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  • 1. AbouZahr, Carla
    et al.
    Boerma, Ties
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Sch Publ Hlth, Johannesburg, South Africa ; Univ Aberdeen, Inst Appl Hlth Sci, Aberdeen, Scotland.
    Bridging the data gaps: do we have the right balance between country data and global estimates?2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1299978Article in journal (Refereed)
  • 2.
    Adcock, Joanna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Overseas Development Institute, London, UK.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    The North-South information highway: case studies of publication access among health researchers in resource-poor countries2008In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 1Article in journal (Refereed)
    Abstract [en]

    Background: Less than 2% of scientific publications originate in low-income countries. Transfer of information from South to North and from South to South is grossly limited and hinders understanding of global health, while Northern-generated information fails to adequately address the needs of a Southern readership.

    Methods: A survey of a new generation of health researchers from nine low-income countries was conducted using a combination of email questionnaires and face-to-face interviews. Data were gathered on personal experiences, use and aspirations regarding access and contribution to published research.

    Results: A total of 23 individuals from 9 countries responded. Preference for journal use over textbooks was apparent, however a preference for print over online formats was described among African respondents compared to respondents from other areas. Almost all respondents (96%) described ambition to publish in international journals, but cited English language as a significant barrier.

    Conclusion: The desire to contribute to and utilise contemporary scientific debate appears to be strong among study respondents. However, longstanding barriers

  • 3.
    Aden, Jamila Ahmed
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Faculty of Medicine and Health Sciences, East Africa University, Bosaso, Puntland State of Somalia, Somalia; Social Medicine and Global Health, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.
    Ahmed, Hinda Jama
    Östergren, Per-Olof
    Causes and contributing factors of maternal mortality in Bosaso District Somalia. A retrospective study of 30 cases using a Verbal Autopsy proach2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1672314Article in journal (Refereed)
    Abstract [en]

    Background: Somali women suffer from one of the highest maternal mortality rates in the world. Somalia characterises a specific low-income country situation with a mix of newly urbanized and nomadic culture combined with a frail health care infrastructure set in a post-conflict era. Very little is known about the effects that these contextual factors can have on maternal mortality.

    Objectives: To explore and describe causes and contributing factors concerning maternal deaths in the Bosaso District, Puntland State of Somalia.

    Methods: Data was collected using an adapted Verbal Autopsy tool. In 2017 30 cases of maternal deaths occurring in 2016 in the Bosaso District were reviewed. Information was assessed by three independent reviewers who classified the cause of death and the contributing factors. The Three Delay Model was employed to identify socio-cultural and economic and health system factors that may have contributed to these maternal deaths.

    Results: Direct obstetric deaths accounted for 28 cases. Among these, haemorrhage was the leading cause, followed by eclampsia, sepsis and obstructed labour. Two cases were indirect obstetric deaths, caused by anaemia. All three types of delay were frequent among the studied cases. Delay in deciding to seek care was found in 25 cases, delay in reaching care in 22 cases and delay in receiving health care in 24 cases. Lack of knowledge, money, transportation, poor access and availability of adequate services, as well as substandard management by health care providers, were all underlying the delays.

    Conclusion: A comprehensive intervention programme is needed in order to decrease maternal mortality among Somali women. Such a programme must include health education, improved referral systems and strategic upgrading of care services.

  • 4. Adlard, B.
    et al.
    Donaldson, S. G.
    Odland, J. O.
    Weihe, P.
    Berner, J.
    Carlsen, A.
    Bonefeld-Jorgensen, E. C.
    Dudarev, A. A.
    Gibson, J. C.
    Krümmel, E. M.
    Olafsdottir, K.
    Abass, K.
    Rautio, A.
    Bergdahl, Ingvar A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Mulvad, G.
    Future directions for monitoring and human health research for the Arctic Monitoring and Assessment Programme2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1480084Article in journal (Refereed)
    Abstract [en]

    For the last two and a half decades, a network of human health experts under the Arctic Monitoring and Assessment Program (AMAP) has produced several human health assessment reports. These reports have provided a base of scientific knowledge regarding environmental contaminants and their impact on human health in the Arctic. These reports provide scientific information and policy-relevant recommendations to Arctic governments. They also support international agreements such as the Stockholm Convention on Persistent Organic Pollutants (POPs) and the Minamata Convention on Mercury. Key topics discussed in this paper regarding future human health research in the circumpolar Arctic are continued contaminant biomonitoring, health effects research and risk communication. The objective of this paper is to describe knowledge gaps and future priorities for these fields.

  • 5. Ahmed, Syed Masud
    et al.
    Hadi, Abdullahel
    Razzaque, Abdur
    Ashraf, Ali
    Juvekar, Sanjay
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Indonesia.
    Kanungsukkasem, Uraiwan
    Soonthornthada, Kusol
    Van Minh, Hoang
    Huu Bich, Tran
    Clustering of chronic non-communicable disease risk factors among selected Asian populations: levels and determinants2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, no 1, p. 68-75Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The major chronic non-communicable diseases (NCDs) operate through a cluster of common risk factors, whose presence or absence determines not only the occurrence and severity of the disease, but also informs treatment approaches. Primary prevention based on mitigation of these common risk factors through population-based programmes is the most cost-effective approach to contain the emerging epidemic of chronic NCDs.

    OBJECTIVES: This study was conducted to explore the extent of risk factors clustering for the major chronic NCDs and its determinants in nine

    INDEPTH Health and Demographic Surveillance System (HDSS) sites of five Asian countries. DESIGN: Data originated from a multi-site chronic NCD risk factor prevalence survey conducted in 2005. This cross-sectional survey used a standardised questionnaire developed by the WHO to collect core data on common risk factors such as tobacco use, intake of fruits and vegetables, physical inactivity, blood pressure levels, and body mass index. Respondents included randomly selected sample of adults (25-64 years) living in nine rural HDSS sites in Bangladesh, India, Indonesia, Thailand, and Vietnam.

    RESULTS: Findings revealed a substantial proportion (>70%) of these largely rural populations having three or more risk factors for chronic NCDs. Chronic NCD risk factors clustering was associated with increasing age, being male, and higher educational achievements. Differences were noted among the different sites, both between and within country.

    CONCLUSIONS: Since there is an extensive clustering of risk factors for the chronic NCDs in the populations studied, the interventions also need to be based on a comprehensive approach rather than on a single factor to forestall its cumulative effects which occur over time. This can work best if it is integrated within the primary health care system and the HDSS can be an invaluable epidemiological resource in this endeavor.

  • 6. Ajeani, Judith
    et al.
    Ayiasi, Richard Mangwi
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Namazzi, Gertrude
    Kananura, Rornald Muhumuza
    Kiwanuka, Suzanne Namusoke
    Beyeza-Kashesya, Jolly
    A cascade model of mentorship for frontline health workers in rural health facilities in Eastern Uganda: processes, achievements and lessons2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1345497Article in journal (Refereed)
    Abstract [en]

    Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers.

    Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model.

    Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors.

    Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better.

    Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff.

  • 7.
    Akuamoah-Boateng, Henrietta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Self-reported vision health status among older people in the Kassena-Nankana District, Ghana2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Background: If current trends continue, Ghana's aged population will increase in the coming decades. Currently, there is little knowledge on the health of the aged in Ghana. Research on vision problems among this group is virtually non-existent. This research gap needs to be filled immediately in order to promote the general health among older people in Ghana.

    Objective: The objective of the study was to analyse vision health and its determinants among the older adult population in a district in one of the poorest regions in Ghana - the Kassena-Nankana district.

    Methods: Data were obtained from the WHO multi-country studies unit (SAGE). A total of 4,294 people over the age of 50 responded to the survey. Data analysis was conducted using Stata statistical package. The aim of the analysis was to identify the prevalence of self-reported vision problems and assistive device use. Age, level of education, marital status, living arrangement, socio-economic status and proportion of people aged 50 and over in a household were used as determinants of vision health.

    Results: In total, 54 and 63% (p-value, 0.00) of men and women reported having far-sightedness, while 35% of men and 40.6% of women reported having near-sightedness (p-value, 0.00). In total, 33.5% of men and 38.6% of women reported having both near-sightedness and far-sightedness (p-value, 0.00). Of those who reported having either vision problems, 2.9% reported the use of visual assistive devices. Men had a higher assistive device use of 4.5% compared to 2.1% among women (p = 0.002). Age and household socio-economic status was positively associated with reporting vision problems and assistive device use, respectively.

    Conclusions: The results from this analysis showed that despite the high reporting of vision problems, only 2.9% reported using assistive devices. This outcome shows that there is a need to prevent vision problems and increase access to assistive devices among older people in the Kassena-Nankana district in Ghana.

  • 8.
    Alemu, Andinet Worku
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Determinants of survival in adult HIV patients on antiretroviral therapy in Oromiyaa, Ethiopia2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, article id 5398Article in journal (Refereed)
    Abstract [en]

    Background: The antiretroviral treatment (ART) scale-up service has been a recent development in Ethiopia, but its impact on mortality has not been well investigated. The aim of this study was to assess the early survival outcome of the scale-up service by utilizing routine hospital data.

