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  • 1.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Estrella: a gifted narrative2009In: Childhoods Today, ISSN 1753-0849, E-ISSN 1753-0849, Vol. 3, no 1Article in journal (Refereed)
    Abstract [en]

    This paper analyses a short written account by a young Nicaraguan girl who narrates an experience she had while taking care of her small niece. She describes a turning point in her life, and narrative analysis was applied to interpret the meaning of her story. The importance and implications of becoming a mother are the key elements in her narrative. Her contribution was part of a larger study on sibling caretaking conducted in León, Nicaragua, in which multiple tools were used for exploration and analysis.

  • 2.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Home alone: sibling caretakers in León, Nicaragua2008Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Sibling caretaking, although common across time and cultures, has not been well researched from the carer’s point of view. In Nicaragua, ranked as one of the poorest countries in the Americas, sibling caretaking is common. The country’s historical background and its state of chronic poverty, widespread unemployment, loose family structures, and migration and mobility makes of the old practise of shared management child care a necessity. Households headed by sing¬le mothers constitute a particular Nica¬raguan charact¬eristic. Many children are expected to help in their own families and care for their siblings and other children living in their households. In its broadest sense sibling caretaking is a public health concern, and we conducted this study to widen the understanding of the phenomenon as it is represented in a setting undergoing a rapid social transition.

    The main objectives were to identify, describe and analyse the life situation of sibling caretakers in poor areas in León, Nicaragua, with focus on how they perceived it themselves. A combined qualitative and quantitative methodological design was used, mainly applying an ethnographic approach. A further ambition was to explore involvement of children in a participatory research process in accordance with the ‘Convention on the Rights of the Child’.

    The overall emotion expressed among the caretakers was pride, even if their situation often was characterized by stress and coping problems. They perceived their work as important for their families and they appreciated to fend for their siblings. Household work and nurturing of siblings were shaping the future lives of the caretakers and constituted part of their socialization.

    Even if many of these children achieve essential life skills as caretakers, they are at risk of falling behind as they grow older. Their long-term personal development is likely to be hampered by the obligations they have as caretakers. The carers' awareness of missing out on education was the most problematic issue for them.

    From a societal point of view, caretaking has negative consequences. The individual child is marginalised with limited access to basic education, contributing to overall low educational levels in Nicaragua.

    While the structuring conditions leading to sibling caretaking may be difficult to change, awareness of how these can affect children might make way for improvements in terms of access to school education and support from the society. The knowledge gained from this study should be further utilised to plan for interventions that take children’s perspectives into consideration.

  • 3.
    Dahlblom, Kjerstin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Herrera Rodríguez, Andrés
    Peña, Rodolfo
    Dahlgren, Lars
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Home alone: children as caretakers in León, Nicaragua2009In: Children and society, ISSN 0951-0605, Vol. 23, no 1, p. 43-56Article in journal (Refereed)
    Abstract [en]

    This article seeks to explore and understand the life situations of sibling caretakers in poor areas in León, Nicaragua. The every day lives for caretakers were studied through observations and interviews with children, informants and parents. The children themselves were satisfied and proud to be trusted as caretakers and felt useful in contributing to their families' livelihood. However, in a life course perspective the caretaking role implies a narrowing of life options. Early on they seem to acquire essential life skills but as they grow older many are at risk of falling behind due to their marginalised situation and lack of basic education.

  • 4.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    What constitute health promoting living environments from children's perspectives?2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 508-Article in journal (Other academic)
    Abstract [en]

    Background: Swedish research on the effects of living environment on children's health is limited, and very few studies bring up children’s own views and experiences from their everyday lives. The overall aim of this study is to explore what constitutes health promoting living environments from children’s own perspectives.

    Methods: This is an ongoing qualitative exploratory study, building on children’s active involvement using Photovoice method. Schoolchildren in grade five, living in a medium sized Swedish municipality were equipped with digital cameras to document places of importance for their well-being. These photographs were discussed in sex-stratified focus groups. By discussing their photos, the children could identify and portray their choices of places, which gave valuable insights of how they view their worlds and what they perceive as health promoting in their living environments. Data were initially analyzed thematically.

