’ the police officers need to be ‘professional’, ‘flexible’ and ‘not influenced by prestige’ and behave ‘clearly’, ‘correctly and nicely’, ‘calmly and harmoniously’.

Police officers at two police authorities discussed the legal possibilities of taking children into custody before deportation. The police officers argued that it would be better, and more dignified, to take children into custody for the time it required

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to get travel documents in order and make other travel arrangements than to show up early in the morning at a care home and try to catch a child before he or she disappeared.

The police authorities had implemented a LEAN-based system to increase the number of deportations. The cases were divided into three groups. The first included cases that could easily be enforced, requiring no more work than reserving a ticket. The second group included enforceable cases where there was work to do, for example, contacting an embassy in order to get travel documents. The third group included cases that, due to external circumstances, were often practically unenforceable. This could be the case when the country of origin declares that it will not receive a person who does not want to return voluntarily. These cases were prioritized by category to increase the number of deportations, in ascending order of difficulty. This categorizing was frustrating for some of the police officers. They noted that ‘the friendly and cooperative ones are sent home, but we let the troublesome stay’. In one police authority the unit had experienced a reduction in resources but was still expected to increase enforcements. They chose to take action in cases involving the deportation of criminals, but not in cases involving children. The police officers in this authority reported that they had enough immigrant criminals to deport and no time left for unaccompanied, asylum-seeking refugee children; one officer stated, ‘It suits me fine’.

One officer argued for incentives to voluntarily return to the country of origin and not the other way around. The officer meant that individuals in Sweden who have been refused asylum can still receive benefits from the Swedish government. They can still go to school, access the healthcare system even though they are not allowed to remain in Sweden. The officer described how the police try to find these individuals while they simultaneously exist in the systems of other authorities. In addition, this officer referred to migrants coming to Sweden to exploit the welfare system.

The officers described situations in which they did more than was legally expected or demanded of them. They would help a child to pick up a cell phone from a workshop before leaving Sweden, check in an extra suitcase for the child at the airport or help the child to get Swedish school grades validated and translated into the child’s mother tongue.

Unaccompanied Asylum-Seeking Refugee Children's Forced Repatriation: Social Workers' and Police Officers' Health and Job Characteristics (article II) The findings show that poorer mental health is associated with working with UARC among social workers but not among police officers. Working with UARC

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is associated with perceiving higher psychological demands and lower decision latitude among social workers. There was no such an association among police officers. Taken together, these results suggest that there is an association between working with UARC and stress among social workers, but not among police officers. However, taking into consideration all the independent variables (age, gender, working experience, education, and marital status) psychological demands was the only significant predictor for psychological disturbance among social workers while psychological demands (OR=1.35, 95% CI: 1.23-1.48, p < 0.001), decision latitude (OR=0.86, 95% CI: .79-0.94, p < 0.001), and marital status single (OR=1.90, 95% CI: 1.24-3.02, p < 0.01) were predictors for psychological disturbance among police officers.

Swedish Police Officers’ Job Strain, Work-Related Social Support and General Mental Health (article III) The findings show a relationship between work-related social support and job strain, suggesting that those with low work-related social support experience high job strain, and those with high work-related social support experience low job strain. There was no such significant relationship among police officers in the active and passive job strain groups. Separately, high job demands and low decision latitude are associated with low work-related social support. Furthermore, low levels of work-related social support, active job and high job strain are associated with psychological disturbance. In addition, police officers with active and high strain jobs together with low work-related social support show significantly higher odds of reporting psychological disturbance compared to those with low strain and high work-related social support.

The Swedish Police Service’s deportations of unaccompanied, asylum-seeking refugee children: The role of coping and general mental health (article IV) In this study, a five-factor solution with 55 items was used according to the results of the CFA and EFA, which showed reasonable fit indices1: RMSEA= .0377 (CI 90% .0345 - .0408), CFI= .917, IFI = .918 and GFI = .849 and adjusted GFI (AGFI) of .873. The coping categories (internal consistency2) were escape-avoidance (.83), planful problem solving (.84), self-control, (.84) distancing (.76) and positive reappraisal .67). Items 1, 2, 5, 6, 9, 18, 26, 28, 38, 42 and 53 were

1 These indices show the correctness of the model (see closer description in the method section).

2 Cronbach’s alpha, which ranges from 0 to 1, with values greater than .60 – 70 is considered to have acceptable reliability.

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omitted due to low loading factors and/or poor fit to the factor scale. The coping categories confrontive coping, seeking social support and accepting responsibility did not load in the factor analysis.

The findings show escape-avoidance, planful problem solving, self-control and distancing are used more often among those with no experience of UARC. Escape-avoidance and self-control are used more often among those with psychological disturbance than those without. There is a significant association between psychological disturbance and marital status, as well as work schedule. Single individuals and shift workers were more often present among those with psychological disturbance compared to those without psychological disturbance.

The strongest predictor for reporting psychological disturbance is escape-avoidance (OR=2.32, 95% CI: 1.23-2.92, p < 0.01), followed by shift work (OR=1.97, 95% CI: 1.08-3.59, p < 0.05). Self-control (OR=1.74, 95% CI: 1.09-2.80, p < 0.05) shows the same level of prediction for psychological disturbance in the multivariable analysis and the univariate logistic regression. Marital status single (OR=1.78, 95% CI: 1.12-2.83, p < 0.05) was the only significant variable that shows lower prediction for psychological disturbance when controlling for other variables. Positive reappraisal (OR=0.61, 95% CI: 0.39-0.95, p < 0.05) has a protective effect on psychological disturbance when controlling for other variables.

