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  • 1.
    Abdelhay, Amro Gaber
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Antibiotic misuse in Egypt from the community pharmacists' perspective.: A study protocol.2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Introduction/Background: Antibiotic resistance (AR) has become a danger threats to all countries and regions in the world. Decreased effectiveness of antibiotics in treating some infections due to antibiotic resistance is leading to more suffering for patients, increased treatment costs, increased days of hospitalization as well as increasing morbidity and mortality. In order to tackle AR, a much more responsible use of antibiotics is needed including avoidance of overuse, overprescribing and any other type of inappropriate use of antibiotics. Egypt is one of the countries with high rate of antibiotic misuse- In the study that this study protocol is outlining, the reasons for misuse will be explored from the community pharmacists’ perspectives in order to suggest possible solutions.

    Objective: The general objective is to study factors contributing to antibiotic misuse in Egypt from the perspective of community pharmacists.

    Method: A cross sectional study will be conducted using structured questionnaire. Answers will be collected from community pharmacists in Fayoum governorate in Egypt whereafter data analysis will be done.

    Study work plan: It is intended that the study period altogether will be six months.

  • 2. Abraha, Atakelti
    et al.
    Myléus, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Kahsay, Asmelash
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
    The effects of maternal and child HIV infection on health equity in Tigray Region, Ethiopia, and the implications for the health system: a case-control study2019Inngår i: AIDS Care, ISSN 0954-0121, E-ISSN 1360-0451, Vol. 31, nr 10, s. 1271-1281Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Services that aim to prevent mother-to-child HIV transmission (PMTCT) can simultaneously reduce the overall impact of HIV infection in a population while also improving maternal and child health outcomes. By taking a health equity perspective, this retrospective case control study aimed to compare the health status of under-5 children born to HIV-positive and HIV-negative mothers in Tigray Region, Ethiopia. Two hundred and thirteen HIV-positive women (cases), and 214 HIV-negative women (controls) participated through interviews regarding their oldest children. Of the children born to HIV-positive mothers, 24% had not been tested, and 17% of those who had been tested were HIV-positive themselves. Only 29% of the HIV-positive children were linked to an ART programme. Unexpectedly, exposed HIV-negative children had fewer reports of perceived poor health as compared to unexposed children. Over 90% of all the children, regardless of maternal HIV status, were breastfed and up-to-date with the recommended immunizations. The high rate of HIV infection among the babies of HIV-positive women along with their low rates of antiretroviral treatment raises serious concerns about the quality of outreach to pregnant women in Tigray Region, and of the follow-up for children who have been exposed to HIV via their mothers.

  • 3.
    Aden, Jamila Ahmed
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Faculty of Medicine and Health Sciences, East Africa University, Bosaso, Puntland State of Somalia, Somalia; Social Medicine and Global Health, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.
    Ahmed, Hinda Jama
    Östergren, Per-Olof
    Causes and contributing factors of maternal mortality in Bosaso District Somalia. A retrospective study of 30 cases using a Verbal Autopsy proach2019Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, nr 1, artikkel-id 1672314Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

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

  • 4.
    Al- Rubaye, Ali Kadhim Qasim
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Health Behavioral Risk Factors Associated to Quality of Life: A Cross-Sectional Study in Northern Sweden2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Introduction: Obesity, smoking, low level of physical activity, lack of fruit and vegetable intake, and harmful consumption of alcohol, are all established risk factors that have undesirable effects on health. These behavioural risk factors have a joint adverse effect on both morbidity and mortality. This thesis aims to explore the relationship between these risk factors and the quality of life among adults population with an age range between 16 to 84 year old livings in Northern Sweden.

    Methodology: This cross-sectional study is based on data from Sweden‘s national public health survey Hälsa på lika villkor – HLV (Health on Equal Terms) that was conducted between February and May 2014 in the four Northern counties in Sweden: Norrbotten, Västerbotten, Västernorrland, and Jämtland. With a response rate of 50%, the final sample consisted of 25.667 individuals. In this study, individuals with missing data from any of the study variables were dropped to assure complete analysis. The final study population was 17,138 (67% of those who responded to the HET 2014 survey) Multivariable linear regression was used to statistically analyze the relationship between the outcome variable, the EQ5D utility score which is a standardized instrument widely used for measuring the generic health status, and the following independent variables: BMI, physical activity, smoking status, fruit and vegetable intake, and alcohol consumption. The association was presented in terms of coefficient factor and CI 95%.

    Results: The findings showed that risk factors namely obesity, less than the recommended daily level of physical activity, low daily consumption of fruits and vegetables, daily use of tobacco and the heavy episodic drinking of alcohol had significantly associated with Low EQ5D.

    Conclusion: The results of the study suggest that HRQoL measured by EQ5D-3L might have a significant relation with lifestyle behaviours. This finding would emphasize the role of public health interventions for better overall health to the population. More research is needed to fully understand and explore the determinants of the relationship between the lifestyle behaviours and the HRQol.

  • 5.
    Al-Alawi, Kamila
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Team-based approach in the management of diabetes at primary health care level in Muscat, Oman: challenges and opportunities2019Doktoravhandling, med artikler (Annet vitenskapelig)
    Abstract [en]

    Introduction: The growth of type 2 diabetes is considered an alarming epidemic in Oman. The efficient team-based approach to diabetes management in primary health care is an essential component for providing ideal diabetic care. This thesis aimed to explore the current situation related to team-based management of type 2 diabetes in public Primary Health Care Centres (PHCCs) under the Ministry of Health (MOH) in Oman, including the various challenges associated with diabetes management and the most preferable Human Resources for Health (HRH) management mechanism, and to examine how this could be optimized from provider and patient perspectives.

    Materials and methods: The entire project was conducted in Muscat Governorate and was based on one quantitative and three qualitative studies. In the quantitative study, 26 public PHCCs were approached through cross-sectional study. The core diabetes management team recommended by the MOH for PHCCs in Oman was explored in terms of their competencies, values, skills, and resources related to the team-based approach to diabetes management. For the qualitative studies, five public purposely-selected PHCCs were approached. The diabetes consultations conducted by the core members and other supportive members involved in diabetes management were observed and later the Primary Health Care Providers (PHCPs) were interviewed. The different approaches explored challenges related to diabetes management and the most preferable HRH mechanism by PHCPs. Seven type 2 diabetes patients with different gender, employment status, and education were consequently interviewed to explore their perceptions towards the current diabetes management service and their opinions towards nurse-led clinics.

    Results: The survey provided significant and diverse perceptions of PHCPs towards their competencies, values, skills, and resources related to diabetes management. Physicians considered themselves to have better competencies than nurses and dieticians. Physicians also scored higher on team-related skills and values compared with health educators. In terms of team-related skills, the difference between physicians and nurses was statistically significant and showed that physicians perceived themselves to have better skills than nurses. Confusion about the leadership concept among PHCPs with a lack of pharmacological, technical, and human resources was also reported. The observations and interviews with PHCPs disclosed three different models of service delivery at diabetes management clinics. The challenges explored involved PHCCs’ infrastructure, nurses’ knowledge, skills, and non-availability of technical and pharmaceutical support. Other challenges that evolved into the community were cultural beliefs, traditions, health awareness, and public transportation. Complete implementation of task-sharing mechanisms within the team-based approach was selected by all PHCPs as the most preferable HRH mechanism. The selection was discussed in the context of positive outcomes, worries, and future requirements. The physicians stated that nurses’ weak contribution to the team within the selected mechanism could be the most significant aspect. Other members supported the task-sharing mechanism between physicians and nurses. However, type 2 diabetes patients’ non-acceptance of a service provided by the nurses created worries for the nurses. The interviews with type 2 diabetes patients disclosed positive perceptions towards the current diabetes management visits; however, opinions towards nurse-led clinics varied among the patients.

    Conclusions and recommendations: The team-based approach at diabetes management clinics in public PHCCs in Oman requires thoughtful attention. Diverse presence of the team members can form challenges during service delivery. Clear roles for team members must be outlined through a solid HRH management mechanism in the context of a sharp leadership concept. Nurse-led clinics are an important concept within the team; however, their implementation requires further investigation. The concept must involve clear understandings of independence and interdependence by the team members, who must be educated to provide a strong gain for team-based service delivery.

  • 6.
    Al-Alawi, Kamila
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Training and Studies, Royal Hospital, Ministry of Health, Muscat, Oman.
    Al Mandhari, Ahmed
    Johansson, Helene
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Care providers' perceptions towards challenges and opportunities for service improvement at diabetes management clinics in public primary health care in Muscat, Oman: a qualitative study2019Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 19, artikkel-id 18Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BackgroundThe literature has described several challenges related to the quality of diabetes management clinics in public primary health care centres in Oman. These clinics continue to face challenges due to the continuous growth of individuals diagnosed with type 2 diabetes. We sought to explore the challenges faced in these clinics and discuss opportunities for improvement in Oman.MethodsThis qualitative study was designed to include non-participant observations of diabetic patients and care providers during service provision at diabetes management clinics, as well as semi-structured interviews with care providers, at five purposively selected public primary health care centres. Care providers included physicians, nurses, dieticians, health educators, pharmacists, an assistant pharmacist, a psychologist, and a medical orderly. The data were analysed using qualitative content analysis.ResultsThe study disclosed three different models of service delivery at diabetes management clinics, which, to varying degrees, face challenges related to health centre infrastructure, technical and pharmaceutical support, and care providers' interests, knowledge, and skills. Challenges related to the community were also found in terms of cultural beliefs, traditions, health awareness, and public transportation.ConclusionThe challenges encountered in diabetes management clinics fall within two contexts: health care centres and community. Although many challenges exist, opportunities for improvement are available. However, improvements in the quality of diabetic clinics in primary health care centres might take time and require extensive involvement, shared responsibilities, and implications from the government, health care centres, and community.