    Results: Children presented photos from their homes showing mostly their own rooms and their computers, sports- and other facilities for leisure activities as well as photos from playgrounds, forests and neighborhood venues. These places were all perceived as important for their wellbeing. Preliminary analyzes reveal how these places in different ways are characterized as; Places allowing Socializing; Places for Activities; Places for Relaxation, and Places providing a sense of Freedom. Having a Space of one’s own was also perceived as important for well-being.

    Conclusions: A safe environment, allowing positive activities, relaxation, togetherness as well as freedom and a space of one’s own, characterizes health-promoting places for Children in a Swedish context.

    Key messages:

    • Children are active actors in their living environments and are well aware of aspects in their living environments of importance for their well-being.
    • Children’s voices and experiences needs to be taken into account in the planning and design of health promoting living environments.
  • 5.
    Hernández, Alison
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Supporting the performance of rural nurses: a concept mapping study with regional health system actors in GuatemalaManuscript (preprint) (Other academic)
    Abstract [en]

    Background: The performance of front-line health workers is critical for improving the health of vulnerable populations. Performance is a complex behavior generated through interactions between health workers, the health system and communities served. In Guatemala, where front-line nurses serve rural communities with great health needs, a concept mapping study was carried out with actors from different levels of a regional health system to develop an integrated view on how performance can be supported in this setting.

    Methods: The concept mapping process began with four sessions engaging a total of 93 regional and district managers, and primary and secondary care health workers in generating ideas on actions needed to support nurses’ performance. Ideas were consolidated into 30 action items, which were sorted by 12 managers and rated by a total of 135 managers and health workers from different levels. Maps depicting domains of action and dynamics in sub-groups’ interests were generated using a sequence of multivariate statistical analyses and were interpreted by regional managers.

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

    Conclusions: This study indicates that rural nurses’ performance is interconnected with the performance of other actors in the regional health system who require support, including managers and community-level collaborators. Organizational climate is critical for making rural nurses feel supported, and the nature of relationships across levels shapes the way actions to support performance are implemented and received. The participatory nature of the conceptmapping process enables regional health system actors to collaborate in co-production of context-specific knowledge needed to guide efforts to strengthen performance.

  • 6.
    Hernández, Alison
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Translating community connectedness to practice: a qualitative study of midlevel health workers in rural Guatemala2012In: ISRN Nursing, ISSN 2090-5483, E-ISSN 2090-5491, Vol. 2012, p. 648769-Article in journal (Refereed)
    Abstract [en]

    Background. The performance of midlevel health workers is a critical lever for strengthening health systems and redressing inequalities in underserved areas. Auxiliary nurses form the largest cadre of health workers in Guatemala. In rural settings, they provide essential services to vulnerable communities, and thus have great potential to address priority health needs. This paper examines auxiliary nurses' motivation and satisfaction, and the coping strategies they use to respond to challenges they confront in their practice.

    Methods. Semistructured interviews were conducted with 14 auxiliary nurses delivering health services in Alta Verapaz, Guatemala.

    Results. Community connectedness was central to motivation in this rural Guatemalan setting. Participants were from rural communities and conveyed a sense of connection to the people they were serving through shared culture and their own experiences of health needs. Satisfaction was derived through recognition from the community and a sense of valuing their work. Auxiliary nurses described challenges commonly faced in low-resource settings. Findings indicated they were actively confronting these challenges through their own initiative.

    Conclusions. Strategies to support the performance of midlevel health workers should focus on mechanisms to make training accessible to rural residents, support problem-solving in practice, and emphasize building relationships with communities served.

