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  • 1.
    Amroussia, Nada
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernandez, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Reproductive health policy in Tunisia: women's right to reproductive health and gender empowerment2016Inngår i: Health and Human Rights: An International Journal, ISSN 1079-0969, E-ISSN 2150-4113, Vol. 18, nr 2, s. 183-194Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Although Tunisia is regarded as a pioneer in the Middle East and North Africa in terms of women's status and rights, including sexual and reproductive health and rights, evidence points to a number of persisting challenges. This article uses the Health Rights of Women Assessment Instrument (HeRWAI) to analyze Tunisia's reproductive health policy between 1994 and 2014. It explores the extent to which reproductive rights have been incorporated into the country's reproductive health policy, the gaps in the implementation of this policy, and the influence of this policy on gender empowerment. Our results reveal that progress has been slow in terms of incorporating reproductive rights into the national reproductive health policy. Furthermore, the implementation of this policy has fallen short, as demonstrated by regional inequities in the accessibility and availability of reproductive health services, the low quality of maternal health care services, and discriminatory practices. Finally, the government's lack of meaningful engagement in advancing gender empowerment stands in the way as the main challenge to gender equality in Tunisia.

  • 2.
    Amroussia, Nada
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernandez, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    "Is the doctor God to punish me?!": An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia2017Inngår i: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 14, artikkel-id 32Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Disrespectful and abusive treatment during childbirth is a violation of women's right to dignified, respectful healthcare throughout pregnancy and childbirth. Although reports point out that marginalized groups in society such as single mothers are particularly vulnerable to abusive and disrespectful care, there is a lack of in-depth research exploring single mothers' encounters at the maternal healthcare facilities, especially in Tunisia. In Tunisia, single mothers are particularly vulnerable due to their social stigmatization and socio-economic marginalization. This study examines the self-perceptions and childbirth experiences of single mothers at the public healthcare facilities in Tunisia.

    METHODS: This study follows a qualitative design. Eleven single mothers were interviewed in regard to their experiences with maternal healthcare services and their perceptions of the attitudes of the health workers towards them. The interviews also addressed the barriers faced by the participants in accessing adequate maternal healthcare services, and their self-perceptions as single mothers. The data were analyzed using an inductive thematic approach guided by the feminist intersectional approach. Emergent codes were grouped into three final themes.

    RESULTS: Three themes emerged during the data analysis: 1) Experiencing disrespect and abuse, 2) Perceptions of regret and shame attributed to being a single mother, and 3) The triad of vulnerability: stigma, social challenges, and health system challenges. The study highlights that the childbirth experiences of single mothers are shaped by intersectional factors that go beyond the health system. Gender plays a major role in constructing these experiences while intersecting with other social structures. The participants had experienced disrespectful and discriminatory practices and even violence when they sought maternal healthcare services at the public healthcare facilities in Tunisia. Those experiences reflect not only the poor quality of maternal health services but also how health system practices translate the stigma culturally associated with single motherhood in this setting. Social stigma did not only affect how single mothers were treated during the childbirth, but also how they perceived themselves and how they perceived their care.

    CONCLUSION: Ensuring women's right to dignified, respectful healthcare during childbirth requires tackling the underlying causes of social inequalities leading to women's marginalization and discrimination.

  • 3. Banda, Emmanuel
    et al.
    Svanemyr, Joar
    Sandoy, Ingvild Fossgard
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Zulu, Joseph Mumba
    Acceptability of an economic support component to reduce early pregnancy and school dropout in Zambia: a qualitative case study2019Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, nr 1, artikkel-id 1685808Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

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

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

  • 4.
    Baroudi, Mazen
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Waenerlund, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessing the dimensionality of YFHS-Swe; a new questionnaire to assess youth friendliness2017Inngår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, nr suppl_3, s. 343-Artikkel i tidsskrift (Annet vitenskapelig)
    Abstract [en]

    Background: Ensuring the youth friendliness of health services can increase the utilization of these services and contribute to improve youth’s health. Few validated instruments to assess youth-friendliness exist worldwide and none in Sweden. To assess the youth-friendliness of Swedish youth clinics (differentiated services for youth that exist since the 70s), an adapted version of YFHS WHO+ questionnaire called (YFHS-Swe) was developed. YFHS-Swe proved to have good internal homogeneity and consistency over time. The aim of our study was to perform a psychometric analysis to assure the quality and reliability of the questionnaire, and to assess the dimensionality of YFHS-Swe to identify possible subdomains that might be of importance for policy making.

    Methods: YFHS-Swe was answered by 1,110 youths aged 16 to 25 years visiting 20 youth clinics in Northern Sweden between September 2016 and February 2017. YFHS-Swe was assessed using exploratory and confirmatory factor analysis.

    Results: Thirteen factors could be identified; ability to get contact; access to sexual and reproductive health (SRH) service; access to psychosocial health services; parental support of SRH services; parental support of psychosocial health services; equity with diverse concerns; equity with legal concerns; fear of exposure; respect; privacy and confidentiality; no judgement; quality of consultation and quality of facility. Except for “quality of facility”, all other twelve factors recorded good α reliability ranging from 0.76 to 0.97, good ρ reliability ranging from 0.77 to 0.97 and acceptable measure of fit (SRMR<0.08).

    Conclusions: The YFHS-Swe proved to be credible and suitable for assessing youths-friendliness of the Swedish youth clinics. The identified factors might be of an importance to capture different dimensions of youth friendliness. With some cultural and linguistic adaptations, this instrument can be used in other differentiated youth health services internationally.

    Key messages:

    • YFHS-Swe is credible and suitable instrument in the Swedish context and it can be used as a basis for validating other instruments to assess youth-friendliness in other contexts.
    • The dimensions identified of this novel instrument might be of importance in assessing distinct aspects of friendliness in differentiated health services and might be of importance for policy making.
  • 5.
    Baroudi, Mazen
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Waenerlund, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessing the dimensionality of YFHS-Swe: a questionnaire to assess youth-friendliness in differentiated health services2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, nr 1, artikkel-id 1380399Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 6.
    Briones-Vozmediano, Erica
    et al.
    Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante Public Health Research Group, San Vicente del Raspeig RoadAlicante, Spain.
    Agudelo-Suarez, Andres A
    Faculty of Dentistry, University of Antioquia, Street 67Medellín, Colombia.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Vives-Cases, Carmen
    Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante Public Health Research Group, San Vicente del Raspeig RoadAlicante, Spain; CIBER of Epidemiology and Public Health, Carlos III Institute of Health, Street Melchor Fernández AlmagroMadrid, Spain.
    Economic crisis, immigrant women and changing availability of intimate partner violence services: a qualitative study of professionals' perceptions in Spain2014Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, artikkel-id 79Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 7. Briones-Vozmediano, Erica
    et al.
    Carmen Davo-Blanes, Ma
    Garcia-de la Hera, Manuela
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. b Grupo de Investigación en Salud Pública, Universidad de Alicante, Alicante, Espa˜na.
    Vives-Cases, Carmen
    Discursos profesionales sobre la violencia del compañero íntimo: implicación en la atención de las mujeres inmigrantes en España2016Inngår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 30, nr 5, s. 326-332Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: 1) to examine the discourses of professionals involved in the care of female victims of intimate partner violence (IPV), with emphasis on how they describe the immigrant women, the perpetrators and their own responsibility of care; and 2) to compare these discourses with the other professions involved in caring for these women (social services, associations and police and justice). Methods: Qualitative study based on semi-structured interviews with 43 professionals from social services, associations and the police and judicial systems. A discourse analysis was carried out to identify interpretive repertoires about IPV, immigrant women and their aggressors, their culture and professional practices. Results: Four interpretive repertoires emerged from professional discourses: "Cultural prototypes of women affected by IPV", "Perpetrators are similar regardless of their culture of origin", "Are victims credible and the perpetrators responsible?" and "Lack of cultural sensitivity of professionals in helping immigrant women in abusive situations". These repertoires correspond to preconceptions that professionals construct about affected women and their perpetrators, the credibility and responsibility they attribute to them and the interpretation of their professional roles. Conclusions: The employment of IPV-trained cultural mediators in the services responsible for caring for the female victims, together with cultural training for the professionals, will facilitate the provision of culturally sensitive care to immigrant female victims of intimate partner violence. (C) 2016 SESPAS. Published by Elsevier Espana, S.L.U.

