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  • 1.
    Amani, Paul Joseph
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
    Tungu, Malale
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Kiwara, Angwara Denis
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Responsiveness of health care services towards the elderly in Tanzania: does health insurance make a difference? A cross-sectional study2020Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, nr 1, artikel-id 179Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Responsiveness has become an important health system performance indicator in evaluating the ability of health care systems to meet patients' expectations. However, its measurement in sub-Saharan Africa remains scarce. This study aimed to assess the responsiveness of the health care services among the insured and non-insured elderly in Tanzania and to explore the association of health insurance (HI) with responsiveness in this population.

    Methods: A community-based cross-sectional study was conducted in 2017 where a pre-tested household survey, administered to the elderly (60 + years) living in Igunga and Nzega districts, was applied. Participants with and without health insurance who attended outpatient and inpatient health care services in the past three and 12 months were selected. Responsiveness was measured based on the short version of the World Health Organization (WHO) multi-country responsiveness survey study, which included the dimensions of quality of basic amenities, choice, confidentiality, autonomy, communication and prompt attention. Quantile regression was used to assess the specific association of the responsiveness index with health insurance adjusted for sociodemographic factors.

    Results: A total of 1453 and 744 elderly, of whom 50.1 and 63% had health insurance, used outpatient and inpatient health services, respectively. All domains were rated relatively highly but the uninsured elderly reported better responsiveness in all domains of outpatient and inpatient care. Waiting time was the dimension that performed worst. Possession of health insurance was negatively associated with responsiveness in outpatient (− 1; 95% CI: − 1.45, − 0.45) and inpatient (− 2; 95% CI: − 2.69, − 1.30) care.

    Conclusion: The uninsured elderly reported better responsiveness than the insured elderly in both outpatient and inpatient care. Special attention should be paid to those dimensions, like waiting time, which ranked poorly. Further research is necessary to reveal the reasons for the lower responsiveness noted among insured elderly. A continuous monitoring of health care system responsiveness is recommended.

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  • 2. Amroussia, Nada
    et al.
    Pearson, Jennifer L.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    What drives us apart?: Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults2019Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 18, artikel-id 109Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented; however, there is a lack of research examining the social processes driving these complex inequalities. Using an intersectional framework, the current study examines key processes contributing to inequalities in smoking between four intersectional groups by education and sexual orientation.

    Methods: The sample (28,362 adults) was obtained from Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Four intersectional positions were created by education (high- and low-education) and sexual orientation (heterosexual or lesbian, gay, bisexual, or queer/questioning (LGBQ). The joint inequality, the referent socio-economic inequality, and the referent sexual orientation inequality in smoking were decomposed by demographic, material, tobacco marketing-related, and psychosocial factors using non-linear Oaxaca decomposition.

    Results: Material conditions made the largest contribution to the joint inequality (9.8 percentage points (p.p.), 140.9%), referent socio-economic inequality (10.01 p.p., 128.4%), and referent sexual orientation inequality (4.91 p.p., 59.8%), driven by annual household income. Psychosocial factors made the second largest contributions to the joint inequality (2.12 p.p., 30.3%), referent socio-economic inequality (2.23 p.p., 28.9%), and referent sexual orientation inequality (1.68 p.p., 20.5%). Referent sexual orientation inequality was also explained by marital status (20.3%) and targeted tobacco marketing (11.3%).

    Conclusion: The study highlights the pervasive role of material conditions in inequalities in cigarette smoking across multiple dimensions of advantage and disadvantage. This points to the importance of addressing material disadvantage to reduce combined socioeconomic and sexual orientation inequalities in cigarette smoking.

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  • 3.
    Andersson, Jenny
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Salander, Pär
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete. Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Brandstetter-Hiltunen, Marie
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för psykologi.
    Knutsson, Emma
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för psykologi.
    Hamberg, Katarina
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Is it possible to identify patient´s sex when reading blinded illness narratives? An experimental study about gender bias2008Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 7, nr 21, s. 1-9Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: In many diseases men and women, for no apparent medical reason, are not offered the same investigations and treatment in health care. This may be due to staff's stereotypical preconceptions about men and women, i.e., gender bias. In the clinical situation it is difficult to know whether gender differences in management reflect physicians' gender bias or male and female patients' different needs or different ways of expressing their needs. To shed some light on these possibilities this study investigated to what extent it was possible to identify patients' sex when reading their blinded illness narratives, i.e., do male and female patients express themselves differently enough to be recognised as men and women without being categorised on beforehand?

    Methods: Eighty-one authentic letters about being diseased by cancer were blinded regarding sex and read by 130 students of medicine and psychology. For each letter the participants were asked to give the author's sex and to explain their choice. The success rates were analysed statistically. To illuminate the participants' reasoning the explanations of four letters were analysed qualitatively.

    Results: The patient's sex was correctly identified in 62% of the cases, with significantly higher rates in male narratives. There were no differences between male and female participants. In the qualitative analysis the choice of a male writer was explained by: a short letter; formal language; a focus on facts and a lack of emotions. In contrast the reasons for the choice of a woman were: a long letter; vivid language; mention of emotions and interpersonal relationships. Furthermore, the same expressions were interpreted differently depending on whether the participant believed the writer to be male or female.

    Conclusion: It was possible to detect gender differences in the blinded illness narratives. The students' explanations for their choice of sex agreed with common gender stereotypes implying that such stereotypes correspond, at least on a group level, to differences in male and female patients' illness descriptions. However, it was also obvious that preconceptions about gender obstructed and biased the interpretations, a finding with implications for the understanding of gender bias in clinical practice.

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  • 4.
    Anyatonwu, Obinna Princewill
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Rural-urban disparities in postpartum contraceptive use among women in Nigeria: a Blinder-Oaxaca decomposition analysis2022Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 21, nr 1, artikel-id 71Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Unintended pregnancies are a global public health concern that could be prevented with appropriate access to contraceptive methods. Evidence from research has indicated that avoidance of closely space birth/pregnancy within the first year of postpartum, mitigates the risk of adverse health outcomes such as preterm birth, low birth-weight, etc. Postpartum family planning helps women to minimize closely spaced and unplanned pregnancies within the first 12 months after delivery. Less contraceptive use is often present in more socially disadvantaged groups. Studies from Nigeria have shown a persistent disparity on contraceptive use between rural and urban residents. To identify the factors explaining these inequalities is important to implement targeted interventions. This study aimed to identify the factors contributing to the rural-urban disparity in postpartum contraceptive use among women in Nigeria. Methods: This is a cross-sectional study using the Nigerian Demographic Health Survey. In total, 28,041 postpartum Nigerian women were included. Self-reported contraceptive use was the outcome, while the selected explanatory variables were grouped according to three theoretical perspectives: materialistic, behavioural/cultural, and psychosocial variables. Descriptive statistics and Blinder-Oaxaca decomposition were used to summarize and identify the factors contributing to the rural-urban disparity in postpartum contraceptive use. Results: In this study, 27% of women reported to have used contraceptives during the postpartum period. The rural-urban disparity in postpartum contraceptive use accounted for 18.2 percentage points. The findings further showed that the disparities in postpartum contraceptive use between rural-urban residence were mostly explained by materialistic variables (82%), followed by the behavioural/cultural variables and age (included as covariate) accounting for 15.6 and 3.0%, respectively. Household wealth (37%) and educational attainment (38%) had the most significant contribution to the differences in postpartum contraceptive use. Only 15% of the difference in postpartum contraceptive use remained unexplained. Conclusion: This study has shown important inequalities in postpartum contraceptive use between rural and urban residents in Nigeria. These differences were mainly explained by materialistic factors. These findings highlight crucial areas for the government to target in order to close the existing gap between rural and urban settings in contraceptive use in the country.

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  • 5. Apolot, Rebecca R.
    et al.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Nyachwo, Evelyne B.
    Waldman, Linda
    Morgan, Rosemary
    Aanyu, Christine
    Mutebi, Aloysius
    Kiwanuka, Suzanne N.
    Ekirapa, Elizabeth
    Maternal health challenges experienced by adolescents; could community score cards address them?: A case study of Kibuku District- Uganda2020Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, nr 1, artikel-id 191Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Approximately 34.8% of the Ugandan population is adolescents. The national teenage pregnancy rate is 25% and in Kibuku district, 17.6% of adolescents aged 12-19 years have begun child bearing. Adolescents mothers are vulnerable to many maternal health challenges including; stigma, unfriendly services and early marriages. The community score card (CSC) is a social accountability tool that can be used to point out challenges faced by the community in service delivery and utilization and ultimately address them. In this paper we aimed to document the challenges faced by adolescents during pregnancy, delivery and postnatal period and the extent to which the community score card could address these challenges.

    Methods: This qualitative study utilized in-depth interviews conducted in August 2018 among 15 purposively selected adolescent women who had given birth 2 years prior to the study and had attended CSC meetings. The study was conducted in six sub counties of Kibuku district where the CSC intervention was implemented. Research assistants transcribed the audio-recorded interviews verbatim, and data was analyzed manually using the framework analysis approach.

    Findings: This study found five major maternal health challenges faced by adolescents during pregnancy namely; psychosocial challenges, physical abuse, denial of basic human rights, unfriendly adolescent services, lack of legal and cultural protection, and lack of birth preparedness. The CSC addressed general maternal and new born health issues of the community as a whole rather than specific adolescent health related maternal health challenges.

    Conclusion: The maternal health challenges faced by adolescents in Kibuku have a cultural, legal, social and health service dimension. There is therefore need to look at a multi-faceted approach to holistically address them. CSCs that are targeted at the entire community are unlikely to address specific needs of vulnerable groups such as adolescents. To address the maternal health challenges of adolescents, there is need to have separate meetings with adolescents, targeted mobilization for adolescents to attend meetings and deliberate inclusion of their maternal health challenges into the CSC.

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  • 6.
    Boldis, Beáta Vivien
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Unsafe and unequal: a decomposition analysis of income inequalities in fear of crime in northern Sweden2018Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, artikel-id 110Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Fear of crime is not solely an individual concern, but as a social determinant of health structured by gender it also poses a threat to public health. Social inequalities are thought to represent a breeding ground for fear of crime, which subsequently may contribute to social inequalities in health. However, little research has focused on social inequalities in fear of crime, particularly in Sweden where the level of fear of crime and income and gender inequalities are comparatively low. With a conceptual model as a point of departure, the present study aimed to estimate and decompose income-related inequalities and explore gender differences in fear of crime in northern Sweden.

    METHODS: Participants (N = 22,140; 10,220 men and 11,920 women aged 16 to 84 years) came from the Health on Equal Terms cross-sectional survey with linked register data, carried out in the four northernmost counties of Sweden in 2014. Disposable income was used as the socio-economic indicator, fear of crime as the binary outcome variable, and sociodemographic characteristics, residential context, socio-economic and material conditions and psychosocial conditions as explanatory factors. Concentration curve and concentration index were used to estimate the income inequality in fear of crime, and decomposition analysis to identify the key determinants of the inequalities, in collapsed and gender-stratified analyses.