  • 7.
    Hernández, Alison R
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Integrating views on support for mid-level health worker performance: a concept mapping study with regional health system actors in rural Guatemala2015In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 14, article id 91Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 8.
    Hernández, Alison R
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala2014In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, no 1, p. 112-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Mid-level health workers (MLHWs) form the front-line of service delivery in many low- and middle-income countries. Supervision is a critical institutional intervention linking their work to the health system, and it consists of activities intended to support health workers' motivation and enable them to perform. However its impact depends not only on the frequency of these activities but also how they are carried out and received. This study aims to deepen understanding of the mechanisms through which supervision activities support the performance of auxiliary nurses, a cadre of MLHWs, in rural Guatemala.

    METHODS: A multiple case study was conducted to examine the operation of supervision of five health posts using a realist evaluation approach. A program theory was formulated describing local understanding of how supervision activities are intended to work. Data was collected through interviews and document review to test the theory. Analysis focused on comparison of activities, outcomes, mechanisms and the influence of context across cases, leading to revision of the program theory.

    RESULTS: The supervisor's orientation was identified as the main mechanism contributing to variation observed in activities and their outcomes. Managerial control was the dominant orientation, reflecting the influence of standardized performance criteria and institutional culture. Humanized support was present in one case where the auxiliary nurse was motivated by the sense that the full scope of her work was valued. This orientation reflected the supervisor's integration of her professional identity as a nurse.

    CONCLUSIONS: The nature of the support health workers received was shaped by supervisors' orientation, and in this study, nursing principles were central to humanized support. Efforts to strengthen the support that supervision provides to MLHWs should promote professional ethos as a means of developing shared performance goals and orient supervisors to a more holistic view of the health worker and their work.

  • 9.
    Herrera Rodríguez, Andrés
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Dahlgren, Lars
    Umeå University, Faculty of Social Sciences, Department of Sociology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Pathways to suicidal behaviour among adolescent girls in Nicaragua2006In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 62, no 4, p. 805-814Article in journal (Refereed)
    Abstract [en]

    Adolescent girls are the most frequent suicide attempters worldwide. However, there is little knowledge about pathways leading to suicidal behaviour among young people, in particular in low-income countries. This study explores the motives and processes related to suicidal behaviour among young girls in Nicaragua. Individual in-depth interviews were conducted with eight girls aged between 12 and 19 admitted to hospital after attempting suicide. The audio-taped interviews lasted 2–4 h and were transcribed, translated into English and coded for content. Grounded theory and content analysis were used to construct a theory of the mechanisms behind their suicidal behaviour.

    A tentative model exploring pathways to suicidal behaviour is described with four main categories: structuring conditions, triggering events, emotions and actions taken. The model illustrates the dialectic interplay between structure and actions taken. Actions taken were categorized as problem solving or various forms of escape where failure with either of these strategies resulted in a suicide attempt.

    Dysfunctional families, absent fathers and lack of integration into society were some of the structuring conditions that lead to emotional distress. Abuse, deaths in the family, break-up with boyfriends or suicide among friends acted as triggering events. A striking finding was the obvious narrative competence of the girls.

    Our findings indicate that suicide prevention programmes for young people must offer support from professionals, independent of their family and social networks. Institutions in the community in contact with young people with suicidal behaviour must develop communicative skills to offer a trusting environment mobilising the resources that young people have.

  • 10.
    Jegannathan, Bhoomikumar
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Outcome of a school-based intervention to promote life-skills amongyoung people in Cambodia2014In: Asian Journal of Psychiatry, ISSN 1876-2018Article in journal (Refereed)
    Abstract [en]

    Background Most of the school-based interventions to prevent suicide are from high income countries and there is a need for evidence based interventions in resource-poor settings. The aim of this study is to evaluate the outcome of a school based intervention to reduce risk factors for suicide among young people in Cambodia by promoting life skills.

    Method Six classes were randomly selected from two schools each, one designated as experimental and the other as control school, respectively. In experimental school 168 young people (M = 92, F = 76) received 6 sessions of life skills education and in the control school 131 students (M = 53, F = 78) received three general sessions on health. We looked at the pre-post differences on Life-Skills Development Scale Adolescent Form (LSDS-AF)- and Youth Self-Report (YSR) questionnaire to measure the effect size (ES) from the intervention after 6 months. We analyzed the data by stratifying for gender and for those who reported more severe suicidal expressions at baseline (high-risk group).