  • 8. Briones-Vozmediano, Erica
    et al.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ortiz-Barreda, Gaby
    Gil-González, Diana
    Vives-Cases, Carmen
    Professionals' perceptions of support resources for battered immigrant women: chronicle of an anticipated failure2014Inngår i: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, Vol. 29, nr 6, s. 1006-1027Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The aim of this study was to explore the experience of service providers in Spain regarding their daily professional encounters with battered immigrant women and their perception of this group's help-seeking process and the eventual abandonment of the same. Twenty-nine in-depth interviews and four focus group discussions were conducted with a total of 43 professionals involved in providing support to battered immigrant women. We interviewed social workers, psychologists, intercultural mediators, judges, lawyers, and public health professionals from Spain. Through qualitative content analysis, four categories emerged: (a) frustration with the victim's decision to abandon the help-seeking process, (b) ambivalent positions regarding differences between immigrant and Spanish women, (c) difficulties in the migratory process that may hinder the help-seeking process, and (d) criticisms regarding the inefficiency of existing resources. The four categories were cross-cut by an overarching theme: helping immigrant women not to abandon the help-seeking process as a chronicle of anticipated failure. The main reasons that emerged for abandoning the help-seeking process involved structural factors such as economic dependence, loss of social support after leaving their country of origin, and limited knowledge about available resources. The professionals perceived their encounters with battered immigrant women to be frustrating and unproductive because they felt that they had few resources to back them up. They felt that despite the existence of public policies targeting intimate partner violence (IPV) and immigration in Spain, the resources dedicated to tackling gender-based violence were insufficient to meet battered immigrant women's needs. Professionals should be trained both in the problem of IPV and in providing support to the immigrant population.

  • 9. Briones-Vozmediano, Erica
    et al.
    Maquibar, Amaia
    Vives-Cases, Carmen
    Öhman, Ann
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS). Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group of the University of Alicante, Spain.
    Health-Sector Responses to Intimate Partner Violence: fitting the Response Into the Biomedical Health System or Adapting the System to Meet the Response?2018Inngår i: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, Vol. 33, nr 10, s. 1653-1678Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This study aims to analyze how middle-level health systems' managers understand the integration of a health care response to intimate partner violence (IPV) within the Spanish health system. Data were obtained through 26 individual interviews with professionals in charge of coordinating the health care response to IPV within the 17 regional health systems in Spain. The transcripts were analyzed following grounded theory in accordance with the constructivist approach described by Charmaz. Three categories emerged, showing the efforts and challenges to integrate a health care response to IPV within the Spanish health system: "IPV is a complex issue that generates activism and/or resistance," "The mandate to integrate a health sector response to IPV: a priority not always prioritized," and "The Spanish health system: respectful with professionals' autonomy and firmly biomedical." The core category, "Developing diverse responses to IPV integration," crosscut the three categories and encompassed the range of different responses that emerge when a strong mandate to integrate a health care response to IPV is enacted. Such responses ranged from refraining to deal with the issue to offering a women-centered response. Attempting to integrate a response to nonbiomedical health problems as IPV into health systems that remain strongly biomedicalized is challenging and strongly dependent both on the motivation of professionals and on organizational factors. Implementing and sustaining changes in the structure and culture of the health care system are needed if a health care response to IPV that fulfills the World Health Organization guidelines is to be ensured.

  • 10. Briones-Vozmediano, Erica
    et al.
    Vives-Cases, Carmen
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group, University of Alicante, Alicante, Spain.
    "I'm not the woman I was": Women's perceptions of the effects of fibromyalgia on private life2016Inngår i: Health Care for Women International, ISSN 0739-9332, E-ISSN 1096-4665, Vol. 37, nr 8, s. 836-854Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    In this qualitative study, we explored how gender shapes women's experiences of living with fibromyalgia and how it affects their private lives. Through thematic analysis of data from 13 in-depth interviews in Spain, we identified seven themes which reflect that these women feel remorse and frustration for not being able to continue to fulfill the gender expectation of caring for others and for the home. This research contributes to a better understanding of what suffering from fibromyalgia implies for women and provides insights into how families and providers can support women with fibromyalgia in order to achieve a beneficial lifestyle.

  • 11. Briones-Vozmediano, Erica
    et al.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group of Alicante University, Alicante, Spain.
    Vives-Cases, Carmen
    "The complaining women": health professionals' perceptions on patients with fibromyalgia in Spain2018Inngår i: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 40, nr 14, s. 1679-1685Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    PURPOSE: The aim of this study is twofold: (1) to explore health service providers' perceptions regarding fibromyalgia patients in Spain and (2) to analyze possible consequences of these perceptions in terms of how health service providers construct the disease and treat their patients.

    DESIGN: Qualitative study.

    SUBJECTS/PATIENTS: Twelve health service providers (eight men, four women) involved in the care of fibromyalgia patients. Providers were from different disciplines and included general practitioners, rheumatologists, occupational doctors, psychologists, psychiatrists, physiotherapists and behavioral specialists from Spain.

    METHOD: We performed individual semistructured interviews, which were recorded and transcribed to conduct a qualitative content analysis supported by Atlas.ti-7.

    RESULTS: We identified three categories from the interviews: (1) the fibromyalgia patient prototype: the complaining woman, (2) fibromyalgia is considered a women's health issue, but male patients are a privileged minority, and (3) health professionals' attitudes toward fibromyalgia patients: are they really suffering or pretending?

    CONCLUSION: The uncertainty surrounding fibromyalgia together with the fact that those affected are primarily women, seem to influence professional practice in terms of lack of recognition of Fibromyalgia as a severe disease. Increased training of all health professionals is essential to improving the support and attention given to patients suffering from fibromyalgia.

    Implications for rehabilitation: Fibromyalgia

    • In order to improve fibromyalgia patients' attention, health providers should learn how to assist patients without prejudices.

    • Training programs for health providers should include sensitization about the severity of fibromyalgia.

    • Health providers should be aware of the existence of stereotypes about women suffering from fibromyalgia.

    • Fibromyalgia protocols should give skills to health providers to avoid offering a gender-biased attention to patients.

  • 12.
    Coe, Anna-Britt
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Understanding how young people do activism: Youth strategies on sexual health in Ecuador and Peru2015Inngår i: Youth & society, ISSN 0044-118X, E-ISSN 1552-8499, Vol. 47, nr 1, s. 3-28Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    While social movement research employs “tactical repertoire” to emphasize protest tactics directed at the state, literature on youth activism globally indicates that young people do politics outside the realm of formal political spheres. Youth activism on body politics in Latin America offers evidence that enhances conceptual tools intended for understanding how young people make claims and towards whom they make them. This paper takes young activists’ strategies as its point of departure through a study that explored how young people perceived their activism to advance sexual health in Ecuador and Peru. Young activists employed a range of interconnected strategies that went beyond protests directed at the state, including responding to adult allies, carrying out social advocacy among youth, building organizations, carrying out political advocacy and developing themselves as activists. Strategies were shaped by the degree to which young activists negotiated alternative notions of ‘youth’ with different actors.

  • 13.
    Coe, Anna-Britt
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    How gender hierarchies matter in youth activism: young people's mobilizing around sexual health in Ecuador and Peru2013Inngår i: Journal of Youth Studies, ISSN 1367-6261, E-ISSN 1469-9680, Vol. 16, nr 6, s. 695-711Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Despite a growing body of research on youth activism, few studies examine how this intersects with gender. Our study aimed to explore whether and how young activists themselves perceived gender hierarchies as needing to be addressed through their collective action on sexual health in Peru and Ecuador. Using Grounded Theory, qualitative data was collected and analyzed from young activists across four cases. Cases ranged in complexity from a single youth organization operating at the district level to numerous youth organizations articulating at the national level. We linked the GT analysis to a conceptual framework based on Tayor’s (1999) theorizing of gender and social movements. Accordingly, young activists perceived gender, and even class, “race” and age, as salient to their collective actions. These actions corresponded to the social movement concept of mobilizing structures that consist of pre-existing structures, tactics and organizations. Young activists understood gender and other social categories as imbued by power differentials and therefore as social hierarchies, within which their activism was embedded. The paper thereby demonstrates the need for an enhanced conceptual framework for the study of youth activism and its intersection with gender hierarchies.