    Methods: All adult HIV/AIDS patients who started on antiretroviral treatment in Shashemene and Assela hospitals from January 1, 2006 to May 31, 2006 were included and followed up for 2 years. Data were extracted from standard patient medical registrations. Kaplan-Meier curves were used to estimate survival probability and the Cox proportional hazard model was applied to determine predictors of mortality. Two alterative assumptions (real case and worst case) were made in determining predictors of mortality.

    Results: The median age of patients was 33 years and 57% were female. Eighty-five percent had CD4 <200 cells/mu L with a median CD4 count of 103 cells/mu L. The median survival time was 104.4 weeks. A total of 28 (10.3%) deaths were observed during the 2-year period and 48 patients (18%) were lost to follow up. The majority of deaths occurred in the first 4 months of treatment. In multivariate analysis, 2-year survival was significantly associated with the clinical stage of the disease, baseline hemoglobin, and cotrimoxazole prophylaxis therapy (CPT) at or before ART initiation in both assumptions. The median CD4 count and body weight showed a marked improvement during the first 6 months of treatment, followed by stagnation thereafter.

    Conclusion: The study has shown an overall low mortality but a high loss to follow-up rate of the cohort. Advanced clinical stage, anemia, low body weight, and lack of CPT initiation were independent predictors of mortality - but not gender. CPT initiation should be encouraged in routine HIV care services, and patient retention mechanisms have to be strengthened. Stagnation in immunological and weight recovery after the first 6 months should be further investigated. The utilization of routine data should be encouraged in order to facilitate appropriate decision making.

  • 9.
    Alfredsson, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jeghannathan, Bhoomikumar
    Attitudes towards mental health and the integration of mental health services into primary health care: a cross-sectional survey among health-care workers in Lvea Em District, Cambodia2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1331579Article in journal (Refereed)
    Abstract [en]

    Background: Cambodia is a country where the resources for treating mental health disorders are far from sufficient. One strategy to narrow the treatment gap is to integrate mental health into primary health care (PHC). Understanding the knowledge and attitudes towards mental health integration that health-care workers have is important for assessing the challenges and opportunities when planning a potential integration project. Objective: The aim of this study was to assess these basic conditions in Lvea Em District, Cambodia. Design: A structured self-reporting questionnaire regarding attitudes and knowledge about mental health and its integration into PHC was collected from 75 health-care workers in Lvea Em District, Cambodia in October 2015. Firstly, descriptive analyses were carried out, and secondly, linear regression analyses to assess the relationship between attitudes and socio-demographic variables were conducted. Results: There was clear support towards integrating mental health services into PHC among these participants as 81.3% were interested in personally delivering mental health care at their units. Respondents who reported having received some kind of mental health-care training tended to have a more positive attitude towards mentally ill people (p = 0.005) and those who thought there was a high need for mental health care had a more favourable attitude towards the integration of mental health services (p = 0.007). Conclusions: The most important finding from this survey was the willingness and the acceptance of the need for integration of mental health care. This enhances the feasibility of integrating mental health services at the PHC level. Improving the competence of mental health care in these settings will likely help to reduce the treatment gap for mental, neurological and substance use disorders in Cambodia.

  • 10. Ali, Tazeen S
    et al.
    Krantz, Gunilla
    Gul, Raisa
    Asad, Nargis
    Johansson, Eva
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 7448-Article in journal (Refereed)
    Abstract [en]

    Background: Pakistan is a patriarchal society where men are the primary authority figures and women are subordinate. This has serious implications on women’s and men’s life prospects.

    Objective: The aim was to explore current gender roles in urban Pakistan, how these are reproduced and maintained and influence men’s and women’s life circumstances.

    Design: Five focus group discussions were conducted, including 28 women representing employed, unemployed, educated and uneducated women from different socio-economic strata. Manifest and latent content analyses were applied.

    Findings: Two major themes emerged during analysis: ‘Reiteration of gender roles’ and ‘Agents of change’. The first theme included perceptions of traditional gender roles and how these preserve women’s subordination. The power gradient, with men holding a superior position in relation to women, distinctive features in the culture and the role of the extended family were considered to interact to suppress women. The second theme included agents of change, where the role of education was prominent as well as the role of mass media. It was further emphasised that the younger generation was more positive to modernisation of gender roles than the elder generation.

    Conclusions: This study reveals serious gender inequalities and human rights violations against women in the Pakistani society. The unequal gender roles were perceived as static and enforced by structures imbedded in society. Women routinely faced serious restrictions and limitations of autonomy. However, attainment of higher levels of education especially not only for women but also for men was viewed as an agent towards change. Furthermore, mass media was perceived as having a positive role to play in supporting women’s empowerment.

  • 11. Ameh, Soter
    et al.
    Gomez-Olive, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Klipstein-Grobusch, Kerstin
    Predictors of health care use by adults 50 years and over in a rural South African setting2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 1-11Article in journal (Refereed)
    Abstract [en]

    Background: South Africa's epidemiological transition is characterised by an increasing burden of chronic communicable and non-communicable diseases. However, little is known about predictors of health care use (HCU) for the prevention and control of chronic diseases among older adults.

    Objective: To describe reported health problems and determine predictors of HCU by adults aged 50+ living in a rural sub-district of South Africa.

    Design: A cross-sectional study to measure HCU was conducted in 2010 in the Agincourt sub-district of Mpumalanga Province, an area underpinned by a robust health and demographic surveillance system. HCU, socio-demographic variables, reception of social grants, and type of medical aid were measured, and compared between responders who used health care services with those who did not. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables.

    Results: Seventy-five percent of the eligible adults aged 50+ responded to the survey. Average age of the targeted 7,870 older adults was 66 years (95% CI: 65.3, 65.8), and there were more women than men (70% vs. 30%, p<0.001). All 5,795 responders reported health problems, of which 96% used health care, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e. g. hypertension), acute conditions (27% - e. g. flu and fever), other conditions (26% - e. g. musculoskeletal pain), chronic communicable diseases (3% - e. g. HIV and TB), and injuries (3%). In multivariate logistic regression, responders with chronic communicable disease (OR = 5.91, 95% CI: 1.44, 24.32) and non-communicable disease (OR = 2.85, 95% CI: 1.96, 4.14) had significantly higher odds of using health care compared with those with acute conditions. Responders with six or more years of education had a two-fold increased odds of using health care (OR = 2.49, 95% CI: 1.27, 4.86) compared with those with no formal education.

    Conclusion: Chronic communicable and non-communicable diseases were the most prevalent and main predictors of HCU in this population, suggesting prioritisation of public health care services for chronic diseases among older people in this rural setting.

  • 12.
    Amroussia, Nada
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Explaining mental health inequalities in Northern Sweden: a decomposition analysis2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1305814Article in journal (Refereed)
    Abstract [en]

    Background: There has been a substantial increase of income inequalities in Sweden over the last 20 years, which also could be reflected in health inequalities, including mental health inequalities. Despite the growing body of literature focusing on health inequalities in Sweden, income-related inequalities in mental health have received little attention. Particularly scarce are research from Northern Sweden and examinations of the social determinants of health inequalities.

    Objectives: The present study seeks to provide evidence regarding inequalities in mental health in Northern Sweden. The specific aims were to (1) quantify the income-related inequality in mental health in Northern Sweden, and (2) determine the contribution of social determinants to the inequality.

    Methods: The study population comprised 25,646 participants of the 2014 Health on Equal Terms survey in the four northernmost counties of Sweden, aged 16 to 84 years old. Income-related inequalities in mental health were quantified by the concentration index and further decomposed by applying Wagstaff-type decomposition analysis.

    Results: The overall concentration index of mental health in Northern Sweden was −0.15 (95% CI: −0.17 to −0.13), indicating income inequalities in mental health disfavoring the less affluent population. The decomposition analysis results revealed that socio-economic conditions, including employment status (31%), income (22.6%), and cash margin (14%), made the largest contribution to the pro-rich inequalities in mental health. The second-largest contribution came from demographic factors, mainly age (11.3%) and gender (6%). Psychosocial factors were of smaller importance, with perceived discrimination (8%) and emotional support (3.4%) making moderate contributions to the health inequalities. 

    Conclusions: The present study demonstrates substantial income-related mental health inequalities in Northern Sweden, and provides insights into their underpinnings. These findings suggest that addressing the root causes is essential for promoting mental health equity in this region.

