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Bakgrund och syfte: Allmänna arvsfonden beviljar ekonomiskt stöd till utvecklingsprojekt inom civilsamhället. Projekten ska vara av ideell karaktär till förmån för barn,ungdomar, äldre eller personer med funktionsnedsättning. För att stödja fler projekt med fokus på barn och ungas psykiska hälsa lanserade Arvsfonden år 2019 en kommunikationssatsning med målet att verka för att få fler ansökningar med fokus på psykisk hälsa hos barn och ungdomar. Satsningen hade även som mål att öka kännedomen hos relevanta aktörer om metoder, modeller och lärdomar hos tidigare och pågående arvsfondsprojekt som arbetar med att stärka den psykiska hälsan hos barn och ungdomar. Den här utvärderingen är en del i denna kunskapsspridning. 

Social sustainability has increasingly become a goal for urban policy and planning, and for local and regional developmental strategies. Neighbourhoods are a common spatial scale for studying social sustainability and there is a growing focus on social sustainability in urban neighbourhoods for both researchers and policymakers. This paper is based on a qualitative case study of a neighbourhood defined by the municipality as at-risk of negative social development in a municipality in northern Sweden. The aim is to describe the perceived threats and promoters for social sustainable development in a neighbourhood defined as at-risk, and to analyse these in relation to a perspective of spatial scale. The study is based on data from interviews with municipal representatives, local professionals and residents, representing different experiences and perspectives in the neighbourhood. Four themes illustrating threats to socially sustainable development were identified: crime, unrest and unsafety; segregation and social exclusion; reputation and stigmatisation; and low involvement in municipal processes. The promoters for socially sustainable development identified in the respondents’ stories reflect four themes: strong community spirit; safety and low criminality; lively civic society and well-functioning public services. Our results show that neighbourhood social sustainability cannot be studied or acted upon without being put in a context of spatial scale and an understanding that processes occurring at a particular scale only can be adequately understood when considered in relation to other scales, i.e. the development in the neighbourhood can only be understood in relation to the development in the city and at national level. There is also a need for an awareness of how different aspects of socially sustainable development relate to each other, by strengthening or counteracting each other.

The objectives are to, for neighborhoods with different levels of social capital, (1) map out the levels of social interactions, emotional support, and instrumental support before the COVID-19 crisis, (2) analyze how social interactions, emotional support, and instrumental support had changed during the pandemic and, (3) analyze changes in self-rated health during the pandemic. This study is based on a telephone survey with a subsample of 168 respondents in Umeå municipality who participated in a large base-line social capital survey in 2006. We asked whether neighbors talk to, care for, and help each other, before and during the Covid crisis. Individuals rated their health as poor or good. We compared people's self-rated health and their perceptions about their neighborhoods between those who lived in high or low/medium social capital neighborhoods. Before the pandemic, participants in high social capital neighborhoods reported more active neighborhood interaction and support. During the crisis, social interaction and support increased in all neighborhoods, but more in high social capital neighborhoods. Overall, people seemed to help and care for each other more during than before the crisis. More individuals in the high social capital neighborhoods reported improvement in their health during the pandemic, than those in the low/medium social capital neighborhoods. Our findings indicate that neighborhoods social capital can be strengthened during a crisis, in particular in areas with existing high levels of social capital. The findings need to be interpreted carefully due to its small sample size but observed patterns warrant further investigation.

The development of social capital is acknowledged as key for sustainable social development. Little is known about how social capital changes over time and how it correlates with socio-demographic and socioeconomic factors. This study was conducted in 46 neighbourhoods in Umeå Municipality, northern Sweden. The aim was to examine neighbourhood-level characteristics associated with changes in neighbourhood social capital and to discuss implications for local policies for sustainable social development. We designed an ecological study linking survey data to registry data in 2006 and 2020. Over 14 years, social capital increased in 9 and decreased in 15 neighbour-hoods. Higher levels of social capital were associated with specific sociodemographic factors, but these differed in urban and rural areas. Urban neighbourhoods with a higher proportion of older pensioners (OR = 1.49, CI: 1.16–1.92), children under 12 (OR= 2.13, CI: 1.31–3.47), or a lower proportion of foreign-born members (OR= 0.32, CI: 0.19–0.55) had higher odds for higher social capital levels. In rural neighbourhoods, a higher proportion of single-parent households was associated with higher levels of social capital (OR = 1.44, 95% CI = 1.04–1.98). Neighbourhood socioeconomic factors such as income or educational level did not influence neighbourhood social capital. Using repeated measures of social capital, this study gives insights into how social capital changes over time in local areas and the factors influencing its development. Local policies to promote social capital for sustainable social development should strive to integrate diverse demographic groups within neighbourhoods and should increase opportunities for inter-ethnic interactions.