  • 14.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Guzman-Rivero, Miguel
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Rojas, Ernesto
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Illanes, Daniel
    Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessment of a Leishmaniasis Reporting System in Tropical Bolivia Using the Capture-Recapture Method2018Inngår i: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 98, nr 1, s. 134-138Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This study evaluates the level of underreporting of the National Program of Leishmaniasis Control (NPLC) in two communities of Cochabamba, Bolivia during the period 2013-2014. Montenegro skin test-confirmed cases of cutaneous leishmaniasis (CL) were identified through active surveillance during medical campaigns. These cases were compared with those registered in the NPLC by passive surveillance. After matching and cleaning data from the two sources, the total number of cases and the level of underreporting of the National Program were calculated using the capture-recapture analysis. This estimated that 86 cases of CL (95% confidence interval [CI]: 62.1-110.8) occurred in the study period in both communities. The level of underreporting of the NPLC in these communities was very high: 73.4% (95% CI: 62.1-110.8). These results can be explained by the inaccessibility of health services and centralization of the NPLC activities. This information is important to establish priorities among policy-makers and funding organizations as well as implementing adequate intervention plans.

  • 15.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Institute of Biomedical Research, Faculty of Medicine, San Simon University, Aniceto Arce Avenue 371, Cochabamba, Bolivia.
    Guzman-Rivero, Miguel
    Rojas, Ernesto
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Illanes, Daniel
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Risk factors for cutaneous leishmaniasis in the rainforest of Bolivia: a cross-sectional study2018Inngår i: Tropical Medicine and Health, ISSN 1348-8945, E-ISSN 1349-4147, Vol. 46, artikkel-id 9Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Cutaneous leishmaniasis (CL) is an endemic disease in Bolivia, particularly in the rainforest of Cochabamba, in the municipality of Villa Tunari. The precarious, dispersed, and poorly accessible settlements in these farming communities make it difficult to study them, and there are no epidemiological studies in the area. The aim of the present study was to identify the risk factors associated with cutaneous leishmaniasis.

    Methods: A cross-sectional study was conducted in August 2015 and August 2016 in two communities of Villa Tunari, Cochabamba. The cases were diagnosed through clinical examinations, identification of the parasite by microscopic examination, and the Montenegro skin test. Risk factors were identified through logistic regression.

    Results: A total of 274 participants (40.9% female and 59.1% male) were surveyed, of which 43% were CL positive. Sex was the only factor associated with CL with three times more risk for men than for women; this finding suggests a sylvatic mechanism of transmission in the area.

    Conclusions: It is advisable to focus on education and prevention policies at an early age for activities related to either leisure or work. Further research is needed to assess the influence of gender-associated behavior for the risk of cutaneous leishmaniasis.

  • 16.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, 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 folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Leishmaniasis patients' pilgrimage to access health care in rural Bolivia: a qualitative study using human rights to health approach2019Inngår i: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 19, nr 1, artikkel-id 12Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Leishmaniasis is a neglected tropical disease endemic in Bolivia that disproportionately affects people with little social and political capital. Although the treatment is provided free of charge by the Bolivian government, there is an under-utilization of treatments in relation to the estimated affected population. This study explores the experiences of patients with leishmaniasis and the challenges faced when searching for diagnosis and treatment in Bolivia using a human rights approach.

    Methods: We conducted open-ended interviews with 14 participants diagnosed with leishmaniasis. The qualitative data were analysed using thematic analysis and were interpreted under a human rights approach to health care.

    Results: Four themes emerged during data analysis: (1) the decision for seeking a cure takes time; (2) the severity of symptoms and disruption of functioning drives the search for Western medicine; (3) the therapeutic journey between Western and traditional medicine; and (4) accessibility barriers to receive adequate medical treatment. This study showed that access to health care limitations were the most important factors that prevented patients from receiving timely diagnosis and treatment. Cultural factors played a secondary role in their decision to seek medical care.

    Conclusions: Accessibility barriers resulted in a large pilgrimage between public health care and traditional medicinal treatments for patients with leishmaniasis. This pilgrimage and the related costs are important factors that determine the decision to seek health care. This study contributes to the understanding of the under-utilisation problems of medical services in leishmaniasis and other similar diseases in remote and poor populations.

  • 17. Escolar-Pujolar, Antonio
    et al.
    Córdoba Doña, Juan Antonio
    Goicolea Julían, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Jesús Rodríguez, Gabriel
    Santos Sánchez, Vanesa
    Mayoral Sánchez, Eduardo
    Aguilar Diosdado, Manuel
    El efecto del estado civil sobre las desigualdades sociales y de género en la mortalidad por diabetes mellitus en Andalucía2018Inngår i: Endocrinología, Diabetes y Nutrición, ISSN 2530-0180, Vol. 65, nr 1, s. 21-29Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objetivos: Evaluar el efecto modificador del estado civil sobre las desigualdades sociales y de género en la mortalidad por diabetes mellitus (DM) en Andalucía.

    Material y métodos: Estudio transversal a partir de la Cohorte Censal 2001 de Andalucía. Se estudiaron defunciones por DM entre 2002 y 2013 según nivel de estudios y estado civil. Se calcularon tasas de mortalidad ajustadas por edad (TA) y razones de tasas de mortalidad (RTM) mediante modelos de regresión de Poisson, controladas por otras variables sociodemográficas. Se evaluó el efecto modificador del estado civil incorporando a los modelos un término de interacción. Todos los análisis se realizaron separadamente para hombres y mujeres.

    Resultados: Sobre un total de 4.229.791 sujetos se registraron 18.158 muertes por DM (10.635 mujeres y 7.523 hombres). A medida que disminuye el nivel educativo aumenta el riesgo de muerte. El estado civil modifica la desigualdad social en la mortalidad por DM de forma diferente en cada sexo. Las mujeres viudas y separadas/divorciadas con menor nivel de estudios presentan las mayores RTM: 5,1 (IC 95%: 3,6-7,3) y 5,6 (IC 95%: 3,6-8,5), respectivamente, mientras que los hombres solteros tienen la RTM más elevada: 3,1 (IC 95%: 2,7-3,6).

    Conclusiones: El nivel de estudios es un determinante fundamental de la mortalidad por DM en ambos sexos; su relevancia es mayor entre las mujeres, mientras que en los hombres también el estado civil es un factor clave. Para abordar las desigualdades en la mortalidad nuestros resultados sugieren que el énfasis actual en los factores individuales y el autocuidado debería extenderse hacia intervenciones sobre la familia, la comunidad y los contextos sociales más cercanos a los pacientes.

  • 18.
    Gebrehiwet, Tesfay
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian Chasco, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Edin, Kerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health extension program and its association with change in utlization of selected maternal health services in Tigray regionArtikkel i tidsskrift (Fagfellevurdert)
  • 19.
    Gebrehiwot, Tesfay Gebregzabher
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Edin, Kerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The Health Extension Program and Its Association with Change in Utilization of Selected Maternal Health Services in Tigray Region, Ethiopia: A Segmented Linear Regression Analysis2015Inngår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, nr 7, artikkel-id e0131195Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: In 2003, the Ethiopian Ministry of Health established the Health Extension Program (HEP), with the goal of improving access to health care and health promotion activities in rural areas of the country. This paper aims to assess the association of the HEP with improved utilization of maternal health services in Northern Ethiopia using institution-based retrospective data.

    METHODS: Average quarterly total attendances for antenatal care (ANC), delivery care (DC) and post-natal care (PNC) at health posts and health care centres were studied from 2002 to 2012. Regression analysis was applied to two models to assess whether trends were statistically significant. One model was used to estimate the level and trend changes associated with the immediate period of intervention, while changes related to the post-intervention period were estimated by the other.

    RESULTS: The total number of consultations for ANC, DC and PNC increased constantly, particularly after the late-intervention period. Increases were higher for ANC and PNC at health post level and for DC at health centres. A positive statistically significant upward trend was found for DC and PNC in all facilities (p<0.01). The positive trend was also present in ANC at health centres (p = 0.04), but not at health posts.