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Discussion The discussion is divided into two parts, separating discussion of results and methodological reflections. The discussion of results aims to put the main findings into a wider perspective by using theoretical frameworks and to view them in relation to previous research. The methodological reflections cover discussions on trustworthiness, causality, generalization, reliability and validity, and ethical considerations.

Discussion of the results This thesis sought to gain knowledge about police officer´s perceptions of how to interpret the seemingly contradictory demands for more deportations, that is efficiency, and concerns about human rights during the deportation process, that is dignity. This is conceptualized using the following three theoretical frameworks: a) street-level bureaucracy, b) the job demand-control-support (JDCS) model and c) coping. These theoretical frameworks indicate the complexity of the issue and functioned as constructions on which to build an understanding of the police officers’ perceptions of deportation work involving unaccompanied, asylum-seeking refugee children (UARC).

No tensions between efficiency and dignity One important finding is that police officers do not perceive any obvious tension between efficiency and dignity in forced deportations of UARC. Most seem to think of the two as being mutually reinforcing. One possible explanation for this lies in their executive role as police officers in general. In other words, they are used to carrying out and not questioning orders in their daily work as police officers. However, within the executive role in the process of forced deportations, a police officer’s awareness of dealing with a child threatened with deportation could activate a sense of needing to provide protection, safety and security. In the interview study, the police officers seemed to interpret the work task in accordance with what is appropriate for themselves and what they believe is the best for the children. In other words, they interpret the situation and think of the ‘child’s best interest’ from their own point of view. More specifically, the police officers, in their own view, are doing what is ‘best for the child’ during the deportation. This is similar to what Ottosson, Eastmond, and Schierenbeck (2013) found in their study of children’s case workers; these workers emphasized the importance of the child’s perspective. Comparable to how the children’s case workers saw the child’s perspective, but on their own terms (Ottosson et al., 2013), the findings in the current study show that the police officers have their own personal definitions of dignity. They try to treat the children with kindness and decency, and listen to their needs. However, they still carry out their work

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task and seem to use their discretionary power to construct a situation that makes it possible for them to combine efficiency and dignity (Figure 7).

Figure 7. Police Officers Balancing Efficiency and Dignity

The decision has been made – police officers make policy In the interview study, the police officers all argued that they are unable to do anything about the enforcement order once they received an assignment to deport a child. At this stage the decision has been made by the Swedish Migration Board. This is a characteristic situation for a police officer, who can be seen as a street-level bureaucrat and a shock absorber between the legislature and the citizen (Kanstroom, 2007; Lipsky, 2010) (Figure 8). According to Lipsky (2010) it is street-level bureaucrats who, by utilizing their discretionary powers, “make policy”. In deportations of UARC, the police officers are expected to combine efficiency and dignity in carrying out the task as stipulated by the law. In addition, they must interpret the government’s demands, which can be contradictory. In this situation, the officers seem to focus on their relation to the child and how they treat the child in the specific situation. Although this task seems impossible to accomplish the police officers somehow seem to manage it well. One possible explanation lies in their broad discretionary powers, which may have a positive effect on the police officers’ mental health as well as on how the UARC are treated in a situation that cannot be changed; that is, the deportation will be carried out regardless. For example, the police officers try to help the children with small things like ‘picking up a cell phone at the workshop’. Another example of using discretion explained by one police officer is: ‘I am only taking hand luggage on the flight, and then I can check in an extra bag for the child’. These police officers’ statements capture how discretion is important for them to be able to cope with

dignityefficiency

BALANCING

Police officers

DISCRETION

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this difficult task of deportation. In a study on decision-making in the context of Oslo nightlife, Buvik (2016) identifies how discretionary assessment depends on different variables. Police officers’ decisions depend on situational, system and offender variables. Furthermore, Buvik (2016) adds individual and attitudinal explanations to gain a fuller picture of the police officers’ decision-making. In the current study, the police officers both prioritized and accomplished the deportations using a combination of these variables.

Figure 8. Police Officers as Shock-absorbers

One example of discretion in relation to system and offender variables (Buvik, 2016) was found, especially in one police authority, where the officers utilized discretion to avoid carrying out deportations of children and instead prioritized deportations of criminals. The police officers’ own interpretations of what constitutes dignity make it cognitively possible for them to combine efficiency and dignity. For instance, most officers interpret the best outcome for the child as being reunited with their family. Consequently, they ‘believe’ that repatriation is best for the child. Discretion allows police officers the possibility to interpret and prioritize their work regarding efficiency and dignity. This is an example of an attitudinal variable and of how police officers utilize discretion to “make policy”. This interpretation of “the child’s best” may explain why police officers with experience of deportations of UARC do not perceive their work situation as more demanding than that of other police officers.

Do these children belong to the public? In the situation described above, the police are responsible for ensuring that the deportation is actually carried out. One police officer stated: ‘Somewhere,

EFFICIENCYAppropriation

Directions – increase the number of deportations

DIGNITYAliens Act, EU:s Return Directive,

Convention on the Rights of the Child – child’s best

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someone has decided that it is acceptable to ship children here and there’. The deportations of UARC are not directly connected to the police authority’s main mission, but regulated migration is related to public safety. Indirectly, this affects the deportations of UARC and how the police officers interpret the policies. According to the Police Act (SFS 1984:387), the Swedish Police mission is to reduce crime and increase public safety. The findings show that police officers try to make the best of the situation although the interpretations lack explicit references to children’s human rights. One explanation for this may be that society is changing and the role of the police is being challenged. Historically the role of the police has been “To serve and protect” (LAPD, 1955) and “The police are the public and the public are the police” (Peel, 1829), which are similar to the terms used in the Swedish Police Act 1§, that is, maintain public order and safety, and provide protection and assistance for the public (SFS 1984:387). Thus, a question one can ask is: “Who is the public?” and “Do these children belong to the public?”