  • 7.
    Al-Alawi, Kamila
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Johansson, Helene
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Perceptions of type-two diabetes patients towards diabetes management visits at public primary health care centres with diverse opinions towards nurse-led clinics in Muscat, Oman: a pilot qualitative studyManuskript (preprint) (Annet vitenskapelig)
  • 8.
    Al-Alawi, Kamila
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Johansson, Helene
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    The question is not what we want; the question is, are we ready?: a qualitative study exploring primary health care providers`perceptions towards different human resources for health management mechanisms at diabetes management clinics in primary health care centres in Muscat, OmanManuskript (preprint) (Annet vitenskapelig)
  • 9. Alberto Diaz-Sanchez, Adrian
    et al.
    Corona-Gonzalez, Belkis
    Meli, Marina L.
    Obregon Alvarez, Dasiel
    Vega Canizares, Ernesto
    Fonseca Rodriguez, Osvaldo
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för demografi och åldrandeforskning (CEDAR). Centro Nacional de Sanidad Agropecuaria (CENSA), San José de las Lajas, Mayabeque, Cuba.
    Lobo Rivero, Evelyn
    Hofmann-Lehmann, Regina
    First molecular evidence of bovine hemoplasma species (Mycoplasma spp.) in water buffalo and dairy cattle herds in Cuba2019Inngår i: Parasites & Vectors, ISSN 1756-3305, E-ISSN 1756-3305, Vol. 12, artikkel-id 78Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Hemotropic mycoplasmas (aka hemoplasmas) are small bacteria which cause infectious anemia in several mammalian species including humans. Information on hemoplasma infections in Cuban bovines remains scarce and no studies applying molecular methods have been performed so far. The aim of the present study was to utilize real-time PCR and sequence analysis to investigate dairy cattle and buffalo from Cuba for the presence of bovine hemoplasma species.

    Results: A total of 80 blood samples from 39 buffalo and 41 dairy cattle were investigated for the presence of Mycoplasma wenyonii and Candidatus Mycoplasma haemobos using two species-specific real-time TaqMan PCR assays. PCR results revealed overall 53 (66.2%; 95% CI: 55.3-75.7%) positive animals for M. wenyonii and 33 (41.2%; 95% CI: 31.1-52.2%) for Ca. M. haemobos; the latter were all co-infections with M. wenyonii. The sample prevalences were similar in cattle and buffalo. Based on the sequence analysis of the nearly full-length 16S rRNA gene from two cattle and two buffalo, the presence of M. wenyonii and Ca. M. haemobos was confirmed. Statistical analysis revealed that buffalo and cattle one year of age or older were more frequently infected with M. wenyonii or Ca. M. haemobos than younger animals. PCR-positivity was not associated with anemia; however, the infection stage was unknown (acute infection versus chronic carriers).

    Conclusions: The high occurrence of bovine hemoplasma infections in buffalo and dairy cattle may have a significant impact on Cuban livestock production. To the best of our knowledge, this is the first molecular evidence of bovine hemoplasma species infection in dairy cattle and buffalo from Cuba and the Caribbean.

  • 10.
    Ali, Saeeda
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    “Marry them off quickly and get the responsibility over”: A qualitative study of exploring perceptions of child marriage among Rohingya refugees in Cox’s Bazar camps, Bangladesh; Grounded theory approach2019Independent thesis Advanced level (degree of Master (Two Years)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Background: Child marriage, early marriage, or marriage of minors is a widely recognized as a harmful and discriminatory act violating human rights. Any marriage where one or both partners are under 18 years of age is considered child marriage. It is generally thought that child marriage occurs in girls, but boys also could be exposed to such an issue. Poverty, illiteracy, cultural and religious factors contribute to the rise in child marriage worldwide. In addition, its impacts affect multiple levels of the country, such as disempowerment and neglection of the individual, spread of inequality, and increase in child and maternal mortalities. Child marriage was also been seen in refuge contexts, as in Rohingya refugees living in Cox’s Bazar refugee camps in Bangladesh. Yet, there is lack of in-depth research examining the perception of this particular group on child marriage. This thesis aims to discover families’ perceptions of child marriage in “unstable” contexts. Also, the study explores the reason behind parents marrying their children off in exceptionally young age, and searches for ways to reduce child marriage in refugees.

    Method: The study used qualitative design. It engaged 26 Rohingya informants from Cox’s Bazar camps in in-depth interviews to gather data on their views related to child marriage. 12 male and 14 female parents arriving the camps from 2000 to 2018 were included. Data collection and analysis followed a grounded theory approach. All the emerged codes from the transcribed data went through diverse levels of clustering; selective coding, theoretical or sub-categories, main categories, and the final core category.

    Result: Five categories that emerged from the data were; fulfilment of family needs, parental obligations, judgement based on fearful thoughts, twistable child protection law, and beyond parent’s desire. The core category “perceptions on child marriage act in the middle of acceptance and rejection” was seen to linked with the categories in terms of whether parents accept the act or not, child marriage is a widespread practice among Rohingya families.

    Conclusion: Child marriage is found to be a deeply-rooted tradition among Rohingya families. It was viewed mostly as a fulfilment of a need, a religious and cultural obligation, a mean of protection, and an undesirable act at the same time. In order to change the views in Rohingya communities, religious leaders along with families must be engaged in the long-term interventions of child marriage eradication.

  • 11.
    Andersson, Anne
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    von Wachenfeldt Väppling, Anna
    de Jong, Anna
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Adherence to adjuvant endocrine therapy after breast cancer in Sweden 2008-2010: a nationwide survey2019Konferansepaper (Annet vitenskapelig)
    Abstract [en]

    Background: In estrogen receptor (ER) positive early breast cancer (EBC) adjuvant endocrine therapy (AET) is crucial to reduce recurrence and mortality. Previous studies have shown that adherence to AET is lower than expected and could negatively affect outcome. Since the year of 2000, BC patients in Sweden are treated in accordance to national guidelines. Treatment is offered at a low cost for the patient. The aim of the study was to estimate the adherence to AET in Sweden by regions and age groups. Methods: Women with a first primary EBC diagnosis 2008-2010 were identified through the Swedish Cancer Registry (SCR). Individual tumour and treatment data were retrieved from the Swedish National Breast Cancer Registry (SNBCR). Patients with ER negative tumours, small tumours (≤ 10 mm) and metastatic disease was excluded from the study since there were no indication to AET. Likewise, were individuals with AET registered to be administered by a third part excluded. Dispensed treatment from pharmacies was obtained through the Swedish Prescription Registry and medication possession rate (MPR) was calculated as number of dispensed doses divided by treatment duration in days. Good adherence to treatment in a patient was set at MPR ≥ 80 %. Adherence was calculated for 3 and 5 years. Results: Twenty-one thousand sixteen (21 016) individuals with a first primary BC between 2008 and 2010 was identified through SCR of which 20 596 were registered in the SNBCR. A total of 10 176 met the inclusion criteria in the study. Adherence after 3 years was 88.0 % and after 5 years 82.5 %. Adherence differed between regions in Sweden and was positively associated with age at diagnosis between 41-74 years. Urban areas had a lower adherence than rural areas (80.7 % vs 83.6 %; p= <0.001). Conclusions: Adherence to AET in Sweden was good, although there were differences by age and urban and rural areas. Further studies are needed to identify factors affecting differences in adherence, with the purpose of initiate actions to increase adherence to AET in ER positive EBC patients.

  • 12.
    Anyango, Cartrine
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    “I am their youth clinic”: - perceptions and attitudes towards Swedish youth clinics from the perspective of African immigrant parents2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Introduction: Good health for young people is essential for they are both the present and the hope of tomorrow’s generation. Despite youth being in general a healthy period, young people are also in the high end of experiencing negative health outcomes including sexual and reproductive health. Parent-young people communication play a great role in shaping their sexual and reproductive health and decisions. Many studies have targeted youth clinics from different perspectives, but none from the perspective of immigrant parents with African origin. Thus, the aim of this study was to explore the perceptions and attitudes towards the Swedish youth clinic services from the perspective of the African immigrant parents.

    Methods: A qualitative study design was selected using semi-structured interviews with African immigrant parents in a medium sized city in northern Sweden. A semi structured interview guide with open ended questions was utilized following an emergent design. Four parents were interviewed. The interviews were recorded and later transcribed verbatim. Data was analysed inductively using qualitative content analysis.

    Results: Overall, the participants had mixed feelings about the youth clinics and services in almost all aspects. Parents acknowledged, appreciated, but on the other hand feared, the youth clinics which they perceived as providing too much freedom and openness regarding sexual and reproductive services and communication. Parents perceived culture and religion as playing a pivotal role in shaping parent-young people communication and sources of sexual and reproductive health information.

    Conclusion: This study shows that parents’ role could influence young people in accessing sexual and reproductive services. Parent-young people communication skills need to be improved by programs aimed at building parents’ skills through training. Due to the dilemma on cultural safe services depicted, a follow-up study to explore the perceptions from the perspective of the young people with African background in Sweden, is recommended.

  • 13.
    Assarsson, Rebecka
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Nationell jämställdhet i relation till självmordstankar hos ungdomar i låg- och medelinkomstländer2018Independent thesis Basic level (professional degree), 20 poäng / 30 hpOppgave
  • 14.
    Assarsson, Rebecka
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Petersen, Solveig
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Högberg, Björn
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Strandh, Mattias
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete. Center for Research on Child and Adolescent Mental Health, Karlstad University, Karlstad, Sweden.
    Johansson, Klara
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Gender inequality and adolescent suicide ideation across Africa, Asia, the South Pacific and Latin America: a cross-sectional study based on the Global School Health Survey (GSHS)2019Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, artikkel-id 1663619Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

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

  • 15.
    Baldeh, Samba N
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Impact of cooking fuels and other factors on acute respiratory infection among children under-fives in The Gambia2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Introduction: Solid fuels still stand as the most widely major source of energy for cooking globally, more than half of the population in the world are using solid fuels for the preparation of their daily meals. About 2.4 billion of the population depend on biomass (wood, animal dung, crop wastes) and o.6 billion on coal. Epidemiologically the hazard associated with the exposure to indoor air pollution generated as result of the used of biomass fuels may account for about two million deaths in developing countries and 4% of the global burden of disease. This study aims to find out the impact of cooking fuels and other factors on acute respiratory infection among children under five in The Gambia.