    CONCLUSION: Our findings revealed an increase in the use of antenatal, delivery and post-natal care after the introduction of the HEP. We are aware that other factors, that we could not control for, might be explaining that increase. The figures for DC and PNC are however low and more needs to be done in order to increase the access to the health care system as well as the demand for these services by the population. Strengthening of the health information system in the region needs also to be prioritized.

  • 20.
    Gebrehiwot, Tesfay
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Edin, Kerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian Chasco, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Making pragmatic choices: women's experiences of delivery care in Northern Ethiopia2012Inngår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 12, nr 113Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: In 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care. Despite enormous effort, utilization of maternal health services remains limited, and the reasons for the low utilization of the services offered through the HEP previously have not been explored in depth.This study explores women's experiences and perceptions regarding delivery care in Tigray, a northern region of Ethiopia, and enables us to make suggestions for better implementation of maternal health care services in this setting.

    METHODS: We used six focus group discussions with 51 women to explore perceptions and experiences regarding delivery care. The data were analysed by means of grounded theory.

    RESULTS: One core category emerged, 'making pragmatic choices', which connected the categories 'aiming for safer deliveries', 'embedded in tradition', and 'medical knowledge under constrained circumstances'. In this setting, women -- aiming for safer deliveries -- made choices pragmatically between the two available models of childbirth. On the one hand, choice of home delivery, represented by the category 'embedded in tradition', was related to their faith, the ascendancy of elderly women, the advantages of staying at home and the custom of traditional birth attendants (TBAs). On the other, institutional delivery, represented by the category 'medical knowledge under constrained circumstances', and linked to how women appreciated medical resources and the support of health extension workers (HEWs) but were uncertain about the quality of care, emphasized the barriers to transportation.In Tigray women made choices pragmatically and seemed to not feel any conflict between the two available models, being supported by traditional birth attendants, HEWs and husbands in their decision-making. Representatives of the two models were not as open to collaboration as the women themselves, however.

    CONCLUSIONS: Although women did not see any conflict between traditional and institutional maternal care, the gap between the models remained and revealed a need to reconcile differing views among the caregivers. The HEP would benefit from an approach that incorporates all the actors involved in maternal care, at institutional, community and family levels alike. Reconsideration is required of the role of TBAs, and a well-designed, community-inclusive, coordinated and feasible referral system should be maintained.

  • 21.
    Gebrehiwot, Tesfay
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Edin, Kerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health workers' perceptions of facilitators of and barriers to institutional delivery in Tigray, Northern Ethiopia2014Inngår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, artikkel-id 137Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Evidence shows that the three delays, delay in 1) deciding to seek medical care, 2) reaching health facilities and 3) receiving adequate obstetric care, are still contributing to maternal deaths in low-income countries. Ethiopia is a major contributor to the worldwide death toll of mothers with a maternal mortality ratio of 676 per 100,000 live births. The Ethiopian Ministry of Health launched a community-based health-care system in 2003, the Health Extension Programme (HEP), to tackle maternal mortality. Despite strong efforts, universal access to services remains limited, particularly skilled delivery attendance. With the help of 'the three delays' framework, this study explores health-service providers' perceptions of facilitators and barriers to the utilization of institutional delivery in Tigray, a northern region of Ethiopia.

    Methods: Twelve in-depth interviews were carried out with eight health extension workers (HEWs) and four midwives. Each interview lasted between 90 and 120 minutes. Data were analysed through a thematic analysis approach.

    Results: Three themes emerged from the analysis: the struggle between tradition and newly acquired knowledge, community willingness to deal with geographical barriers, and striving to do a good job with insufficient resources. These themes represent the three steps in the path towards receiving adequate institutional delivery care at a health facility. Of the themes, 'increased community awareness', 'organization of the community' and 'hospital with specialized staff' were recognized as facilitators. On the other hand, 'delivery as a natural event', 'cultural tradition and rituals', 'inaccessible transport', 'unmet community expectation' and 'shortage of skilled human resources' were represented as barriers to institutional delivery.

    Conclusions: The participants in this study gave emphasis to the major barriers to institutional delivery that are closely connected with the three delays model. Despite the initiatives being implemented by the Tigray Regional Health Bureau, much is still needed to enhance the humanization approach of delivery care on a broader level of the region. A quick solution is needed to address the major issue of lack of transport accessibility. The poor capacity of the HEWs to provide delivery services, calls for reconsidering staffing patterns of remote health posts and readdressing the issue of downgraded health facilities would address unmet community needs.

  • 22.
    Goicoela, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wulff, Marianne
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Women's reproductive rights in the Amazon basin of Ecuador: Challenges for transforming policy into practicce2008Inngår i: Health and Human Rights: An International Journal, ISSN 1079-0969, E-ISSN 2150-4113, Vol. 10, nr 2, s. 91-103Artikkel i tidsskrift (Fagfellevurdert)
  • 23.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Adolescent pregnancies in the Amazon Basin of Ecuador: a rights and gender approach to adolescents' sexual and reproductive health2010Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, artikkel-id 5280Artikkel, forskningsoversikt (Fagfellevurdert)
    Abstract [en]

    In the Andean region of Latin America over one million adolescent girls get pregnant every year. Adolescent pregnancy (AP) has been associated with adverse health and social outcomes, but it has also been favorably viewed as a pathway to adulthood. AP can also be conceptualized as a marker of inequity, since it disproportionately affects girls from the poorest households and those who have not been able to attend school. Using results from a study carried out in the Amazon Basin of Ecuador, this paper explores APs and adolescents' sexual and reproductive health from a rights and gender approach. The paper points out the main features of a rights and gender approach, and how it can be applied to explore APs. Afterward it describes the methodologies (quantitative and qualitative) and main results of the study, framing the findings within the rights and gender approach. Finally, some implications that could be generalizable to global research on APs are highlighted. The application of the rights and gender framework to explore APs contributes to a more integral view of the issue. The rights and gender framework stresses the importance of the interaction between rights-holders and duty-bearers on the realization of sexual and reproductive rights, and acknowledges the importance of gender-power relations on sexual and reproductive decisions. A rights and gender approach could lead to more integral and constructive interventions, and it could also be useful when exploring other sexual and reproductive health matters.

  • 24.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Adolescent pregnancies in the Amazon basin of Ecuador: a rights and gender approach to girls' sexual and reproductive health2009Doktoravhandling, med artikler (Annet vitenskapelig)
    Abstract [en]

    Adolescent pregnancy has been associated with adverse health and social outcomes, but it has also been favorably viewed as a pathway to adulthood. In Ecuador, where 20% of girls aged between 15-19 years get pregnant, the adolescent fertility rate has increased and inequalities between adolescent girls from different educational, socio-economic levels and geographical regions are prominent: 43% of illiterate adolescents become pregnant compared to 11% with secondary education. The highest adolescent fertility rates are found in the Amazon Basin.

     

    The overall aim of this study was to explore adolescent pregnancy in the Amazon Basin of Ecuador (Orellana province) from a rights and gender approach. Specific aims and methodologies included: to explore women‟s reproductive health situation, focusing on government‟s obligations, utilization of services, inequities and implementation challenges, assessed through a community-based cross-sectional survey and a policy analysis (Paper I); to examine risk factors associated with adolescent pregnancy, through a case-control study (Paper II); to explore experiences and emotions around pregnancy and motherhood among adolescent girls, using content analysis (Paper III); and to analyze providers‟ and policy makers‟ discourses on adolescent pregnancies (Paper IV).