    RESULTS: Substantial gender differences were found in the prevalence of fear of crime (20.8% in women and 3.5% and men) and among the contributing factors to fear of crime. Additionally, the analyses revealed considerable income inequalities in fear of crime in the northern Swedish context (C = - 0.219). Gender, socio-economic and material, and psychosocial conditions explained the most in income inequalities of fear of crime in the total population.

    CONCLUSIONS: The existing gender and socio-economic inequities need to be approached as a greater structural problem to mitigate inequalities in fear of crime. Further research is needed to reveal more aspects of income inequalities in fear of crime and to develop efforts to create safe environments for all.

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  • 7. Bozorgmehr, Kayvan
    et al.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Brenner, Hermann
    Razum, Oliver
    Maier, Werner
    Saum, Kai-Uwe
    Holleczek, Bernd
    Miksch, Antje
    Szecsenyi, Joachim
    Analysing horizontal equity in enrolment in Disease Management Programmes for coronary heart disease in Germany 2008-20102015Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 14, artikel-id 28Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Disease Management Programmes (DMPs) have been introduced in Germany ten years ago with the aim to improve effectiveness and equity of care, but little is known about the degree to which enrolment in the programme meets the principles of equity in health care. We aimed to analyse horizontal equity in DMP enrolment among patients with coronary heart disease (CHD). Methods: Cross-sectional analysis of horizontal inequities in physician-reported enrolment in the DMP for CHD in a large population-based cohort-study in Germany (2008-2010). We calculated horizontal inequity indices (HII) and their 95% confidence intervals [95% CI] for predicted need-standardised DMP enrolment across two measures of socio-economic status (SES) (educational attainment, regional deprivation) stratified by sex. Need-standardised DMP enrolment was predicted in multi-level logistic regression models. Results: Among N = 1,280 individuals aged 55-84 years and diagnosed with CHD, DMP enrolment rates were 22.2% (women) and 35.0% (men). Education-related inequities in need-standardised DMP enrolment favoured groups with lower education, but HII estimates were not significant. Deprivation-related inequities among women significantly favoured groups with higher SES (HII = 0.086 [0.007; 0.165]. No such deprivation-related inequities were seen among men (HII = 0.014 [-0.048; 0.077]). Deprivation-related inequities across the whole population favoured groups with higher SES (HII estimates not significant). Conclusion: Need-standardised DMP enrolment was fairly equitable across educational levels. Deprivation-related inequities in DMP enrolment favoured women living in less deprived areas relative to those living in areas with higher deprivation. Further research is needed to gain a better understanding of the mechanisms that contribute to deprivation-related horizontal inequities in DMP enrolment among women.

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  • 8.
    Brattlöf, Frida
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Gustafsson, Per E
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Prevalence and change in social inequalities in physical activity before and during the COVID-19 pandemic in Sweden2023Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 22, nr 1, artikel-id 21Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Physical activity is crucial for our wellbeing. Since the COVID-19 pandemic emerged, physical activity behaviour has changed globally, and social inequalities that already exist in physical activity have increased. However, there is limited knowledge of how these inequalities have evolved in Sweden. Thus, the aim of this study was to assess the prevalence of physical activity, and the socioeconomic inequalities in physical activity before and during the COVID-19 pandemic.

    Methods: This study analysed data from the national ‘Health on Equal Terms’ survey which was conducted on participants between 16 and 84, through a repeated cross-sectional design in 2018 (pre-pandemic) and 2021 (during the pandemic). The socioeconomic variables included gender, age, education, occupation, income, and place of birth. For both years, the prevalence of low physical activity, the absolute risk differences, the slope index of inequality, and the slope index difference for each of the variables were calculated.

    Results: The level of physical activity increased for the total population studied. However, the social inequalities that existed in 2018 increased over time and across age, education, occupation, income, and place of birth, but not with regard to gender.

    Conclusions: Even though the Swedish population increased their levels of physical activity during the COVID-19 pandemic, the social inequalities that already existed in physical activity increased. Interventions to increase the level of physical activity among the young, people with low socioeconomic status, and those born outside Sweden are needed to reduce these social inequalities, and to improve the Swedish population’s wellbeing.

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  • 9.
    Briones-Vozmediano, Erica
    et al.
    Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante Public Health Research Group, San Vicente del Raspeig RoadAlicante, Spain.
    Agudelo-Suarez, Andres A
    Faculty of Dentistry, University of Antioquia, Street 67Medellín, Colombia.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Vives-Cases, Carmen
    Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante Public Health Research Group, San Vicente del Raspeig RoadAlicante, Spain; CIBER of Epidemiology and Public Health, Carlos III Institute of Health, Street Melchor Fernández AlmagroMadrid, Spain.
    Economic crisis, immigrant women and changing availability of intimate partner violence services: a qualitative study of professionals' perceptions in Spain2014Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 13, artikel-id 79Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Since 2008, Spain has been in the throes of an economic crisis. This recession particularly affects the living conditions of vulnerable populations, and has also led to a reversal in social policies and a reduction in resources. In this context, the aim of this study was to explore intimate partner violence (IPV) service providers' perceptions of the impact of the current economic crisis on these resources in Spain and on their capacity to respond to immigrant women's needs experiencing IPV. Methods: A qualitative study was performed based on 43 semi-structured in-depth interviews to social workers, psychologists, intercultural mediators, judges, lawyers, police officers and health professionals from different services dealing with IPV (both, public and NGO's) and cities in Spain (Barcelona, Madrid, Valencia and Alicante) in 2011. Transcripts were imported into qualitative analysis software (Atlas.ti), and analysed using qualitative content analysis. Results: We identified four categories related to the perceived impact of the current economic crisis: a) "Immigrant women have it harder now", b) "IPV and immigration resources are the first in line for cuts", c) " Fewer staff means a less effective service" and d) "Equality and IPV policies are no longer a government priority". A cross-cutting theme emerged from these categories: immigrant women are triply affected; by IPV, by the crisis, and by structural violence. Conclusion: The professionals interviewed felt that present resources in Spain are insufficient to meet the needs of immigrant women, and that the situation might worsen in the future.

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  • 10.
    Brydsten, Anna
    et al.
    Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.
    Hammarström, Anne
    Department of Public Health and Caring Sciences, Public Health Unit, Uppsala University, Uppsala, Sweden.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health inequalities between employed and unemployed in northern Sweden: a decomposition analysis of social determinants for mental health2018Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, nr 59, artikel-id 59Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Even though population health is strongly influenced by employment and working conditions, public health research has to a lesser extent explored the social determinants of health inequalities between people in different positions on the labour market, and whether these social determinants vary across the life course. This study analyses mental health inequalities between unemployed and employed in three age groups (youth, adulthood and mid-life), and identifies the extent to which social determinants explain the mental health gap between employed and unemployed in northern Sweden.

    Methods: The Health on Equal Terms survey of 2014 was used, with self-reported employment (unemployed or employed) as exposure and the General Health Questionnaire (GHQ-12) as mental health outcome. The social determinants of health inequalities were grouped into four dimensions: socioeconomic status, economic resources, social network and trust in institutional systems. The non-linear Oaxaca decomposition analysis was applied, stratified by gender and age groups.

    Results: Mental health inequality was found in all age groups among women and men (difference in GHQ varying between 0.12 and 0.20). The decomposition analysis showed 43–51% of the total inequality among youths, 42–98% among adults and 60–65% among middle-aged. The main contributing factors were shown to vary between age groups: cash margin (among youths and middle-aged men), financial strain (among adults and middle-aged women), income (among men in adulthood), along with trust in others (all age groups), practical support (young women) and social support (middle-aged men); stressing how the social determinants of health inequalities vary across the life course.

    Conclusions: The health gap between employments was explained by the difference in access to economic and social resources, and to a smaller extent in the trust in the institutional systems. Findings from this study corroborate that much of the mental health inequality in the Swedish labour market is socially and politically produced and potentially avoidable. Greater attention from researchers, policy makers on unemployment and public health should be devoted to the social and economic deprivation of unemployment from a life course perspective to prevent mental health inequality.

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  • 11.
    Brydsten, Anna
    et al.
    Department of Public Health Science, Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, SE-105 91, Stockholm, Sweden.
    Mikael, Mikael
    Department of Public Health Science, Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, SE-105 91, Stockholm, Sweden.
    Dunlavy, Andrea
    Department of Public Health Science, Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, SE-105 91, Stockholm, Sweden.
    Social integration and mental health - a decomposition approach to mental health inequalities between the foreign-born and native-born in Sweden2019Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 18, s. 1-11, artikel-id 48Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The increasing mental health inequalities between native- and foreign-born persons in Sweden is an important public health issue. Improving social integration has been stressed as a key strategy to combat this development. While a vast amount of studies have confirmed the importance of social integration for good mental health, less is known about the role of different types of social integration, and how they relate to mental health inequalities. This study aimed to examine the extent to which indicators of social integration explained mental health inequalities between the native- and foreign-born.

    METHODS: Based on the Health on Equal Terms survey from 2011/2015 in Västra Götaland, Sweden (n = 71,643), a non-linear Oaxaca-Blinder decomposition analysis was performed comparing native- and foreign-born individuals from Nordic-, European- and non-European countries. The General Health Questionnaire was used to assess psychological distress, while 11 items assessed employment conditions and economic disparities, social relations, and experiences of discrimination to measure different aspects of social integration.

    RESULTS: Differences in social integration explained large proportions of observed mental health differences between the native- and foreign-born. Important indicators included low levels of social activity (20%), trust in others (17%) and social support (16%), but also labour market disadvantages, such as being outside the labour market (15%), unemployment (10%) and experiencing financial strain (16%). In analyses stratified by region of origin, low trust in others and discrimination contributed to the mental health gap between the native-born and European-born (17 and 9%, respectively), and the native-born and non-European-born (19 and 10%, respectively). Precarious labour market position was a particularly important factor in the mental health gap between the native-born and Nordic-origin (22%), and non-European origin (36%) populations.

    CONCLUSION: Social integration factors play a central role in explaining the mental health inequality between natives and migrants in Sweden. Our findings suggest that public health actions targeting mental health gaps could benefit from focusing on inequalities in social and economic recourses between natives and migrants in Sweden. Areas of priority include improving migrants' financial strain, as well as increasing trust in others and social support and opportunities for civic engagement.

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  • 12.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Escolar-Pujolar, Antonio
    Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    Martínez-Faure, Jesús Enrique
    Empresa Pública de Emergencias Sanitarias, Cádiz, Spain.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain2014Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 13, artikel-id 55Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Although suicide rates have increased in some European countries in relation to the current economic crisis and austerity policies, that trend has not been observed in Spain. This study examines the impact of the economic crisis on suicide attempts, the previously neglected endpoint of the suicidal process, and its relation to unemployment, age and sex.