    Methods: Data from the nationally representative Gambia demographic and health survey was used to select all children less than five years old. The number of under five children was 8088 and after exclusion due to missing data and those who didn’t answer the questions, the unweighted children (n= 7605) and the weighted number of children was 7266. The outcome measure was acute respiratory infection and the exposure variables is cooking fuels. The other factors that were captures in the study were child age, gender, mother’s education, household wealth quintile and residence. In the analysis, descriptive statistics was used to estimate the frequencies and distribution of each of the variable. Logistic regression and chi squares test were also used in the analysis to investigate the relation between cooking fuels and acute respiratory infection.

    Results: The finding of this study shows that more than three quarter (80%) of the children belong to household that used wood/straw as their main source of cooking fuels while the remaining use other fuels. Before adjusting for other variables cooking fuels was not significant but after adjusting for residence a decrease risk of ARI was observed in the household that used wood compared to charcoal (adjusted OR = 0.71 0.52 -0 .97). In this study there was no significant association between cooking fuels and acute respiratory infection. It was also noticed that children whose mothers are educated were more likely to suffered from ARI compared to those belonging to mothers with no education and the same trends was observed for mother’s occupation.

    Conclusion: There is no association reported between the types of cooking fuel and ARI in The Gambia. This and other study that use similar approaches and did not find any association. However, majority of studies were able to establish association with ARI. Other factors like gender of the child, mother’s education, mother’s occupation predicted a significant association with ARI. There is need for more further research since many studies around the world are reporting increase risk of ARI among those who are using cooking fuels.

  • 16.
    Balwiire, Davis
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    DOES MATERNAL POSTPARTUM DEPRESSION AFFECT EARLY CHILD DEVELOPMENT?: A study protocol for a prospective cohort study in rural Uganda2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Background: Mothers in Uganda and all over the world are at risk to postpartum depression due to diverse factors present in their communities. Approximately 10% to 15% suffer from postpartum depression with its prevalence at 6.1% in Uganda. It has adverse effects on mothers and their families with severe consequences. Depressed mothers loose interest in most aspects of their life including their children who are strongly dependent on them, leading to serious neglect. This may affect the children’s development.

    Aims: The aim of this study protocol is to examine if maternal postpartum depression affects child development amongst one-year olds in rural Uganda.

    Methods: It will be a prospective cohort study and a quantitative approach will be used with structured questionnaires for data collection that’s maternal postpartum depression status and socio demography data, and the child’s development. Mother’s postpartum depression will be assessed first at 2 months after birth. Secondly their children’s development will be measured and assessed at 6 months and at 12 months in the one-year follow-up period. A sample of 114 mother-infant pairs is required and quantitative statistical methods will be used for data analyzes.

    Expected Outcomes: This study will generate scientific knowledge on the effects of postpartum depression on child development in a rural setting of a developing country. The findings will identify which children are at most risk of having development issues. Lastly, the findings could be used to formulate appropriate strategies and interventions to combat depression and its effects on child development.

  • 17.
    Baroudi, Mazen
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Petersen, Solveig
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Namatovu, Fredinah
    Umeå universitet, Humanistiska fakulteten, Institutionen för idé- och samhällsstudier.
    Annelie, Carlsson
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Norström, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Preteen children’s health related quality of life in Sweden: changes over time and disparities between different sociodemographic groups2019Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, artikkel-id 139Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Assessing disparities in health-related quality of Life (HRQoL) is important as a part of health-related disparities in the society. The aim of this study was to explore HRQoL among 12-year-olds in Sweden in terms of differences between years 2005 and 2009 and disparities related to sociodemographic background.

    Methods: During the school years 2005 and 2009, a total of 18,325 sixth grade students in Sweden were invited to a celiac disease screening study; 13,279 agreed to participate. Jointly with the celiac screening, the children answered a questionnaire that included EuroQol 5 Dimensions-youth (EQ-5D-Y) and their parents responded to separate questionnaires about their own and their child’s country of birth, family structure, their employment status, occupation, and education. In total 11,009 child-parent questionnaires were collected. Logistic regression was used to study differences in HRQoL between 2005 and 2009, and between various sociodemographic subgroups.

    Results: Compared with 2005, children in 2009 reported more pain (OR: 1.20, 95% CI: 1.1–1.3) and more mood problems (OR: 1.35, 95% CI: 1.2–1.5). In general, girls reported more pain and mood problems and had more disparities than boys. There were no significant differences based on parents’ occupation, however, children of parents with low or medium education levels reported less “mood problems” than those of parents with high education levels (OR: 0.65, 95% CI: 0.46–0.92) and (OR: 0.84, 95% CI: 0.73–0.96), respectively. A slight variation was seen in HRQoL between children with different migration background. Girls living in small municipalities reported more pain (OR: 1.51, 95% CI: 1.14–2.01), and problems performing usual activities (OR: 3.77, 95% CI: 2.08–6.84), compared to girls living in large municipalities. In addition, children living with two parents had less mood problems than children living in other family constellations.

    Conclusion: More children reported pain and mood problems in 2009 compared with 2005. To study future trends, health outcomes among children in Sweden should continue to be reported periodically. More efforts should be invested to increase the awareness of health-related disparities as highlighted in this study especially for girls living in small municipalities and children of parents with high education level.

  • 18. Baschieri, Angela
    et al.
    Gordeev, Vladimir S
    Akuze, Joseph
    Kwesiga, Doris
    Blencowe, Hannah
    Cousens, Simon
    Waiswa, Peter
    Fisker, Ane B
    Thysen, Sanne M
    Rodrigues, Amabelia
    Biks, Gashaw A
    Abebe, Solomon M
    Gelaye, Kassahun A
    Mengistu, Mezgebu Y
    Geremew, Bisrat M
    Delele, Tadesse G
    Tesega, Adane K
    Yitayew, Temesgen A
    Kasasa, Simon
    Galiwango, Edward
    Natukwatsa, Davis
    Kajungu, Dan
    Enuameh, Yeetey Ak
    Nettey, Obed E
    Dzabeng, Francis
    Amenga-Etego, Seeba
    Newton, Sam K
    Manu, Alexander A
    Tawiah, Charlotte
    Asante, Kwaku P
    Owusu-Agyei, Seth
    Alam, Nurul
    Haider, M M
    Alam, Sayed S
    Arnold, Fred
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Croft, Trevor N
    Herbst, Kobus
    Kishor, Sunita
    Serbanescu, Florina
    Lawn, Joy E
    "Every Newborn-INDEPTH" (EN-INDEPTH) study protocol for a randomised comparison of household survey modules for measuring stillbirths and neonatal deaths in five Health and Demographic Surveillance sites2019Inngår i: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 9, nr 1, s. 1-15, artikkel-id 010901Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Under-five and maternal mortality were halved in the Millennium Development Goals (MDG) era, with slower reductions for 2.6 million neonatal deaths and 2.6 million stillbirths. The Every Newborn Action Plan aims to accelerate progress towards national targets, and includes an ambitious Measurement Improvement Roadmap. Population-based household surveys, notably Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys, are major sources of population-level data on child mortality in countries with weaker civil registration and vital statistics systems, where over two-thirds of global child deaths occur. To estimate neonatal/child mortality and pregnancy outcomes (stillbirths, miscarriages, birthweight, gestational age) the most common direct methods are: (1) the standard DHS-7 with Full Birth History with additional questions on pregnancy losses in the past 5 years (FBH+) or (2) a Full Pregnancy History (FPH). No direct comparison of these two methods has been undertaken, although descriptive analyses suggest that the FBH+ may underestimate mortality rates particularly for stillbirths.

    Methods: This is the protocol paper for the Every Newborn-INDEPTH study (INDEPTH Network, International Network for the Demographic Evaluation of Populations and their Health Every Newborn, Every Newborn Action Plan), aiming to undertake a randomised comparison of FBH+ and FPH to measure pregnancy outcomes in a household survey in five selected INDEPTH Network sites in Africa and South Asia (Bandim in urban and rural Guinea-Bissau; Dabat in Ethiopia; IgangaMayuge in Uganda; Kintampo in Ghana; Matlab in Bangladesh). The survey will reach >68 000 pregnancies to assess if there is ≥15% difference in stillbirth rates. Additional questions will capture birthweight, gestational age, birth/death certification, termination of pregnancy and fertility intentions. The World Bank's Survey Solutions platform will be tailored for data collection, including recording paradata to evaluate timing. A mixed methods assessment of barriers and enablers to reporting of pregnancy and adverse pregnancy outcomes will be undertaken.

    Conclusions: This large-scale study is the first randomised comparison of these two methods to capture pregnancy outcomes. Results are expected to inform the evidence base for survey methodology, especially in DHS, regarding capture of stillbirths and other outcomes, notably neonatal deaths, abortions (spontaneous and induced), birthweight and gestational age. In addition, this study will inform strategies to improve health and demographic surveillance capture of neonatal/child mortality and pregnancy outcomes.