     

    Reproductive health status findings for women in Orellana indicated a reality more dismal than that depicted in official national health data and policies. Inequities existed within the province, with rural indigenous women having reduced access to reproductive health services. In Orellana, 37.4% of girls aged 15-19 had experienced pregnancy, almost double the national average. Risk factors associated with adolescent pregnancy at the behavioral level included early sexual debut and non-use of contraception, and at the structural level poverty, having suffered from sexual abuse, and family disruption. Gender inequity played a key role through the machismo-marianismo system. Girls were raised to be fearful and ignorant regarding sexuality and reproduction, to be submissive and obedient, to be fatalistic, and to accept the established order of the male and adult dominance. Sexuality was conceptualized as negative, while motherhood was idealized. Those gender structures constrained girls‟ agency, making them less able to make choices regarding their sexual and reproductive lives. Providers‟ discourses and practices were also strongly influenced by gender structures. Adolescent sexuality was not sanctioned, girls‟ access to contraceptives still faced opposition, adolescent autonomy was regarded as dangerous, and pregnancy and reproductive health issues were conceptualized as girls‟ responsibility. However, mechanisms of resistance and challenge were also found both among adolescent girls and providers.

     

    Programs addressing adolescent pregnancies in the area need to look at the general situation of women‟s reproductive health and address the gaps regarding access and accountability. Adolescent pregnancy prevention programs should acknowledge the key role of structural factors and put emphasis on gender issues. Gender inequity affects many of the factors that influence adolescent pregnancies; sexual abuse, girls‟ limited access to use contraceptives, and girls‟ curtailed capability to decide regarding marriage or sexual intercourse, are strongly linked with young women‟s subordination. By challenging negative attitudes towards adolescents‟ sexuality, the encounter between providers and adolescents could become an opportunity for strengthening girls‟ reproductive and sexual agency.

  • 25.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Alicante, España.
    Aguilo, Elena
    Madrid, España.
    Madrid, Juan
    Madrid, España.
    Is youth-friendly primary care feasible in Spain?2015Inngår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 29, nr 4, s. 241-243Artikkel i tidsskrift (Annet vitenskapelig)
  • 26.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group, Department of Community Nursing, Alicante, Spain.
    Briones-Vozmediano, Erica
    Öhman, Ann
    Preventive Medicine and Public Health and History of Science, Alicante University, Alicante, Spain.
    Edin, Kerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Minvielle, Fauhn
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    Public Health Research Group, Department of Community Nursing, Alicante and CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain.
    Mapping and exploring health systems' response to intimate partner violence in Spain2013Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, nr 1, artikkel-id 1162Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: For a comprehensive health sector response to intimate partner violence (IPV), interventions should target individual and health facility levels, along with the broader health systems level which includes issues of governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. This study aims to map and explore the integration of IPV response in the Spanish national health system.

    METHODS: Information was collected on five key areas based on WHO recommendations: policy environment, protocols, training, monitoring and prevention. A systematic review of public documents was conducted to assess 39 indicators in each of Spain's 17 regional health systems. In addition, we performed qualitative content analysis of 26 individual interviews with key informants responsible for coordinating the health sector response to IPV in Spain.

    RESULTS: In 88% of the 17 autonomous regions, the laws concerning IPV included the health sector response, but the integration of IPV in regional health plans was just 41%. Despite the existence of a supportive national structure, responding to IPV still relies strongly on the will of health professionals. All seventeen regions had published comprehensive protocols to guide the health sector response to IPV, but participants recognized that responding to IPV was more complex than merely following the steps of a protocol. Published training plans existed in 43% of the regional health systems, but none had institutionalized IPV training in medical and nursing schools. Only 12% of regional health systems collected information on the quality of the IPV response, and there are many limitations to collecting information on IPV within health services, for example underreporting, fears about confidentiality, and underuse of data for monitoring purposes. Finally, preventive activities that were considered essential were not institutionalized anywhere.

    CONCLUSIONS: Within the Spanish health system, differences exist in terms of achievements both between regions and between the areas assessed. Progress towards integration of IPV has been notable at the level of policy, less outstanding regarding health service delivery, and very limited in terms of preventive actions.

  • 27.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Carson, Dean
    Umeå universitet, Arktiskt centrum vid Umeå universitet (Arcum). Demography and Growth Planning, Northern Institute, Charles Darwin University, Darwin, Australia; Centre for Rural Medicine, Storuman, Sweden.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Wiklund, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Fysioterapi.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health care access for rural youth on equal terms?: A mixed methods study protocol in northern Sweden2018Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, artikkel-id 6Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

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

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

  • 28.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wiklund, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering.
    Searching for best practices of youth friendly services - a study protocol using qualitative comparative analysis in Sweden2016Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, artikkel-id 321Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Swedish youth clinics constitute one of the most comprehensive and consolidated examples of a nationwide network of health care services for young people. However, studies evaluating their 'youth-friendliness' and the combination of factors that makes them more or less 'youth-friendly' have not been conducted. This protocol will scrutinise the current youth-friendliness of youth clinics in northern Sweden and identify the best combination of conditions needed in order to implement the criteria of youth-friendliness within Swedish youth clinics and elsewhere.

    Methods/design: In this study, we will use qualitative comparative analysis to analyse the conditions that are sufficient and/or necessary to implement Youth Friendly Health Services in 20 selected youth-clinics (cases). In order to conduct Qualitative Comparative Analysis, we will first identify the outcomes and the conditions to be assessed. The overall outcome - youth-friendliness - will be assessed together with specific outcomes for each of the five domains - accessible, acceptable, equitable, appropriate and effective. This will be done using a questionnaire to be applied to a sample of young people coming to the youth clinics. In terms of conditions, we will first identify what might be the key conditions, to ensure the youth friendliness of health care services, through literature review, interviews with professionals working at youth clinics, and with young people. The combination of conditions and outcomes will form the hypothesis to be further tested later on in the qualitative comparative analysis of the 20 cases. Once information on outcomes and conditions is gathered from each of the 20 clinics, it will be analysed using Qualitative Comparative Analysis.

    Discussion: The added value of this study in relation to the findings is twofold: on the one hand it will allow a thorough assessment of the youth-friendliness of northern Swedish youth clinics. On the other hand, it will extract lessons from one of the most consolidated examples of differentiated services for young people. Methodologically, this study can contribute to expanding the use of Qualitative Comparative Analysis in health systems research.

  • 29.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mechanisms for achieving adolescent-friendly services: a realist evaluation approach2012Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, s. 18748-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Despite evidence showing that adolescent-friendly health services (AFSs) increase young people's access to these services, health systems across the world are failing to integrate this approach.

    In Latin America, policies aimed at strengthening AFS abound. However, such services are offered only in a limited number of sites, and providers' attitudes and respect for confidentiality have not been addressed to a sufficient extent.

    Methods: The aim of this study was to explore the mechanisms that triggered the transformation of an 'ordinary' health care facility into an AFS in Ecuador. For this purpose, a realist evaluation approach was used in order to analyse three well-functioning AFSs. Information was gathered at the national level and from each of the settings including: (i) statistical information and unpublished reports; (ii) in-depth interviews and focus group discussions with policy makers, health care providers, users and adolescents participating in youth organisations and (iii) observations at the health care facilities. Thematic analysis was carried out, driven by the realist evaluation approach, namely exploring the connections between mechanisms, contexts and outcomes.

    Results: The results highlighted that the development of the AFSs was mediated by four mechanisms: grounded self-confidence in trying new things, legitimacy, a transformative process and an integral approach to adolescents. Along this process, contextual factors at the national and institutional levels were further explored.

    Conclusion: The Ministry of Health of Ecuador, based on the New Guidelines for Comprehensive Care of Adolescent Health, has started the scaling up of AFSs. Our research points towards the need to recognise and incorporate these mechanisms as part of the implementation strategy from the very beginning of the process.

    Although contextually limited to Ecuador, many mechanisms and good practices in these AFS may be relevant to the Latin American setting and elsewhere.

  • 30.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Coe, Anna-Britt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Developing and sustaining adolescent-friendly health services: a multiple case study from Ecuador and Peru2017Inngår i: Global Public Health, ISSN 1744-1692, E-ISSN 1744-1706, Vol. 12, nr 8, s. 1004-1017Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Adolescent-Friendly Health Services (AFHSs) are those that are accessible, acceptable, equitable, appropriate and effective for different youth sub-populations. This study investigated the process through which four clinics in two countries - Peru and Ecuador - introduced, developed and sustained AFHSs. A multiple case study design was chosen, and data from each clinic were collected through document review, observations and informant interviews. National level data were also collected. Data were analysed following thematic analysis. The findings showed that the process of introducing, developing and sustaining AFHSs was long term, and required a creative team effort and collaboration between donors, public institutions and health providers. The motivation and external support was crucial to initiating and sustaining the implementation of AFHSs. Health facilities' transformation into AFHSs was linked to the broader organisation of country health systems, and the evolution of national adolescent health policies. In Peru, the centralised approach to AFHSs introduction facilitated the dissemination of a comprehensive national model to health facilities, but dependency on national directives made it more difficult to systemise them when ideological and organisational changes occurred. In Ecuador, a less centralised approach to introducing AFHSs made for easier integration of the AFHSs model.