    METHODS: The study was carried out in Andalusia, the most populated region of Spain, and which has a high level of unemployment. Information on suicide attempts attended by emergency services was extracted from the Health Emergencies Public Enterprise Information System (SIEPES). Suicide attempts occurring between 2003 and 2012 were included, in order to cover five years prior to the crisis (2003-2007) and five years after its onset (2008-2012). Information was retrieved from 24,380 cases (11,494 men and 12,886 women) on sex, age, address, and type of attention provided. Age-adjusted suicide attempt rates were calculated. Excess numbers of attempts from 2008 to 2012 were estimated for each sex using historical trends of the five previous years, through time regression models using negative binomial regression analysis. To assess the association between unemployment and suicide attempts rates, linear regression models with fixed effects were performed.

    RESULTS: A sharp increase in suicide attempt rates in Andalusia was detected after the onset of the crisis, both in men and in women. Adults aged 35 to 54 years were the most affected in both sexes. Suicide attempt rates were associated with unemployment rates in men, accounting for almost half of the cases during the five initial years of the crisis. Women were also affected during the recession period but this association could not be specifically attributed to unemployment.

    CONCLUSIONS: This study enhances our understanding of the potential effects of the economic crisis on the rapidly increasing suicide attempt rates in women and men, and the association of unemployment with growing suicidal behaviour in men. Research on the suicide effects of the economic crisis may need to take into account earlier stages of the suicidal process, and that this effect may differ by age and sex.

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  • 13.
    Daca, Chanvo
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Ministry of Health, Directorate of Planning and Cooperation, Maputo, Mozambique.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Arnaldo, Carlos
    Universidade Eduardo Mondlane, Maputo, Mozambique.
    Schumann, Barbara
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Socio-economic and demographic factors associated with reproductive and child health preventive care in Mozambique: a cross-sectional study2020Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, nr 1, artikel-id 200Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Reproductive and child health interventions are essential to improving population health in Africa. In Mozambique, although some progress on reproductive and child health has been made, knowledge of social inequalities in health and health care is lacking.

    OBJECTIVE: To investigate socio-economic and demographic inequalities in reproductive and child preventive health care as a way to monitor progress towards universal health coverage.

    METHODS: A cross-sectional study was conducted, using data collected from the 2015 Immunization, AIDS and Malaria Indicators Survey (IMASIDA) in Mozambique. The sample included 6946 women aged 15 to 49 years. Outcomes variables were the use of insecticide treated nets (ITN) for children under 5 years, full child immunization and modern contraception use, while independent variables included age, marital status, place of residence, region, education, occupation, and household wealth index. Prevalence ratios (PR) with 95% confidence intervals (95% CI) were calculated by log binomial regression to assess the relationship between the socio-economic and demographic characteristics and the three outcomes of interest.

    RESULTS: The percentage of mothers with at least one child under 5 years that did not use ITN was 51.01, 46.25% of women had children aged 1 to 4 years who were not fully immunized, and 74.28% of women were not using modern contraceptives. Non-educated mothers (PR = 1.33; 95% CI: 1.16-1.51) and those living in the Southern region (PR = 1.36; 95% CI: 1.17-1.59) had higher risk of not using ITN, while the poorest quintile (PR = 1.34; 95% CI: 1.04-1.71) was more likely to have children who were not fully immunized. Similarly, non-educated women (PR = 1.17; 95% CI: 1.10-1.25), non-working women (PR = 1.09; 95% CI: 1.04-1.16), and those in the poorest quintile (PR = 1.13; 95% CI: 1.04-1.24) had a higher risk of not using modern contraceptives.

    CONCLUSION: Our study showed a low rate of ITN utilization, immunization coverage of children, and modern contraceptive use among women of reproductive age. Several socio-economic and demographics factors (region, education, occupation, and wealth) were associated with these preventive measures. We recommend an equity-oriented resource allocation across regions, knowledge dissemination on the importance of ITN and contraceptives use, and an expansion of immunization services to reach socio-economically disadvantaged families in order to achieve universal health coverage in Mozambique.

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  • 14. Daniels, Karen
    et al.
    Loewenson, Rene
    George, Asha
    Howard, Natasha
    Koleva, Gergana
    Lewin, Simon
    Marchal, Bruno
    Nambiar, Devaki
    Paina, Ligia
    Sacks, Emma
    Sheikh, Kabir
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Makerere University School of Public Health, Makerere, Uganda.
    Theobald, Sally
    Topp, Stephanie M.
    Zwi, Anthony B.
    Fair publication of qualitative research in health systems: a call by health policy and systems researchers2016Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 15, artikel-id 98Artikel i tidskrift (Övrigt vetenskapligt)
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  • 15.
    Degerlund Maldi, Kinza
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Gustafsson, Per E
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Jonsson, Frida
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Widespread and widely widening?: Examining absolute socioeconomic health inequalities in northern Sweden across twelve health indicators2019Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 18, artikel-id 197Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Socioeconomic inequalities in health is a widely studied topic. However, epidemiological research tends to focus on one or a few outcomes conditioned on one indicator, overlooking the fact that health inequalities can vary depending on the outcome studied and the indicator used. To bridge this gap, this study aims to provide a comprehensive picture of the patterns of socioeconomic health inequalities in Northern Sweden over time, across a range of health outcomes, using an 'outcome-wide' epidemiological approach.

    Method: Cross-sectional data from three waves of the 'Health on Equal Terms' survey, distributed in 2006, 2010 and 2014 were used. Firstly, socioeconomic inequalities by income and education for twelve outcomes (self-rated health, self-rated dental health, overweight, hypertension, diabetes, long-term illness, stress, depression, psychological distress, smoking, risky alcohol consumption, and physical inactivity) were examined by calculating the Slope Index of Inequality. Secondly, time trends for each outcome and socioeconomic indicator were estimated.

    Results: Income inequalities increased for psychological distress and physical inactivity in men as well as for selfrated health, overweight, hypertension, long-term illness, and smoking among women. Educational inequalities increased for hypertension, long-term illness, and stress (the latter favouring lower education) in women. The only instance of decreasing income inequalities was seen for long-term illness in men, while education inequalities decreased for long-term illness in men and poor self-rated health, poor self-rated dental health, and smoking in women.

    Conclusion: Patterns of absolute socioeconomic inequalities in health vary by health and socioeconomic indicator, as well as between men and women. Overall, trends appear more stagnant in men while they fluctuate in women. Income inequalities seem to be generally greater than educational inequalities when looking across several different health indicators, a message that can only be derived from this type of outcome-wide study. These disparate findings suggest that generalised and universal statements about the development of health inequalities can be too simplistic and potentially misleading. Nonetheless, despite inequalities being complex, they do exist and tend to increase. Thus, an outcome-wide approach is a valuable method which should be utilised to generate evidence for prioritisations of policy decisions

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  • 16. Dei, Vincent
    et al.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Is healthcare really equal for all?: Assessing the horizontal and vertical equity in healthcare utilisation among older Ghanaians2018Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, artikel-id 86Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: There is a lack of focused research on the older population in Ghana and about issues pertaining to their access to healthcare services. Furthermore, information is lacking regarding the fairness in the access to these services. This study aimed to ascertain whether horizontal and vertical equity requirements were being met in the healthcare utilisation among older adults aged 50 years and above. Methods: This study was based on a secondary cross-sectional data from the World Health Organization's Study on global AGEing (SAGE) and adult health wave 1 conducted from 2007 to 2008 in Ghana. Data on 4304 older adults aged 50 years-plus were analysed. Bivariate and multivariable analyses were carried out to analyse the association between outpatient/inpatient utilisation and (1) socioeconomic status (SES), controlling for need variables (horizontal equity) and (2) need variables, controlling for SES (vertical equity). Odds ratios with 95% confidence intervals were calculated to analyse the association between relevant variables. Results: Horizontal and vertical inequities were found in the utilisation of outpatient services. Inpatient healthcare utilisation was both horizontally and vertically equitable. Women were found to be more likely to use outpatient services than men but had reduced odds of using inpatient services. Possessing a health insurance was also significantly associated with the use of both inpatient and outpatient services. Conclusion: Whilst equity exists in inpatient care utilisation, more needs to be done to achieve equity in the access to outpatient services. The study reaffirms the need to evaluate both the horizontal and vertical dimensions in the assessment of equity in healthcare access. It provides the basis for further research in bridging the healthcare access inequity gap among older adults in Ghana.

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  • 17.
    Edeby, Agnes
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Prevalence and sociogeographical inequalities of violence against women in Ecuador: a cross-sectional study2021Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 20, nr 1, artikel-id 130Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Violence against women (VAW) is a vast public health problem in Latin America. The aim of this study was to determine the prevalence of violence against women and to assess its sociogeographical inequalities in Ecuador during 2019.

    Methods: This cross-sectional study used data from a national survey conducted in 2019 (n = 17,211) among women aged 15 years and over. Independent variables included age, marital status, education, ethnicity, place of residence and region. The chosen outcomes were lifetime experience of total violence, sexual violence, physical violence, psychological violence and economic violence. Frequency tables were first calculated, and then crude and adjusted regression models estimating risk differences and their 95% confidence intervals were computed.

    Results: Nearly two-thirds (64.86%) of the participating women had experienced some form of violence during their lifetime, mainly psychological violence (56.92%). The second most prevalent type of violence was physical (35.44%) closely followed by sexual (32.67%). Almost one-fifth (16.38%) stated to have experienced some form of economic violence. Physical and psychological violence were more common among women aged 26–35 and less among older women. All forms of violence were more often reported among women with no education except for sexual violence, which was more frequent among those with higher education. Physical, psychological and economic violence were more often reported by those living with a partner, being married or divorced/separated. Sexual violence was associated with those belonging to a non-indigenous ethnic group, while all types of violence were more common among those living in an urban setting (except physical violence), in the Highlands or in the Amazon region.

    Conclusions: Our study showed that VAW is a common event in Ecuador and identified several sociogeographical inequalities that varied depending on the type of violence. VAW was more common among the younger age groups, those with low education, those living with a partner or being divorced/separated, or residing in an urban setting, in the Highlands or in the Amazon. Further studies including more social factors and a continuous monitoring of VAW are recommended. Current policies and laws to protect women need to be expanded and effectively implemented to reduce VAW in the Ecuador.

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  • 18.
    Egondi, Thaddaeus
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. African Population and Health Research Center (APHRC), Nairobi, Kenya.
    Oyolola, Maharouf
    Mutua, Martin Kavao
    Elung'ata, Patricia
    Determinants of immunization inequality among urban poor children: evidence from Nairobi's informal settlements2015Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 14, artikel-id 24Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Despite the relentless efforts to reduce infant and child mortality with the introduction of the National Expanded Programmes on Immunization (EPI) in 1974, major disparities still exist in immunizations coverage across different population sub-groups. In Kenya, for instance, while the proportion of fully immunized children increased from 57% in 2003 to 77% in 2008-9 at national level and 73% in Nairobi, only 58% of children living in informal settlement areas are fully immunized. The study aims to determine the degree and determinants of immunization inequality among the urban poor of Nairobi.