The government does not allow police officers the conditions to consider the child’s best All five police authorities had made changes to increase and measure the number of deportations. Diefenbach (2009) suggests that the effect of monitoring and controlling can be devastating. If the leaders lack experience and do not possess a good knowledge of the core business there might be a risk that management and support activities have lives of their own at the expense of the core business (Diefenbach, 2009). The police officers’ interpretation of dignity may be a result of the conditions they were given by the government, that is to increase the number of deportations but to accomplish the deportations with dignity. In conclusion, the police officers do the best they can in this situation and try to accomplish an assignment they were given by the government, despite the government not allowing them the conditions that would make it possible to consider the child’s best, according to the CRC. However, the police officers carry out the deportation by using discretion and acting in accordance with Swedish Law, that is, the Aliens Act and the Police Act.

Deportations of UARC do not affect police officers’ mental health The findings in our study do not support the view that working with forced deportations of UARC negatively affects police officers’ mental health. According to Karasek and Theorell (1990), psychological demands and control may impact an employee’s stress and health. They suggest high psychological demands and low decision latitude may have a negative effect on health. In our study, the police officers with experience of forced deportations of UARC did not perceive psychological demands or decision latitude differently from officers without such experience. Consequently, these job characteristics connected to deportation did

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not have a negative effect on their mental health. This may be related to their already demanding work tasks, which often expose the police officers to extreme situations (Paton & Smith, 1999). These experiences may accustom them to difficult situations. Another explanation for the apparent lack of effect on the police officers’ mental state might be that they perceive their executive role in the forced deportation process as being the same as in any other work task.

Experience with deportations of UARC associated with low work-related social support The findings show that police officers with experience of deportations of UARC reported lower levels of work-related social support compared to police officers without such experience. This might be difficult to explain, but this finding and the fact that social support buffers stress (Mitchell, 1999; Schwarzer, Bowler, & Cone, 2013) further support the idea that this work task does not affect the police officers’ mental health. In other words, if the officers with experience of deportations had had high work-related social support they would have had even better mental health. Nevertheless, in the interviews the border police officers emphasized the importance of discussing the cases within the team. The discussions were mainly in relation to how to cope with the individuals in the deportations. A possible explanation for this finding could be that police officers, in general, to a large extent discuss and process the difficulties involved in their work within their teams. Previous research has shown strong associations between the quality of work-related social support and adverse mental health among human service professionals employed in crisis settings (Brown & O'Brien, 1998). A further study focused more on the quality of work-related social support is therefore suggested.

Psychosocial job characteristics and sociodemographic variables in relation to mental health The findings in the current study show that high job demand, low decision latitude, single marital status and shift work are associated with poor mental health. The present findings are consistent with previous findings regarding demands (Backteman-Erlanson et al., 2013; Chopko, 2010; Karasek & Theorell, 1990) and decision latitude (Garbarino et al., 2012; Garbarino et al., 2011; Karasek & Theorell, 1990). The findings in the present study show that police officers’ job strain and work-related social support are associated with mental health, both in combination and separately. High job strain is associated with low work-related social support. High job strain and low work-related social support are associated with poor mental health. These findings are consistent with those of earlier research (Andre-Petersson, Engstrom, Hedblad, Janzon, & Rosvall, 2007; Cohen & Wills, 1985; Karasek & Theorell, 1990; Morash et al., 2006). The association between low levels of work-related social support and poor mental

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health is stronger among male than among female officers. Although this result differs from that of Andre-Petersson et al. (2007), it is consistent with the results found by Backteman-Erlanson et al. (2013) in a study on burnout and job characteristics among male and female police officers in Sweden. One possible explanation for the finding that psychologically disturbed men receive a lower level of work-related social support is that men tend to be less open about seeking help for mental health problems (Britt, Jennings, Cheung, Pury, & Zinzow, 2015; Ward, Wiltshire, Detry, & Brown, 2013).

The fact that shift work is associated with poor mental health in the current study supports earlier research (Ma et al., 2015; Violanti, 2012; Violanti & Aron, 1995). According to studies conducted by Violanti (2012) on police officers in the USA, the combination of shift work and lack of sleep is associated with poor health. Ma et al. (2015) found that police shift workers are exposed to more stressful events, while Violanti and Aron (1995) found that police officers rank shift work and inadequate support from the department highest among organizational stressors. Nabe-Nielsen, Jensen, Hansen, Kristiansen, and Garde (2016) found that police officers who prefer working four or seven repeated night shifts more frequently preferred night work, find night work less demanding and are better able to sleep at different times of the day. Russell (2014) suggests that individuals in high-risk occupations are influenced by leader behaviours under stressful conditions. Alexopoulos et al. (2014) found, in a study of police officers in Greece, that perceived stress levels have a profound negative effect on job satisfaction, quality of life and general health. Interventions to reduce or manage stress that are tailored according to shift work, decision latitude and work-related social support may be considered.