  • 19. Bashir, Fatima
    et al.
    Ba Wazir, Maha
    Schumann, Barbara
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Lindvall, Kristina
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    The realities of HIV prevention. A closer look at facilitators and challenges faced by HIV prevention programmes in Sudan and Yemen.2019Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, nr 1, artikkel-id 1659098Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: HIV/AIDS prevention has historically encountered many obstacles. Understanding the factors affecting HIV/AIDS prevention is central to designing and implementing suitable context-specific interventions. Research relating to HIV prevention in the Middle East and North African region is required to address the gradually increasing HIV epidemic. Objective: This study aimed to explore the perspectives of employees/health care professionals who are working or have worked within HIV prevention in Sudan and Yemen on the challenges and facilitating factors facing HIV prevention. Methods: A qualitative approach was employed using an open-ended questionnaire. Sixteen stakeholders from governmental and non-governmental agencies participated in the study. The questionnaire focused on the various challenges and facilitating factors facing HIV prevention as well as proposed possible solutions from the perspectives of the participants. The data were analysed using thematic analysis. Results: The study illustrated the similarities in context and HIV prevention systems between Sudan and Yemen. Thematic analysis resulted in three main themes: I) much is achieved despite difficulties; II) a programme left to be paralysed; this theme addressed the main obstacles facing HIV prevention in Sudan and Yemen generating a total of six sub-themes; III) comprehensive change is needed. The participants drew focus and attention to vital changes required to improve the delivery of HIV prevention services. Conclusion: Increased financial support for HIV prevention in Sudan and Yemen is urgently needed. De-stigmatisation and increased political support, advocacy and improved legislation for people living with HIV (PLHIV) are required for the sustainability and effectiveness of HIV prevention programmes in Sudan and Yemen. Civil society organisations must be aided and supported in their role in engaging key populations.

  • 20.
    Baxter, Rebecca
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lövheim, Hugo
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Geriatrik.
    Björk, Sabine
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för hållbar hälsa.
    Sköldunger, Anders
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lindkvist, Marie
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Sjögren, Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Sandman, Per-Olof
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden.
    Bergland, Ådel
    Winblad, Bengt
    Edvardsson, David
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. School of Nursing & Midwifery, La Trobe University, Melbourne, Australia.
    The thriving of older people assessment scale: Psychometric evaluation and short‐form development2019Inngår i: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 75, nr 12, s. 3831-3843Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Aim: To evaluate the psychometric properties and performance of the 32‐item Thriving of Older People Assessment Scale (TOPAS) and to explore reduction into a short‐form.

    Background: The 32‐item TOPAS has been used in studies of place‐related well‐being as a positive measure in long‐term care to assess nursing home resident thriving; however, item redundancy has not previously been explored.

    Design: Cross‐sectional.

    Method: Staff members completed the 32‐item TOPAS as proxy‐raters for a random sample of Swedish nursing home residents (N = 4,831) between November 2013 and September 2014. Reliability analysis, exploratory factor analysis and item response theory‐based analysis were undertaken. Items were systematically identified for reduction using statistical and theoretical analysis. Correlation testing, means comparison and model fit evaluation confirmed scale equivalence.

    Results: Psychometric properties of the 32‐item TOPAS were satisfactory and several items were identified for scale reduction. The proposed short‐form TOPAS exhibited a high level of internal consistency (α=0.90) and strong correlation (r=0.98) to the original scale, while also retaining diversity among items in terms of factor structure and item difficulties.

    Conclusion: The 32‐item and short‐form TOPAS' indicated sound validity and reliability to measure resident thriving in the nursing home context.

    Impact: There is a lack of positive life‐world measures for use in nursing homes. The short‐form TOPAS indicated sound validity and reliability to measure resident thriving, providing a feasible measure with enhanced functionality for use in aged care research, assessments and care planning for health promoting purposes in nursing homes.

  • 21.
    Bergman, Joakim
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för farmakologi och klinisk neurovetenskap, Klinisk neurovetenskap.
    Svenningsson, A.
    Liv, Per
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Burman, J.
    Poor correlation between protein levels in different CNS compartments in patients with progressive MS2019Inngår i: Multiple Sclerosis, ISSN 1352-4585, E-ISSN 1477-0970, Vol. 25, s. 432-433Artikkel i tidsskrift (Annet vitenskapelig)
  • 22.
    Björnebäck, Michaela
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Health care access for rural youths: a qualitative study in Northern Sweden2018Independent thesis Basic level (professional degree), 20 poäng / 30 hpOppgave
  • 23.
    Blomfeldt, Marcus
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Medical students’ views on and attitude towards prevention and health promotion in health care2018Independent thesis Basic level (professional degree), 20 poäng / 30 hpOppgave
  • 24.
    Blomstedt, Yulia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Ng, Nawi
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Boman, Kurt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Research Unit Medicine-Geriatric Clinic, Skellefteå County Hospital, SE-931 86 Skellefteå, Sweden..
    Lönnberg, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Stenlund, Hans
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Wall, Stig
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Flawed conclusions on the Vasterbotten Intervention Program by San Sebastian et .al2019Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, nr 1, artikkel-id 1095Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    An evaluation of Vasterbotten Intervention Programme (VIP) was recently conducted by San Sebastian et al. (BMC Public Health 19:202, 2019). Evaluation of health care interventions of this kind require 1) an understanding of both the design and the nature of the intervention, 2) correct definition of the target population, and 3) careful choice of the appropriate evaluation method. In this correspondence, we review the approach used by San Sebastian et al. as relates to these three criteria. Within this framework, we suggest important explanations for why the conclusions drawn by these authors contradict a large body of research on the effectiveness of the VIP.

  • 25.
    Blåhed, Hanna
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Politics and health outcomes in Sweden: Does voter turnout influence health? A path analysis approach2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Background: Previous studies on politics and health heavily stems from research by Navarro et al and Mackenbach et al. Their findings have shown that political traditions have influenced implementation of health-policies differently, which have had impacts on health outcomes. While previous authors have approached the subject of politics and health by studying political traditions, I wished to examine whether political participation in the shape of voter turnout, had any influence on health. Thus, the objective of this study was to examine if voter turnout was associated to health, and if the labour market, welfare state and the level of socioeconomic inequalities mediated this possible relationship, in the context of Sweden.

    Methods: Aggregated data on county level (in total 21) was used to perform the analysis. Variables used included voter turnout, unemployment, non-eligibility to enter upper secondary school, trust towards health care, the Gini coefficient and the regional GDP per capita. The health outcomes included heart attack rate, overweight and psychosocial distress prevalence. The data was collected between the years of 2014-2018, and retrieved from Statistics Sweden, the Swedish National Agency for Education, the Swedish Association of Local Authorities and Regions, the Public Health Agency of Sweden and the National Board of Health and Welfare. Path analysis, a form of structural equation modelling, was applied and direct, indirect and total effects were calculated in order to establish relationships.

    Results: No relationship was found between voter turnout and health outcomes in the final model. However, associations were observed between unemployment and heart attack both in the female (b = -0.43, p = 0.027) and male population (b = -0.39, p = 0.043). Lack of education, in terms of non-eligibility to enter upper secondary school, was correlated to heart attack among women (b =0.63, p = 0.004) as well as among men (b = 0.65, p = 0.002). Both unemployment and lack of education were mediated by Gini and GDP. Gini and heart attack among women was directly correlated (b =-0.44, p = 0.011), likewise for men (b = -0.48, p = 0.003). Gini was also related to overweight among women (b =-0.50, p = 0.041). GDP showed an association between heart attack among the female (b =-0.40, p = 0.008) and the male population (b = -039, p = 0.006), respectively. Lastly, an observed negative correlation between GDP and overweight in men was detected (b =-0.26, p = 0.001).

    Conclusion: This study concluded that health outcomes are not directly linked to political participation, in terms of voter turnout. Instead, the analysed health outcomes seemed to be mainly associated with unemployment, lack of education, and socioeconomic and income inequalities. Surprisingly, the results showed that unemployment seemed to decrease heart attack among both women and men. However, as lack of education increased, heart attack among women and men increased. It was also unexpected that high income inequalities (Gini) seemed to decrease heart attack among both women and men, as well among overweight women. Further research including sub-analysis, confounders and specific variables is required in order to confirm, or not, these findings.

  • 26.
    Brunström, Mattias
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Ng, Nawi
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden.
    Dahlström, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lindholm, Lars H.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lönnberg, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Norberg, Margareta
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Carlberg, Bo
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Association of Physician Education and Feedback on Hypertension Management With Patient Blood Pressure and Hypertension Control2020Inngår i: JAMA Network Open, ISSN 2574-3805, Vol. 3, nr 1, artikkel-id e1918625Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Importance: Elevated systolic blood pressure (SBP) is the most important risk factor for premature death worldwide. However, hypertension detection and control rates continue to be suboptimal.

    Objective: To assess the association of education and feedback to primary care physicians with population-level SBP and hypertension control rates.

    Design, Setting, and Participants: This pooled series of 108 population-based cohort studies involving 283 079 patients used data from primary care centers in 2 counties (Västerbotten and Södermanland) in Sweden from 2001 to 2009. Participants were individuals aged 18 years or older who had their blood pressure (BP) measured and recorded in either county during the intervention period. All analyses were performed in February 2019.

    Exposures: An intervention comprising education and feedback for primary care physicians in Västerbotten County (intervention group) compared with usual care in Södermanland County (control group).

    Main Outcomes and Measures: Difference in mean SBP levels between counties and likelihood of hypertension control in the intervention county compared with the control county during 24 months of follow-up.

    Results: A total of 136 541 unique individuals (mean [SD] age at inclusion, 64.6 [16.1] years; 57.0% female; mean inclusion BP, 142/82 mm Hg) in the intervention county were compared with 146 538 individuals (mean [SD] age at inclusion, 65.7 [15.9] years; 58.3% female; mean inclusion BP, 144/80 mm Hg) in the control county. Mean SBP difference between counties during follow-up, adjusted for inclusion BP and other covariates, was 1.1 mm Hg (95% CI, 1.0-1.1 mm Hg). Hypertension control improved by 8.4 percentage points, and control was achieved in 37.8% of participants in the intervention county compared with 29.4% in the control county (adjusted odds ratio, 1.30; 95% CI, 1.29-1.31). Differences between counties increased during the intervention period and were more pronounced in participants with higher SBP at inclusion. Results were consistent across all subgroups.