    Method: We used data from the Nairobi Cross-Sectional Slum Survey of 2012 and the health outcome was full immunization status among children aged 12-23 months. The wealth index was used as a measure of social economic position for inequality analysis. The potential determinants considered included sex of the child and mother's education, their occupation, age at birth of the child, and marital status. The concentration index (CI) was used to quantify the degree of inequality and decomposition approach to assess determinants of inequality in immunization.

    Results: The CI for not fully immunized was -0.08 indicating that immunization inequality is mainly concentrated among children from poor families. Decomposition of the results suggests that 78% of this inequality is largely explained by the mother's level of education.

    Conclusion: There exists immunization inequality among urban poor children in Nairobi and efforts to reduce this inequality should aim at targeting mothers with low level of education during immunization campaigns.

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  • 19.
    Elwer, Sofia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Alex, Lena
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hammarström, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Gender (in)equality among employees in elder care: implications for health2012Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 11, nr 1Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Gendered practices of working life create gender inequalities through horizontal and vertical gender segregation in work, which may lead to inequalities in health between women and men. Gender equality could therefore be a key element of health equity in working life. Our aim was to analyze what gender (in) equality means for the employees at a woman-dominated workplace and discuss possible implications for health experiences.

    Methods: All caregiving staff at two workplaces in elder care within a municipality in the north of Sweden were invited to participate in the study. Forty-five employees participated, 38 women and 7 men. Seven focus group discussions were performed and led by a moderator. Qualitative content analysis was used to analyze the focus groups.

    Results: We identified two themes. "Advocating gender equality in principle" showed how gender (in) equality was seen as a structural issue not connected to the individual health experiences. "Justifying inequality with individualism" showed how the caregivers focused on personalities and interests as a justification of gender inequalities in work division. The justification of gender inequality resulted in a gendered work division which may be related to health inequalities between women and men. Gender inequalities in work division were primarily understood in terms of personality and interests and not in terms of gender.

    Conclusion: The health experience of the participants was affected by gender (in) equality in terms of a gendered work division. However, the participants did not see the gendered work division as a gender equality issue. Gender perspectives are needed to improve the health of the employees at the workplaces through shifting from individual to structural solutions. A healthy-setting approach considering gender relations is needed to achieve gender equality and fairness in health status between women and men.

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    Gender (In)Equality among Employees in Elder Care
  • 20. Escolar Pujolar, Antonio
    et al.
    Bacigalupe, Amaia
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Looking beyond the veil of the European crisis: the need to uncover the structural causes of health inequalities2016Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 15, artikel-id 39Artikel i tidskrift (Refereegranskat)
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  • 21.
    Escolar-Pujolar, Antonio
    et al.
    Delegación Territorial de Igualdad, Salud y Políticas Sociales, Junta de Andalucía, Cádiz, Spain.
    Bacigalupe, Amaia
    Department of Sociology, University of the Basque Country (UPV/EHU), Leioa, Spain.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    European economic crisis and health inequities: research challenges in an uncertain scenario2014Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 13, s. 59-Artikel i tidskrift (Övrigt vetenskapligt)
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  • 22.
    Flores Jimenez, Sergio E.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Assessing the impact of the 2008 health reform in Ecuador on the performance of primary health care services: an interrupted time series analysis2021Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 20, nr 1, artikel-id 169Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: In 2008, Ecuador started a national health reform based on the principles of Alma Ata to achieve Universal Health Coverage. While coverage indicators have increased, a systematic assessment of the impact of the reform on the delivery of health services at primary level is lacking. The aim of this study was to assess the impact of the 2008 health reform on the performance of primary health care services in Ecuador.

    Methods: Ambulatory Care Sensitive Conditions (ACSC) are a subset of diseases where hospital admission is potentially avoidable by high quality well-functioning primary care. Thus, observing the behaviour of ACSC hospitalizations can serve as an indicator of how the primary health care level is performing. Crude and adjusted rates, stratified by sex, were calculated from ten selected ACSC hospitalization discharges during 22 years of data representing 11 years before and after the health reform. An interrupted time series analysis was then conducted by applying a negative binomial regression and adjusting for overdispersion and autocorrelation.

    Results: Overall higher crude and adjusted rates for ACSC hospitalizations were observed in women compared to men; both increased gradually since the start of the observation, reaching a peak around 2010, and then started a downwards trend. In men, the incidence rate ratio increased significantly by 3 % per year during the period before the intervention. During the first year after intervention, an increase (13 %) was detected, and then a statistically significant 1 % decrease (IRR = 0.99; 95 % CI: 0.98, 0.99) was observed in the ACSC rate ratio per year in the period after the intervention. Similar trends and effect sizes were found for women.

    Conclusions: The study revealed significant decreasing trends of the ACSC hospitalization rates in both sexes, indicating an improvement of the performance of the primary health care services following the 2008 national health reform. A continuous strengthening of the primary care model as well as a regular monitoring of ACSC hospitalization rates in the country is recommended. A health economic evaluation considering hospitalizations avoided and associated costs is also advisable.

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  • 23.
    Fonseca Rodriguez, Osvaldo
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    "The devil is in the detail": geographical inequalities of femicides in Ecuador2021Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 20, nr 1, artikel-id 115Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Femicide is a very important public health problem in Ecuador. Since regional and country-level femicide rates can obscure significant variations at the sub-national level, it is important to provide information at the lowest relevant level of disaggregation to be able to develop targeted preventive policies. The aim of this study was to assess the spatial distribution of the femicide rate and to examine its spatial clustering at the canton level in Ecuador in the period 2018-2019.

    METHODS: Data on cases were collected by a national network of non-governmental organizations. Two age-disaggregated analyses were done, one for the 15 to 24 years-olds and the other for the female population of 15 and older. Age-specific population data were obtained from the National Institute of Statistics for the study period. Standardized mortality ratios for mapping the mortality were calculated using hierarchical Bayesian models and spatial scan statistics were applied to identify local clusters. Thematic maps of age-specific femicide rates were also constructed.

    RESULTS: During the two-year period, 61 and 183 women were killed in the age ranges 15-24 and 15 years and older, respectively. The annual rate of femicides in Ecuador was 1.0 and 0.8 per 100,000 in the female population aged 15-24 and 15+, respectively, with substantial variations among cantons. The spatial analysis contributed to visualize high risk cantons, which were mainly located in a small area in the central part of the country (for those 15+) but especially in the Amazon region, for both of the studied age groups.

    CONCLUSIONS: This study has shown the usefulness of applying spatial analysis to the problem of femicides in Ecuador. The study has revealed important variations among cantons but also a spatial clustering, mainly in the Amazon region of the country. The results should help policymakers to focus on current prevention programmes for violence against women into these high-risk areas. Continuous monitoring of femicides at low-level geographical areas is highly recommended.

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  • 24.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Carson, Dean
    Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum). Demography and Growth Planning, Northern Institute, Charles Darwin University, Darwin, Australia; Centre for Rural Medicine, Storuman, Sweden.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Wiklund, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Fysioterapi.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health care access for rural youth on equal terms?: A mixed methods study protocol in northern Sweden2018Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, artikel-id 6Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The purpose of this paper is to propose a protocol for researching the impact of rural youth health service strategies on health care access. There has been no published comprehensive assessment of the effectiveness of youth health strategies in rural areas, and there is no clearly articulated model of how such assessments might be conducted. The protocol described here aims to gather information to; i) Assess rural youth access to health care according to their needs, ii) Identify and understand the strategies developed in rural areas to promote youth access to health care, and iii) Propose actions for further improvement. The protocol is described with particular reference to research being undertaken in the four northernmost counties of Sweden, which contain a widely dispersed and diverse youth population.

    METHODS: The protocol proposes qualitative and quantitative methodologies sequentially in four phases. First, to map youth access to health care according to their health care needs, including assessing horizontal equity (equal use of health care for equivalent health needs,) and vertical equity (people with greater health needs should receive more health care than those with lesser needs). Second, a multiple case study design investigates strategies developed across the region (youth clinics, internet applications, public health programs) to improve youth access to health care. Third, qualitative comparative analysis of the 24 rural municipalities in the region identifies the best combination of conditions leading to high youth access to health care. Fourth, a concept mapping study involving rural stakeholders, care providers and youth provides recommended actions to improve rural youth access to health care.

    DISCUSSION: The implementation of this research protocol will contribute to 1) generating knowledge that could contribute to strengthening rural youth access to health care, as well as to 2) advancing the application of mixed methods to explore access to health care.

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  • 25.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Unintended pregnancy in the amazon basin of Ecuador: a multilevel analysis2010Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 9, s. 14-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This study showed the significance of individual factors in increasing the risk of unintended pregnancy, while the role of community factors was found to be negligible. In order for all women to be able to realize their right to reproductive autonomy, there needs to be a diverse range of solutions, with particular attention paid to cultural issues.

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  • 26.
    Gustafsson, Per E.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Linander, Ida
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mosquera, Paola A.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Embodying pervasive discrimination: a decomposition of sexual orientation inequalities in health in a population-based cross-sectional study in Northern Sweden.2017Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 16, artikel-id 22Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Studies from Sweden and abroad have established health inequalities between heterosexual and non-heterosexual people. Few studies have examined the underpinnings of such sexual orientation inequalities in health. To expand this literature, the present study aimed to employ decomposition analysis to explain health inequalities between people with heterosexual and non-heterosexual orientation in Sweden, a country with an international reputation for heeding the human rights of non-heterosexual people.

    METHODS: Participants (N = 23,446) came from a population-based cross-sectional survey in the four northernmost counties in Sweden in 2014. Participants completed self-administered questionnaires, covering sexual orientation, mental and general physical health, social conditions and unmet health care needs, and sociodemographic data was retrieved from total population registers. Sexual orientation inequalities in health were decomposed by Blinder-Oaxaca decomposition analysis.

    RESULTS: Results showed noticeable mental and general health inequalities between heterosexual and non-heterosexual orientation groups. Health inequalities were partly explained (total explained fraction 64-74%) by inequalities in degrading treatment (24-26% of the explained fraction), but to a considerable degree also by material conditions (38-45%) and unmet care needs (25-43%).

    CONCLUSIONS: Psychosocial experiences may be insufficient to explain and understand health inequalities by sexual orientation in a reputedly 'gay-friendly' setting. Less overt forms of structural discrimination may need to be considered to capture the pervasive material discrimination that seems to underpin the embodiment of sexual minority inequalities. This ought to be taken into consideration in research, policy-making and monitoring aiming to work towards equity in health across sexual orientations.