Active jobs category associated with poor mental health The findings show that active jobs category is associated with poor mental health. This result differs to some extent from that of Karasek and Theorell’s (1990) estimate of job strain. They claim that the tensions created by the requirements of the active jobs category, that is demand/control, are translated into action through effective problem solving, and there is therefore little residual strain to cause psychological strain. However, the finding from the current study is consistent with data obtained in a study on job strain and coronary heart diseases by Ferrario, Veronesi, Bertù, Grassi, and Cesana (2017) and a study on job strain and family wellbeing by Jirapongsuwan, Likitpornswan, Triamchaisri, and Chandanasotthi (2011). Overall, this supports the major role played by job demand in determining the increased risk of poor health. The inconsistent result in the current study can be related to the contradictory demands that police officers often have to deal with. Although police officers with high decision latitude have the possibility of impacting their work on various levels, their broad

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discretionary powers expose them to contradictory demands in the decision process. Further, being exposed to contradictory demands is theoretically the domain of demands and not decision latitude (Karasek & Theorell, 1990). One example is the deportations of UARC where the police officers must consider both the demand to increase the number of deportations executed, that is efficiency, and the human rights and the children’s best interest, that is dignity. The findings from our interviews show that the officers did not perceive these demands as contradictory. Nevertheless, as coping with such situations may be stressful, study IV describes police officers’ coping with the deportation of UARC and investigates the moderating effect of coping on mental health.

Coping and deportations of UARC The findings show a significant difference in coping between police officers with experience with deportations of UARC and police officers without such experience. Escape-avoidance, planful problem solving, self-control and distancing were reported more often among those with no experience with deportations. Furthermore, the findings show associations between reporting coping escape-avoidance and self-control, and poor mental health. These findings support the hypothesis that coping moderates the effect of experience with deportations of UARC in relation to mental health. Police officers with experience of deportations of UARC seemed to report more adaptive coping. A feasible explanation for this is their awareness of the possibility of utilizing discretion in the deportation work. It is likely that the use of discretion that was reported makes it possible for the police officers to carry out the deportations, while they cope cognitively with the situation in an adaptive way.

The results show that the police officers utilize both emotional and problem-solving coping in the same situation. One possible explanation may lie in the complexity of the situation, which requires a flexible police officer, considering both the demand to increase the number of deportations and to carry out the forced deportations with dignity. According to Lazarus and Folkman (1984) it is more adaptive to utilize emotional coping if the situation cannot be changed and to utilize problem-solving coping if it is possible to influence the situation. Consequently, because the police officers can use discretion, as in the deportation situation of UARC, they are more likely to utilize adaptive coping. However, these data must be interpreted with caution because coping is process oriented, that is, it focuses on what the person actually does and thinks in the specific situation, and it is also contextual, that is, it changes from situation to situation (Folkman et al., 1986).

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General Conclusion In the following part of the thesis I will strengthen my own voice, and reflect on the findings of the study with regard to the main question raised. Why is the mental health of police officers not affected by deporting children from what has been their safe haven for several years, back to something these children fear? Being allowed to exercise discretion, they appraise and interpret the situation they perceive and try to cope with it. Their access to discretion might give the police officers the ability to take a step back and reflect on how they can deal with a UARC in a vulnerable position. I want to emphasize that it is extremely important that the police organization values discretion in meeting the contradictory demands which are characteristic of police work. The suggestion, if the police authority takes discretion seriously, is that they simultaneously highlight the police officers’ job demands, decision latitude and work-related social support, which eventually affect coping and stress management in police work.

As mentioned above there is no relationship between police officers’ deportations of UARC and poorer mental health. However, high demands, low decision latitude, low work-related social support, and coping escape-avoidance and self-control are associated with poor mental health. As long as other elements are present, that is, reasonable demands, possession of high decision latitude and access to work-related social support, and that adaptive coping is utilized, it does not seem that this deportation work affects the officers’ mental health. In other words, they are able to cope with stressful work tasks in a healthy way, but if one or more of these cease to apply, then the situation might deteriorate. However, the officers interpret demands that we assume are contradictory, in accordance with their work task and their role. This interpretation is one of the keys to understanding the complicated situation of deportations of UARC, and other complex police tasks.

One could reflect that if the police officers have access to discretion, they can evaluate the situation, balancing perceived demands against perceived resources in order to cope. As police officers, they meet vulnerable people and utilize their discretionary powers to deal with seemingly contradictory demands, that is, for efficiency and dignity. In the interviews, I listened to police officers who cared about ‘being human’ and tried to ‘do what is best in the situation’. They described the importance of communication in meeting the UARC. ‘Someone has to do it and I think I can do it in a human way’ and ‘We talk and discuss very much how to treat UARC well and meet their needs’ are two examples of how the police officers carry out the law and regulations, but do so focusing on the individuals they encounter. They utilize their discretion to treat the child with care and dignity, although as police officers they cannot do anything about the decision to

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deport the child. The function of this approach could be to help ensure the wellbeing of police officers and their ability to handle difficult and stressful work tasks in a professional manner, considering contradictory demands, such as efficiency and dignity, equally. The police officers cope with the situation in an adaptive way if they can utilize discretion and perceive that they are doing good. In other words, they need the flexibility to adapt to the stressful situation. The opposite is demands that are too high and decision latitude that is too low together with a feeling of being trapped in a situation that it is impossible to influence.