    Conclusions and Relevance: This study suggests that SBP levels and hypertension control rates in a county population may be improved by educational approaches directed at physicians and other health care workers. Similar strategies may be adopted to reinforce the implementation of clinical practice guidelines for hypertension management.

  • 27.
    Burgos Macías, D. I.
    et al.
    Technical University of Manabí (UTM), Av. Urbina y Che Guevara, EC 130103, Portoviejo, Ecuador.
    Pérez Ruano, Miguel
    Agricultural University of Havana (UNAH), Carretera de Jamaica y Autopista Nacional, Apartado 18, San José de las Lajas, Mayabeque, Cuba.
    Bulnes Goicochea, Carlos A.
    Technical University of Manabí (UTM), Av. Urbina y Che Guevara, EC 130103, Portoviejo, Ecuador.
    Zambrano Aguayo, M.D.
    Technical University of Manabí (UTM), Av. Urbina y Che Guevara, EC 130103, Portoviejo, Ecuador.
    Sandoval Valencia, H.P.
    Laboratories of the Animal Diagnostics Directorate, Av. Interoceánica Km 14 1/2 y González Suárez, Sector La Granja, Tumbaco, Quito, Ecuador.
    Falconí Flores, M.A.
    Laboratories of the Animal Diagnostics Directorate, Av. Interoceánica Km 14 1/2 y González Suárez, Sector La Granja, Tumbaco, Quito, Ecuador.
    Vera Loor, L.
    Ecuadorian Agency for Agriculture Quality Assurance (AGROCALIDAD), Manabí, Ecuador.
    Revelo Ruales, A.P.
    National Institute of Public Health Research (INSPI), Av. Huayna Capac 1–212 and Pisar Capac, Cuenca 010104, Ecuador.
    Fonseca Rodriguez, Osvaldo
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Determination of the seroprevalence of Leptospira spp. and the main serovars circulating in cattle in the province of Manabí, Ecuador2019Inngår i: Revue scientifique et technique (International Office of Epizootics), ISSN 0253-1933, Vol. 38, nr 3, artikkel-id 14032019-00143-ESArtikkel i tidsskrift (Fagfellevurdert)
  • 28.
    Burlac, Mihaela
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Health economic evaluation: Cost-Effectiveness Analysis of Antenatal Obesity Prevention Program among Children in Sweden. A Markov model.2019Independent thesis Advanced level (degree of Master (Two Years)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Background: A hypothetical antenatal obesity prevention program was developed, consisting of a 5-day workshop led by a licensed psychologist, nutritionist and a trained nurse. The goals of the program were to train volunteer midwives on how properly provide the future mothers with reliable information needed in order to promote healthy behaviors, such as the importance of physical activities during pregnancy and after, breastfeeding, and healthy eating. Hence, it will bring a positive effect on the lifestyle of children.

    Objectives: To perform a cost-effectiveness analysis of implementing antenatal obesity prevention program among children in Sweden against no-intervention using a health care perspective with a time horizon of 15 years.

    Methodology: A Markov model based cost-effectiveness analysis method was used for the study’s purpose. Data was obtained from various sources previously published from Sweden, US, UK, Australia and Germany. A hypothetical cohort of 1000 children were used to stimulate moving between four health states, such as normal weight, overweight, obese and death state in order to estimate the possible health outcomes of the intervention. Incremental cost-effectiveness ratios (ICERs) were calculated revealing the intervention cost per cases of obesity averted, and cost per quality adjusted life years gained (QALYs).

    Results: The antenatal obesity prevention program provides additional 0.02 cases of obesity averted, and 0.05 QALYs gained at an additional cost of 3,741.92 $ when compared with no-intervention. According to the analysis, the ICER calculated as the cost per cases of obesity averted is 187,096.00 $, and the ICER calculated as cost per QALYs gained is 74,838.40$.

    Conclusion: The cost-effective analysis of the antenatal obesity prevention program shows no significant health benefits compared with no-intervention, so that we can state that the program is not cost-effective.

  • 29.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Correlation between noncommunicable disease mortality in people aged 30-69 years and those aged 70-89 years2019Inngår i: Bulletin of the World Health Organization, ISSN 0042-9686, E-ISSN 1564-0604, Vol. 97, nr 9, s. 589-596Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: To investigate whether the key metric for monitoring progress towards sustainable development goal target 3.4 that is measuring premature noncommunicable disease mortality (deaths among people aged 30-69 years), is ageist.

    Methods: To examine the relationship between premature noncommunicable disease mortality and noncommunicable disease mortality in older people, a database of mortality rates for cardiovascular disease, cancer, chronic obstructive pulmonary disease and diabetes in people aged 30 to 69 years and 70 to 89 years was compiled using estimates from the Global Burden of Disease Study 2017. The data covered 195 countries, six time-points and both sexes, giving 2340 instances. The World Health Organization's (WHO's) life-table method for the premature noncommunicable disease mortality metric was applied to the data.

    Findings: There was a strong correlation between noncommunicable disease mortality patterns in the premature and older age groups, which suggests that measuring premature noncommunicable disease mortality is informative about such mortality in later life. Neither time nor geographical location had a substantial effect on this correlation. However, there were female-to-male differences in age-specific probabilities of death due to noncommunicable disease, implying that noncommunicable disease mortality should be assessed using a sex-disaggregated approach.

    Conclusion: As the established WHO metric for premature noncommunicable disease mortality was predictive of noncommunicable disease mortality in older people, the metric should not be construed as ageist Focusing resources on measuring premature noncommunicable disease mortality will be appropriate, particularly in settings without universal civil death registration. This approach should not prejudice the provision of health services throughout the life-course.

  • 30.
    Byass, Peter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa.
    Hussain-Alkhateeb, Laith
    D'Ambruoso, Lucia
    Clark, Samuel
    Davies, Justine
    Fottrell, Edward
    Bird, Jon
    Kabudula, Chodziwadziwa
    Tollman, Stephen M.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa; INDEPTH Network, Accra, Ghana.
    Schiöler, Linus
    Petzold, Max
    An integrated approach to processing WHO-2016 verbal autopsy data: the InterVA-5 model2019Inngår i: BMC Medicine, ISSN 1741-7015, E-ISSN 1741-7015, Vol. 17, artikkel-id 102Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Verbal autopsy is an increasingly important methodology for assigning causes to otherwise uncertified deaths, which amount to around 50% of global mortality and cause much uncertainty for health planning. The World Health Organization sets international standards for the structure of verbal autopsy interviews and for cause categories that can reasonably be derived from verbal autopsy data. In addition, computer models are needed to efficiently process large quantities of verbal autopsy interviews to assign causes of death in a standardised manner. Here, we present the InterVA-5 model, developed to align with the WHO-2016 verbal autopsy standard. This is a harmonising model that can process input data from WHO-2016, as well as earlier WHO-2012 and Tariff-2 formats, to generate standardised cause-specific mortality profiles for diverse contexts.

    The software development involved building on the earlier InterVA-4 model, and the expanded knowledge base required for InterVA-5 was informed by analyses from a training dataset drawn from the Population Health Metrics Research Collaboration verbal autopsy reference dataset, as well as expert input.

    Results: The new model was evaluated against a test dataset of 6130 cases from the Population Health Metrics Research Collaboration and 4009 cases from the Afghanistan National Mortality Survey dataset. Both of these sources contained around three quarters of the input items from the WHO-2016, WHO-2012 and Tariff-2 formats. Cause-specific mortality fractions across all applicable WHO cause categories were compared between causes assigned in participating tertiary hospitals and InterVA-5 in the test dataset, with concordance correlation coefficients of 0.92 for children and 0.86 for adults.

    The InterVA-5 model’s capacity to handle different input formats was evaluated in the Afghanistan dataset, with concordance correlation coefficients of 0.97 and 0.96 between the WHO-2016 and the WHO-2012 format for children and adults respectively, and 0.92 and 0.87 between the WHO-2016 and the Tariff-2 format respectively.

    Conclusions: Despite the inherent difficulties of determining “truth” in assigning cause of death, these findings suggest that the InterVA-5 model performs well and succeeds in harmonising across a range of input formats. As more primary data collected under WHO-2016 become available, it is likely that InterVA-5 will undergo minor re-versioning in the light of practical experience. The model is an important resource for measuring and evaluating cause-specific mortality globally.