  • 31.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Easy to Oppose, Difficult to Propose: Young Activist Men's Framing of Alternative Masculinities under the Hegemony of Machismo in Ecuador2014Inngår i: Young - Nordic Journal of Youth Research, ISSN 1103-3088, E-ISSN 1741-3222, Vol. 22, nr 4, s. 399-419Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Debates are ongoing on whether man can engage in gender change and challenge hegemonic masculinities. The study aimed to analyze in what ways young Ecuadorian mencurrently or recently involved in activism to advance gender equality and reproductive rightsdefined different masculinities, hegemonic and alternative. We used Grounded Theory to collect and analyze three focus group discussions and 15 individual interviews with 30 young activist men in Ecuador. A core category captured the process of defining masculinities: Moving from passive acceptance of machismo to critical reflection and action' that in turn linked to three theoretical categories: Opposing machismo', From machos to men', and Inspiring opposition to machismo'. We drew upon framing theory in social movement studies to interpret the findings and thereby enhance the theory of hegemonic masculinity. Young activist men successfully framed the problem and motives for collective mobilization, but they wavered when it came to framing solutions.

  • 32.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hultstrand Ahlin, Cecilia
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Waenerlund, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Wiklund, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Fysioterapi.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Accessibility and factors associated with utilization of mental health services in youth health centers: a qualitative comparative analysis in northern Sweden2018Inngår i: International Journal of Mental Health Systems, ISSN 1752-4458, E-ISSN 1752-4458, Vol. 12, artikkel-id 69Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Youth-friendly health care services can facilitate young people's access to health care services and promote their health, including their mental health. In Sweden, a network of youth health centers exist since the 1970s, incorporated within the public health system. Even if such centers take a holistic approach to youth health, the focus has been in sexual and reproductive health care, and the extent of integrating mental health care services is less developed though it varies notably between different centers. This study aims to analyse the various conditions that are sufficient and/or necessary to make Swedish youth health centers accessible for mental and psychosocial health.

    Methods: Multiple case study design, using qualitative comparative analysis to assess the various conditions that makes a youth health center accessible for mental and psychosocial issues and mental health. The cases included 18 youth health centers (from a total of 22) in the four northern counties of Sweden.

    Results: In order to enhance accessibility for mental health services, youth health centers need to be trusted by young people. Trust was necessary but not sufficient, meaning that it had to be combined with other conditions: either having a team with a variety of professions represented in the youth health center, or being a youth health center that is both easy to contact and well-staffed with mental health professionals.

    Conclusions: Differentiated, first-line services for youth can play an important role in promoting youth mental health if certain conditions are fulfilled. Trust is necessary, but has to be combined with either multidisciplinary teams, or expertise on mental health and easy accessibility.

  • 33.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Univ Alicante, Grp Invest Salud Publ, E-03080 Alicante, Spain.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    Vives-Cases, Carmen
    Using realist evaluation to assess primary healthcare teams' responses to intimate partner violence in Spain2015Inngår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 29, nr 6, s. 431-436Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE: Few evaluations have assessed the factors triggering an adequate health care response to intimate partner violence. This article aimed to: 1) describe a realist evaluation carried out in Spain to ascertain why, how and under what circumstances primary health care teams respond to intimate partner violence, and 2) discuss the strengths and challenges of its application.

    METHODS: We carried out a series of case studies in four steps. First, we developed an initial programme theory (PT1), based on interviews with managers. Second, we refined PT1 into PT2 by testing it in a primary healthcare team that was actively responding to violence. Third, we tested the refined PT2 by incorporating three other cases located in the same region. Qualitative and quantitative data were collected and thick descriptions were produced and analysed using a retroduction approach. Fourth, we analysed a total of 15 cases, and identified combinations of contextual factors and mechanisms that triggered an adequate response to violence by using qualitative comparative analysis.

    RESULTS: There were several key mechanisms -the teams' self-efficacy, perceived preparation, women-centred care-, and contextual factors -an enabling team environment and managerial style, the presence of motivated professionals, the use of the protocol and accumulated experience in primary health care- that should be considered to develop adequate primary health-care responses to violence.

    CONCLUSION: The full application of this realist evaluation was demanding, but also well suited to explore a complex intervention reflecting the situation in natural settings.

  • 34.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Univ Alicante, Dept Community Nursing Prevent Med & Publ Hlth &, Publ Hlth Res Grp, E-03080 Alicante, Spain.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    Marchal, Bruno
    Developing a programme theory to explain how primary health care teams learn to respond to intimate partner violence: a realist case-study2015Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, artikkel-id 228Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Despite the progress made on policies and programmes to strengthen primary health care teams' response to Intimate Partner Violence, the literature shows that encounters between women exposed to IPV and health-care providers are not always satisfactory, and a number of barriers that prevent individual health-care providers from responding to IPV have been identified. We carried out a realist case study, for which we developed and tested a programme theory that seeks to explain how, why and under which circumstances a primary health care team in Spain learned to respond to IPV. Methods: A realist case study design was chosen to allow for an in-depth exploration of the linkages between context, intervention, mechanisms and outcomes as they happen in their natural setting. The first author collected data at the primary health care center La Virgen (pseudonym) through the review of documents, observation and interviews with health systems' managers, team members, women patients, and members of external services. The quality of the IPV case management was assessed with the PREMIS tool. Results: This study found that the health care team at La Virgen has managed 1) to engage a number of staff members in actively responding to IPV, 2) to establish good coordination, mutual support and continuous learning processes related to IPV, 3) to establish adequate internal referrals within La Virgen, and 4) to establish good coordination and referral systems with other services. Team and individual level factors have triggered the capacity and interest in creating spaces for team leaning, team work and therapeutic responses to IPV in La Virgen, although individual motivation strongly affected this mechanism. Regional interventions did not trigger individual and/ or team responses but legitimated the workings of motivated professionals. Conclusions: The primary health care team of La Virgen is involved in a continuous learning process, even as participation in the process varies between professionals. This process has been supported, but not caused, by a favourable policy for integration of a health care response to IPV. Specific contextual factors of La Virgen facilitated the uptake of the policy. To some extent, the performance of La Virgen has the potential to shape the IPV learning processes of other primary health care teams in Murcia.

  • 35.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Public Health Research Group, Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Alicante University, Alicante, Spain.
    Marchal, Bruno
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    Briones-Vozmediano, Erica
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Why do certain primary health care teams respond better to intimate partner violence than others?: A multiple case study2019Inngår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 33, nr 2, s. 169-176Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: To analyse how team level conditions influenced health care professionals’ responses to intimate partner violence.

    Methods: We used a multiple embedded case study. The cases were four primary health care teams located in a southern region of Spain; two of them considered "good" and two s "average". The two teams considered good had scored highest in practice issues for intimate partner violence, measured via a questionnaire (PREMIS - Physicians Readiness to Respond to Intimate Partner Violence Survey) applied to professionals working in the four primary health care teams. In each case quantitative and qualitative data were collected using a social network questionnaire, interviews and observations.

    Results: The two "good" cases showed dynamics and structures that promoted team working and team learning on intimate partner violence, had committed social workers and an enabling environment for their work, and had put into practice explicit strategies to implement a women-centred approach.

    Conclusions: Better individual responses to intimate partner violence were implemented in the teams which: 1) had social workers who were knowledgeable and motivated to engage with others; 2) sustained a structure of regular meetings during which issues of violence were discussed; 3) encouraged a friendly team climate; and 4) implemented concrete actions towards women-centred care.