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  • 27. Haghparast-Bidgoli, Hassan
    et al.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Institute for Global Health, University College London, London, UK.
    Lafort, Yves
    Beksinska, Mags
    Rambally, Letitia
    Roy, Anuradha
    Reza-Paul, Sushena
    Ombidi, Wilkister
    Gichangi, Peter
    Skordis-Worrall, Jolene
    Inequity in costs of seeking sexual and reproductive health services in India and Kenya2015Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 14, artikel-id 84Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: This study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending. Methods: Data for this study were collected as a part of the situational analysis for the "Diagonal Interventions to Fast Forward Enhanced Reproductive Health" (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. Results: The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03-7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were "receiving [money] from partner or household members" (69 %) and "using own savings or regular income" (44 %), respectively. Conclusion: Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.

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  • 28. Hernandez, Alison
    et al.
    Ruano, Ana Lorena
    Marchal, Bruno
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Flores, Walter
    Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity2017Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 16, artikel-id 26Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The 400 million indigenous people worldwide represent a wealth of linguistic and cultural diversity, as well as traditional knowledge and sustainable practices that are invaluable resources for human development. However, indigenous people remain on the margins of society in high, middle and low-income countries, and they bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators in relation to the 15-year push to meet the Millennium Development Goals. As we enter the Sustainable Development Goals (SDGs) era, there is growing consensus that efforts to achieve Universal Health Coverage (UHC) and promote sustainable development should be guided by the moral imperative to improve equity. To achieve this, we need to move beyond the reductionist tendency to frame indigenous health as a problem of poor health indicators to be solved through targeted service delivery tactics and move towards holistic, integrated approaches that address the causes of inequalities both inside and outside the health sector. To meet the challenge of engaging with the conditions underlying inequalities and promoting transformational change, equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilizing networks of collective action. The application of systems thinking approaches offers a pathway for the evolution of equity-oriented research and practice in collaborative, politically informed and mutually enhancing efforts to understand and transform the systems that generate and reproduce inequities in indigenous health. These approaches hold the potential to strengthen practice through the development of more nuanced, context-sensitive strategies for redressing power imbalances, reshaping the service delivery environment and fostering the dynamics of collective action for political reform.

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  • 29.
    Hernández, Alison R
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Integrating views on support for mid-level health worker performance: a concept mapping study with regional health system actors in rural Guatemala2015Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 14, artikel-id 91Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Mid-level health workers are on the front-lines in underserved areas in many LMICs, and their performance is critical for improving the health of vulnerable populations. However, improving performance in low-resource settings is complex and highly dependent on the organizational context of local health systems. This study aims to examine the views of actors from different levels of a regional health system in Guatemala on actions to support the performance of auxiliary nurses, a cadre of mid-level health workers with a prominent role in public sector service delivery. A concept mapping study was carried out to develop an integrated view on organizational support and identify locally relevant strategies for strengthening performance.

    METHODS: A total of 93 regional and district managers, and primary and secondary care health workers participated in generating ideas on actions needed to support auxiliary nurses' performance. Ideas were consolidated into 30 action items, which were structured through sorting and rating exercises, involving a total of 135 of managers and health workers. Maps depicting participants' integrated views on domains of action and dynamics in sub-groups' interests were generated using a sequence of multivariate statistical analyses, and interpreted by regional managers.

    RESULTS: The combined input of health system actors provided a multi-faceted view of actions needed to support performance, which were organized in six domains, including: Communication and coordination, Tools to orient work, Organizational climate of support, Motivation through recognition, Professional development and Skills development. The nature of relationships across hierarchical levels was identified as a cross-cutting theme. Pattern matching and go-zone maps indicated directions for action based on areas of consensus and difference across sub-groups of actors.

    CONCLUSIONS: This study indicates that auxiliary nurses' performance is interconnected with the performance of other health system actors who require support, including managers and community-level collaborators. Organizational climate is critical for making auxiliary nurses feel supported, and greater attention to improving the quality of hierarchical relationships is needed in LMIC settings. The participatory nature of the concept-mapping process enabled health system actors to collaborate in co-production of context-specific knowledge needed to guide efforts to strengthen performance in a vulnerable region.

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  • 30.
    Jat, Tej Ram
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ng, Nawi
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis2011Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 10, nr 1, s. 59-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background Improving maternal health is one of the eight Millennium Development Goals. It is widely accepted that the use of maternal health services helps in reducing maternal morbidity and mortality. The utilization of maternal health services is a complex phenomenon and it is influenced by several factors. Therefore, the factors at different levels affecting the use of these services need to be clearly understood. The objective of this study was to estimate the effects of individual, community and district level characteristics on the utilisation of maternal health services with special reference to antenatal care (ANC), skilled attendance at delivery and postnatal care (PNC).

    Methods This study was designed as a cross sectional study. Data from 15,782 ever married women aged 15-49 years residing in Madhya Pradesh state of India who participated in the District Level Household and Facility Survey (DLHS-3) 2007-08 were used for this study. Multilevel logistic regression analysis was performed accounting for individual, community and district level factors associated with the use of maternal health care services. Type of residence at community level and ratio of primary health center to population and percent of tribal population in the district were included as district level variables in this study.

    Results The results of this study showed that 61.7% of the respondents used ANC at least once during their most recent pregnancy whereas only 37.4% women received PNC within two weeks of delivery. In the last delivery, 49.8% mothers were assisted by skilled personnel. There was considerable amount of variation in the use of maternal health services at community and district levels. About 40% and 14% of the total variance in the use of ANC, 29% and 8% of the total variance in the use of skilled attendance at delivery and 28% and 8.5% of the total variance in the use of PNC was attributable to differences across communities and districts, respectively. When controlled for individual, community and district level factors, the variances in the use of skilled attendance at delivery attributed to the differences across communities and districts were reduced to 15% and 4.3% respectively. There were only marginal reductions observed in the variance at community and district level for ANC and PNC use. The household socio-economic status and mother's education were the most important factors associated with the use of ANC and skilled attendance at delivery. The community level variable was only significant for ANC and skilled attendance at delivery but not for PNC. None of the district level variables used in this study were found to be influential factors for the use of maternal health services.

    Conclusions We found sufficient amount of variations at community and district of residence on each of the three indicators of the use of maternal health services. For increasing the utilisation of these services in the state, in addition to individual-level, there is a strong need to identify and focus on community and district-level interventions.

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  • 31.
    Jonsson, Frida
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum).
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Carson, Dean B.
    Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum). School of Business and Law, CQUniversity, Rockhampton, Australia.
    Wiklund, Maria
    Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum). Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Landscapes of care and despair for rural youth: a qualitative study in the northern Swedish 'periphery'2020Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, nr 1, artikel-id 171Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: This study emerges as a response to the lack of youth perspectives when it comes to discussions about access to and experiences of health and social services in rural areas. It subsequently contributes to the literature by positioning young people at the centre of this debate, and by taking a more holistic approach to the topic than is typically the case. Specifically, based on the idea that a good life in proper health for young people may be contingent on notions of care that are bounded up in multi-layered social and spatial environments, the aim of this study was to explore what characterises 'landscapes of care' for rural youth.

    METHODS: In this qualitative study, the participants included young people and professionals residing in five diverse areas across the northern Swedish 'peripheral' inland. Individual interviews (16 in total) and focus group discussions (26 in total) were conducted with 63 youth aged 14-27 years and with 44 professionals operating across sectors such as health centres, school health, integration units, youth clinics and youth clubs. Following an emergent design and using thematic analysis, we developed one main theme, 'landscapes of care and despair', comprising the two themes: '(dis)connectedness' and 'extended support or troubling gaps'.

    RESULTS: The findings illustrate how various health-promoting and potentially harmful aspects acting at structural, organisational and interpersonal levels contributed to dynamic landscapes characterised simultaneously by care and despair. In particular, our study shows how rural youths' feelings of belongingness to people and places coupled with opportunities to participate in society and access practical and emotional support appear to facilitate their care within rural settings. However, although the results indicate that some in the diverse group of rural youth were cared for and about, a negative picture was painted in parallel. These aspects of despair included youths' senses of exclusion and marginalisation, degrading attitudes towards them and their problems, as well as recurrent gaps in the provision and practices of care.

    CONCLUSIONS: To gain a more comprehensive understanding about the health of rural youth, this study highlights the benefits investigating 'care-ful' and 'uncaring' aspects bounded up in dynamic and multi-layered landscapes.

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  • 32.
    Jonsson, Frida
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hammarström, Anne
    Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Intragenerational social mobility and functional somatic symptoms in a northern Swedish context: analyses of diagonal reference models2017Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 16, artikel-id 1Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Research indicate that social class mobility could be potentially important for health, but whether this is due to the movement itself or a result of people having been integrated in different class contexts is, to date, difficult to infer. In addition, although several theories suggest that transitions between classes in the social hierarchy can be stressful experiences, few studies have empirically examined whether such movements may have health effects, over and above the implications of "being" in these classes. In an attempt to investigate whether intragenerational social mobility is associated with functional somatic symptoms in mid-adulthood, the current study tests three partially contrasting theories.

    METHOD: The dissociative theory suggests that mobility in general and upward mobility in particular may be linked to psychological distress, while the falling from grace theory indicates that downward mobility is especially stressful. In contrast, the acculturation theory holds that the health implications of social mobility is not due to the movement itself but attributed to the class contexts in which people find themselves. Diagonal Reference Models were used on a sample of 924 individuals who in 1981 graduated from 9(th) grade in the municipality of Luleå, Sweden. Social mobility was operationalized as change in occupational class between age 30 and 42 (measured in 1995 and 2007). The health outcome was functional somatic symptoms at age 42, defined as a clustering self-reported physical symptoms, palpitation and sleeping difficulties during the last 12 months.

    RESULTS: Overall mobility was not associated with higher levels of functional somatic symptoms compared to being immobile (p = 0.653). After controlling for prior and current class, sex, parental social position, general health, civil status, education and unemployment, the association between downward mobility was borderline significant (p = 0.055) while upward mobility was associated with lower levels of functional somatic symptoms (p = 0.03).

    CONCLUSION: The current study did not find unanimous support for any of the theories. Nevertheless, it sheds light on the possibility that upward mobility may be beneficial to reduce stress-related health problems in mid-life over and above the exposure to prior and current class, while downward mobility can be of less importance for middle-age health complaints.

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  • 33. Kailembo, Alexander
    et al.
    Preet, Raman
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Stewart Williams, Jennifer
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Research Centre for Generational Health and Ageing, Faculty of Health, University of Newcastle, New Lambton Heights, Australia.
    Socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over in China, Ghana, and India2018Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, artikel-id 99Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The 2015 Global Burden of Disease Study estimated that oral conditions affect 3.5 billion people worldwide with a higher burden among older adults and those who are socially and economically disadvantaged. Studies of inequalities in the use of oral health services by those in need have been conducted in high-income countries but evidence from low- and middle-income countries (LMICs) is limited. This study measures and describes socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over, in China, Ghana and India.