  • 31.
    Byass, Peter
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Ng, Nawi
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Wall, Stig
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Nurturing Global Health Action through its first decade2019Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, nr 1, artikkel-id 1569847Artikkel i tidsskrift (Fagfellevurdert)
  • 32.
    Byskov, Jens
    et al.
    University of Zambia.
    Maluka, Stephen A.
    University of Dar Es Salaam, Tanzania.
    Marchal, Bruno
    Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium.
    Shayo, Elizabeth H.
    National Institute for Medical Research (NIMR), Dar Es Salaam, Tanzania.
    Blystad, Astrid
    Department of Global Health and Primary Care, University of Bergen, Norway.
    Bukachi, Salome
    Institute of Anthropology, Gender and African Studies University of Nairobi, Nairobi, Kenya.
    Zulu, Joseph M.
    School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia.
    Michelo, Charles
    School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Bloch, Paul
    Steno Diabetes Center Copenhagen, Niels Steensens Vej 6, Gentofte, Denmark.
    A systems perspective on the importance of global health strategy developments for accomplishing today’s Sustainable Development Goals2019Inngår i: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 34, nr 9, s. 635-645Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise and preferences. Based on a historical account, this article analyses if contemporary health systems are appropriate to optimize population health within the framework of cross cutting targets of the Sustainable Development Goals (SDGs). We applied a scoping review approach to identify and review literature of scientific databases and other programmatic web and library-based documents on historical and contemporary health systems policies and strategies at the global level. Early literature supported the 1977 launching of the global target of Health for All by the year 2000. Reviewed literature was used to provide a historical overview of systems components of global health strategies through describing the conceptualizations of health determinants, user involvement and mechanisms of priority setting over time, and analysing the importance of historical developments on barriers and opportunities to accomplish the SDGs. Definitions, scope and application of health systems-associated priority setting fluctuated and main health determinants and user influence on global health systems and priority setting remained limited. In exploring reasons for the identified lack of SDG-associated health systems and priority setting processes, we discuss issues of accountability, vested interests, ethics and democratic legitimacy as conditional for future sustainability of population health. To accomplish the SDGs health systems must engage beyond their own sector boundary. New approaches to Health in All Policies and One Health may be conducive for scaling up more democratic and inclusive priority setting processes based on proper process guidelines from successful pilots. Sustainable development depends on population preferences supported by technical and managerial expertise.

  • 33.
    Bölenius, Karin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Lämås, Kristina
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Sandman, Per-Olof
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Division of Caring Sciences, Depart Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden..
    Lindkvist, Marie
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik. Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Edvardsson, David
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. School of Nursing and Midwifery, La Trobe University, Melbourne, Australia..
    Perceptions of self-determination and quality of life among Swedish home care recipients - across-sectional study2019Inngår i: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 19, artikkel-id 142Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: It is acknowledged that preservation of self-determination is very important in order for older adults to experience good quality of life, but to what degree and in what areas people receiving help from home care service experience self-determination is unknown. Few studies have examined the perception of self-determination in relation to quality of life among older adults living at home with help from home care services. Thus, the aim of this study was to explore perceptions of self-determination among older adults living at home with the support of home care services, and to test whether older adults who perceive a higher degree of self-determination also feel they have a better quality of life.

    Methods: This cross-sectional study was conducted in one municipality in northern Sweden. A total of 134 older adults (≥ 65 years) were included. Data were collected by means of a survey including questionnaires about background characteristics, self-determination, and health-related quality of life. Descriptive statistics regarding background characteristics for groups with high and low self-determination respectively were presented and the differences between the groups were analyzed using the Chi-square test and the Mann-Whitney U test.

    Results: Our main finding shows that the majority of older adults with support from home care services experience self-determination in the dimensions use of time, and self-care. However, a wide variation was found in self-reported self-determination in all dimensions. Results also show that the group with higher self-reported self-determination also reported a greater degree of experienced quality of life in comparison with the group with lower self-reported self-determination.

    Conclusions: In line with earlier research, our results found a positive relation between self-determination and quality of life. The results are relevant for the care of older adults and indicate a need of further research. The results presented in this paper could serve as a guide when planning for improved self-determination among older adults in home care service.

  • 34. Capasso, Ariadna
    et al.
    Ompad, Danielle C.
    Vieira, Dorice L.
    Wilder-Smith, Annelies
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.
    Tozan, Yesim
    Incidence of Guillain-Barre Syndrome (GBS) in Latin America and the Caribbean before and during the 2015-2016 Zika virus epidemic: A systematic review and meta-analysis2019Inngår i: PLoS Neglected Tropical Diseases, ISSN 1935-2727, E-ISSN 1935-2735, Vol. 13, nr 8, artikkel-id e0007622Artikkel, forskningsoversikt (Fagfellevurdert)
    Abstract [en]

    Background: A severe neurological disorder, Guillain-Barré syndrome (GBS) is the leading cause of acute flaccid paralysis. Enhanced surveillance of GBS in Latin America and the Caribbean (LAC) following the 2015–2016 Zika virus (ZIKV) epidemic presents an opportunity to estimate, for the first time, the regional incidence of GBS.

    Methods and findings: For this systematic review and meta-analysis, we searched nine scientific databases and grey literature from January 1, 1980 to October 1, 2018. Sources with primary data on incident GBS cases in LAC within a well-defined population and timeframe, published in English, Spanish, Portuguese, or French, were included. We calculated the annual GBS incidence rates (IRs) and 95% confidence intervals (CIs) for each source based on published data. Following an assessment of heterogeneity, we used random-effects meta-analysis to calculate the pooled annual IR of GBS. The study is registered with PROSPERO, number CRD42018086659. Of the 6568 initial citation hits, 31 were eligible for inclusion. Background annual GBS IRs in Latin America ranged from 0.40 in Brazil to 2.12/100,000 in Chile. The pooled annual IR in the Caribbean was 1.64 (95% CI 1.29–2.12, I2<0.01, p = 0.44). During the ZIKV epidemic, GBS IRs ranged from 0.62 in Mexico to 9.35/100,000 in Martinique. GBS increased 2.6 (95% CI 2.3–2.9) times during ZIKV and 1.9 (95% CI 1.1–3.4) times during chikungunya outbreaks over background rates. A limitation of this review is that the studies included employed different methodologies to find and ascertain cases of GBS, which could contribute to IR heterogeneity. In addition, it is important to consider that data on GBS are lacking for many countries in the region.

    Conclusions: Background IRs of GBS appear to peak during arboviral disease outbreaks. The current review contributes to an understanding of the epidemiology of GBS in the LAC region, which can inform healthcare system planning and preparedness, particularly during arboviral epidemics.

  • 35.
    Carson, Dean B.
    et al.
    Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum). Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Sweden Centre for Rural Medicine (GMC), Storuman, Sweden.
    Lundmark, Linda
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för geografi. Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum).
    Carson, Doris A.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för geografi. Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum).
    The Continuing Advance and Retreat of Rural Settlement in the Northern Inland of Sweden2019Inngår i: Journal of Northern Studies, ISSN 1654-5915, Vol. 13, nr 1, s. 7-33Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    In 1960, a range of leading rural geographers started a debate about population development and the “advance and retreat” of human settlement in sparsely populated rural areas, including in the inland north of Sweden. In what came to be known as the “Siljan Symposium,” they identified a number of key themes in relation to migration and human mobility that were thought to determine settlement patterns in the inland north, including: internal migration and urbanisation of populations; the role of simultaneous in- and out-migration in re-shaping settlement patterns; redistribution of rural populations through return migration and international migration; and changing preferences for settlement in different northern “zones” based on the methods for exploiting natural resources for agriculture, forestry, mining and energy production. This paper re-visits the main themes from the 1960 Siljan Symposium and examines Swedish register data to identify how migration patterns and the resulting “advance and retreat” of human settlement have changed across the inland of Västerbotten and Norrbotten. The results suggest that, while general urban-rural and regional- local settlement patterns appear to have been relatively consistent, new forms of migration (including internal, return and international) with different preferences for rural settlement emerging in different localities as a result of both persistent (mining, forestry, energy) and changing (tourism, lifestyle) values of natural resources. We also observe substantial differences in migration and urbanisation rates between Norrbotten and Västerbotten. The paper then discusses how the persistence and discontinuity of experiences over the past decades may provide insights into the potential future patterns of northern settlement.

  • 36.
    Cheik, Aung Khun
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Is women empowerment important for maternal health care seeking practice in Myanmar?: A cross sectional study2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Introduction: Women in low and middle-income countries are often vulnerable in their sexual and reproductive health. Women empowerment has been highlighted in many studies as important for better sexual and reproductive health outcomes. However, even if many studies have examined the relationship between women empowerment and maternal health care seeking practice in the developing world, this issue rarely has been studied in the context of Myanmar. The aim of this research thus is to examine the association between women empowerment and skilled birth attendance in Myanmar.

    Methods: In this study, data comes from the cross-sectional Myanmar Demographic and Health Survey carried out in 2015-2016, which is a nationally representative survey covering demographic and health-related characteristics in Myanmar. The analytical sample included 3,617 women aged 15-49 years who had given birth in last five years, selecting from a total number of 12,885 women aged 15-49 years. The ability for women to decide jointly with partner or independently over health care utilization was used as an indicator of women empowerment while delivery care by skilled birth attendant was used as a measure of maternal health care seeking practice. Odds Ratio was used in logistic regression analyses to study the association between indicator of women empowerment and skilled birth attendance in Myanmar.

    Results: Results from the univariate logistic regression indicated that women with higher levels of empowerment had a 1.62 times (95% CI=1.27-2.06) higher odds of having skilled birth attendance, compared to women with less empowerment. After adjusting for potential confounders such as women and partner education, women age group, area of residence, in a multivariate logistic regression analysis, the results still showed that women with higher levels of empowerment had a 1.44 times (95% CI=1.11-1.87) higher odds of having skilled birth attendance, compared to women with less empowerment.

    Conclusion: Our findings suggest that women empowerment might be important to obtain birth attendance from a skilled professional in Myanmar. This result remained even after controlling for known social- and sociodemographic characteristic. Policies and health promotion programs working to expand the utilization of skilled birth attendants should consider women empowerment as a potentially important factor. For example, school education about association of womeniiiempowerment and maternal health outcome would be bargained investment for future generation.

  • 37.
    Cholponkulova, Asel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Job Insecurity effects on health: EQ-5D based survey on health-related quality of life2018Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Background: Due to the rising financialization of the global economy in the recent decades (including Sweden’s 3 financial crises in 1992, 2000 and 2008) job insecurity is increasing even for highly educated groups and high-income countries.

    Aim: to measure how job insecurity is associated with health-related quality of life, with a focus on the effect on subgroups, divided by age, gender, education, marital status and previous health.