  • 36.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Grupo de Investigación de Salud Pública, Universidad de Alicante, Alicante, Spain.
    Mosquera, Paola
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Briones-Vozmediano, Erica
    Otero-García, Laura
    García-Quinto, Marta
    Vives-Cases, Carmen
    Primary health care attributes and responses to intimate partner violence in Spain2017Inngår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 31, nr 3, s. 187-193Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE: This study provides an overview of the perceptions of primary care professionals on how the current primary health care (PHC) attributes in Spain could influence health-related responses to intimate partner violence (IPV).

    METHODS: A qualitative study was conducted using semi-structured interviews with 160 health professionals working in 16 PHC centres in Spain. Data were analysed using a qualitative content analysis.

    RESULTS: Four categories emerged from the interview analysis: those committed to the PHC approach, but with difficulties implementing it; community work relying on voluntarism; multidisciplinary team work or professionals who work together?; and continuity of care hindered by heavy work load. Participants felt that person-centred care as well as other attributes of the PHC approach facilitated detecting IPV and a better response to the problem. However, they also pointed out that the current management of the health system (workload, weak supervision and little feedback, misdistribution of human and material resources, etc.) does not facilitate the sustainability of such an approach.

    CONCLUSION: There is a gap between the theoretical attributes of PHC and the "reality" of how these attributes are managed in everyday work, and how this influences IPV care.

  • 37.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Salazar Torres, Mariano
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Edin, Kerstin
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Öhman, Ann
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    When sex is hardly about mutual pleasure: Dominant and resistant discourses on sexuality and its consequences for young people's sexual health2012Inngår i: International Journal of Sexual Health, ISSN 1931-7611, E-ISSN 1931-762X, Vol. 24, nr 4, s. 303-317Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This study explores gendered discourses about sexuality in Ecuador, the consequences of these discourses for young people's sexual health, and the possibility of the emergence of resistance and challenge. We analyzed and compared individual interviews and focus-group discussions with: young women, youth service providers, ordinary young men, and activist young men. Five interpretative repertoires emerged: (1) becoming sexually respectable women, (2) policing young women's sexuality, (3) men threatening and protecting women, (4) sexual relations (abusing, fooling, or seducing?), and (5) emerging resistance. The repertoires constructed a hierarchy of sexualities in which heterosexual monogamous lifelong coupledom was normative and women's pleasure was absent, but resistance was emerging.

  • 38.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Unintended pregnancy in the amazon basin of Ecuador: a multilevel analysis2010Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 9, s. 14-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

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

  • 39.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Grupo de Investigación de Salud Pública, Universidad de Alicante, Spain.
    Vives-Cases, Carmen
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    Briones-Vozmediano, Erica
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Grupo de Investigación de Salud Pública, Universidad de Alicante, Spain ; .
    Otero-Garcia, Laura
    Garca-Quinto, Marta
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mechanisms that Trigger a Good Health-Care Response to Intimate Partner Violence in Spain. Combining Realist Evaluation and Qualitative Comparative Analysis Approaches2015Inngår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, nr 8, artikkel-id e0135167Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background

    Health care professionals, especially those working in primary health-care services, can play a key role in preventing and responding to intimate partner violence. However, there are huge variations in the way health care professionals and primary health care teams respond to intimate partner violence. In this study we tested a previously developed programme theory on 15 primary health care center teams located in four different Spanish regions: Murcia, C Valenciana, Castilla-León and Cantabria. The aim was to identify the key combinations of contextual factors and mechanisms that trigger a good primary health care center team response to intimate partner violence.

    Methods

    A multiple case-study design was used. Qualitative and quantitative information was collected from each of the 15 centers (cases). In order to handle the large amount of information without losing familiarity with each case, qualitative comparative analysis was undertaken. Conditions (context and mechanisms) and outcomes, were identified and assessed for each of the 15 cases, and solution formulae were calculated using qualitative comparative analysis software.

    Results

    The emerging programme theory highlighted the importance of the combination of each team’s self-efficacy, perceived preparation and women-centredness in generating a good team response to intimate partner violence. The use of the protocol and accumulated experience in primary health care were the most relevant contextual/intervention conditions to trigger a good response. However in order to achieve this, they must be combined with other conditions, such as an enabling team climate, having a champion social worker and having staff with training in intimate partner violence.

    Conclusions

    Interventions to improve primary health care teams’ response to intimate partner violence should focus on strengthening team’s self-efficacy, perceived preparation and the implementation of a woman-centred approach. The use of the protocol combined with a large working experience in primary health care, and other factors such as training, a good team climate, and having a champion social worker on the team, also played a key role. Measures to sustain such interventions and promote these contextual factors should be encouraged.

  • 40.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    Minvielle, Fauhn
    Briones-Vozmediano, Erica
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Applying the WHO recommendations on health-sector response to violence against women to assess the Spanish health system: a mixed methods approach2014Inngår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 28, nr 3, s. 238-41Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This methodological note describes the development and application of a mixed-methods protocol to assess the responsiveness of Spanish health systems to violence against women in Spain, based on the World Health Organization (WHO) recommendations.

    Five areas for exploration were identified based on the WHO recommendations: policy environment, protocols, training, accountability/monitoring, and prevention/promotion. Two data collection instruments were developed to assess the situation of 17 Spanish regional health systems (RHS) with respect to these areas: 1) a set of indicators to guide a systematic review of secondary sources, and 2) an interview guide to be used with 26 key informants at the regional and national levels.

    We found differences between RHSs in the five areas assessed. The progress of RHSs on the WHO recommendations was notable at the level of policies, moderate in terms of health service delivery, and very limited in terms of preventive actions. Using a mixed-methods approach was useful for triangulation and complementarity during instrument design, data collection and interpretation.

  • 41.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Vives-Cases, Carmen
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Marchal, Bruno
    Kegels, Guy
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol2013Inngår i: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8, s. 36-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of intimate partner violence (IPV) within healthcare facilities, research that explores how health innovations that go beyond biomedical issues-such as IPV management-get integrated into health systems, and that focuses on healthcare teams' learning processes is, to the best of our knowledge, very scarce if not absent. This realist evaluation protocol aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services.

    METHODS: This study will be conducted in Spain using a multiple-case study design. Data will be collected from selected cases (primary healthcare teams) through different methods: individual and group interviews, routinely collected statistical data, documentary review, and observation. Cases will be purposively selected in order to enable testing the initial middle-range theory (MRT). After in-depth exploration of a limited number of cases, additional cases will be chosen for their ability to contribute to refining the emerging MRT to explain how primary healthcare learn to integrate intimate partner violence management.

    DISCUSSION: Evaluations of health sector responses to IPV are scarce, and even fewer focus on why, how, and when the healthcare services integrate IPV management. There is a consensus that healthcare professionals and healthcare teams play a key role in this integration, and that training is important in order to realize changes. However, little is known about team learning of IPV management, both in terms of how to trigger such learning and how team learning is connected with changes in organizational culture and values, and in service delivery. This realist evaluation protocol aims to contribute to this knowledge by conducting this project in a country, Spain, where great endeavours have been made towards the integration of IPV management within the health system.

  • 42.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wulff, Marianne
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Adolescent pregnancies and girls' sexual and reproductive rights in the Amazon Basin of Ecuador: an analysis of providers' and policy makers' discourses2010Inngår i: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 10, nr 12Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Adolescent pregnancies are a common phenomenon that can have both positive and negative consequences. The rights framework allows us to explore adolescent pregnancies not just as isolated events, but in relation to girls' sexual and reproductive freedom and their entitlement to a system of health protection that includes both health services and the so called social determinants of health. The aim of this study was to explore policy makers' and service providers' discourses concerning adolescent pregnancies, and discuss the consequences that those discourses have for the exercise of girls' sexual and reproductive rights' in the province of Orellana, located in the amazon basin of Ecuador.

    Methods: We held six focus-group discussions and eleven in-depth interviews with 41 Orellana's service providers and policy makers. Interviews were transcribed and analyzed using discourse analysis, specifically looking for interpretative repertoires.