Introduction: Promoting inclusive, safe, resilient, and sustainable communities is one of the 17 Sustainable Development Goals ratified in 2015 by 193 UN member states, not least in Sweden. Social sustainability involves preserving particular societal values (e.g., local identity) as well as developing values (e.g., social cohesion) that are perceived as needed. Socially sustainable development also implies promoting integration and preventing segregation. Social capital is one important indicator to measure how socially sustainable an area is. This project aims to explore how social capital can be used as a conceptual tool in developing housing policy for social sustainability in Umeå Municipality.

Methods: The three sub-studies in this project combine quantitative and qualitative methods. We will conduct a review of the municipality’s documents to understand how the ideas of social sustainability have influenced political declarations and implemented social and housing policies and interventions during the period 2006–2020. The quantitative study includes a longitudinal follow-up to the 2006 survey’s respondents to assess the longitudinal impacts of neighborhood social capital on health and well-being; as well as a new repeated cross-sectional survey to investigate how social capital has changed in local neighborhoods from 2006 to 2020. The qualitative study includes case studies in neighborhoods with different social capital dynamics to understand how different resident sub-groups perceive their neighborhoods and how implemented social and housing policies have influenced the social capital dynamics and responded to the needs of different sub-groups. The project is run in close collaboration with the Commission for a Socially Sustainable Umeå.

Discussions: This project will create new and unique perspectives on long-term structural changes of relevance for a socially sustainable housing policy; knowledge that is highly valuable for continuous municipal planning; and will outline recommendations to guide local housing policies for social sustainable neighborhoods in Umeå Municipality.

Utifrån tidigare forskning om öppen psykiatrisk tvångsvård har två paradoxer i förhållande till lagstiftningen identifierats: Öppen psykiatrisk tvångsvård (ÖPT) innebär både mer och mindre autonomi för patienten. ÖPT innebär att autonoma individer tvångsvårdas till autonomi. Syftet med artikeln att tydliggöra vilka normativa ställningstaganden som ligger till grund för tvångsvårdsformen genom att de två paradoxerna belyses utifrån fyra perspektiv på autonomi.

Den första paradoxen förklaras genom att lagstiftaren förhåller sig till både en liberal och en medicinsk-etisk autonomidefinition. I ett liberalt perspektiv är öppen tvångsvård en inskränkning av individens rätt till frihet. I ett medicinsk-etiskt perspektiv kan öppen tvångsvård öka autonomi genom att det ökar eller skyddar patientens autonomi i framtiden. I ett medicinsk-etiskt perspektiv kan andra värden, som hälsa och livskvalitet, också motivera inskränkningar i patientens autonomi.

Den andra paradoxen kan förklaras genom att lagstiftaren blandar proceduriella och substantiella rekvisit för autonomi. Patienten förutsätts vara autonom enligt proceduriella rekvisit eftersom patienten inte anses vara beslutsoförmögen. Samtidigt är utfallet av patientens val avgörande för om det respekteras. Om patienten vill avstå vård förutsätts detta inte vara patientens autentiska önskan, vilket är ett uttryck för en substantiell syn på autonomi. Vården ska istället återge patienten dess substantiella autonomi. Vid ÖPT förutsätts patientens i praktiken frivilligt medverka till vården. Det betyder att patienten uppfyller även autenticitetsrekvisiten. Men eftersom syftet med tvångsvården är att återupprätta just den autentiska viljan genom att patienten blir i stånd att frivilligt ta emot tvångsvård är autonomikraven för öppen tvångsvård uppfyllda samtidigt som autonomikraven för vårdens upphörande också är uppfyllda.

Om ÖPT ska kunna motiveras utifrån ett medicinskt-etiskt perspektiv krävs att tvångsvården faktiskt ger mer autonomi senare eller andra vinster. I dagsläget finns inget vetenskapligt stöd för att tvångsvårdsformen fungerar. Mot denna bakgrund är det svårt att se vilket värde som tillförs som väger tyngre än patientens autonomi.

In earlier research about compulsory community care, two contradictions related to the legislation have been identified: First, compulsory community care (CCC) means both more and less autonomy for the patient. Second, it means that autonomous individuals are being coerced to autonomy. The aim of the article is to clarify the normative underpinning of the law in light of four perspectives of autonomy to that help understand the two contradictions.

The first contradiction can be explained by the fact that the legislator operates with two different definitions of autonomy: liberalistic and bioethical. In a liberalistic perspective, CCC restricts the right to autonomy. From a bioethical perspective, CCC potentially increases autonomy since it may enhance or protect the future autonomy of the patient. According to this perspective, other values, like health and quality of life, can also motivate restriction of autonomy.