    Results The girls showed improvement in Human Relationship (ES = 0.57), Health Maintenance (ES = 0.20) and the Total Life Skills Dimensions (ES = 0.24), whereas boys with high-risk behavior improved on Human Relationship (ES = 0.48), Purpose in Life (ES = 0.26) and Total Life Skills Dimensions (ES = 0.22). Effect size for YSR-syndrome scores among all individuals showed no improvement for either gender. Among high-risk individuals boys had a small to moderate effect size from intervention on Withdrawn/Depressed (ES = 0.40), Attention problems (ES = 0.46), Rule breaking behavior (ES = 0.36), Aggressive behavior (ES = 0.48) and Externalizing syndrome (ES = 0.64).

    Conclusion Promoting life skills in schools may enhance the overall mental health of young people, indirectly influencing suicide, particularly among boys with high-risk behavior in Cambodia.

  • 11.
    Jegannathan, Bhoomikumar
    et al.
    Center for Child and Adolescent Mental Health, Chey Chumneas Hospital, Takhmau, Cambodia.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    ‘Plue plun’ male, ‘kath klei’ female: gender differences in suicidal behavior as expressed by young people in Cambodia2014In: International Journal of Culture and Mental Health, ISSN 1754-2863, E-ISSN 1754-2871, Vol. 7, no 3, p. 326-338Article in journal (Refereed)
    Abstract [en]

    Few studies from low- and middle-income countries use qualitative methodologyto explore suicidal behavior among young people. In Cambodia, young peopleface the challenge of rapidly changing times and are vulnerable for suicidalbehavior as revealed by research in transitional economies. This study seeks togain a deeper understanding of the suicidal phenomena from a gender, psychosocialand cultural perspective. Six focus-group discussions were conductedamong boys and girls, aged 15–19 years, in two secondary schools in a suburbanarea close to Phnom Penh, the capital city. The data was analyzed using thematicanalysis approach. The participants highlighted the gender difference in suicidalbehavior by describing the suicide-prone, acting-out male as ‘plue plun’, whilesuicide-prone females were described as caught in constricted, tunneled-thinkingbehavior, expressed as ‘kath klei’. Parental attitude and family environment werealso pointed out as the chief causes of discontent and there was a strong wish onthe part of young people to find space for modern values within the traditionalfamily. The young people’s awareness of their challenges in everyday life suggeststhat school-based programs to prevent suicidal behavior ought to be gendersensitiveand peer-focused.

  • 12.
    Jegannathan, Bhoomikumar
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Religion, culture, media and their impact on suicide in the eyes of young people in CambodiaManuscript (preprint) (Other academic)
  • 13.
    Jegannathan, Bhoomikumar
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry. Center for Child and Adolescent Mental Health, Chey Chumneas Referral Hospital, Takhmau, Cambodia.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    How do young people in Cambodia perceive the impact of societal attitudes, media and religion on suicidal behaviour?2016In: International Journal of Social Psychiatry, ISSN 0020-7640, E-ISSN 1741-2854, Vol. 62, no 2, p. 114-122Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Young people in low and middle income countries (LMICs) in societal transitions with rapidly changing norms face an increased risk of suicide. This study explores how young people in Cambodia understand the impact on suicidal behaviour from societal attitudes, media and religion.

    MATERIAL: Focus group discussions were held with school students from a suburban area. Thematic analysis was used to interpret the data.

    DISCUSSION: Participants perceived the prevailing suicide-stigmatizing societal attitudes, the double-edged media and suicide-ambiguity in Buddhist religion as challenging. Globalization was recognized as contradicting with traditional Cambodian norms and values.

    CONCLUSION: Suicide prevention programmes should take into consideration the complex picture of suicide that young people are exposed to.