  • 13.
    Annandale, Ellen
    et al.
    Department of Sociology, University of York, York, England.
    Wiklund, Maria
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Hammarström, Anne
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Theorising women's health and health inequalities: shaping processes of the 'gender-biology nexus'.2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no sup3, p. 1-10, article id 1669353Article in journal (Refereed)
    Abstract [en]

    Since the theoretical frameworks and conceptual tools we employ shape research outcomes by guiding research pathways, it is important that we subject them to ongoing critical reflection. A thoroughgoing analysis of the global production of women's health inequality calls for a comprehensive theorization of how social relations of gender and the biological body mutually interact in local contexts in a nexus with women's health. However, to date, the predominant concern of research has been to identify the biological effects of social relations of gender on the body, to the relative neglect of the co-constitutive role that these biological changes themselves may play in ongoing cycles of gendered health oppressions. Drawing on feminist and gender theoretical approaches, and with the health of women and girls as our focus, we seek to extend our understanding of this recursive process by discussing what we call the 'shaping processes' of the 'gender-biology nexus' which call attention to not only the 'gender-shaping of biology' but also the 'biologic-shaping of gender'. We consider female genital mutilation/cutting as an illustration of this process and conclude by proposing that a framework which attends to both the 'gender-shaping of biology' and the 'biologic-shaping of gender' as interweaving processes provides a fruitful approach to theorising the wider health inequalities experienced by women and girls.

  • 14.
    Anticona, Cynthia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Anemia and malnutrition in indigenous children and adolescents of the Peruvian Amazon in a context of lead exposure: a cross-sectional study2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7Article in journal (Refereed)
    Abstract [en]

    Background: Indigenous children and adolescents of the Peruvian Amazon live in precarious conditions that could increase the risk of malnutrition. A particular problem in the Corrientes river communities is the high exposure to lead among children and adolescents. Objective: This study aimed to determine the nutritional status of children and adolescents in indigenous communities in the Corrientes river basin and examine risk factors for anemia, stunting, underweight, and wasting. Design: This was a cross-sectional assessment in children and adolescents aged 0-17 years from six communities (n = 330). Data collection included measurement of hemoglobin levels, anthropometrics, blood lead levels (BLLs); a parental questionnaire including demographic and dwelling information; parents' occupation; and the child's duration of breastfeeding and food consumption. Analysis included univariate, bivariate, and logistic regression. Results: Overall, anemia prevalence was 51.0%, stunting (proxy for chronic malnutrition) 50.0%, and underweight 20.0%. Bivariate analysis showed that anemia and underweight prevalence was higher in the 0-4 years group (p<0.05). No association was found between anemia, stunting, or underweight with gender, community exposure to oil activity, or consumption of river water. Stunting prevalence was higher in the group whose BLLs were >5 mu g/dL (p<0.05). In the logistic regression analysis, no variable was associated with anemia or underweight. The group 5-11 years and >12 years had 1.9 and 3.1 times higher risk of stunting than the group under five years, respectively. Children and adolescents with BLLs >5 mu g/dL had twice the risk of stunting compared to those with lower BLLs. Conclusions: Half of the study population was found with anemia and stunting. Anemia was more prevalent in the 0- to 5-year age group and stunting in the 12- to 17-year group. The association between stunting and BLLs might be attributed to a direct effect of lead on human growth. Also, poor nutrition and other socioeconomic-related factors may contribute to the simultaneous existence of stunting and elevated BLLs.

  • 15. Arthur, Samuelina S.
    et al.
    Nyide, Bongiwe
    Soura, Abdramane Bassiahi
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weston, Mark
    Sankoh, Osman
    Tackling malnutrition: a systematic review of 15-year research evidence from INDEPTH health and demographic surveillance systems2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-13, article id 28298Article, review/survey (Refereed)
    Abstract [en]

    Background: Nutrition is the intake of food in relation to the body's dietary needs. Malnutrition results from the intake of inadequate or excess food. This can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. Objective: To perform a systematic review to assess research conducted by the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) of health and demographic surveillance systems (HDSSs) over a 15-year period on malnutrition, its determinants, the effects of under and over nutrition, and intervention research on malnutrition in low- and middle-income countries (LMICs). Methods: Relevant publication titles were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords 'nutrition', 'malnutrition', 'over and under nutrition', we selected publications that were based only on data generated through the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion in this study, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight paperswere identified and reviewed, and 67 were selected for this study. Results: The INDEPTH research identified rising levels of overweight and obesity, sometimes in the same settings as under-nutrition. Urbanisation appears to be protective against under-nutrition, but it heightens the risk of obesity. Appropriately timed breastfeeding interventions were protective against malnutrition. Conclusions: Although INDEPTH has expanded the global knowledge base on nutrition, many questions remain unresolved. There is a need for more investment in nutrition research in LMICs in order to generate evidence to inform policies in these settings.

  • 16. Ashraf, Ali
    et al.
    Quaiyum, M.A.
    Ng, Nawi
    Purworejo Health and Demographic Surveillance System, Indonesia.
    Van Minh, Hoang
    Razzaque, Abdur
    Masud Ahmed, Syed
    Hadi, Abdullahel
    Juvekar, Sanjay
    Kanungsukkasem, Uraiwan
    Soonthornthada, Kusol
    Huu Bich, Tran
    Self-reported use of tobacco products in nine rural INDEPTH Health and Demographic Surveillance Systems in Asia2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, p. 19-27Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Tobacco use is the most preventable cause of premature death and disability. Even though tobacco use is common in many Asian countries, reliable and comparable data on the burden imposed by tobacco use in this region are sparse, and surveillance systems to track trends are in their infancy.

    OBJECTIVE: To assess and compare the prevalence of tobacco use and its associated factors in nine selected rural sites in five Asian countries.

    METHODS: Tobacco use among 9,208 men and 9,221 women aged 25-64 years in nine Health and Demographic Surveillance System (HDSS) sites in five Asian countries of the INDEPTH Network were examined in 2005 as part of a broader survey of the major chronic non-communicable disease risk factors. All sites used a standardised protocol based on the WHO STEPS approach to risk factor surveillance; expanded questions of local relevance, including chewing tobacco, were also included. Multivariable logistic regression was used to assess demographic factors associated with tobacco use.

    RESULTS: Tobacco use, whether smoked or chewed, was common across all sites with some notable variations. More than 50% of men smoked daily; this applied to almost all age groups. Few women smoked daily in any of the sites. However, women were more likely to chew tobacco than men in all sites except Vadu in India. Tobacco use in men began in late adolescence in most of the sites and the number of cigarettes smoked daily ranged from three to 15. Use of both forms of tobacco, smoked and chewed, was associated with age, gender and education. Men were more likely to smoke compared to women, smoking increased with age in the four sites in Bangladesh but not in other sites and with low level of education in all the sites.

    CONCLUSION: The prevalence of tobacco use, regardless of the type of tobacco, was high among men in all of these rural populations with tobacco use started during adolescence in all HDSS sites. Innovative communication strategies for behaviour change targeting adolescents in schools and adult men and women at work or at home, may create a mass awareness about adverse health consequences of tobacco smoking or chewing tobacco. Such efforts, to be effective, however, need to be supported by strong legislation and leadership. Only four of the five countries involved in this multi-site study have ratified the Framework Convention on Tobacco Control, and even where it has been ratified, implementation is uneven.

  • 17.
    Assarsson, Rebecka
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Petersen, Solveig
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Högberg, Björn
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Strandh, Mattias
    Umeå University, Faculty of Social Sciences, Department of Social Work. Center for Research on Child and Adolescent Mental Health, Karlstad University, Karlstad, Sweden.
    Johansson, Klara
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gender inequality and adolescent suicide ideation across Africa, Asia, the South Pacific and Latin America: a cross-sectional study based on the Global School Health Survey (GSHS)2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, article id 1663619Article in journal (Refereed)
    Abstract [en]

    Background: Suicide ideation is a health issue affecting adolescents worldwide. There are significant variations in suicide ideation between countries and genders, which have not been fully explained. Research is especially lacking in countries outside Europe and North America. Gender equality has been shown to matter in other aspects of adolescent mental health, such as life satisfaction, but has not been researched in relation to suicide ideation at national level.

    Objective: To investigate how national gender inequality is related to self-reported suicide ideation among adolescents, and whether this association differs between boys and girls.

    Methods: This is a cross-national, cross-sectional study using individual survey data from the Global School-based Student Health Survey, a survey in Africa, Asia, Latin America and the South Pacific, developed and supported by among others the WHO and the CDC; connecting this to national data: the gender inequality index from the UNDP; controlling for GDP per capita and secondary school enrolment. The data was analysed using a multilevel logistic regression method and included 149,306 students from 37 countries.

    Results: Higher national gender inequality, as measured by the gender inequality index, was significantly associated with a higher likelihood of suicide ideation in both girls and boys (odds ratio: 1.38 p-value: 0.015), but for girls and both sexes this was only after adjusting for selection bias due to secondary school enrolment (as well as GDP/capita). Interaction models showed that this association was stronger in boys than in girls.

    Conclusions: National gender inequality seems to be associated with higher levels of suicide ideation among adolescents in mainly low- and middle-income countries, especially among boys.