However, discretion can be an obstacle to the improvement of police legitimacy (Gundhus, 2017). For example, Gundhus (2017) has found police officers being trained to use immigration law as a tool to combat crime. Gundhus (2017) suggests more organizational control as the solution to excessive use of discretion among police officers. According to Gundhus (2017) this would not only lead to a more manageable organization, but also provide opportunities for improved achievement and success across an array of new performance indicators. In my opinion, this would not solve the problem. It is possible to measure efficiency in an objective manner, but measuring dignity is much more difficult. There is a risk that discretion will be utilized in a way that is not in the child's best interests. If the focus is only on efficiency, if police officers focus on short-term results and if arrests lead to newspaper headlines being the feedback sought, then there is a risk of losing credibility in the eyes of the public. This might be a result of a system that focuses extremely strongly on quantitative results instead of having a big picture of what matters in policing. van Dijk et al. (2016) discuss “what matters in policing” and state that integrity, legality, professionalism, transparency and accountability should be core institutional values that are implemented by police leaders, to be followed as simply the right thing to do. Furthermore, they claim that the police would gain trust, driven by a value-based philosophy of policing in a highly professional manner ‘without fear or favour’ through honest, solid and nuanced police work. If the focus is on quantity instead of credibility police work might be counter-productive instead of protecting and serving the public (N. Fyfe, Director of the Scottish Institute for Policing Research, oral communication, September 8th, 2016). One example of focusing on quantitative results is the LEAN-based system the Police Authority implemented to increase the number of deportations. The deportation cases were prioritized by category, in ascending order of difficulty, to increase their number. This system led to a focus on the cases that were easiest to carry out but perhaps not the most important ones. One officer said: ‘the friendly and cooperative ones are sent home, but we let the troublesome stay’. Diefenbach (2009, p. 906) claims that New Public Management (NPM) is “a so-called business-like strategy that bulldozes traditional values and ideas, convictions and attitudes that do not fit the NPM concept”. This might be a reason for reflecting on what matters in policing.

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Gundhus (2017) admittedly proposes a change in performance indicators that would go beyond the traditional clear-up rate and detection rates, and crime statistics. Specifically, a more profound focus on goals and performance management needs to be more dynamically understood. Nevertheless, the police officer as an individual and how he or she copes with situations cannot be neglected in the complex world of policing.

Organizational changes, for example changing performance indicators, might influence the police officers’ mental health. Previous research has established that organizational factors, such as contradictory demands, may have a greater influence on police officers’ mental health than operational factors (Biggam, Power, Macdonald, Carcary, & Moodie, 1997; Chhabra & Chhabra, 2013; Collins & Gibbs, 2003; Kop et al., 1999; Kula, 2017; Morash et al., 2006; Shane, 2010), such as dealing with violent or vulnerable people. Björk (2016) claims that some of the most basic knowledge of sociology can be applied to the police. For example, involvement brings a sense of interest that unites professionals in a judicious practice. Thus, police management would need to be less controlling and instead trust the police officers’ individual judgment and believe that involvement brings engagement (Björk, 2016).

A police officer must have the emotional skills to take care of individuals who are affected by their emotions and who are exposed to difficulties, but must also be able to execute decision and take action regarding these individuals depending on the situation, the law and regulations, and other circumstances. To be able to meet the contradictory demands, be professional, and to meet the requirements of vulnerable populations police officers must be mentally balanced and aware of cognitive and emotional discretion. The following section is a brief description of what can be called the missing link and about how discretion and coping might be integrated in the context of deportations of UARC.

The missing link There are still many unanswered questions about deportations of UARC. Reflections and discussions between myself and professor Ghazinour3 about theoretical constructs and concepts in relation to the findings convinced us that there should be some other input than Lipsky´s idea of discretion from a policy point of view. The situation itself has an impact on how discretion is utilized, that is, personal coping is utilized to manage the situation. One example is the police officer who prioritizes the deportation of criminals and avoids the child cases. The officers try to solve current problems and change unhelpful patterns in cognition (thoughts, beliefs, attitudes), behaviours, and emotions (feelings). In the findings 3 Ghazinour’s research includes mental health, trauma and coping. He has acted as main supervisor in this thesis.

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from the interviews the police officers show signs of empathy in the deportations of UARC. This could happen when the officers try to do something more than they are supposed to do, for example help with translations of school grades or pick up a cell phone from the workshop. Therefore, we tried to put these two constructs of empathy and discretion together. Further reflection convinced us that cognitive and emotional discretion better describes how discretion and coping are integrated in policing. One missing link that should have been added in this thesis is the link between discretion and the scenario that assessed coping. If the scenario had been used in the interviews framed by Lipsky’s (2010) street-level bureaucracy theory it would have been possible to explore the police officers’ use of discretion in a specific scenario, and to explore cognitive versus emotional discretion. Using a scenario in relation to discretion would make it possible to explore whether the police officers think, feel and behave in a particular way to satisfy their own needs or if they think, feel and behave with the child’s best in focus, in accordance with the CRC. We became aware of this during the work on the thesis and that it would make it possible to carry out an even more interdisciplinary study, including the context of deportations of UARC, governance, discretion, psychosocial job characteristics and coping. Further studies, which integrate these theories and constructs, will need to be undertaken.

Methodological reflections Methodological considerations are important in evaluating the quality of the research. The following paragraphs cover some methodological reflections.

This research project brought together a group of collaborating researchers, of whom three were my doctoral supervisors. In addition, the project involved one more doctoral student and several other researchers. I was registered as a doctoral student at the Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit at the Medical Faculty, Umeå University. Hence, I had a doctoral supervisor affiliated to that unit. In addition, I had supervisors affiliated to the Police Education Unit, who were involved in a larger research project. My research colleagues and supervisors, in various combinations, are co-authors of the articles in this thesis. It has been an advantage, but also a challenge to have more supervisors than the average doctoral student. To work in a research group with many colleagues at different levels requires a high level of flexibility, but also firmness. I believe the latter is important for retaining one’s self-respect; and, the former for retaining that of one´s colleagues. I was given a great opportunity to learn as much as possible and still enjoy it. I recommend this design for doctoral studies, because it has provided a supportive, but also demanding, environment.