    Results: Four interpretative repertoires emerged from the interviews. The first repertoire identified was "sex is not for fun" and reflected a moralistic construction of girls' sexual and reproductive health that emphasized abstinence, and sent contradictory messages regarding contraceptive use. The second repertoire -"gendered sexuality and parenthood"-constructed women as sexually uninterested and responsible mothers, while men were constructed as sexually driven and unreliable. The third repertoire was "professionalizing adolescent pregnancies" and lead to patronizing attitudes towards adolescents and disregard of the importance of non-medical expertise. The final repertoire -"idealization of traditional family"-constructed family as the proper space for the raising of adolescents while at the same time acknowledging that sexual abuse and violence within families was common.

    Conclusions: Providers' and policy makers' repertoires determined the areas that the array of sexual and reproductive health services should include, leaving out the ones more prone to cause conflict and opposition, such as gender equality, abortion provision and welfare services for pregnant adolescents. Moralistic attitudes and sexism were present - even if divergences were also found-, limiting services' capability to promote girls' sexual and reproductive health and rights.

  • 43.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wulff, Marianne
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gender structures constraining girls’ agency: exploring pregnancy and motherhood among adolescent gilrs in Ecuador’s Amazon Basin2010Inngår i: Sexuality, Health and Society, ISSN 1984-6487, Vol. 5, s. 50-73Artikkel i tidsskrift (Fagfellevurdert)
  • 44.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Wulff, Marianne
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Gender structures constraining girls' agency: exploring pregnancy and motherhood among adolescent girls in Ecuador's Amazon basinManuskript (Annet vitenskapelig)
  • 45.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Wulff, Marianne
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Öhman, Ann
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Risk factors for pregnancy among adolescent girls in Ecuador's Amazon basin: a case-control study2009Inngår i: Revista panamericana de salud pùblica, ISSN 1020-4989, E-ISSN 1680-5348, Vol. 26, nr 3, s. 221-228Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective. To examine risk factors for pregnancy among adolescent girls in the Amazonbasin of Ecuador.Methods. A matched case-control study with cases and controls identified within a community-based demographic and health survey was conducted in Orellana, Ecuador, from Mayto November 2006. A questionnaire focused on socioeconomic status, family structure, education,reproductive health, and childhood-adolescent trauma was applied. Conditional logisticregression was used to adjust for potential confounders.Results. Respondents included 140 cases and 262 controls. Factors associated with increasedrisk of adolescent pregnancies through multivariate analysis were: sexual abuse duringchildhood-adolescence (odds ratio (OR) 3.06, 95% confidence interval (CI) 1.08–8.68);early sexual debut (OR 8.51, 95% CI 1.12–64.90); experiencing periods without mother andfather (OR 10.67, 95% CI 2.67–42.63); and living in a very poor household (OR 15.23, 95%CI 1.43–162.45). Another two factors were statistically associated in the bivariate analysis:being married or in a consensual union (OR 44.34, 95% CI 17.85–142.16) and not being enrolledin school at the time of the interview (OR 6.31, 95% CI 3.70–11.27). For a subsampleof sexually initiated adolescents, “non-use of contraception during first sexual intercourse”was also found to be a risk factor (OR 4.30, 95% CI 1.33–13.90).Conclusion. The study found that early sexual debut, non-use of contraception during firstsexual intercourse, living in a very poor household, having suffered from sexual abuse duringchildhood-adolescence, and family disruption (living extended periods of life without both parents)were associated with adolescent pregnancy in Orellana.

  • 46.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Öhman, Ann
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS). Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Salazar Torres, Mariano
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Morras, Ione
    Medicus Mundi Gipuzkoa, San Sebastian, Spain.
    Edin, Kerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Condemning violence without rejecting sexism?: Exploring how young men understand intimate partner violence in Ecuador2012Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, s. 1-12Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: This study aims to explore young men's understanding of intimate partner violence (IPV) in Ecuador, examining similarities and differences between how ordinary and activist young men conceptualize IPV against women. Methods: We conducted individual interviews and focus group discussions (FGDs) with 35 young men - five FGDs and five interviews with ordinary young men, and 11 interviews with activists - and analysed the data generated using qualitative content analysis. Results: Among the ordinary young men the theme 'too much gender equality leads to IPV' emerged, while among the activists the theme 'gender inequality is the root of IPV'. Although both groups in our study rejected IPV, their positions differed, and we claim that this is relevant. While activists considered IPV as rooted in gender inequality, ordinary young men understood it as a response to the conflicts generated by increasing gender equality and women's attempts to gain autonomy.

  • 47.
    Goicolea, Isabel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Öhman, Ann
    Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Vives-Cases, Carmen
    Intersections between gender and other relevant social determinants of health inequalities2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1397909Artikkel i tidsskrift (Fagfellevurdert)
  • 48. Hernandez, Alison
    et al.
    Lorena Ruano, Ana
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Flores, Walter
    Pathways to accountability in rural Guatemala: a qualitative comparative analysis of citizen-led initiatives for the right to health of indigenous populations2019Inngår i: World Development, ISSN 0305-750X, E-ISSN 1873-5991, Vol. 113, s. 392-401Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Strengthening citizen-led accountability initiatives is a critical rights-based strategy for improving health services for indigenous and other marginalized populations. As these initiatives have gained prominence in health and other sectors, there is great interest in how they operate and what makes them effective. Scholarly focus is shifting from measuring the efficacy of their tools and tactics to deepening understanding of the context-sensitive pathways through which change occurs. This paper examines how citizen-led initiatives' actions to strengthen grassroots networks, monitor health services and engage with authorities interact with local sociopolitical conditions and contribute to accountability achievements for indigenous populations in rural Guatemala. We used qualitative comparative analysis to first systematize and score structured qualitative monitoring data gathered in 29 municipal-level initiatives, and then analyze patterns in the presence of different forms of citizen action, contextual conditions and accountability outcomes across cases. Our study identifies pathways of collective action through which citizen-led initiatives bolster their power to engage and negotiate with authorities and bring about solutions to some of the health system deficiencies that they face. While constructive engagement is widely advocated as the most effective approach to interaction with authorities, our study indicates that success depends on wider processes of community mobilization. To overcome the power asymmetries that marginalized groups face when engaging with authorities, iterative processes of network building and participatory monitoring as well as persistence in their demands are critical. These processes further provide an enabling environment for moving beyond the local and projecting indigenous voices to engage with authorities at higher governance levels. Initiatives also applied adversarial legal action as an alternative engagement strategy that contributed to bolster citizen power. Our findings indicate the potential of collective power generated by the actions of citizen-led initiatives to enable marginalized populations to hold authorities accountable for health system failures. 

  • 49.
    Hultstrand Ahlin, Cecilia
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Carson, Dean
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    "There is no reward penny for going out and picking up youths": issues in the design of accessible youth healthcare services in rural northern Sweden2019Inngår i: BMC Research Notes, ISSN 1756-0500, E-ISSN 1756-0500, Vol. 12, nr 1, artikkel-id 74Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: There is a continuing challenge to ensure equitable access to youth healthcare services in small rural communities. Sweden’s ‘youth clinic’ system is an attempt to provide comprehensive youth health services from a single centre, but many small rural communities have not adopted the youth clinic model. This study uses one case study to examine what the issues might be in establishing a youth clinic in a small rural community. The objective of this paper is to examine the issues around youth healthcare access in one municipality without a youth clinic, and to explore whether and how a youth clinic model might contribute to access in this municipality.

    Results: Three categories emerged from the analysis; (i) rural closeness; both good and bad, (ii) youth are not in the centre of the healthcare organization, and (iii) adapting youth clinics to a rural setting. While limited to one case example, the study provides valuable insights into youth health service planning in particular types of rural communities. This paper identified structural barriers to developing youth-specific services, and some alternative approaches that might be more suitable to smaller communities.

  • 50.
    Jat, Tej Ram
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Deo, Prakash R.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Umeå centrum för genusstudier (UCGS).
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sebastian, Miguel San
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens2015Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, s. 1-15Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery-related dimensions of maternal deaths in rural central India using a human rights lens. Design: Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the 'three delays' framework and were examined by using a human rights lens. Results: All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility. Conclusions: The study highlighted various socio-cultural and service delivery - related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i. e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not successful in meeting their obligations. Based on the findings of our study, we conclude that to prevent maternal deaths, further concentrated efforts are required for better community education, women's empowerment, and health systems strengthening to provide appropriate and timely services, including emergency obstetric care, with good quality.

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