The second contradiction can be explained by how the legislator confuses procedural with substantial conceptions of autonomy. Since the patient is not assumed to be incompetent, the patient is assumed to have procedural autonomy. At the same time, whether or not the patient’s will is accepted depends on the eventual outcome of the patient’s choice. If the patient refuses care, her opinion is not presumed authentic, which is an expression of a substantive conception of autonomy. The coercive care provided is supposed to re-install the patient’s substantive autonomy. When it comes to the practice of CCC, the patient is assumed to voluntarily accept the coercive elements. This means that the patient is also autonomous according to a substantive conception of autonomy. Since the objective of compulsory care is to enable the patient to accept care voluntarily and thus restoring her/his authentic opinion, the legal requisites for allowing and discharging from CCC are met at the same time.

If compulsory community care is to be acceptable from a bioethical perspective, it must provide the patient with actual benefits or more autonomy. There is no research evidence that compulsory community works. Accordingly, it is hard to identify what benefits CCC provide that can trump the autonomy of the patient.

This thesis aims to analyze compulsory community care (CCC) as a social and normative practice in different contexts in the Swedish welfare system. The research questions are:

- How can the motives to introduce CCC in Sweden and other Western countries be understood?

- What happens in and between psychiatric and social service organizations when CCC is implemented?

- How are the legal rights of patients protected and what forms of social control of patients is discernible in written court decisions regarding CCC?

- What normative positions regarding autonomy is the CCC legislation based on?

- How can CCC be understood from steering, historic and power perspectives?

The four first research questions corresponds to the four research studies included in the thesis and the fifth question relates to the material as a whole.

The empirical material for the first study mainly consists of documents from the parliamentary process. For the second study, 15 interviews with employees in psychiatric and social services were conducted. For the third study, all written court decisions over a 6 month period (N=541) were investigated. In the fourth study, the analysis is primarily based on the current legislation and its history.

Community care has already taken over most tasks of the old institutions. With the adoption of CCC, even the coercive measures are now formally found in community settings. CCC was adopted despite lack of evidence supporting its effectiveness. Although the policy process started in the aftermath of high-profile crimes, the government bill was focused on integration and rehabilitation with the stated intention to reduce coercive powers. While CCC entails an actual expansion of coercive powers, those coercive elements are downplayed in the bill. CCC allows for preventative restrictions on non-violent civilly committed patients. The CCC example shows that political steering is not something that automatically restricts discretion over the medical profession. Earlier political steering strategies had failed to reduce the excessive clinical use of use of temporary leave. The introduction of CCC meant that politicians adapted legislation to previously undesired practices.

In psychiatric and social services, CCC is materialized as a physical object in the coordinated care plan. The interviewees talked about the template form for the coordinated care plan as almost synonymous with CCC. It helped clarify responsibilities and facilitated coordination between the organizations. These changes extended even beyond services for the targeted patients under CCC. The requirement of a coordinated care plan thus served as a political steering strategy for enhancing collaboration.

In the written court decisions about CCC we found deficiencies in procedural fairness in all four requirements for a fair trial that were investigated: transparency, clarity, consistency and impartiality. For example, more than 99 % of the decisions were made in favor of the claims of treating psychiatrist and a substantial minority of courts routinely delegated decision-making authority to treating psychiatrists. The special provisions often involved surveillance controlling techniques. The control is mostly physical, because of the unique role of medication, but also spatial and temporal. Even though no formal coercive measures are allowed, the special provisions as controlling measures seem to have real impact on patients. CCC may therefore be understood as disciplinary power.

A legal requisite for coercive care is that the patient oppose care. However, in practice it is assumed that a patient under CCC will accept the coercive elements (i.e. special provisions). The legal requisites for allowing and discharging from CCC are thus met at the same time. Restrictions of patient autonomy in the legislation is often motivated in terms of enhanced autonomy in the future, for example through avoiding relapse. Another rationale for the restriction of autonomy is to safeguard the health and quality of life of patients. There is no research evidence that compulsory community works. Accordingly, it is hard to identify what benefits CCC provide that can trump the autonomy of the patient.

In 2008, compulsory community care (CCC) for people with severe mental illness was introduced in Sweden. CCC requires co-operation between psychiatric and social services, thus further complicating the longstanding difficulties with service coordination in the mental health field.

This article investigates what happens when a new policy is introduced that assumes complex co-operation of two organisations bestowed with high degrees of discretion. The process of institutionalisation will be analysed in terms of how an idea is translated and materialised on local levels. This has been investigated by interviewing key informants within psychiatric and social services at three different locations.

The implementation was perceived as relatively successful and occurred without major conflict. The main effect of the new legislation was improvement in the coordination of services, where designing a template form for a coordinated care plan was central. The inter-organisational discussions about service coordination that arose had a spill-over effect on services for other patient groups.

In essence, respondents describe CCC as a pedagogical reform to promote the coordination of services, rather than a reform to increase coercive powers over patients. This raises concerns about the legitimacy of the reform.