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Trustworthiness Trustworthiness is valuable for assessing quality in qualitative research. Graneheim and Lundman (2004) argue that trustworthiness is commonly used in the tradition of qualitative content analysis similarly to how concepts such as validity, reliability and generalizability are used in the quantitative tradition. Qualitative research must be evaluated in relation to the methods used to generate the research findings and should be as trustworthy as possible. Trustworthiness entails a visible and transparent research process and can be tested at all stages of the research process (Graneheim & Lundman, 2004). Trustworthiness can be divided into three constructs: credibility, dependability and transferability.

Credibility deals with the focus of the study, selection of context, participants and approach to gathering data. In our study the respondents varied regarding gender and age, and observers with various perspectives and geographical locations, contributed to a richer variation among the phenomena studied. Regarding the selection and its impact on the result, Tasker (2000) suggests that the selection should be as representative as possible. We found interviews to be the most appropriate method for data collection and conducted the number of interviews necessary to answer the research question in a credible way (Kvale & Brinkmann, 2009). The number of interviews can vary depending on the data quality and the complexity of the phenomena being studied (Graneheim & Lundman, 2004).

Dependability is another aspect of trustworthiness. Dependability deals with how the researcher’s decisions during the analysis process affect the analysis and the degree to which data change over time (Graneheim & Lundman, 2004). The interviews were conducted in a relatively short space of time by the same researcher. Further, we used an interview guide to ensure that the questions covered the same areas for all respondents. This limited the risk of inconsistency during the data collection. To acquire new insights into the phenomenon studied I used follow-up questions during the interviews. One example of how I as a researcher could affect the data occurred several times during the interviews. The respondent said: ‘You are a police officer and know what I mean!’ In this situation, I answered: ‘Yes, I think I know what you mean, but can you explain in more detail or give me an example of what you said?’. When I answered in this way I was able to sustain the trust I had as a former police officer, but at the same time distance myself in relation to the data. In addition, we had an open dialogue within the research team and discussed the extent to which similarities and differences between respondents changed over time.

Transferability is also included in trustworthiness. Transferability refers to the extent to which the findings can be transferred to other contexts (Graneheim & Lundman, 2004). The author can suggest that the findings can be transferred to

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other settings or groups, but it is the reader who decides if this is possible. We gave a clear and well-defined description of the context, selection and characteristics of the participants, of the data collection and process of analysis to facilitate transferability. In addition, we used quotations from the interviews to illustrate general patterns but also to highlight differences regarding perceptions, experiences and interpretations. We used a theoretical framework and raised analytical questions in order to learn how the police officers interviewed balance the goals of increased efficiency and respect for UARC’s dignity and human rights.

According to Graneheim and Lundman (2004) there is only the most probable meaning to be gained from a particular perspective and no single correct meaning or universal application of research findings. In our study, trustworthiness occurs when we establish arguments that support the most probable interpretations.

Causality and generalization The cross-sectional design could be a limitation, since no causal inferences can be reported; for this reason longitudinal studies would be valuable. Despite its limitations, this thesis brings new knowledge and new insights, not previously reported, regarding police officers’ deportations of UARC, psychosocial job characteristics, coping and mental health. This must be considered a great strength of the thesis. Another strength is that the sample is comparable, regarding gender structure and mean age, to all of Sweden’s police officers (Swedish National Police Board, 2014). We used a convenience sample with a response rate of 34%. This response rate is calculated from the number of surveys sent to contact persons at 18 police authorities. It is therefore impossible to know who did not reply to the survey. However, it has been shown that even with only moderate response rates, studies on health issues, prevalence figures, and associations between variables are relatively unbiased (Sogaard, Selmer, Bjertness, & Thelle, 2004). The issue of selection bias is raised with a response rate that is less than optimal and the convenience sample that we were required to use due to secrecy rules and the difficulty of collecting data from the police authority. Although a probability sample is preferable (Dawson & Trapp, 2004), the importance of this study makes this limitation reasonable. However, while selection bias may have affected the absolute levels of the variables measured, I do not see a plausible mechanism that would have caused bias in the measures of association. The findings in this thesis can be generalized to the police population in Sweden, and probably also to other police services in Scandinavia. However, the generalization should be made with caution because, if we do want the thesis to reflect the broader world, we need to ensure its external validity. To ensure external validity, the sample of people in the studies needs to be representative of the broader population (Gleitman et al., 2011). This thesis includes detailed

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information about the sample population, the context and the study itself. Thus, the readers of this thesis can more confidently generalize and transfer the findings to other situations. In order to generalize the findings from this thesis the context of policing has to be considered.

Reliability and validity Reliability and validity are important concepts in assessing the quality of research. Reliability is the overall consistency of an instrument. An instrument has a high reliability if, under consistent conditions, it produces similar results (Stanovich, 2007). To achieve high validity in research, high reliability is necessary. High reliability, however, does not guarantee high validity. The validity of an assessment instrument is considered to be the degree to which the instrument measures what it is supposed to measure (Gleitman et al., 2011). Validity is important because it can help determine the types of instruments to be used and which instrument will truly measure the construct in question. There are different types of validity: content, face, criterion and construct validity.

Content validity involves the degree to which the content of the instrument matches a content domain associated with the construct. Face validity relates to whether a test appears to be a good measure or not. Criterion validity compares the instrument with other measures or outcomes already held to be valid. Construct validity refers to the extent to which an instrument truly measures a construct as defined by a theory. Construct validity includes statistical analyses of the internal structure of the instrument, including the relationships between responses to different items in the instrument.