  • 14.
    Melander, Marianne
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jegannathan, Bhoomikumar
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Exploring communication of traumatic experiences from Khmer Rouge genocide survivors to their offspring: In-depth interviews with both generations2016In: International Journal of Social Psychiatry, ISSN 0020-7640, E-ISSN 1741-2854, Vol. 62, no 4, p. 327-333Article in journal (Refereed)
    Abstract [en]

    Background: Traumatic events experienced by parents who have survived genocide influence mental health among their offspring. This study aims at exploring how the communication of traumatic events between Khmer Rouge survivors and their offspring was perceived by both generations.

    Methods: Qualitative interviews were performed with six Khmer Rouge survivors and with six young people representing the second generation and were analysed using a content analysis approach.

    Discussion: Parents felt that informing their children was important to instill gratitude for living a better life and to empower them. Among children, this was met with empathy but sometimes also disbelief and at times they blamed their parents for being too submissive.

    Conclusion: The study discloses the complexity, pros and cons of intergenerational sharing of trauma.

  • 15.
    Mosquera Mendez, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Hernández, Jineth
    Vega, Román
    Labonte, Ronald
    Sanders, David
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Challenges of implementing a primary health care strategy in a context of a market-oriented health care system: the experience of Bogota, Colombia2014In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 29, no 4, p. E347-E367Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although Colombia has a health system based on market and neoliberal principles, in 2004, the government of the capital-Bogota-took the decision to formulate a health policy that included the implementation of a comprehensive primary health care (PHC) strategy. This study aims to identify the enablers and barriers to the PHC implementation in Bogota. METHODS: The study used a qualitative multiple case study methodology. Seven Bogota's localities were included. Eighteen semi-structured interviews with key informants (decision-makers at each locality and members of the District Health Secretariat) and fourteen FGDs (one focus group with staff members and one with community members) were carried out. Data were analysed using a thematic analysis approach. RESULTS: The main enablers found across the district and local levels showed a similar pattern, all were related to the good will and commitment of actors at different levels. Barriers included the approach of the national policies and a health system based on neoliberal principles, the lack of a stable funding source, the confusing and rigid guidelines, the high turnover of human resources, the lack of competencies among health workers regarding family focus and community orientation, and the limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation. CONCLUSION: Significant efforts are required to overcome the market approach of the national health system. Interventions must be designed to include well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

  • 16.
    Obando Medina, Claudia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlgren, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Herrera, Andres
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    I keep my problems to myself: pathways to suicide attempts in Nicaraguan young men2011In: Suicidology Online, ISSN 2078-5488, E-ISSN 2078-5488, Vol. 2, p. 17-28Article in journal (Refereed)
    Abstract [en]

    This qualitative study is an attempt to understand the pathways leading to attempted suicide of young men in León, Nicaragua. Our research is based on in-depth interviews with twelve young men between the ages of 15 and 24 who had recently attempted to take their own life. The analysis is based on a grounded theory approach. The young men who participated in this study had a broadly similar background, insofar as they all came from broken families and had dropped out from school at an early age. They also all faced similar problems, such as unemployment and alcohol abuse. On this basis a model describing the pathways leading to the suicide attempts was constructed based on the informants’ experiences. In all cases the decision to attempt suicide was found to be an expression of frustration with the present conditions of life. Combined with this was the traumatic influence of a troubled childhood within an unloving, unstable family. Attention has been paid to the ambivalent and antagonistic relationships that the informants experienced within their own families from childhood onwards, and the subsequent inability to establish any meaningful relationships in later life. This study aims to increase our understanding of the complexity of suicidal behaviours in order to help develop genderspecific prevention strategies.