    Methods: Health effects were measured by a cross-sectional survey among 967 respondents (38.7% response rate), aged 20-64, who were registered in Sweden. Questionnaire included demographic background (age, education, marital status), health status, job-insecurity exposure, and EQ-D5 instrument with 5 dimensions of health-related quality of life: mobility, self-care, usual activities, pain and discomfort, and anxiety and depression. Statistical analysis was done by multiple logistic regression.

    Results: of the 967 respondents 808 were included into analysis. The individuals with job insecurity had significantly higher problems with usual activities (OR= 2.78, CI= 1.47-5.28, p = 0.002), anxiety and depression (OR 2.36, CI= 1.52-3.66, p= 0.000), and pain and discomfort (OR= 1.67, CI= 1.06-2.61, p= 0.024). In stratified results, poorer health was found for groups of women, middle aged, primary school graduates, living with a partner, and with previous bad health.

    Conclusion: Results show that physical and especially mental health are both affected negatively by job insecurity. Research considerations: further country level and cross-country comparative research, with labor policies, unemployment insurance coverage, level of financialization, level of voter financial literacy, could help to explain wide differences in previous results (especially between US, Germany and Sweden), and to shape better integrated labor, health, fiscal and monetary policy.

  • 38. Coates, Matthew M.
    et al.
    Kamanda, Mamusu
    Kintuc, Alexander
    Arikpo, Iwara
    Chauque, Alberto
    Mengesha, Melkamu Merid
    Price, Alison J.
    Sifuna, Peter
    Wamukoya, Marylene
    Sacoor, Charfudin N.
    Ogwang, Sheila
    Assefa, Nega
    Crampin, Amelia C.
    Macete, Eusebio, V
    Kyobutungi, Catherine
    Meremikwu, Martin M.
    Otieno, Walter
    Adjaye-Gbewonyo, Kafui
    Marx, Andrew
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Sankoh, Osman
    Bukhman, Gene
    A comparison of all-cause and cause-specific mortality by household socioeconomic status across seven INDEPTH network health and demographic surveillance systems in sub-Saharan Africa2019Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, nr 1, artikkel-id 1608013Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

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

  • 39. Cook, Caylee J.
    et al.
    Howard, Steven J.
    Scerif, Gaia
    Twine, Rhian
    Kahn, Kathleen
    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, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Norris, Shane A.
    Draper, Catherine E.
    Associations of physical activity and gross motor skills with executive function in preschool children from low-income South African settings2019Inngår i: Developmental Science, ISSN 1363-755X, E-ISSN 1467-7687, Vol. 22, nr 5, s. 1-13, artikkel-id e12820Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Executive function is foundational for cognitive development. Previous research has shown both gross motor skills and physical activity to be related to executive function. However, evidence for these relationships in the preschool years, as well as in low- and middle-income countries is lacking. Therefore, this study aimed to investigate the relationships between components of executive function (inhibition, shifting and working memory) and gross motor skills (locomotor skills and object control skills) in a sample of preschool children from urban and rural low-income settings in South Africa. Results revealed that inhibition and working memory, but not shifting, were associated with gross motor skills. More specifically: inhibition was associated with both locomotor [beta = 0.20, p = 0.047] and object control skills [beta = 0.24, p = 0.024], whereas working memory was only associated with locomotor skills [beta = 0.21, p = 0.039]. Physical activity was not associated with inhibition and shifting but was negatively associated with working memory. These results elaborate a growing evidence base linking executive function and gross motor skills in the early years, and it is the first to look at specific associations of locomotor and object control skills with executive function in the South African context (a low- and middle-income country).

  • 40.
    Coronado, Liani
    et al.
    Centro Nacional de Sanidad Agropecuaria (CENSA), OIE Collaborating Centre for Diagnosis and Risk Analysis of the Caribbean Region, La Habana 32700, Cuba.
    Rios, Liliam
    University of New Brunswick, Reiman Cancer Research Laboratory, Faculty of Medicine, Saint John, NB, E2L 4L5 Canada.
    Frías, María Teresa
    Centro Nacional de Sanidad Agropecuaria (CENSA), OIE Collaborating Centre for Diagnosis and Risk Analysis of the Caribbean Region, La Habana 32700, Cuba.
    Amarán, Laymara
    National Laboratory for Veterinary Diagnostic (NLVD), Avenida 51 No. 33 222, Arroyo Arenas, La Lisa, La Habana, Cuba.
    Naranjo, Paula
    Veterinary Medicine Institute, Havana, Cuba.
    Percedo, María Irian
    Centro Nacional de Sanidad Agropecuaria (CENSA), OIE Collaborating Centre for Diagnosis and Risk Analysis of the Caribbean Region, La Habana 32700, Cuba.
    Perera, Carmen Laura
    Centro Nacional de Sanidad Agropecuaria (CENSA), OIE Collaborating Centre for Diagnosis and Risk Analysis of the Caribbean Region, La Habana 32700, Cuba.
    Prieto, Felix
    National Laboratory for Veterinary Diagnostic (NLVD), Avenida 51 No. 33 222, Arroyo Arenas, La Lisa, La Habana, Cuba.
    Fonseca Rodriguez, Osvaldo
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Perez, Lester J
    University of Illinois, College of Veterinary Science, Department of Clinical Veterinary Medicine, Urbana, Illinois, 61802 United States.
    Positive selection pressure on E2 protein of classical swine fever virus drives variations in virulence, pathogenesis and antigenicity: implication for epidemiological surveillance in endemic areas2019Inngår i: Transboundary and Emerging Diseases, ISSN 1865-1674, E-ISSN 1865-1682, Vol. 66, nr 6, s. 2362-2382Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Classical swine fever (CSF), caused by CSF virus (CSFV), is considered one of the most important infectious diseases with devasting consequences for the pig industry. Recent reports describe the emergence of new CSFV-strains resulting from the action of positive selection pressure, due mainly to the bottleneck effect generated by ineffective vaccination. Even though a decrease in the genetic diversity of the positive selected CSFV-strains has been observed by several research groups, there is little information about the effect of this selective force on the virulence degree, antigenicity and pathogenicity of this type of strains. Hence, the aim of the current study was to determine the effect of the positive selection pressure on these three parameters of CSFV-strains, emerged as result of the bottleneck effects induced by unproper vaccination in a CSF-endemic area. Moreover, the effect of the positive selected strains on the epidemiological surveillance system was assessed. By the combination of in vitro, in vivo and immunoinformatic approaches we revealed that the action of the positive selection pressure induces a decrease in virulence and alteration in pathogenicity and antigenicity. However, we also noted that the evolutionary process of CSFV, especially in segregated microenvironments, could contribute to the gain-fitness event, restoring the highly virulent pattern of the circulating strains. Besides, we denoted that the presence of low virulent strains selected by bottleneck effect after inefficient vaccination can lead to a relevant challenge for the epidemiological surveillance of CSF, contributing to under-reports of the disease, favoring the perpetuation of the virus in the field. In this study B-cell and CTL epitopes on the E2 3D-structure model were also identified. Thus, the current study provides novel and significant insights into variation in virulence, pathogenesis and antigenicity experienced by CSFV strains after the positive selection pressure effect.

  • 41.
    Das, Shuchesmita
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Expansion In Digital Mental Health Application- Are Interventions Evidence Based? What Is In Store For Health Technology Assessment?2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
  • 42.
    De Fuentes, Susana Daniela
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    “We must treat intimate partner violence like we treat diabetes”: Exploring Spanish nurses’ perceptions on their role in responding to intimate partner violence.2019Independent thesis Advanced level (degree of Master (One Year)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Introduction: Intimate Partner violence (IPV) affects 1 in 5 women around the world. It has devastating effects on all aspects of women’s lives, as well as on their children and families, and it has a significant cost to society. IPV victims need access to supportive care services. However, the number of IPV cases handled in the Spanish healthcare system is low despite measures that have been taken to improve this. With nurses being of the most accessible of front-line healthcare professionals, it is important to discover how they view their role in relation to IPV. This may inform those in healthcare leadership positions on how to adapt the health system to improve the services provided to IPV victims.

    Methods: Thematic analysis was used to analyse 12 in-depth interviews of primary health care nurses in the regions of Murcia, Castilla-La Mancha, and Cantabria. The interviews covered the topics of perceptions on the primary healthcare team’s response to IPV, how IPV had been merged into teamwork, relationships within teams, and the different degrees of individual involvement in IPV. The ecological systems model was used to explain the findings.

    Results: One overarching theme and three main themes were developed during the data analysis. The overarching theme “Responding to IPV is a personal choice” describes how responding or not to IPV is up to each nurse. The theme “Nurses ideology and professional style” observes how individual views on IPV along with each nurse’s professional approach influence the way nurses perceive their role in responding to IPV. The theme “Health system factors” illustrates how decisions made at health system level have an effect on nurses’ perception of their role. The final theme “Social values” is about how societal values affect nurses’ perception of their role. The combination of factors from each of those main themes affects nurses’ perception of their role which in turn can make them more likely to either respond or not to IPV.

    Conclusion: This study explains how nurses’ decision to respond or not to IPV is closely related to the interplay between social values, health system factors and nurses' ideology and professional style.

  • 43.
    Degerlund Maldi, Kinza
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    A cost-effectiveness analysis of ketamine for treatment resistant depression2019Independent thesis Advanced level (degree of Master (Two Years)), 10 poäng / 15 hpOppgave
  • 44.
    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 indicators2019Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, artikkel-id 197Artikkel i tidsskrift (Fagfellevurdert)
    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

  • 45.
    Dong, Xiaowei
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Understanding the mechanisms between visual impairment and depression: A mediation analysis among Chinese older adults2019Independent thesis Advanced level (degree of Master (Two Years)), 10 poäng / 15 hpOppgave
    Abstract [en]

    Background: The association of visual impairment with mental disorder has been investigated in some high-income countries. However, this relationship was not clear among Chinese population. Besides, the underlying mechanisms remain unclear. Hence, the aim of this study was to investigate the association between these two health conditions among Chinese older adults, and further examine the contribution of material, psychosocial and behavioural factors (based on the aetiological pathways model) in the explanation of the association.