In the present thesis, three internationally well-validated instruments were used to assess the various constructs. All were originally in the English language. Swedish versions that had been translated earlier and validated in Swedish populations were used. Although all applied instruments had been translated and adapted to fit the Swedish context following established guidelines, contextual differences might have caused some biases in the understanding of item content. Different values, the structure of concepts, and ways of asking questions can influence the data obtained. For example, one statement in the WOCQ is “I prayed”, which in a secular society like Sweden might be interpreted as avoiding coping, whereas in the original Folkman and Lazarus (1988) version praying was categorized as positive reappraisal. However, using internationally established assessment instruments has the advantage of allowing direct comparisons with results obtained in other studies. We conducted validity and reliability analyses for using the WOCQ in the context of UARC. The construct validity of the WOCQ was investigated using confirmatory factor analysis (CFA) and exploratory factor analysis (EFA). We found a five-factor solution with an internal consistency

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(Cronbach’s alpha) between .67 and .84 for the different coping categories, which indicates a high reliability. Since all assessment instruments applied in this thesis have been validated internationally and in Sweden, I can conclude that the validity of my investigation is confirmed for all the above-mentioned types of validity. Additionally, the reliability was verified in sub-study IV, utilizing Cronbach’s alpha.

In article III, the findings showed that both high strain jobs and active jobs were associated with psychological disturbance. Many other studies often use a method for obtaining a continuous variable, termed “perceived job strain”, and divide demand by control (weighted by item numbers) where a ratio of 1 indicates a balance between demand and control; and values > 1 indicate excessive perceived job strain (Garbarino et al., 2013; Garbarino et al., 2012; Garbarino et al., 2011; Theorell et al., 1988). Thus, they do not use categorical variables, which complicates comparison with our findings. Regarding the active jobs category, our finding can be explained by the fact that we used low strain jobs category as the reference variable. Therefore, the difference between the low strain and active categories can be explained by the job demands, that is, low strain includes low job demands and active includes high job demands but both low strain and active categories include high decision latitude.

Ethical considerations Early on in the research project, the research proposal was approved by the Regional Ethical Review Board at Umeå University, Dn 2014/69-31Ö.

The paper surveys were coded into a database by the author. Theoretically, I had the possibility of combining variables concerning police authority, unit, age and gender and other background data and thereby identifying individuals. However, that possibility never lay within my interest as a researcher or fitted in with the purpose of the thesis. That purpose was always to use the data on a general group level, for example, to compare those with and without the experience of working with UARC. The database and the interview data have only been accessible to researchers participating in this project and it has been stored on computers protected by individual passwords in locked rooms.

In the introductory letter, the respondents were informed that the survey was conducted on the basis of ethical guidelines for social science research (Research Council, 2002). The letter also stated the purpose of the study, that participation was voluntary, that anonymity and confidentiality were ensured and that the data would only be used in this specific research project. Contact information for myself and for the project manager was supplied in the survey and respondents

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were encouraged to contact us if they had any questions. During the interviews the respondents were verbally informed about the ethical guidelines.

During the quantitative data collection, a couple of police officers contacted me and had questions concerning the survey. They were concerned about the coping scenario in the survey. After these conversations, I felt that their issues had been dealt with.

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Recommendations In this thesis, I explored and analysed how Swedish police officers perceive the deportations of UARC, and investigated police officers’ perceptions of job demands, decision latitude on the job, work-related social support, coping and mental health in relation to such work. Providing knowledge about these issues can facilitate the development of interventions to improve the police organization and thus the resilience of police officers. Effective interventions might influence the police officers’ treatment of vulnerable populations, such as UARC.

Considering the findings of this research, I would like to make the following recommendations:

• To further investigate the construct of police officers’ emotional and cognitive discretion, appropriate measurement tools need to be developed and longitudinal investigations need to be conducted using random samples that include police officers from other countries.

• To raise the importance of police officers’ mental health the police authority needs to value the police officers’ discretion. Broad discretionary power might lead to responsible police officers who can successfully manage contradictory demands.

• To improve the work-related social support and provide the police officers with external counselling/supervision. The purpose of such counselling/supervision is to bring about a change in perspective through talking and listening to other individuals in the work team. The counselling/supervision may provide a means of learning about theories that could be useful in understanding and handling stressful situations. In addition, the method may lead to the improvement of individuals on a personal and professional level. It may also function as a form of organizational social support where the police officers can reflect in their teams. The reflections based on their experiences will throw light on the officers’ needs and will probably change the work climate and their communication skills.

• To provide police officers with counselling and health promotion, but also proper staffing with sufficient resources to handle the work. Officers need appropriate working methods and equipment, support from their immediate supervisors and support from the entire organization. This would help police officers to be more resilient in the face of adversity.

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• To make provision for police officers to be emotionally and cognitively equipped over time to undertake demanding and difficult work tasks.

I hope this investigation provides evidence that will enable the Ministry of the Interior and the Swedish Police Authority to take action to improve police officers’ working conditions and their health, which could well have a direct effect on the vulnerable populations the police officers encounter.

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Acknowledgement I would like to thank those police officers who meet vulnerable people in their daily work and whose participation in the studies made this project possible. Let´s be careful out there! Thanks to the staff at the Police Authorities, who helped me collect the survey data.

I would like to express my particular gratitude to my main supervisor, colleague and friend, Professor Mehdi Ghazinour, for your most important contribution to this thesis. You have been a tremendous mentor, and I would like to express my appreciation of the way you encouraged my research and allowed me to grow as a researcher. Your advice on both research and on my career has been invaluable. I could not imagine having a better advisor and mentor. Thank you for your patience, motivation, and immense knowledge and for so generously sharing your time, experience and research ideas and projects with me.