    METHODS: A cross-sectional analysis of national survey data from the WHO SAGE Wave 1 (2007-2010) was conducted. Study samples in China (n = 1591), Ghana (n = 425) and India (n = 1307) were conditioned on self-reported need for oral health services in the previous 12 months. The binary dependent variable, unmet need for oral health services, was derived from questions about self-reported need and service use. Prevalence was estimated by country. Unmet need was measured and compared in terms of relative levels of education and household wealth. The methods were logistic regression and the relative index of inequality (RII). Models were adjusted for age, sex, area of residence, marital status, work status and self-rated health.

    RESULTS: The prevalence of unmet need was 60, 80, and 62% in China, Ghana and India respectively. The adjusted RII for education was statistically significant for China (1.5, 95% CI:1.2-1.9), Ghana (1.4, 95% CI: 1.1-1.7), and India (1.5, 95% CI:1.2-2.0), whereas the adjusted RII for wealth was significant only in Ghana (1.3, 95% CI:1.1-1.6). Male sex was significantly associated with self-reported unmet need for oral health services in India.

    CONCLUSIONS: Given rapid population ageing, further evidence of socioeconomic inequalities in unmet need for oral health services by older adults in LMICs is needed to inform policies to mitigate inequalities in the availability of oral health services. Oral health is a universal public health issue requiring attention and action on multiple levels and across the public private divide.

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  • 34.
    Kien, Vu Duy
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Center for Population Health Sciences, Hanoi School of Public Health, Hanoi, Vietnam.
    Minh, HV
    Giang, KB
    Dao, A
    Tuan, LT
    Ng, Nawi
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Socioeconomic inequalities in catastrophic health expenditure and impoverishment associated with non-communicable diseases in urban Hanoi, Vietnam2016Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 15, artikel-id 169Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The catastrophic health expenditure and impoverishment indices offer guidance for developing appropriate health policies and intervention programs to decrease financial inequity. This study assesses socioeconomic inequalities in catastrophic health expenditure and impoverishment in relation to self-reported non-communicable diseases (NCD) in urban Hanoi, Vietnam. Methods: A cross-sectional survey was conducted from February to March 2013 in Hanoi, the capital city of Vietnam. We estimated catastrophic health expenditure and impoverishment using information from 492 slum household and 528 non-slum households. We calculated concentration indexes to assess socioeconomic inequalities in catastrophic health expenditure and impoverishment. Factors associated with catastrophic health expenditure and impoverishment were modelled using logistic regression analysis. Results: The poor households in both slum and non-slum areas were at higher risk of experiencing catastrophic health expenditure, while only the poor households in slum areas were at higher risk of impoverishment because of healthcare spending. Households with at least one member reporting an NCD were significantly more likely to face catastrophic health expenditure (odds ratio [OR] = 2.4; 95 % confidence interval [CI], 1.8-4.0) and impoverishment (OR = 2.3; 95 % CI, 1.1-6.3) compared to households without NCDs. In addition, households in slum areas, with people age 60 years and above, and belonging to the poorest socioeconomic group were significantly associated with increased catastrophic health expenditure, while only households that lived in slum areas, and belonging to the poor or poorest socioeconomic groups were significantly associated with increased impoverishment because of healthcare spending. Conclusion: Financial interventions to prevent catastrophic health expenditure and impoverishment should target poor households, especially those with family members suffering from NCDs, with older members and those located in slum areas in Hanoi Vietnam. Potential interventions derived from this study include targeting and monitoring of health insurance enrolment, and developing a specialized NCD service package for Vietnam's social health insurance program.

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  • 35. Kiracho, Elizabeth Ekirapa
    et al.
    Namuhani, Noel
    Apolot, Rebecca Racheal
    Aanyu, Christine
    Mutebi, Aloysuis
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Kiwanuka, Suzanne N.
    Ayen, Faith Adong
    Mwesige, Dennis
    Bumbha, Ahmed
    Paina, Ligia
    Peters, David H.
    Influence of community scorecards on maternal and newborn health service delivery and utilization2020Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, nr 1, artikel-id 145Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators.

    Methods: This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework.

    Results: There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders.

    Conclusions and recommendations: The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.

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  • 36.
    Krishnan, Anand
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Amarchand, Ritvik
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pandav, Chandrakant
    Ng, Nawi
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    "No one says 'No' to money": a mixed methods approach for evaluating conditional cash transfer schemes to improve girl children's status in Haryana, India.2014Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 13, nr 1, s. 11-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Haryana was the first state in India to launch a conditional cash transfer (CCT) scheme in 1994. Initially it targeted all disadvantaged girls but was revised in 2005 to restrict it to second girl children of all groups. The benefit which accrued at girl attaining 18 years and subject to conditionalities of being fully immunized, studying till class 10 and remaining unmarried, was increased from about US$ 500 to US$ 2000. Using a mixed methods approach, we evaluated the implementation and possible impact of these two schemes.

    METHODS: A survey was conducted among 200 randomly selected respondents of Ballabgarh Block in Haryana to assess their perceptions of girl children and related schemes. A cohort of births during this period was assembled from population database of 28 villages in this block and changes in sex ratio at birth and in immunization coverage at one year of age among boys and girls was measured. Education levels and mean age at marriage of daughters were compared with daughters-in-law from outside Haryana. In-depth interviews were conducted among district level implementers of these schemes to assess their perceptions of programs' implementation and impact. These were analyzed using a thematic approach.

    RESULTS: The perceptions of girls as a liability and poor (9% to 15%) awareness of the schemes was noted. The cohort analysis showed that while there has been an improvement in the indicators studied, these were similar to those seen among the control groups. Qualitative analysis identified a "conspiracy of silence" - an underplaying of the pervasiveness of the problem coupled with a passive implementation of the program and a clash between political culture of giving subsidies and a bureaucratic approach that imposed many conditionalities and documentary needs for availing of benefits.

    CONCLUSION: The apparent lack of impact on the societal mindset calls for a revision in the current approach of addressing a social issue by a purely conditional cash transfer program.

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  • 37.
    Kunna, Rasha
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Stewart Williams, Jennifer
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Research Centre for Generational Health and Ageing Faculty of Health, University of Newcastle.
    Measurement and decomposition of socioeconomic inequality in single and multimorbidity in older adults in China and Ghana: results from the WHO study on global AGEing and adult health (SAGE)2017Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 16, nr 1, artikel-id 79Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Globally people are living longer and enduring non-communicable diseases (NCDs) many of which co-occur as multimorbidity. Demographic and socioeconomic factors are determinants of inequalities and inequities in health. There is a need for country-specific evidence of NCD inequalities in developing countries where populations are ageing rapidly amid economic and social change. The study measures and decomposes socioeconomic inequality in single and multiple NCD morbidity in adults aged 50 and over in China and Ghana.

    METHODS: The data source is the World Health Organization Study on Global AGEing and Adult Health (SAGE) Wave 1 (2007-2010). Nationally representative cross-sectional data collected from adults in China (n = 11,814) and Ghana (n = 4,050) are analysed. Country populations are ranked by a socioeconomic index based on ownership of household assets. The study uses a decomposed concentration index (CI) of single and multiple NCD morbidity (multimorbidity) covering arthritis, diabetes, angina, stroke, asthma, depression, chronic lung disease and hypertension. The CI quantifies the extent of overall inequality on each morbidity measure. The decomposition utilises a regression-based approach to examine individual contributions of demographic and socioeconomic factors, or determinants, to the overall inequality.

    RESULTS: In China, the prevalence of single and multiple NCD morbidity was 64.7% and 53.4%, compared with 65.9% and 55.5% respectively in Ghana. Inequalities were significant and more highly concentrated among the poor in China (single morbidity CI = -0.0365: 95% CI = -0.0689,-0.0040; multimorbidity CI = -0.0801: 95% CI = -0.1233,-0.0368;). In Ghana inequalities were significant and more highly concentrated among the rich (single morbidity CI = 0.1182; 95% CI = 0.0697, 0.1668; multimorbidity CI = 0.1453: 95% CI = 0.0794, 0.2083). In China, rural residence contributed most to inequality in single morbidity (36.4%) and the wealth quintiles contributed most to inequality in multimorbidity (39.0%). In Ghana, the wealth quintiles contributed 24.5% to inequality in single morbidity and body mass index contributed 16.2% to the inequality in multimorbidity.

    CONCLUSIONS: The country comparison reflects different stages of economic development and social change in China and Ghana. More studies of this type are needed to inform policy-makers about the patterning of socioeconomic inequalities in health, particularly in developing countries undergoing rapid epidemiological and demographic transitions.

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  • 38. Lorena Ruano, Ana
    et al.
    Shadmi, Efrat
    Furler, John
    Rao, Krishna
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Uribe, Manuela Villar
    Shi, Leiyu
    Looking forward to the next 15 years: innovation and new pathways for research in health equity2017Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 16, artikel-id 35Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Since our launch in 2002, the International Journal for Equity in Health (IJEqH) has furthered our collective understanding of equity in health and health services by providing a platform on which academics and practitioners can share their work. Today, we celebrate our fifteenth anniversary with an article collection that presents a call for new and novel research in equity in health and we invite our authors to use new approaches and methods, and to focus on emerging areas of research related to health equity in order to set the stage for the next fifteen years of health equity research. Our anniversary issue provides a platform for expanding the conceptualization, diversity of populations and study designs, and for increasing the use of novel methodologies in the field. The IJEqH has helped to support the wider group of researchers, policymakers and practitioners with a commitment to social justice and equity but there is still more to do. With the help of the highly committed editorial team and editorial board, the innovative work of researchers worldwide, and the countless of hours dedicated by hundreds of reviewers, we are confident in the IJEqH's ability to continue supporting the dissemination of health equity research for years to come.

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  • 39.
    Lusey, Hendrew
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. World Council of Churches, Central Africa Regional Coordinator of the Ecumenical HIV and AIDS Initiative in Africa (EHAIA), Kinshasa Gombe, Democratic Republic of Congo.
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Edin, Kerstin E.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Factors associated with gender equality among church-going young men in Kinshasa, Democratic Republic of Congo: a cross-sectional study2017Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 16, artikel-id 213Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: While women and girls are made vulnerable by inequitable and violent versions of masculinities, there is increasing evidence that gender equality will not be achieved without partnering with men. The aim of this study was to assess gender-equitable norms and their determinants among church-going young men in Kinshasa, the Democratic Republic of Congo.

    Method: A cross-sectional study was carried out among 289 church-going young men, aged 18-24 years, residing in three disadvantaged communes of Kinshasa. Variables included sociodemographic characteristics, attitudes towards gender equality and responses to issues related to the Gender-Equitable Men (GEM) scale. Logistic regression was applied to identify the associations between sociodemographic characteristics, attitudes and the GEM scale.

    Results: The findings provide evidence of attitudes and beliefs that act as barriers to gender equality. For instance, the majority of church-going young men (83.74%) agreed that a man is the only decision maker in the home and about half (50.87%) of the respondents supported the statement "There are times a woman deserves to be beaten". Similarly, around half of the participants agreed with the idea of men's uncontrollable sex drive (50.87%) and men's toughness (50.17%). Close to half of the participants (44.29%) agreed that it is women's responsibility to prevent pregnancy. These attitudes co-existed with a few gender-equitable norms as 82.70% agreed on the importance of joint decisions concerning family planning. An association between education, certain places of residence, being single or separated, and supportive attitudes towards gender equality was found with higher scores for the GEM.