    Method: The cross-sectional study was based on the data of Chinese older adults in the WHO Study on Global AGEing and Adult Health (SAGE). A total of 11531 individuals aged 50 or above were included in the analysis. Visual impairment was measured by vision acuity at examination. Depression was measured by the SAGE questionnaire adapted from the ICD-10 diagnostic criteria. Multivariate logistic regression was performed. Mediation analyses using inverse odds ratio weighting (IORW) were conducted to assess the mediating role of three pathways consisting of material (i.e. wealth quintile and perceived income adequacy), behavioural (i.e. leisure activity, sleep and body mass index), and psychosocial (i.e. social participation, trust, and safety). Self-reported vision was used in a sensitivity analysis to compare with objective visual acuity.

    Results: There was a significant association between visual impairment (assessed by visual acuity) and depression controlling for age, sex and multimorbidities. The association was attenuated substantially after accounting for material, behavioural and psychosocial factors and became insignificant. Material factors contributed most to the total effect, with wealth quintile and perceived income adequacy explaining 31.7% of total effect. The proportion of total effect which was mediated by psychosocial factors was 24.2%. Behavioural factors also mediated 22.5% of the total effect between visual impairment and depression. When these three mediators were considered together in the full model, they accounted for 43.5% of the total effect between visual impairment and depression.

    Conclusion: Visual impairment in old age is a significant predictor for late-life depression. About 44% of the effects of visual impairment on depression are mediated by material, behavioural and psychosocial factors, making them a point of entry to intervention. Public health programme addressing these mediators could be developed to alleviate the effects of visual impairment on depression.

  • 46. Draper, Catherine E.
    et al.
    Tomaz, Simone A.
    Jones, Rachel A.
    Hinkley, Trina
    Twine, Rhian
    Kahn, Kathleen
    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, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Norris, Shane A.
    Cross-sectional associations of physical activity and gross motor proficiency with adiposity in South African children of pre-school age2019Inngår i: Public Health Nutrition, ISSN 1368-9800, E-ISSN 1475-2727, Vol. 22, nr 4, s. 614-623Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: The study aimed to investigate the relationship between physical activity, gross motor skills and adiposity in South African children of pm-school age.

    Design: Cross-sectional study.

    Setting: High-income urban, and low-income urban and rural settings in South Africa.

    Participants: Children (3-6 years old, n 268) were recruited from urban high-income (n 46), urban low-income (n 91) and rural low-income (n 122) settings. Height and weight were measured to calculate the main outcome variables: BMI and BMI-for-age Z-score (BAZ). Height-for-age and weight-for-age Z-scores were also calculated. Actigraph GT3X+ accelerometers were used to objectively measure physical activity; the Test of Gross Motor Development (Version 2) was used to assess gross motor skills.

    Results: More children were overweight/obese and had a higher BAZ from urban low-income settings compared with urban high-income settings and rural low-income settings. Being less physically active was associated with thinness, but not overweight/obesity. Time spent in physical activity at moderate and vigorous intensities was positively associated with BMI and BAZ. Gross motor proficiency was not associated with adiposity in this sample.

    Conclusions: The findings of this research highlight the need for obesity prevention particularly in urban low-income settings, as well as the need to take into consideration the complexity of the relationship between adiposity, physical activity and gross motor skills in South African pre-school children.

  • 47. Dubouis, Ghislain
    et al.
    Sovacool, Benjamin
    Aall, Carlo
    Nilsson, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Barbier, Carine
    Herrmann, Alina
    Bruyère, Sébastien
    Andersson, Camilla
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper.
    Sköld, Bore
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Nadaud, Franck
    Dorner, Florian
    Moberg, Karen Richardsen
    Ceron, Jean Paul
    Fischer, Helen
    Amelung, Dorothee
    Baltruszewicz, Marta
    Fischer, Jeremy
    Benevise, Françoise
    Valerie, Valérie R
    Sauerborn, Rainer
    It starts at home? Climate policies targeting household consumption and behavioral decisions are key to low-carbon futures2019Inngår i: Energy Research & Social Science, ISSN 2214-6296, E-ISSN 2214-6326, Vol. 52, s. 144-158Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Through their consumption behavior, households are responsible for 72% of global greenhouse gas emissions. Thus, they are key actors in reaching the 1.5°C goal under the Paris Agreement. However, the possible contribution and position of households in climate policies is neither well understood, nor do households receive sufficiently high priority in current climate policy strategies. This paper investigates how behavioral change can achieve a substantial reduction in greenhouse gas emissions in European high-income countries. It uses theoretical thinking and some core results from the HOPE research project, which investigated household preferences for reducing emissions in four European cities in France, Germany, Norway and Sweden. The paper makes five major points: First, car and plane mobility, meat and dairy consumption, as well as heating are the most dominant components of household footprints. Second, household living situations (demographics, size of home) greatly influence the household potential to reduce their footprint, even more than country or city location. Third, household decisions can be sequential and temporally dynamic, shifting through different phases such as childhood, adulthood, and illness. Fourth, short term voluntary efforts will not be sufficient by themselves to achieve the drastic reductions needed to achieve the 1.5°C goal; instead, households need a regulatory framework supporting their behavioral changes. Fifth, there is a mismatch between the roles and responsibilities conveyed by current climate policies and household perceptions of responsibility. We then conclude with further recommendations for research and policy.

  • 48. Díaz-Sánchez, Adrian Alberto
    et al.
    Meli, Marina L.
    Obregón Álvarez, Dasiel
    Fonseca Rodriguez, Osvaldo
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Cabezas-Cruz, Alejandro
    Hofmann-Lehmann, Regina
    Corona-González, Belkis
    Development and application of a multiplex TaqMan® real-time qPCR assay for the simultaneous detection of anaplasma marginale and theileria annulata and molecular characterization of anaplasma marginale from cattle in Western Cuba."/>2019Inngår i: Ticks and Tick-borne Diseases, ISSN 1877-959X, E-ISSN 1877-9603Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Anaplasmosis and theileriosis are considered the most important tick-borne diseases for livestock production worldwide, causing significant economic losses in tropical and subtropical regions. The present study was aimed to develop a multiplex TaqMan® qPCR assay to simultaneously detect Anaplasma marginale and Theileria annulata and to applied it to investigate naturally infected cattle in Cuba. The assay was highly specific, sensible, and efficient; it was more sensitive than a well-established nested PCR and detected 1 DNA copy of each target. Consistent repeatability and reproducibility within and between multiplex qPCR runs was shown. A total of 223 blood samples collected in western Cuba were analyzed for haemoparasites infection in cattle. The multiplex qPCR assay detected A. marginale in 213 samples (95.5%; CI: 95%; 91.9%–97.5%), but all samples were negative for T. annulata. Additionally, the genetic diversity of A. marginale was assessed using 16S rRNA, MSP1a and MSP4 nucleotide and protein sequences. The MSP1a tandem repeats ranged from three to five, and twelve different MSP1a tandem repeats of A. marginale were found, which presented genotypes C, E, and G in the 5ʹUTR microsatellite region. Phylogenetic analysis using the msp4 gene showed that Cuban strains were closely related to others previously reported in Mexico, Brazil and Asian countries. The multiplex qPCR described here proved to be a rapid, specific and cost-effective mean for the simultaneous detection of A. marginale and T. annulata. Further epidemiological studies using this assay will improve the surveillance of the associated diseases in regions where they are endemic.

  • 49. Edem, Idara J.
    et al.
    Dare, Anna J.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    D'Ambruoso, Lucia
    Kahn, Kathleen
    Leather, Andy J. M.
    Tollman, Stephen
    Whitaker, John
    Davies, Justine
    External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study2019Inngår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, nr 6, artikkel-id e027576Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies.

    Setting: Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa.

    Participants: Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals.

    Methods: A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the ‘three delays framework’ (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs—a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care.

    Results: Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems.

    Conclusions: A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

  • 50.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    "Cheaper and better": an economic analysis of changing first line treatment for cutaneous leishmaniasis in BoliviaManuskript (preprint) (Annet vitenskapelig)
    Abstract [en]

    Introduction: Cutaneous leishmaniasis (CL) is endemic in Bolivia, mostly affecting poor people in rainforest areas. The current first-line treatment consists of systemic pentavalent antimonials (SPA) for 20 days and is paid for by the Ministry of Health (MoH). Long periods of drug shortages, a lack of conditions to deliver treatment safely, treatment interruption are challenges to implementation. Intralesional pentavalent antimonials (ILPA) are an alternative to SPA. This study aims to compare the cost of ILPA and SPA, and to estimate the health and economic impacts of changing the first-line treatment for CL in an endemic area of Bolivia.

    Methods: The cost per patient treated was estimated for SPA and ILPA from the perspectives of the MoH and society. The quantity and unit costs of medications, staff time, transportation and loss of production were obtained through a health facility survey (N=12), official documents and key informants. A one-way sensitivity analysis was conducted on key parameters to evaluate the robustness of the results. The annual number of patients treated and the budget impact of switching to ILPA as the first-line treatment were estimated under different scenarios of increasing treatment utilization using previous estimates of the extent of underreporting. Costs were reported in 2016 international dollars (1 INT$ = 3.10 BOB).

    Results: Treating CL using ILPA was associated with a cost saving of $248 per patient treated from the MoH perspective, and $688 per patient treated from the societal perspective. ILPA was cost-saving even under a hypothetical increase of 80% in the number of cases treated. Switching first-line treatment would allow two-and-a-half times the current number of patients to be treated, while maintaining the current budget.

    Conclusions: The results of this study support a shift to ILPA as the first-line treatment for CL in Bolivia and possibly in other South American countries.

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