I would also like to thank my co-supervisors for their insightful comments and encouragement, but also for the hard questions which gave me the incentive to widen various perspectives of my research. My thanks to Professor Anna-Karin Hurtig, for giving me both the opportunity to join your team at EpiGH, and access to the research facilities. To join an international research environment with experienced senior researchers, junior researchers, PhD and Master’s students has been important and valuable learning experience for me. I am grateful to Dr. Lars-Erik Lauritz, who showed the way and opened the door for me, as a police officer, to study for a PhD and to Dr. Malin E Wimelius, who was always willing to help with a theoretical perspective and science-based view on my perhaps too subjective thoughts.

Dear Dr. Mojgan Padyab, not my official co-supervisor, but my statistics teacher and super advisor. You have supported me more than I can describe in words. Thank you for your great support, encouragement and quick replies to my queries, day or night. I have learned a lot from you.

My PhD study comrade Johanna Sundqvist, you saved me from Monday morning blues. The system balances! Thanks for the long conversations about our studies but also about life and values and for being such a joy to work with.

Dr. Kenneth Ögren, who shared the history of the battle of the dungen. Thank you for pea soup and pancakes, and for going to a baseball game and a Baptist church meeting with me.

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Malin Eriksson and Mattias Hjertstedt, for friendship and joyful work with research applications.

I also want to thank Urban Janlert and Faustine Nkulu Kanengayi for comments on my proposal, John Kinsman and Marie Lindkvist for constructive discussion in my mid-term seminar, and Linda Richter Sundberg and Jacobus Pienaar for comments and discussion at my pre-defence presentation.

I would like to thank the Police Education Unit, especially Eva-Marie Hilli Sandberg, Katrin Pusch, Jenny Sundholm, Kent Björnehall, Mona Wiklund-Hed, Jörgen Henriksson and Jenny Nordhall for being supportive in different ways. My sincere thanks also go to Conny Tärnklev, Mikael Nygren, Bertil Nordström, Bertil Hammarberg, Mats Klingvall, Katarina Weinehall, Kent Löfgren, Stefan Holgersson, Stefan Söderfjell, Staffan Karp and Henric Stenmark for being gate-openers in different ways to academia. My thanks also to David Sjöberg for social support and good advice during many coffee breaks; to Marcus Nilsson, Head of the Border Police Unit in Västerbotten, for our collaboration and for introducing important perspectives and viewpoints on the forced deportations of UARC; to Miguel Inzunza, Pontus Berg and Oscar Rantatalo for good talks during my PhD studies; and to my “brothers” Nils Lundmark, Magnus Ander and Pål Hansson for being my sounding boards and my eyes and ears in the Police Organization.

I would like to thank the Epidemiology and Global Health Unit, especially, Anna Myleus, Göran Lönnberg, Isabel Goicolea, Anna-Britt Coe, Karl-Erik Renhorn, Klara Johansson, Lennart Nyström, Klasse Sahlen, Anneli Ivarsson, Anni-Maria Pulkki Brännström, John Kinsman and Nawi Ng for being helpful and ready for discussions during my time at the EpiGH Unit. Thank you, Kristina Lindvall and Curt Löfgren, for “staan” fika weeks. You light up life at the EpiGH! My thanks also to Fredrik Norström and Miguel San Sebastian, for taking your time to explain advanced research methods to a novice; to Peter Byass, who told me about the Law Enforcement and Public Health Conference; to Linda Richter Sundberg and Marie Lindkvist for being good colleagues and friends.

I would like to thank all former and current PhD students at EpiGH, especially, Dickson Mkoka, Gladys Mahiti, Vijendra Ingole, Alison Hernandez, Mazen Baroudi, Rakhal Gaitonde, Jing Helmersson, Katerina Karhyna, Moses Tetui, Daniel Eid Rodriguez, Julia Schröder and Mikkel Quam for your friendliness and smiles. Many thanks to Masoud Vaezghasemi, I value your smiles and support. Hej då!

I would like to extend my thanks to the administrators at Epidemiology and Global Health Unit: Ulrika Harju, Susanne Walther, Karin Johansson, Lena Mustonen and Birgitta Åström. I appreciate your professionalism, your

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commitment to the staff at the unit and your friendliness. Thank you all for a good time at the EpiGH.

Thanks to all the “Larses”, there are more of us than people know: Lindholm, Weinehall, Ångman, Lauritz and Lindgren.

Thanks to all funding agencies, the European Return Fund, the Wallenberg fund, the J C Kempe’s Academic Memory Fund, the Helge Ax:son Johnson’s Foundation, the J C Kempe’s Memory Foundation, the Harald and Louise Ekman’s Research Foundation, and the Sigtuna Foundation.

Many thanks to Annika Bindler and Pat Shrimpton for your excellent work and the comments on the writing and English language. I like it very much, Appreciated.

Thanks to my mother-in-law Gerd for always supporting our family; to my sister Sara for just being my sister and the haircuts; and to Stefan my brother-in-law, whatever, forever.

Thanks to my wonderful and beautiful wife Maud for your grit and tolerance, and for being such a fantastic mother to Malte and Mimmi.

Thanks Olivia, Ellen, Malte and Mimmi for just being my beloved children. Promise Dad to always support each other and keep spreading love!

Finally, I would like to thank my mother Eva, she has always been there, with a helping hand, since I was a child, and she still is. I know I have taken you for granted, please forgive me for choosing to go to a Bruce Springsteen concert on your 50th birthday. Thanks for deciding to move from Boden to Vännäsby, to be nearer to the university. You have continued to support and encourage me in countless ways.

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