  • 17.
    Obando Medina, Claudia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    "...It's a shock when someone doesn't want to live". Nurses and doctors' perceptions of young people's help-seeking in primary health care in Nicaragua.Manuscript (preprint) (Other academic)
  • 18.
    Obando Medina, Claudia
    et al.
    Centre for Demography and Health Research, Nicaraguan National Autonomous University, León, Nicaragua .
    Jegannathan, Bhoomikumar
    Center for Child and Adolescent Mental Health (CCAMH), Takhmau, Cambodia .
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Suicidal expressions among young people in Nicaragua and Cambodia: a cross-cultural study2012In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 12, p. 28-Article in journal (Refereed)
    Abstract [en]

    Background Whereas prevalence of suicidal expressions among young people is fairly similar in different countries, less is known about associated risk factors. This study compares young people in Nicaragua and Cambodia to examine if the pattern of association between mental health problems and suicidal expressions differs.

    Methods 368 and 316 secondary school students, from each country respectively, participated. Self-reported suicidal expressions, exposure to suicidal behavior in significant others and mental health problems among the students were measured using Attitude Towards Suicide (ATTS) and the Youth Self-Report (YSR) questionnaires.

    Results Prevalence of serious suicidal expressions (plans and attempts) during recent year, did not differ between countries. Cambodian young people scored significantly higher on all eight YSR-syndromes, except for withdrawn/depressed. In Nicaragua, all YSR-syndromes were significantly associated with serious suicidal expressions in both genders compared to Cambodia where only one syndrome showed an association in each gender; Withdrawn/depressed among girls and Somatic complaints among boys. Associations between being exposed to suicide among significant others and serious suicidal expressions also differed between Cambodia and Nicaragua.

    Conclusions While the magnitude of serious suicidal expressions is similar between these structurally similar but culturally different countries, determinants behave differently. Qualitative studies are warranted to further explore cultural specific determinants for suicidal expressions among young people.

  • 19.
    Obando Medina, Claudia
    et al.
    Centre for Demography and Health Research, Nicaraguan National Autonomous University, León, Nicaragua.
    Kullgren, Gunnar
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A qualitative study on primary health care professionals' perceptions of mental health, suicidal problems and help-seeking among young people in Nicaragua2014In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 15, p. 129-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Mental health problems among young peoples are a growing public health issue around the world. In low- income countries health systems are characterized by lack of facilities, human resources and primary health care is rarely an integrated part of overall health care services. This study aims at exploring how primary health care professionals in Nicaragua perceive young people's mental health problems, suicidal problems and help-seeking behaviour.

    METHODS: Twelve in-depth interviews were conducted with nurses and doctors working in primary health care services in León, Nicaragua. A qualitative research design was applied. Data was analysed using thematic analysis approach.

    RESULTS: This study revealed that doctors and nurses were reluctant to deal with young people presenting with suicidal problems at the primary health care. This was more likely to stem from feelings of incompetence rather than from negative attitudes. Other barriers in providing appropriate care to young people with mental health problems were identified such as lack of time, lack of privacy, lack of human resources, lack of trained professionals and difficulties in communicating with young people. The primary health care (PHC) professionals suggested different solutions to improve care for young people with suicidal problems.

    CONCLUSION: PHC doctors and nurses in Nicaragua felt that providing skilled mental health services to young people was a priority for them but they also identified a number of barriers to be able to do so. They discussed ways to improve young people's willingness to share sensitive issues with them and suggested ways to make PHC more appreciated by young people.

  • 20.
    Ruano, Ana Lorena
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastían, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    'If no one else stands up, you have to': a story of community participation and water in rural Guatemala2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. Article nr 6412-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Access to water is a right and a social determinant of health that should be provided by the state. However, when it comes to access to water in rural areas, the current trend is for communities to arrange for the service themselves through locally run projects. This article presents a narrative of a single community's process of participation in implementing and running a water project in the village of El Triunfo, Guatemala.

    METHODS: Using an ethnographic approach, we conducted a series of interviews with five village leaders, field visits, and participant observations in different meetings and activities of the community.

    FINDINGS: El Triunfo has had a long tradition of community participation, where it has been perceived as an important value. The village has a council of leaders who have worked together in various projects, although water has always been a priority. When it comes to participation, this community has achieved its goals when it collaborated with other stakeholders who provided the expertise and/or the funding needed to carry out a project. At the time of the study, the challenge was to develop a new phase of the water project with the help of other stakeholders and to maintain and sustain the tradition of participation by involving new generations in the process.