    Conclusion: Our study findings indicate that a high proportion of church-going young men do not endorse gender-equitable norms. Therefore, churches urgently need comprehensive gender equality and masculinity policies and programmes to influence young men's attitudes and behaviours. The promotion of gender equality in schools and the wider community also need to be encouraged.

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  • 40.
    Mabetha, Denny
    et al.
    Cochrane South Africa, South African Medical Research Council (MRC), Cape Town, South Africa; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, United Kingdom.
    Ojewola, Temitope
    Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, United Kingdom; Health Education England, Northwest, Manchester, United Kingdom.
    van der Merwe, Maria
    MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, United Kingdom; Maria Van Der Merwe Consulting, White River, South Africa.
    Mabika, Reflect
    Mpumalanga Department of Health, Mbombela, South Africa.
    Goosen, Gerhard
    Mpumalanga Department of Health, Mbombela, South Africa.
    Sigudla, Jerry
    Mpumalanga Department of Health, Mbombela, South Africa.
    Hove, Jennifer
    MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, United Kingdom.
    Witter, Sophie
    Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom.
    D'Ambruoso, Lucia
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, United Kingdom; Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom; Public Health, National Health Service (NHS) Grampian, Aberdeen, United Kingdom; Department of Global Health, Stellenbosch University, Stellenbosch, South Africa.
    Realising radical potential: building community power in primary health care through Participatory Action Research2023Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 22, nr 1, artikel-id 94Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.

    Methods: Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.

    Results: Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.

    Conclusions: Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.

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  • 41.
    Mamani-Ortiz, Yercin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Biomedical and Social Research Institute, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Gustafsson, Per E
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastián Chasco, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Armaza Céspedes, Ada Ximena
    Luizaga López, Jenny Marcela
    Illanes Velarde, Daniel Elving
    Mosquera Méndez, Paola A.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Underpinnings of entangled ethnical and gender inequalities in obesity in Cochabamba-Bolivia: an intersectional approach2019Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 18, nr 1, artikel-id 153Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Social inequalities in obesity have been observed not only by gender but also between ethnic groups. Evidence on combined dimensions of inequality in health, and specifically including indigenous populations, is however scarce, and presents a particularly daunting challenge for successful prevention and control of obesity in Bolivia, as well as worldwide.

    OBJECTIVE: The aims of this study were i) to examine intersectional inequalities in obesity and ii) to identify the factors underlying the observed intersectional inequalities.

    METHODS: An intersectional approach study was employed, using the information collected in a cross-sectional community-based survey. The sample consisted of youth and adults with permanent residence in Cochabamba department (N = 5758), selected through a multistage sampling technique. An adapted version of the WHO-STEPS survey was used to collect information about Abdominal obesity and risk factors associated. Four intersectional positions were constructed from gender (woman vs. men) and ethnic group (indigenous vs. mestizo). Joint and excess intersectional disparities in obesity were estimated as absolute prevalence differences between binary groups, using binomial regression models. The Oaxaca-Blinder decomposition was applied to estimate the contributions of explanatory factors underlying the observed intersectional disparities, using Oaxaca command in Stata software v15.1.

    RESULTS: The prevalence of abdominal obesity had a higher prevalence in mestizos (men 35.01% and women 30.71%) as compared to indigenous (men 25.38% and women 27.75%). The joint disparity was estimated at 7.26 percentage points higher prevalence in the doubly advantaged mestizo men than in the doubly disadvantaged indigenous women. The gender referent disparity showed that mestizo-women had a higher prevalence than indigenous-women. The ethnic referent disparity showed that mestizo-men had a higher prevalence than indigenous men. The behavioural risk factors were the most important to explain the observed inequalities, while differences in socioeconomic and demographic factors played a less important role.

    CONCLUSION: Our study illustrates that abdominal obesity is not distributed according to expected patterns of structural disadvantage in the intersectional space of ethnicity and gender in Bolivia. In the Cochabamba case, a high social advantage was related to higher rates of abdominal obesity, as well as the behavioural risk factors associated with them.

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  • 42.
    Mosquera Mendez, Paola A
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernandez, Jinneth
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Vega, Roman
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Martinez, Jorge
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Labonte, Ronald
    Faculty of Medicine, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada.
    Sanders, David
    School of Public Health, University of the Western Cape, Bellville, South Africa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The impact of primary healthcare in reducing inequalities in child health outcomes, Bogota, Colombia: an ecological analysis2012Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 11, artikel-id 66Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Colombia is one of the countries with the widest levels of socioeconomic and health inequalities. Bogota, its capital, faces serious problems of poverty, social disparities and access to health services. A Primary Health Care (PHC) strategy was implemented in 2004 to improve health care and to address the social determinants of such inequalities. This study aimed to evaluate the contribution of the PHC strategy to reducing inequalities in child health outcomes in Bogota.

    Methods: An ecological analysis with localities as the unit of analysis was carried out. The variable used to capture the socioeconomic status and living standards was the Quality of Life Index (QLI). Concentration curves and concentration indices for four child health outcomes (infant mortality rate (IMR), under-5 mortality rate, prevalence of acute malnutrition in children under-5, and vaccination coverage for diphtheria, pertussis and tetanus) were calculated to measure socioeconomic inequality. Two periods were used to describe possible changes in the magnitude of the inequalities related with the PHC implementation (2003 year before - 2007 year after implementation). The contribution of the PHC intervention was computed by a decomposition analysis carried out on data from 2007.

    Results: In both 2003 and 2007, concentration curves and indexes of IMR, under-5 mortality rate and acute malnutrition showed inequalities to the disadvantage of localities with lower QLI. Diphtheria, pertussis and tetanus (DPT) vaccinations were more prevalent among localities with higher QLI in 2003 but were higher in localities with lower QLI in 2007. The variation of the concentration index between 2003 and 2007 indicated reductions in inequality for all of the indicators in the period after the PHC implementation. In 2007, PHC was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-5 mortality (24%), IMR (19%) and acute malnutrition (7%). PHC also contributed approximately 20% to inequality in DPT coverage, favoring the poorer localities.

    Conclusion: The PHC strategy developed in Bogota appears to be contributing to reductions of the inequality associated with socioeconomic and living conditions in child health outcomes.

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  • 43.
    Mosquera, Paola A.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Decomposition of gendered income-related inequalities in multiple biological cardiovascular risk factors in a middle-aged population2018Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 17, artikel-id 102Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Socioeconomic inequalities in cardiovascular disease seem to widen or endure in Sweden. However, research on inequalities in antecedent cardiovascular risk factors (CVRFs), and particularly what underpins them, is scarce. The present study aimed 1) to estimate income-related inequalities in eight biological cardiovascular risk factors in Swedish middle-aged women and men; and 2) to examine the contribution of demographic, socioeconomic, behavioural and psychosocial determinants to the observed inequalities.

    METHODS: Participants (N = 12,481) comprised all 40- and 50-years old women and men who participated in the regional Västerbotten Intervention Programme in Northern Sweden during 2008, 2009 and 2010. All participants completed a questionnaire on behavioural and psychosocial conditions, and underwent measurements with respect to eight CVRFs (body mass index; waist circumference; total cholesterol; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol; triglycerides; systolic/diastolic blood pressure; glucose tolerance). Data on cardiovascular risk, psychosocial and health behaviours were linked to national register data on income and other socioeconomic and demographic factors. To estimate income inequalities in each CVRF concentration indexes were calculated, and to examine the contribution of the underlying determinants to the observed inequalities a Wagstaff-type decomposition analysis was performed separately for women and men.

    RESULTS: Health inequalities ranged from small to substantial with generally greater magnitude in women. The highest inequalities among women were seen in BMI, triglycerides and HDL-cholesterol (Concentration index = - 0.1850; - 0.1683 and - 0.1479 respectively). Among men the largest inequalities were seen in glucose regulation, BMI and abdominal obesity (Concentration index = - 0.1661; - 0.1259 and - 0.1172). The main explanatory factors were, for both women and men socioeconomic conditions (contributions ranging from 54.8 to 76.7% in women and 34.0-72.6% in men) and health behaviours (contributions ranging from 6.9 to 20.5% in women and 9.2 to 26.9% in men). However, the patterns of specific dominant explanatory factors differed between CVRFs and genders.

    CONCLUSION: Taken together, the results suggest that the magnitude of income-related inequalities in CVRFs and their determinants differ importantly between the risk factors and genders, a variation that should be taken into consideration in population interventions aiming to prevent inequalities in manifest cardiovascular disease.

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  • 44.
    Mosquera, Paola A
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Waenerlund, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Equitable health services for the young?: A decomposition of income-related inequalities in young adults' utilization of health care in Northern Sweden2017Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 16, artikel-id 20Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Despite the goal of the Swedish health system to offer health care according to the principle of horizontal equity, little is known about the equality in access to health care use among young people. To explore this issue, the present study aimed i) to assess horizontal inequity in health care utilization among young people in Northern Sweden; and ii) to explore the contribution of different factors to explain the observed inequalities.

    METHODS: Participants (N = 3016 youths aged 16-25 years) came from the "Health on Equal terms" survey conducted in 2014 in the four northernmost counties in Sweden. Concentration indices (C) and horizontal inequity indices (HI) were calculated to measure inequalities in the utilization of two health care services (general practitioners (GP) and youth clinics). The HI was calculated based on health care utilization and variables representing socioeconomic status (household income), health care needs factors and non-need factors affecting health care use. A decomposition analysis was carried out to explain the income-related inequalities.

    RESULTS: Results showed a significant positive income-related inequality for youth clinic utilization in women (C = 0.166) and total sample (C = 0.097), indicating that services were concentrated among the better-off. In contrast, general practitioner visits showed inequality pointing toward a higher utilization among less affluent individuals; significant in women (C = -0.079), men (C = -0.101) and pooled sample (C = -0.097). After taking health care needs into consideration, the utilization of youth clinics remained significantly pro-rich in women (HI = 0.121) and total sample (HI = 0.099); and consistently pro-poor for the GP visits in the pooled sample (HI = -0.058). The decomposition analyses suggest that socioeconomic inequalities explain a considerable portion of the pro-rich utilization of youth clinics services among young women. The corresponding analyses for GP visits showed that need factors and socioeconomic conditions accounted for the pro-poor concentration of GP visits.

    CONCLUSION: The distribution of GP visits among young people in Northern Sweden slightly favored the low-income group, and thus seems to meet the premises of horizontal equity. In contrast, the findings suggest substantial pro-rich horizontal inequity in the utilization of youth clinics among young women, which are largely rooted in socioeconomic inequalities.