  • 18. Banda, Emmanuel
    et al.
    Svanemyr, Joar
    Sandoy, Ingvild Fossgard
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Zulu, Joseph Mumba
    Acceptability of an economic support component to reduce early pregnancy and school dropout in Zambia: a qualitative case study2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1685808Article in journal (Refereed)
    Abstract [en]

    Background: Cash Transfer (CT) schemes have become popular poverty reducing measures in many low and middle-income countries. Research indicates that when provided to girls in resource poor settings, cash transfers can increase education and postpone marriage and pregnancy. However, a few studies indicate that they can also have negative effects which can affect their acceptability, such as generating intra-community tensions.

    Objective: Conceptually informed by Rogers’ diffusion of innovation theory, this paper explores factors affecting the acceptability of economic support in a randomized controlled trial in rural Monze and Pemba Districts of Southern Province in Zambia.

    Methods: Qualitative data were collected through five focus group discussions and six in-depth, semi-structured interviews and analysed using thematic analysis. This study was done in the combined arm of a trial where girls received both economic support and participated in youth clubs offering sexuality and life-skills education.

    Results: In the study communities, acceptability was encouraging by the belief that economic support provided benefits beyond beneficiaries and that it improved access to education, and reduced teen pregnancies, marriages and school drop-out. However, provision of economic support only to selected girls and their parents and fear among some that the support was linked to satanic practices negatively affected acceptability. These fears were mitigated through community sensitisations.

    Conclusion: The study demonstrated that relative advantage, observability, simplicity and compatibility were key factors in influencing acceptability of the economic support. However, to enhance acceptability of cash transfer schemes aimed at addressing early marriage and pregnancy, it is important to explore socio-cultural factors that create suspicions and negative perceptions and to provide schemes that are perceived as relatively better than available similar schemes, understood, compatible and viable beyond the immediate beneficiary.

  • 19. Barkman, Catharina
    et al.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Policymakers and mHealth: roles and expectations, with observations from Ethiopia, Ghana and Sweden2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1337356Article in journal (Refereed)
    Abstract [en]

    The rapid increase in mobile phone use and other telecommunication technologies in health care during the past decade has paved the way for optimism. mHealth (mobile health) initiatives need to be integrated into national health systems and priorities and fit into the system that the country has already invested in. Partnership between government, regional governments, health care systems, Community Health Workers, the private sector and universities is considered as a precondition for success. In turn, this requires strategic and integrative policy decisions on the national/regional level to be defined in the action plans as concrete steps. Decision makers are calling for scale-up plans to be in place even in the pilot phases. Hope is expressed that the initial joy and curiosity that new technology generates in the implementation phase will be transferred to routine work. Standards and a common technical architecture that enables interoperability and upscaling are key issues. Based on publications on policy and national strategies, this paper highlights some key areas for decision makers' role and expectations with regard to mHealth. The paper will also report some mHealth experiences from Ethiopia, Ghana and Sweden.

  • 20.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing the dimensionality of YFHS-Swe: a questionnaire to assess youth-friendliness in differentiated health services2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1380399Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to assess the dimensionality of YFHS-Swe and identify possible unique factors in the evaluation of youth-friendliness. YFHS-Swe was answered by 1110 youths aged 16 to 25 years visiting youth clinics in Northern Sweden. Thirteen factors were identified by exploratory factor analysis and except for one factor they all proved to fit well and have good reliability when assessed by the confirmatory factor analysis. The YFHS-Swe proved to be credible and suitable for assessing youth-friendliness of differentiated health services in Sweden. With cultural and linguistic adaptations, it can be used in similar settings internationally.

  • 21. Batura, Neha
    et al.
    Pulkki-Brännström, Anni-Maria
    Institute for Global Health, University College London, London, UK.
    Agrawal, Priya
    Bagra, Archana
    Haghparast-Bidgoli, Hassan
    Bozzani, Fiammetta
    Colbourn, Tim
    Greco, Giulia
    Hossain, Tanvir
    Sinha, Rajesh
    Thapa, Bidur
    Skordis-Worrall, Jolene
    Collecting and analysing cost data for complex public health trials: reflections on practice2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 23257-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Current guidelines for the conduct of cost-effectiveness analysis (CEA) are mainly applicable to facility-based interventions in high-income settings. Differences in the unit of analysis and the high cost of data collection can make these guidelines challenging to follow within public health trials in low- and middle- income settings.

    OBJECTIVE: This paper reflects on the challenges experienced within our own work and proposes solutions that may be useful to others attempting to collect, analyse, and compare cost data between public health research sites in low- and middle- income countries.

    DESIGN: We describe the generally accepted methods (norms) for collecting and analysing cost data in a single-site trial from the provider perspective. We then describe our own experience applying these methods within eight comparable cluster randomised, controlled, trials. We describe the strategies used to maximise adherence to the norm, highlight ways in which we deviated from the norm, and reflect on the learning and limitations that resulted.

    RESULTS: When the expenses incurred by a number of small research sites are used to estimate the cost-effectiveness of delivering an intervention on a national scale, then deciding which expenses constitute 'start-up' costs will be a nontrivial decision that may differ among sites. Similarly, the decision to include or exclude research or monitoring and evaluation costs can have a significant impact on the findings. We separated out research costs and argued that monitoring and evaluation costs should be reported as part of the total trial cost. The human resource constraints that we experienced are also likely to be common to other trials. As we did not have an economist in each site, we collaborated with key personnel at each site who were trained to use a standardised cost collection tool. This approach both accommodated our resource constraints and served as a knowledge sharing and capacity building process within the research teams.

    CONCLUSIONS: Given the practical reality of conducting randomised, controlled trials of public health interventions in low- and middle- income countries, it is not always possible to adhere to prescribed guidelines for the analysis of cost effectiveness. Compromises are frequently required as researchers seek a pragmatic balance between rigor and feasibility. There is no single solution to this tension but researchers are encouraged to be mindful of the limitations that accompany compromise, whilst being reassured that meaningful analyses can still be conducted with the resulting data.

  • 22.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    What about healthy participants?: the improvement and deterioration of self-reported health at a 10-year follow-up of the Västerbotten Intervention Programme2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 5435-Article in journal (Refereed)
    Abstract [en]

    AIM: The Västerbotten Intervention Programme (VIP) addresses cardiovascular disease and diabetes in the middle-aged population of Västerbotten County, Sweden. Self-reported health (SRH) is one of the risk factors for both conditions. The aim of this study was to analyse the development patterns of SRH among the VIP participants.

    METHODS: Cross-sectional data from 1990 to 2007 were used to analyse the prevalence of poor SRH among 101,396 VIP participants aged 40-60 years. Panel data were used to study the change in SRH among 25,695 persons aged 30-60 years, who participated in the VIP twice within a 10-year interval.

    RESULTS: Prevalence of poor SRH fluctuated between 1990 and 2007 in Västerbotten County. There was a temporary decline around 2000, with SRH continuously improving thereafter. The majority of panel participants remained in good SRH; over half of those with poor or fair SRH at baseline reported better SRH at follow-up. SRH declined in 19% of the panel participants, mostly among those who had good SRH at the baseline. The decline was common among both women and men, in all educational, age and marital status groups.

    CONCLUSIONS: The SRH improvement among those with poor and fair SRH at baseline suggests that VIP has been successful in addressing its target population. However, the deterioration of SRH among 21% of the individuals with good SRH at baseline is of concern. From a public health perspective, it is important for health interventions to address not only the risk group but also those with a healthy profile to prevent the negative development among the seemingly healthy participants.

  • 23.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Souares, Aurelia
    Niamba, Louis
    Sie, Ali
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sauerborn, Rainer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Measuring self-reported health in low-income countries: piloting three instruments in semi-rural Burkina Faso2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, p. 8488-Article in journal (Refereed)
    Abstract [en]

    Background: National surveys in low-income countries increasingly rely on self-reported measures of health. The ease, speed, and economy of collecting self-reports of health make such collection attractive for rapid appraisals. However, the interpretation of these measures is complicated since different cultures understand and respond to the same question in different ways. Objective: The aim of this pilot study was to develop a culturally sensitive tool to study the self-reported health (SRH) of the local adult population in Burkina Faso. Design: The study was carried out in the 2009 rainy season. The sample included 27 men and 25 women aged 18 or older who live in semi-urban Nouna, Burkina Faso. Three culturally adapted instruments were tested: a SRH question, a wooden visual analogue scale (VAS), and a drawn VAS. Respondents were asked to explain their answers to each instrument. The narratives were analyzed with the content analysis technique, and the prevalence of poor SRH was estimated from the quantitative data by stratification for respondent background variables (sex, age, literacy, education, marital status, ethnicity, chronic diseases). The correlation between the instruments was tested with Spearman's correlation test. Results: The SRH question showed a 38.5% prevalence of poor SRH and 44.2% prevalence with both VAS. The correlation between the VAS was 0.89, whereas the correlation between the VAS and the SRH question was 0.60-0.64. Nevertheless, the question used as the basis of each instrument was culturally sensitive and clear to all respondents. Analysis of the narratives shows that respondents clearly differentiated between the various health statuses. Conclusion: In this pilot, we developed and tested a new version of the SRH question that may be more culturally sensitive than its non-adapted equivalents. Additional insight into this population's understanding and reporting of health was also obtained. A larger sample is needed to further study the validity and reliability of the SRH question and the VAS and understand which instrument is best suited to study SRH in the low-income setting of semi-rural Burkina Faso.