    DISCUSSION: This narrative focuses on the participation in this village's efforts to implement a water project. We found that community participation has substituted the role of the central and local governments, and that the collaboration between the council and other stakeholders has provided a way for El Triunfo to satisfy some of its demand for water.

    CONCLUSION: El Triunfo's case shows that for a participatory scheme to be successful it needs prolonged engagement, continued support, and successful experiences that can help to provide the kind of stable participatory practices that involves community members in a process of empowered decision-making and policy implementation.

  • 21.
    Ruano, Ana Lorena
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernández, Alison
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    ‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala2012In: Archives of Public Health, ISSN 0778-7367, E-ISSN 2049-3258, Vol. 70, p. 18-Article in journal (Refereed)
    Abstract [en]

    Background: In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s healthissues required more than just hospital-based and physician-centered policies. The declaration called for a paradigmchange that would allow governments to provide essential care to their population in a universally acceptablemanner. The figure of the community health worker (CHW) remains a central feature of participation within thePHC approach, and being a CHW is still considered to be an important way of participation within the healthsystem.Methods: This study explores how the values and personal motivation of community health workers influencestheir experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, weused an ethnographic approach and collected data in January-March of 2009 and 2010 by using participantobservation and in-depth interviews.Results: We found that the CHWs in the municipality had a close working relationship with the mobile health teamand with the community, and that their positions allowed them to develop leadership and teamwork skills that mayprove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is akey value in Palencia, but there is a lack of infrastructure and growth opportunities.Conclusion: Attention should be paid to keeping the high levels of commitment and integration within the healthteam as well as keeping up supervision and economic funds for the program.

  • 22.
    Salazar, Mariano
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Solórzano, Lucia
    Nicaraguan Natl Autonomous Univ, Ctr Demog & Hlth Res, Leon, Nicaragua.
    Herrera, Andrés
    Nicaraguan Natl Autonomous Univ, Ctr Demog & Hlth Res, Leon, Nicaragua.
    Exposure to intimate partner violence reduces the protective effect that women's high education has on children's corporal punishment: a population-based study2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, p. 24774-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies have shown that women's education is protective against corporal punishment (CP) of children. However, the effect that women's exposure to intimate partner violence (IPV) has on the association between women's education and children's CP has not been studied.

    OBJECTIVE: To understand how the interaction between women's exposure to IPV and their education level influences the occurrence of children's CP at the household level.

    METHODS: We selected 10,156 women who had at least one child less than 16 years old from cross-sectional data from the 2006-2007 Nicaraguan Demographic and Health Survey. Children's CP was defined as the punishment of children by slapping them, hitting them with a fist, or hitting them with a rope, belt, stick, or other object. IPV was measured by using a conflict tactic scale. The WHO Self-Reporting Questionnaire 20 (SRQ-20) was used to assess the women's mental health. We computed adjusted risk ratios (ARR) and 95% confidence intervals (CI) using Poisson regression with a robust variance estimator.

    RESULTS: Women's exposure to IPV was associated with a 10-17% increase in the risk of children's CP. IPV and children's CP were associated with impaired women's mental health. Women's lifetime exposure to emotional IPV and controlling behavior by a partner significantly decreased the protective effect from women's high education level on children's CP. When women were exposed to emotional IPV, the protective effect from having a college education decreased from ARR=0.61 (95% CI 0.47-0.80) to ARR=0.98 (95% CI 0.80-1.19). A similar pattern was found among women exposed to controlling behavior by a partner, the protective effect decreased from ARR=0.71 (95% CI 0.53-0.90) to ARR=0.86 (95% CI 0.70-1.06).

    CONCLUSION: This study shows how significant gains in one positive social determinant of children's well-being can be undermined when it interacts with men's violence toward women. Policies that aim to end children's CP must include actions to end women's exposure to IPV.

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