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  • 45.
    Mulubwa, Chama
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. School of Public Health, University of Zambia, Lusaka, Zambia; Centre of Infectious Diseases and Research in Zambia, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Zulu, Joseph Mumba
    School of Public Health, University of Zambia, Lusaka, Zambia..
    Michelo, Charles
    School of Public Health, University of Zambia, Lusaka, Zambia..
    Sandøy, Ingvild Fossgard
    Department of Global Public Health and Primary Care, Centre for Intervention Science in Maternal and Child Health (CISMAC), Centre for International Health (CIH), University of Bergen, Bergen, Norway..
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Combining photo-elicitation and discourse analysis to examine adolescents' sexuality in rural Zambia2022Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 21, nr 1, artikel-id 60Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: This article aimed to analyse constructions of adolescents' sexualities and sexual health and the consequences of these discourses for adolescents' exercise of their sexual reproductive health and rights (SRHR) in rural Zambia.

    METHODS: Interpretative repertoires, which is rooted in discursive psychology was used to analyse data from photo-elicitations interviews and focus group discussions. Our participants included 25 adolescents who participated in a SRHR intervention that aimed to reduce adolescents' pregnancies and early marriages.

    RESULTS: We identified three interpretative repertories: 1) sex is for mature people in which adolescents positioned themselves as 'immature, and young to engage in sex; 2) gendered respectful behaviours in which what was considered disrespectful (and respectful) behaviour in relation to sexuality were strongly influenced by gender, and more clearly defined for girls than it was for boys. Sexuality was not only about individual choices but about being respectful to parents; and 3) acquiring and using knowledge about sexuality in which adolescents conflicted between having and applying SRHR knowledge.

    CONCLUSION: These repertories offer an important context that shape how adolescents negotiate, adopt and resist SRHR interventions. Future interventions that target adolescents' SRHR must aim to address the sexual scripts that serve to erect barriers against positive sexual behaviours, including access to SRHR services that promote safer sex.

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  • 46.
    Nkulu Kalengayi, Faustine
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Anne, Ouma
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    'HIV ended up in second place' - prioritizing social integration in the shadow of social exclusion: an interview study with migrants living with HIV in Sweden2022Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 21, artikel-id 175Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Migrants are overrepresented among people living with HIV in Sweden as they often face conditions that increased their risk and vulnerability for HIV/STI infections prior, during or after migration. Yet, there is limited research on their experiences and perceptions of living with HIV in the Swedish context. This study aims to explore migrants' experiences of living with HIV in Sweden.

    METHODS: This is a qualitative study based on in-depth interviews with 13 migrants from 11 countries living with HIV in Sweden. Interviews were analysed with thematic analysis using an intersectional perspective to explore the interactions of multiple social identities such as ethnicity, socio-economic status, gender, age, and sexual orientation that shape an individual's or group's experiences.

    RESULTS: The analysis resulted in a main theme: 'Prioritizing social integration-HIV ends up in second place', which is based on four subthemes: 'Better opportunities in the new country than what the home country could offer', 'Better conditions for LGBTQI people than in the home country', 'Navigating a new system: linguistic and bureaucratic challenges' and 'Feeling like a second-class resident: racism, xenophobia and multiple discrimination'. The results suggest that migrants living with HIV in Sweden experience social integration as a greater challenge than HIV infection. Although the new country offers opportunities for better living conditions, many participants described being challenged in their daily life by linguistic and structural barriers in their encounters with public services. They are facing multiple discrimination simultaneously as migrants due to their multiple and intersecting identities (e.g. being non-white, foreigners/foreign-born and non-Swedish speakers), which is compounded by HIV status and thus limit their opportunities in the new country and too often result in an existence of exclusion.

    CONCLUSION: The study shows that most of the challenges that migrants living with HIV face are related to their status as migrants rather than HIV status, which is often not known by the public or authorities. These challenges are similar, but still differ depending on social position, previous experiences, time since arrival and since diagnosis. This emphasizes the importance of both intersectional, intersectoral and multisectoral approaches to address reported issues.

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  • 47.
    Nyamande, Fortune N.
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Mosquera, Paola
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Intersectional equity in health care: assessing complex inequities in primary and secondary care utilization by gender and education in northern Sweden2020Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, nr 1, artikel-id 159Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Knowledge remains scarce about inequities in health care utilization between groups defined, not only by single, but by multiple and intersecting social categories. This study aims to estimate intersectional horizontal inequities in health care utilization by gender and educational level in Northern Sweden, applying a novel methodological approach.

    METHODS: Data on participants (N = 22,997) aged 16-84 years from Northern Sweden came from the 2014 Health on Equal Terms cross sectional survey. Primary (general practitioner) and secondary (specialist doctor) health care utilization and health care needs indicators were self-reported, and sociodemographic information came from registers. Four intersectional categories representing high and low educated men, and high and low educated women, were created, to estimate intersectional (joint, referent, and excess) inequalities, and needs-adjusted horizontal inequities in utilization.

    RESULTS: Joint inequalities in primary care were large; 8.20 percentage points difference (95%CI: 6.40-9.99) higher utilization among low-educated women than high-educated men. Only the gender referent inequity remained after needs adjustment, with high- (but not low-) educated women utilizing care more frequently than high-educated men (3.66 percentage points difference (95%CI: 2.67-5.25)). In contrast, inequalities in specialist visits were dominated by referent educational inequalities, (5.69 percentage points difference (95%CI: 2.56-6.19), but with no significant horizontal inequity - by gender, education, or their combination - remaining after needs adjustment.

    CONCLUSION: This study suggests a complex interaction of gender and educational inequities in access to care in Northern Sweden, with horizontal equity observable for secondary but not primary care. The study thereby illustrates the unique knowledge gained from an intersectional perspective to equity in health care.

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  • 48.
    Padyab, Mojgan
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Centrum för befolkningsstudier (CBS).
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Centrum för befolkningsstudier (CBS).
    Socioeconomic inequalities and body mass index in Västerbotten County, Sweden: a longitudinal study of life course influences over two decades2014Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 13, s. 35-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Life course socioeconomic inequalities in heart disease, stroke and all-cause mortality are well studied in Sweden. However, few studies have sought to explain the mechanism for such associations mainly due to lack of longitudinal data with multiple measures of socioeconomic status (SES) across the life course. Given the population health concern about how socioeconomic inequality is related to poorer health, we aim to tackle obesity as one of the prime suspects that could explain the association between SES inequality and cardiovascular disease and consequently premature death. The aim of this study is to test which life course model best describes the association between socioeconomic disadvantage and obesity among 60 year old inhabitants of Västerbotten County in Northern Sweden.

    METHODS: A birth cohort consisting of 3340 individuals born between 1930 and 1932 was studied. Body mass index (BMI) at the age of 60 and information on socioeconomic status at three stages of life (ages 40, 50, and 60 years) was collected. Independent samples t-test was used to compare BMI between advantaged and disadvantaged groups and one-way ANOVA was used to compare BMI among eight SES trajectories. We applied a structured modeling approach to examine three different hypothesized life course SES models (accumulation, critical period, and social mobility) in relation to BMI.

    RESULTS: We found sex differences in the way that late adulthood socioeconomic disadvantage is associated with BMI among inhabitants of Northern Sweden. Our study suggests that social adversity in all stages of late adulthood is a particularly important indicator for addressing the social gradients in BMI among women in Northern Sweden and that unhealthy behaviors in terms of smoking and physical inactivity are insufficient to explain the relationships between social and lifestyle inequalities and BMI.

    CONCLUSION: In order for local authorities to develop informed preventive efforts, we suggest further research to identify modifiable risk factors across the life course which could explain this health inequality.

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  • 49.
    Pedrós Barnils, Núria
    et al.
    Department of Physics, Polytechnic University of Catalonia, Barcelona, Spain.
    Eurenius, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Self-rated health inequalities in the intersection of gender, social class and regional development in Spain: exploring contributions of material and psychosocial factors2020Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 19, nr 1, artikel-id 85Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Inequalities in health across social class, gender and regional context in Spain are well-known; however, there is a lack of research examining how these dimensions of inequality interact. This study explores self-rated health (SRH) inequalities across intersectional positions of gender, social class and region, and the contribution of material and psychosocial factors to these inequalities.

    METHODS: Participants were drawn from the cross-sectional 2015 National Living Conditions Survey of Spanish residents aged 19-88 years (N = 27,215; 77% response rate). Eight intersectional positions were formed by combining dichotomous variables of gender, social class and regional development. Poisson regression was used to estimate intersectional inequalities in SRH as prevalence ratios, and the contributions of material and psychosocial factors.

    RESULTS: Results showed both cumulative and heterogeneous inequalities within and across intersectional positions. Inequalities in the intersection of social class and regional development were best explained by the joint contributions of material and psychosocial factors, while gender inequalities within non-manual social class were better explained by material factors alone.

    CONCLUSIONS: The results illustrate the complexity of interacting inequalities in health and their underpinnings in Spain. Local and national policies taking this complexity into account are needed to broadly improve equity in health in Spain.

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  • 50. Perez-Urdiales, Iratxe
    et al.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Irazusta, Amaia
    Linander, Ida
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Sub-Saharan African immigrant women's experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain2019Ingår i: International Journal for Equity in Health, E-ISSN 1475-9276, Vol. 18, artikel-id 59Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BackgroundImmigrant populations face diverse barriers to accessing appropriate healthcare services on several levels. In the Basque Country, Sub-Saharan African women were identified as facing the largest barriers to access them. The aim of the study is to analyse Sub-Saharan African immigrant women's perceptions and experiences of access to appropriate healthcare in the public health system in the Basque Country, Spain.MethodsFourteen women from eight Sub-Saharan African countries who have used the Basque public healthcare services were interviewed. A qualitative content analysis was applied: meaning that units were identified, coded and the resulting codes were then organized into three categories.ResultsThe first category, Fearing to enter a health system perceived as not friendly for immigrants, included factors, mainly those related to legal conditions for accessing healthcare services and lack of lawful documentation, that made women avoid or discontinue seeking out healthcare.The second category, Being attended on professionals' own communication terms, comprised how the lack of effective communication compromised not only the access of the immigrant women to healthcare services, but also their health.Lastly, the third category, Is mistreatment based on racism or merely on bad luck? described how being an immigrant and black influenced the way they were (mis)treated in the health system.ConclusionFor Sub-Saharan African immigrant women, accessing appropriate healthcare in the Basque Country was perceived to be subject to institutional barriers. At the legal level, barriers included lack of entitlement, difficulties in fulfilling legal access conditions and lack of documentation. The lack of communication with health centre staff and their attitudes, guided by a stereotyped social image of immigrants and black people, also hindered their possibilities of receiving appropriate healthcare. Facilitators for accessing healthcare included strategies from individual professionals, personal networks and social actors to help them to cope with the barriers. There is a need of reinforcing inclusion values and rights-based approach to attention among staff at the health centres to have more non-discriminatory and culturally appropriate health systems.

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