  • 24. Bocquier, Philippe
    et al.
    Sankoh, Osman
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Are health and demographic surveillance system estimates sufficiently generalisable?2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, p. 1-3, article id 1356621Article in journal (Refereed)
    Abstract [en]

    Sampling rules do not apply in a Health and Demographic Surveillance System (HDSS) that covers exhaustively a district-level population and is not meant to be representative of a national population. We highlight the advantages of HDSS data for causal analysis and identify in the literature the principles of conditional generalisation that best apply to HDSS. A probabilistic view on HDSS data is still justified by the need to model complex causal inference. Accounting for contextual knowledge, reducing omitted-variable bias, detailing order of events, and high statistical power brings credence to HDSS data. Generalisation of causal mechanisms identified in HDSS data is consolidated through systematic comparison and triangulation with national or international data.

  • 25.
    Bonita, Ruth
    et al.
    School of Population Health, University of Auckland, Auckland, New Zealand;.
    Brändström, Anders
    Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Malmberg, Gunnar
    Umeå University, Faculty of Social Sciences, Department of Social and Economic Geography. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Linnaeus: Alive and well2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 5760-2Article in journal (Refereed)
  • 26.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Climate change and population health in Africa: where are the scientists?2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, p. 173-176Article in journal (Refereed)
    Abstract [en]

    Despite a growing awareness of Africans' vulnerability to climate change, there is relatively little empirical evidence published about the effects of climate on population health in Africa. This review brings together some of the generalised predictions about the potential continent-wide effects of climate change with examples of the relatively few locally documented population studies in which climate change and health interact. Although ecologically determined diseases such as malaria are obvious candidates for susceptibility to climate change, wider health effects also need to be considered, particularly among populations where adequacy of food and water supplies may already be marginal.

  • 27.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Epidemiology without borders: an anational view of global health2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Most analyses of global health use country as a unit of observation, not least because countries are intrinsic to health services and to many international organisations. However, this can mask geographical influences on population health, which do not respect political boundaries.

    METHODS: A global anational database was constructed with one degree cells of latitude and longitude, and used to calculate densities for population and key health indicators. These data were aggregated into 240 15 degrees ansectors, 171 of which were populated. Differences in ansector rank orders between population density and health outcomes (infant, maternal and HIV-related deaths and income) were calculated and mapped as quintiles.

    FINDINGS: Individual ansectors contained parts of 1-21 countries. Mapping by ansector showed that the four outcomes analysed were strongly geographically correlated. Sub-Saharan Africa was consistently disadvantaged in terms of health outcomes, while the Indian sub-continent was at an advantage in terms of HIV mortality, despite poverty.

    INTERPRETATION: Although in most cases it makes sense to analyse health on a national basis, these findings highlight the often unquestioned assumptions involved in doing so. Even if global patterns of health do not turn out so differently when analysed anationally, some major effects on health, such as climate change, are not nationally based, and should not necessarily be nationally analysed. Progress towards Millennium Development Goals must be evaluated on a population basis, rather than by counting countries achieving targets. Data files are available in Excel format and attached as separate files to this paper (see Supplementary files under Reading Tools online).

  • 28.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Is global health really global?2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, p. 1-3Article in journal (Refereed)
    Abstract [en]

    This editorial is based on a keynote address given at the International Conference on Global Public Health, Colombo, Sri Lanka, in December 2012. It accompanies a set of papers which were also presented at the conference. So far, these papers describe a range of global health issues, from the health status of the United Arab Emirates through to social determinants of health in India. Two papers from Rwanda and India consider specific aspects of oral public health, which was a major sub-theme of the conference.

  • 29.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Towards a global agenda on ageing2008In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 1Article in journal (Other academic)
  • 30.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Calvert, Clara
    Miiro-Nakiyingi, Jessica
    Lutalo, Tom
    Michael, Denna
    Crampin, Amelia
    Gregson, Simon
    Takaruza, Albert
    Robertson, Laura
    Herbst, Kobus
    Todd, Jim
    Zaba, Basia
    InterVA-4 as a public health tool for measuring HIV/AIDS mortality: a validation study from five African countries2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, no 1, article id 22448Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Reliable population-based data on HIV infection and AIDS mortality in sub-Saharan Africa are scanty, even though that is the region where most of the world's AIDS deaths occur. There is therefore a great need for reliable and valid public health tools for assessing AIDS mortality.

    OBJECTIVE: The aim of this article is to validate the InterVA-4 verbal autopsy (VA) interpretative model within African populations where HIV sero-status is recorded on a prospective basis, and examine the distribution of cause-specific mortality among HIV-positive and HIV-negative people.

    DESIGN: Data from six sites of the Alpha Network, including HIV sero-status and VA interviews, were pooled. VA data according to the 2012 WHO format were extracted, and processed using the InterVA-4 model into likely causes of death. The model was blinded to the sero-status data. Cases with known pre-mortem HIV infection status were used to determine the specificity with which InterVA-4 could attribute HIV/AIDS as a cause of death. Cause-specific mortality fractions by HIV infection status were calculated, and a person-time model was built to analyse adjusted cause-specific mortality rate ratios.

    RESULTS: The InterVA-4 model identified HIV/AIDS-related deaths with a specificity of 90.1% (95% CI 88.7-91.4%). Overall sensitivity could not be calculated, because HIV-positive people die from a range of causes. In a person-time model including 1,739 deaths in 1,161,688 HIV-negative person-years observed and 2,890 deaths in 75,110 HIV-positive person-years observed, the mortality ratio HIV-positive:negative was 29.0 (95% CI 27.1-31.0), after adjustment for age, sex, and study site. Cause-specific HIV-positive:negative mortality ratios for acute respiratory infections, HIV/AIDS-related deaths, meningitis, tuberculosis, and malnutrition were higher than the all-cause ratio; all causes had HIV-positive:negative mortality ratios significantly higher than unity.

    CONCLUSIONS: These results were generally consistent with relatively small post-mortem and hospital-based diagnosis studies in the literature. The high specificity in cause of death attribution achieved in relation to HIV status, and large differences between specific causes by HIV status, show that InterVA-4 is an effective and valid tool for assessing HIV-related mortality.

  • 31.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Chandramohan, Daniel
    Clark, Samuel J.
    D'Ambruoso, Lucia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fottrell, Edward
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Graham, Wendy J.
    Herbst, Abraham J.
    Hodgson, Abraham
    Hounton, Sennen
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krishnan, Anand
    Leitao, Jordana
    Odhiambo, Frank
    Sankoh, Osman A.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Strengthening standardised interpretation of verbal autopsy data: the new InterVA-4 tool2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5Article in journal (Refereed)
    Abstract [en]

    Background: Verbal autopsy (VA) is the only available approach for determining the cause of many deaths, where routine certification is not in place. Therefore, it is important to use standards and methods for VA that maximise efficiency, consistency and comparability. The World Health Organization (WHO) has led the development of the 2012 WHO VA instrument as a new standard, intended both as a research tool and for routine registration of deaths. Objective: A new public-domain probabilistic model for interpreting VA data, InterVA-4, is described, which builds on previous versions and is aligned with the 2012 WHO VA instrument. Design: The new model has been designed to use the VA input indicators defined in the 2012 WHO VA instrument and to deliver causes of death compatible with the International Classification of Diseases version 10 (ICD-10) categorised into 62 groups as defined in the 2012 WHO VA instrument. In addition, known shortcomings of previous InterVA models have been addressed in this revision, as well as integrating other work on maternal and perinatal deaths. Results: The InterVA-4 model is presented here to facilitate its widespread use and to enable further field evaluation to take place. Results from a demonstration dataset from Agincourt, South Africa, show continuity of interpretation between InterVA-3 and InterVA-4, as well as differences reflecting specific issues addressed in the design and development of InterVA-4. Conclusions: InterVA-4 is made freely available as a new standard model for interpreting VA data into causes of death. It can be used for determining cause of death both in research settings and for routine registration. Further validation opportunities will be explored. These developments in cause of death registration are likely to substantially increase the global coverage of cause-specific mortality data.

  • 32.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research and MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    de Savigny, Don
    Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland and University of Basel, Basel, Switzerland.
    Lopez, Alan D
    Melbourne School of Population and Global Health, University of Melbourne, Carlton, Australia.
    Essential evidence for guiding health system priorities and policies: anticipating epidemiological transition in Africa2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 158-168Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite indications that infection-related mortality in sub-Saharan Africa may be decreasing and the burden of non-communicable diseases increasing, the overwhelming reality is that health information systems across most of sub-Saharan Africa remain too weak to track epidemiological transition in a meaningful and effective way.

    PROPOSALS: We propose a minimum dataset as the basis of a functional health information system in countries where health information is lacking. This would involve continuous monitoring of cause-specific mortality through routine civil registration, regular documentation of exposure to leading risk factors, and monitoring effective coverage of key preventive and curative interventions in the health sector. Consideration must be given as to how these minimum data requirements can be effectively integrated within national health information systems, what methods and tools are needed, and ensuring that ethical and political issues are addressed. A more strategic approach to health information systems in sub-Saharan African countries, along these lines, is essential if epidemiological changes are to be tracked effectively for the benefit of local health planners and policy makers.

    CONCLUSION: African countries have a unique opportunity to capitalize on modern information and communications technology in order to achieve this. Methodological standards need to be established and political momentum fostered so that the African continent's health status can be reliably tracked. This will greatly strengthen the evidence base for health policies and facilitate the effective delivery of services.

  • 33.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fantahun, Mesganaw
    Emmelin, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Molla, Mitike
    Berhane, Yemane
    Spatio-temporal clustering of mortality in Butajira HDSS, Ethiopia, from 1987 to 20082010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. 26-31Article in journal (Refereed)
    Abstract [en]

    Background: Mortality in a population may be clustered in space and time for a variety of reasons, including geography, socio-economics, environment and demographics. Analysing mortality clusters can therefore reveal important insights into patterns and risks of mortality in a particular setting. Objective and design: To investigate the extent of spatio-temporal clustering of mortality in the Butajira District, Ethiopia, from 1987 to 2008. The Health and Demographic Surveillance System (HDSS) dataset recorded 10,696 deaths among 951,842 person-years of observation, with each death located by household, in which population time at risk was also recorded. The surveyed population increased from 28,614 in 1987 to 62,322 in 2008, in an area approximately 25 km in diameter. Spatio-temporal clustering analyses were conducted for overall mortality and by specific age groups, grouping the population into a 0.01° latitude-longitude grid. Results: A number of significantly high- and low-mortality clusters were identified at various times and places. Butajira town was characterised by significantly low mortality throughout the period. A previously documented major mortality crisis in 1998-1999, largely resulting from malaria and diarrhoea, dominated the clustering analysis. Other local high-mortality clusters, appreciably attributable to meningitis, malaria and diarrhoea, occurred in the earlier part of the period. In the later years, a more homogeneous distribution of mortality at lower rates was observed. Conclusions: Mortality was by no means randomly distributed in this community during the period of observation. The clustering analyses revealed a clear epidemiological transition, away from localised infectious epidemics, over a generation.

  • 34.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Friberg, Peter
    Blomstedt, Yulia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Beyond 2015: time to reposition Scandinavia in global health?2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6Article in journal (Refereed)
    Abstract [en]

    Global health currently finds itself in an exciting, almost bewildering, state of flux. A plethora of initiatives, statements, high-level meetings, and other activities are generating a continuous flow of new ideas, with the impetus at least partly driven by the advent of the 2015 target date set for the Millennium Development Goals that were adopted in 2000. Whatever shape the post-2015 global health landscape may eventually take, it is already clear that there will be new targets of some kind as the world tries to make further progress on some of the less tractable health issues.

  • 35.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nurturing Global Health Action through its first decade2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1569847Article in journal (Refereed)
  • 36.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Twine, Wayne
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kjellström, Tord
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing a population's exposure to heat and humidity: an empirical approach2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. Article nr 5421-Article in journal (Refereed)
    Abstract [en]

    Background: It is widely accepted that assessing the impact of heat on populations is an important aspect of climate change research. However, this raises questions about how best to measure people’s exposure to heat under everyday living conditions in more detail than is possible by relying on nearby sources of meteorological data. Objective: This study aimed to investigate practical and viable approaches to measuring air temperature and humidity within a population, making comparisons with contemporaneous external data sources. This was done in a rural South African population during the subtropical summer season. Results: Air temperature and humidity were measured indoors and outdoors at three locations over 10 days and the datalogger technology proved reliable and easy to use. There was little variation in measurements over distances of 10 km. Conclusions: Small battery-powered automatic dataloggers proved to be a feasible option for collecting weather data among a rural South African population. These data were consistent with external sources but offered more local detail. Detailed local contemporary data may also allow post hoc modelling of previously unmeasured local weather data in conjunction with global gridded climate models.

  • 37.
    Cameron, David
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ubels, Jasper
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1447828Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: The amount a government should be willing to invest in adopting new medical treatments has long been under debate. With many countries using formal cost-effectiveness (C/E) thresholds when examining potential new treatments and ever-growing medical costs, accurately setting the level of a C/E threshold can be essential for an efficient healthcare system.

    OBJECTIVES: The aim of this systematic review is to describe the prominent approaches to setting a C/E threshold, compile available national-level C/E threshold data and willingness-to-pay (WTP) data, and to discern whether associations exist between these values, gross domestic product (GDP) and health-adjusted life expectancy (HALE). This review further examines current obstacles faced with the presently available data.

    METHODS: A systematic review was performed to collect articles which have studied national C/E thresholds and willingness-to-pay (WTP) per quality-adjusted life year (QALY) in the general population. Associations between GDP, HALE, WTP, and C/E thresholds were analyzed with correlations.

    RESULTS: Seventeen countries were identified from nine unique sources to have formal C/E thresholds within our inclusion criteria. Thirteen countries from nine sources were identified to have WTP per QALY data within our inclusion criteria. Two possible associations were identified: C/E thresholds with HALE (quadratic correlation of 0.63), and C/E thresholds with GDP per capita (polynomial correlation of 0.84). However, these results are based on few observations and therefore firm conclusions cannot be made.

    CONCLUSIONS: Most national C/E thresholds identified in our review fall within the WHO's recommended range of one-to-three times GDP per capita. However, the quality and quantity of data available regarding national average WTP per QALY, opportunity costs, and C/E thresholds is poor in comparison to the importance of adequate investment in healthcare. There exists an obvious risk that countries might either over- or underinvest in healthcare if they base their decision-making process on erroneous presumptions or non-evidence-based methodologies. The commonly referred to value of 100,000$ USD per QALY may potentially have some basis.

  • 38. Chaturvedi, Sarika
    et al.
    Ali, Sayyed
    Randive, Bharat
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sabde, Yogesh
    Diwan, Vishal
    De Costa, Ayesha
    Availability and distribution of safe abortion services in rural areas: a facility assessment study in Madhya Pradesh, India2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-7, article id 26346Article in journal (Refereed)
    Abstract [en]

    Background: Unsafe abortion contributes to a significant portion of maternal mortality in India. Access to safe abortion care is known to reduce maternal mortality. Availability and distribution of abortion care facilities can influence women's access to these services, especially in rural areas. Objectives: To assess the availability and distribution of abortion care at facilities providing childbirth care in three districts of Madhya Pradesh (MP) province of India. Design: Three socio demographically heterogeneous districts of MP were selected for this study. Facilities conducting at least 10 deliveries a month were surveyed to assess availability and provision of abortion services using UN signal functions for emergency obstetric care. Geographical Information System was used for visualisation of the distribution of facilities. Results: The three districts had 99 facilities that conducted > 10 deliveries a month: 74 in public and 25 in private sector. Overall, 48% of facilities reported an ability to provide safe surgical abortion service. Of public centres, 32% reported the ability compared to 100% among private centres while 18% of public centres and 77% of private centres had performed an abortion in the last 3 months. The availability of abortion services was higher at higher facility levels with better equipped and skilled personnel availability, in urban areas and in private sector facilities. Conclusions: Findings showed that availability of safe abortion care is limited especially in rural areas. More emphasis on providing safe abortion services, particularly at primary care level, is important to more significantly dent maternal mortality in India.

  • 39. Coates, Matthew M.
    et al.
    Kamanda, Mamusu
    Kintuc, Alexander
    Arikpo, Iwara
    Chauque, Alberto
    Mengesha, Melkamu Merid
    Price, Alison J.
    Sifuna, Peter
    Wamukoya, Marylene
    Sacoor, Charfudin N.
    Ogwang, Sheila
    Assefa, Nega
    Crampin, Amelia C.
    Macete, Eusebio, V
    Kyobutungi, Catherine
    Meremikwu, Martin M.
    Otieno, Walter
    Adjaye-Gbewonyo, Kafui
    Marx, Andrew
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Sankoh, Osman
    Bukhman, Gene
    A comparison of all-cause and cause-specific mortality by household socioeconomic status across seven INDEPTH network health and demographic surveillance systems in sub-Saharan Africa2019In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1608013Article in journal (Refereed)
    Abstract [en]

    Background: Understanding socioeconomic disparities in all-cause and cause-specific mortality can help inform prevention and treatment strategies.

    Objectives: To quantify cause-specific mortality rates by socioeconomic status across seven health and demographic surveillance systems (HDSS) in five countries (Ethiopia, Kenya, Malawi, Mozambique, and Nigeria) in the INDEPTH Network in sub-Saharan Africa.

    Methods: We linked demographic residence data with household survey data containing living standards and education information we used to create a poverty index. Person-years lived and deaths between 2003 and 2016 (periods varied by HDSS) were stratified in each HDSS by age, sex, year, and number of deprivations on the poverty index (0-8). Causes of death were assigned to each death using the InterVA-4 model based on responses to verbal autopsy questionnaires. We estimated rate ratios between socioeconomic groups (2-4 and 5-8 deprivations on our poverty index compared to 0-2 deprivations) for specific causes of death and calculated life expectancy for the deprivation groups.

    Results: Our pooled data contained almost 3.5 million person-years of observation and 25,038 deaths. All-cause mortality rates were higher among people in households with 5-8 deprivations on our poverty index compared to 0-2 deprivations, controlling for age, sex, and year (rate ratios ranged 1.42 to 2.06 across HDSS sites). The poorest group had consistently higher death rates in communicable, maternal, neonatal, and nutritional conditions (rate ratios ranged 1.34-4.05) and for non-communicable diseases in several sites (1.14-1.93). The disparities in mortality between 5-8 deprivation groups and 0-2 deprivation groups led to lower life expectancy in the higher-deprivation groups by six years in all sites and more than 10 years in five sites.

    Conclusions: We show large disparities in mortality on the basis of socioeconomic status across seven HDSS in sub-Saharan Africa due to disparities in communicable disease mortality and from non-communicable diseases in some sites. Life expectancy gaps between socioeconomic groups within sites were similar to the gaps between high-income and lower-middle-income countries. Prevention and treatment efforts can benefit from understanding subpopulations facing higher mortality from specific conditions.

  • 40.
    Coe, Anna-Britt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The importance of taking into account different perspectives of a health problem: the case of fibromyalgia2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1275189Article in journal (Refereed)
  • 41.
    Collinson, Mark A.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    White, Michael J.
    Bocquier, Philippe
    McGarvey, Stephen T.
    Afolabi, Sulaimon A.
    Clark, Samuel J.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Migration and the epidemiological transition: insights from the Agincourt sub-district of northeast South Africa2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 122-136Article in journal (Refereed)
    Abstract [en]

    Background:

    Migration and urbanization are central to sustainable development and health, but data on temporal trends in defined populations are scarce. Healthy men and women migrate because opportunities for employment and betterment are not equally distributed geographically. The disruption can result in unhealthy exposures and environments and income returns for the origin household.

    Objectives: The objectives of the paper are to describe the patterns, levels, and trends of temporary migration in rural northeast South Africa; the mortality trends by cause category over the period 2000-2011; and the associations between temporary migration and mortality by broad cause of death categories.

    Method:

    Longitudinal, Agincourt Health and Demographic Surveillance System data are used in a continuous, survival time, competing-risk model. Findings: In rural, northeast South Africa, temporary migration, which involves migrants relocating mainly for work purposes and remaining linked to the rural household, is more important than age and sex in explaining variations in mortality, whatever the cause. In this setting, the changing relationship between temporary migration and communicable disease mortality is primarily affected by reduced exposure of the migrant to unhealthy conditions. The study suggests that the changing relationship between temporary migration and non-communicable disease mortality is mainly affected by increased livelihood benefits of longer duration migration.

    Conclusion: Since temporary migration is not associated with communicable diseases only, public health policies should account for population mobility whatever the targeted health risk. There is a need to strengthen the rural health care system, because migrants tend to return to the rural households when they need health care.

  • 42.
    Crowe, Jennifer
    et al.
    Central American Institute for Studies in Toxic Substances (IRET) and the Program on Work and Health in Central America (SALTRA) at the Universidad Nacional in Costa Rica.
    van Wendel de Joode, Berna
    Central American Institute for Studies in Toxic Substances (IRET) and the Program on Work and Health in Central America (SALTRA) at the Universidad Nacional in Costa Rica.
    Wesseling, Catharina
    Central American Institute for Studies in Toxic Substances (IRET) and the Program on Work and Health in Central America (SALTRA) at the Universidad Nacional in Costa Rica.
    A pilot field evaluation on heat stress in sugarcane workers in Costa Rica: what to do next?2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, p. 71-80Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Climate change is producing major impacts including increasing temperatures in tropical countries, like Costa Rica, where the sugarcane industry employs thousands of workers who are exposed to extreme heat.

    OBJECTIVES: This article outlines a pilot qualitative evaluation of working conditions and heat in the sugarcane industry.

    DESIGN: A literature review, direct observations and exploratory interviews with workers were conducted to reach a preliminary understanding of the dimensions of heat-related health issues in the sugarcane industry, as a basis for the design of future studies.

    RESULTS: The industry employs temporary workers from Nicaragua and Costa Rica as well as year-round employees. Temporary employees work 12-hour shifts during the harvest and processing ('zafra') season. In many cases, sugarcane field workers are required to carry their own water and often have no access to shade. Sugar mill workers are exposed to different levels of heat stress depending upon their job tasks, with the most intense heat and workload experienced by the oven ('caldera') cleaners.

    CONCLUSIONS: Research is needed to achieve better understanding of the multiple factors driving and interacting with heat exposures in the sugarcane industry in order to improve the health and safety of workers while maintaining worker productivity.

  • 43. Daar, Abdallah S
    et al.
    Jacobs, Marian
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Groenewald, Johann
    Eaton, Julian
    Patel, Vikram
    dos Santos, Palmira
    Kagee, Ashraf
    Gevers, Anik
    Sunkel, Charlene
    Andrews, Gail
    Daniels, Ingrid
    Ndetei, David
    Declaration on mental health in Africa: moving to implementation2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 24589Article in journal (Refereed)
    Abstract [en]

    Urgent action is needed to address mental health issues globally. In Africa, where mental health disorders account for a huge burden of disease and disability, and where in general less than 1% of the already small health budgets are spent on these disorders, the need for action is acute and urgent. Members of the World Health Organization, including African countries, have adopted a Comprehensive Mental Health Action Plan. Africa now has an historic opportunity to improve the mental health and wellbeing of its citizens, beginning with provision of basic mental health services and development of national mental health strategic plans (roadmaps). There is need to integrate mental health into primary health care and address stigma and violations of human rights. We advocate for inclusion of mental health into the post-2015 Sustainable Development Goals, and for the convening of a special UN General Assembly High Level Meeting on Mental Health within three years.

  • 44. Dalmar, Abdirisak Ahmed
    et al.
    Hussein, Abdullahi Sheik
    Walhad, Said Ahmed
    Ibrahim, Abdirashid Omer
    Abdi, Abshir Ali
    Ali, Mohamed Khalid
    Ereg, Derie Ismail
    Egal, Khadra Ali
    Shirwa, Abdulkadir Mohamed
    Aden, Mohamed Hussain
    Yusuf, Marian Warsame
    Abdi, Yakoub Aden
    Freij, Lennart
    Johansson, Annika
    Mohamud, Khalif Bile
    Abdulkadir, Yusuf
    Emmelin, Maria
    Eriksen, Jaran
    Erlandsson, Kerstin
    Gustafsson, Lars L.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Klingberg-Allvin, Marie
    Kinsman, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Källestål, Carina
    Målqvist, Mats
    Osman, Fatumo
    Persson, Lars-Åke
    Sahlén, Klas-Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Rebuilding research capacity in fragile states: the case of a Somali-Swedish global health initiative2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1348693Article in journal (Refereed)
    Abstract [en]

    This paper presents an initiative to revive the previous Somali-Swedish Research Cooperation, which started in 1981 and was cut short by the civil war in Somalia. A programme focusing on research capacity building in the health sector is currently underway through the work of an alliance of three partner groups: six new Somali universities, five Swedish universities, and Somali diaspora professionals. Somali ownership is key to the sustainability of the programme, as is close collaboration with Somali health ministries. The programme aims to develop a model for working collaboratively across regions and cultural barriers within fragile states, with the goal of creating hope and energy. It is based on the conviction that health research has a key role in rebuilding national health services and trusted institutions.

  • 45. Dambach, Peter
    et al.
    Sie, Ali
    Lacaux, Jean-Pierre
    Vignolles, Cecile
    Machault, Vanessa
    Sauerborn, Rainer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of Heidelberg, Department of Tropical Hygiene & Public Health, Heidelberg, Germany.
    Using high spatial resolution remote sensing for risk mapping of malaria occurrence in the Nouna district, Burkina Faso2009In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 2, p. 149-155Article in journal (Refereed)
    Abstract [en]

    Introduction: Malaria control measures such as early diagnosis and treatment, intermittent treatment of pregnant women, impregnated bed nets, indoor spraying and larval control measures are difficult to target specifically because of imprecise estimates of risk at a small-scale level. Ways of estimating local risks for malaria are therefore important.

    Methods: A high-resolution satellite view from the SPOT 5 satellite during 2008 was used to generate a land cover classification in the malaria endemic lowland of North-Western Burkina Faso. For the area of a complete satellite view of 60 x 60 km, a supervised land cover classification was carried out. Ten classes were built and correlated to land cover types known for acting as Anopheles mosquito breeding sites.

    Results: According to known correlations of Anopheles larvae presence and surface water-related land cover, cultivated areas in the riverine vicinity of Kossi River were shown to be one of the most favourable sites for Anopheles production. Similar conditions prevail in the South of the study region, where clayey soils and higher precipitations benefit the occurrence of surface water. Besides pools, which are often directly detectable, rice fields and occasionally flooded crops represent most appropriate habitats. On the other hand, forests, elevated regions on porous soils, grasslands and the dryer, sandy soils in the north-western part turned out to deliver fewer mosquito breeding opportunities.

    Conclusions: Potential high and low risks for malaria at the village level can be differentiated from satellite data. While much remains to be done in terms of establishing correlations between remotely sensed risks and malaria disease patterns, this is a potentially useful approach which could lead to more focused disease control programmes.

  • 46.
    D'Ambruoso, Lucia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Relating the construction and maintenance of maternal ill-health in rural Indonesia2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, p. 17989-Article, review/survey (Refereed)
    Abstract [en]

    Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly.

  • 47.
    D'Ambruoso, Lucia
    et al.
    Immpact, University of Aberdeen, UK.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of Aberdeen, Dept Publ Hlth, Aberdeen, UK.
    Qomariyan, Siti Nurul
    Univ Indonesia, Fac Publ Hlth, Ctr Family Welf, W Java, Indonesia.
    Can the right to health inform public health planning in developing countries?: A case study for maternal healthcare from Indonesia2008In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 1, p. 10-Article in journal (Refereed)
    Abstract [en]

    Background: Maternal mortality remains unacceptably high in developing countries despite international advocacy, development targets, and simple, affordable and effective interventions. Human rights are powerful advocacy tools, which have become prominent in health and development. In recent years, regard for maternal mortality as a human rights issue as well as one that pertains to health, has emerged.

    Objective: We study a case of maternal death using a theoretical framework derived from the right to health to examine access to and quality of maternal healthcare. Our objective was to explore the potential of rights-based frameworks to inform public health planning from a human rights perspective.

    Design: Information was elicited as part of a verbal autopsy survey investigating maternal deaths in rural settings in Indonesia. The deceased's relatives were interviewed to collect information on medical signs, symptoms and the social, cultural and health systems circumstances surrounding the death.

    Results: In this case, a prolonged, severe fever and a complicated series of referrals culminated in the death of a 19-year-old primagravida at 7 months gestation. The cause of death was acute infection. The woman encountered a range of barriers to access; behavioural, socio-cultural, geographic and economic. Several serious health system failures were also apparent.. The theoretical framework derived from the right to health identified that none of the essential elements of the right were upheld.

    Conclusion: The rights-based approach could identify how and where to improve services. However, there are fundamental and inherent conflicts between the public health tradition (collective and preventative) and the right to health (individualistic and curative). As a result, and in practice, the right to health is likely to be ineffective for public health planning from a human rights perspective. Collective rights such as the right to development may provide a more suitable means to achieve equity and social justice in health planning.

  • 48.
    Dapi, Léonie N
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nguefack-Tsague, Georges
    Tetanye, Ekoe
    Kjellström, Tord
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Heat impact on schoolchildren in Cameroon, Africa: potential health threat from climate change2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. Article nr 5610-Article in journal (Refereed)
    Abstract [en]

    Background: Health impacts related to climate change are potentially an increasing problem in Cameroon, especially during hot seasons when there are no means for protective and adaptive actions.

    Objective: To describe environmental conditions in schools and to evaluate the impact of heat on schoolchildren’s health during school days in the Cameroon cities of Yaounde´ and Douala.

    Methods: Schoolchildren (N=285) aged 12=16 years from public secondary schools completed a questionnaire about their background, general symptoms, and hot feelings in a cross-sectional study. In Yaounde´, 50 schoolchildren were individually interviewed during school days about hourly symptoms (fatigue, headache, and feeling very hot) and performance. Lascar dataloggers were used to measure indoor classroom temperatures and humidity.

    Results: There was a significant correlation between daily indoor temperature and the percentages of schoolchildren who felt very hot, had fatigue, and headaches in Yaounde´. A high proportion of schoolchildren felt very hot (48%), had fatigue (76%), and headaches (38%) in Yaounde´. Prevalences (%) were higher among girls than boys for headaches (58 vs 39), feeling ‘very hot overall’ (37 vs 21), and ‘very hot in head’ (21 vs 18). Up to 62% were absentminded and 45% had slow writing speed. High indoor temperatures of 32.58C in Yaounde´ and 36.68C in Douala were observed in school.

    Conclusions: Headache, fatigue, and feeling very hot associated with high indoor air temperature were observed among schoolchildren in the present study. Longitudinal data in schools are needed to confirm these results. School environmental conditions should be improved in order to enhance learning.

  • 49. de Savigny, Don
    et al.
    Riley, Ian
    Chandramohan, Daniel
    Odhiambo, Frank
    Nichols, Erin
    Notzon, Sam
    AbouZahr, Carla
    Mitra, Raj
    Munoz, Daniel Cobos
    Firth, Sonja
    Maire, Nicolas
    Sankoh, Osman
    Bronson, Gay
    Setel, Philip
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. WHO Collaborating Centre for Verbal Autopsy; MRC-Wits Rural Public Health and Health Transitions Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
    Jakob, Robert
    Boerma, Ties
    Lopez, Alan D.
    Integrating community-based verbal autopsy into civil registration and vital statistics (CRVS): system-level considerations2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1272882Article in journal (Refereed)
    Abstract [en]

    Background: Reliable and representative cause of death (COD) statistics are essential to inform public health policy, respond to emerging health needs, and document progress towards Sustainable Development Goals. However, less than one-third of deaths worldwide are assigned a cause. Civil registration and vital statistics (CRVS) systems in low-and lowermiddle-income countries are failing to provide timely, complete and accurate vital statistics, and it will still be some time before they can provide physician-certified COD for every death.

    Proposals: Verbal autopsy (VA) is a method to ascertain the probable COD and, although imperfect, it is the best alternative in the absence of medical certification. There is extensive experience with VA in research settings but only a few examples of its use on a large scale. Data collection using electronic questionnaires on mobile devices and computer algorithms to analyse responses and estimate probable COD have increased the potential for VA to be routinely applied in CRVS systems. However, a number of CRVS and health system integration issues should be considered in planning, piloting and implementing a system-wide intervention such as VA. These include addressing the multiplicity of stakeholders and sub-systems involved, integration with existing CRVS work processes and information flows, linking VA results to civil registration records, information technology requirements and data quality assurance.

    Conclusions: Integrating VA within CRVS systems is not simply a technical undertaking. It will have profound system-wide effects that should be carefully considered when planning for an effective implementation. This paper identifies and discusses the major system-level issues and emerging practices, provides a planning checklist of system-level considerations and proposes an overview for how VA can be integrated into routine CRVS systems.

  • 50.
    Degerstedt, Frida
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Wiklund, Maria
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Enberg, Birgit
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Physiotherapeutic interventions and physical activity for children in Northern Sweden with cerebral palsy: a register study from equity and gender perspectives2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1272236Article in journal (Refereed)
    Abstract [en]

    Background: Young people with disabilities, especially physical disabilities, report worse health than others. This may be because of the disability, lower levels of physical activity, and discrimination. For children with cerebral palsy, access to physiotherapy and physical activity is a crucial prerequisite for good health and function. To date, there is limited knowledge regarding potential gender bias and inequity in habilitation services.

    Objectives: To map how physiotherapeutic interventions (PTI), physical leisure activity, and physical education are allocated for children with cerebral palsy regarding sex, age, level of gross motor function, and county council affiliation. This was done from a gender and equity perspective.

    Methods: A register study using data from the Cerebral Palsy follow-Up Program (CPUP). Data included 313 children ≤18 years with cerebral palsy from the five northern counties in Sweden during 2013. Motor impairment of the children was classified according to the expanded and revised Gross Motor Function Classification System (GMFCS).

    Results: In three county councils, boys received more physiotherapy interventions and received them more frequently than girls did. Differences between county councils were seen for frequency and reasons for physiotherapy interventions (p < 0.001). The physiotherapist was involved more often with children who had lower motor function and with children who had low physical leisure activity. Children with lower motor function level participated in physical leisure activity less often than children with less motor impairment (p < 0.001). Boys participated more frequently in physical education than did girls (p = 0.028).

    Conclusion: Gender and county council affiliation affect the distribution of physiotherapy interventions for children with cerebral palsy, and there are associations between gender and physical activity. Thus, the intervention is not always determined by the needs of the child or the degree of impairment. A gender-bias is indicated. Further studies are needed to ensure fair interventions.

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