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  • 1.
    Abraha, Atakelti
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Tigray Health Bureau, Tigray and Ethiopian Health Insurance Agency, Addis Ababa, Ethiopia.
    Myléus, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Institutes of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, United Kingdom; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kahsay, Asmelash
    Tigray Health Bureau, Tigray and Ethiopian Health Insurance Agency, Addis Ababa, Ethiopia.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institute, Stockholm, Sweden.
    Social determinants of under-5 child health: A qualitative study in Wolkayit Woreda, Tigray Region, Ethiopia2019Ingår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, nr 6, artikel-id e0218101Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Despite the significant reductions seen in under-5 child mortality in Ethiopia over the last two decades, more than 10,000 children still die each year in Tigray Region alone, of whom 75% die from preventable diseases. Using an equity lens, this study aimed to investigate the social determinants of child health in one particularly vulnerable district as a means of informing the health policy decision-making process. An exploratory qualitative study design was adopted, combining focus group discussions and qualitative interviews. Seven Focus Group Discussions with mothers of young children, and 21 qualitative interviews with health workers were conducted in Wolkayit district in May-June 2015. Data were subjected to thematic analysis. Mothers’ knowledge regarding the major causes of child mortality appeared to be good, and they also knew about and trusted the available child health interventions. However, utilization and practice of these interventions was limited by a range of issues, including cultural factors, financial shortages, limited female autonomy on financial resources, seasonal mobility, and inaccessible or unaffordable health services. Our findings pointed to the importance of a multi-sectoral strategy to improve child health equity and reduce under-5 mortality in Wolkayit. Recommendations include further decentralizing child health services to local-level Health Posts, and increasing the number of Health Facilities based on local topography and living conditions.

  • 2. Afari-Asiedu, Samuel
    et al.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Boamah-Kaali, Ellen
    Abdulai, Martha Ali
    Gyapong, Margaret
    Sankoh, Osman
    Hulscher, Marlies
    Asante, Kwaku Poku
    Wertheim, Heiman
    To sell or not to sell; the differences between regulatory and community demands regarding access to antibiotics in rural Ghana2018Ingår i: Journal of Pharmaceutical Policy and Practice, E-ISSN 2052-3211, Vol. 11, artikel-id 30Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: In Ghana, there is extensive over-the-counter dispensing of antibiotics, resulting in high levels of inappropriate use, and an increase in antibiotic resistance. Regulations prevent Licenced Chemical Sellers (LCS, Over-the-Counter Medicine Sellers) from selling antibiotics other than Cotrimoxazole. In practice, however, these sellers sell a variety of antibiotics. This paper aims to provide insight into the differences between regulatory and community demands on the sale of antibiotics, and to explore how these differences in demand could be resolved to facilitate safe and appropriate use of antibiotics in rural Ghana.

    Methods: A total of 32 in-depth interviews were conducted in the Kintampo North and South Districts in Ghana; 16 among antibiotic suppliers, predominantly LCS, and 16 among community members. Six focus group discussions were also conducted among 40 community members. Data were coded using Nvivo 10 and thematically analyzed in line with study objectives. The results are presented as narratives with quotes to illustrate the findings.

    Results: Generally, antibiotic suppliers were aware that regulations prevent LCS from selling antibiotics except Cotrimoxazole. However, LCS sell all types of antibiotics because of community demand, economic motivations of LCS, and the poor implementation of regulations that are intended to prevent them from selling these medications. Factors that influence community demand for antibiotics include previous knowledge of effectiveness of some antibiotics, delays in seeking care at health facilities, financial constraints, and distance to health facilities. LCS suggested that they should be trained and allowed to sell some types of antibiotics instead of being prevented completely from selling. Community members also suggested that Community-based Health Planning and Services (CHPS) compounds should be equipped to dispense antibiotics.

    Conclusion: The sale of antibiotics by LCS at the community level is influenced by both structural and individual contextual factors. There is a need to educate community members on the appropriate access and use of antibiotics in rural Ghana. In addition, rather than enforcing rules that go against practice, it may be more effective to regulate the sale of antibiotics by LCS and train them to make their dispensing more appropriate. CHPS compound could also be equipped to dispense some antibiotics to improve appropriate antibiotic access at the community level.

  • 3. Cambaco, Olga
    et al.
    Kinsman, John
    Sigauque, Betuel
    Wertheim, Heiman
    Nga, Nga Do Thi Thuy
    Langba, Johannes
    Sevene, Esperanca
    Munguambe, Khatia
    Awareness about appropriate antibiotic use in a rural district in sub-saharan Africa: where is the startin point for prevention of antibiotic resistence?2018Ingår i: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 99, nr 4, s. 251-251Artikel i tidskrift (Övrigt vetenskapligt)
  • 4. Carpenter, Lucy M
    et al.
    Kamali, Anatoli
    Payne, Mary
    Kiwuuwa, Silvia
    Kintu, Peter
    Nakiyingi, Jessica
    Kinsman, John
    Medical Research Council Programme on AIDS, Uganda.
    Nalweyiso, Norah
    Quigley, Maria A
    Kengeya-Kayondo, Jane F
    Whitworth, James A G
    Independent effects of reported sexually transmitted infections and sexual behavior on HIV-1 prevalence among adult women, men, and teenagers in rural Uganda2002Ingår i: Journal of Acquired Immune Deficiency Syndromes, ISSN 1525-4135, E-ISSN 1944-7884, Vol. 29, nr 2, s. 174-180Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To assess whether sexually transmitted infections (STIs) and sexual behavior are independently associated with HIV-1 among adult women, men, and teenagers in rural Uganda.

    DESIGN: Cross-sectional survey.

    METHODS: All adults (13 years and older) residing in 18 communities were invited to participate. HIV status was determined from serum samples and data collected during confidential interview. Independent effects of risk factors for HIV were estimated using adjusted odds ratios (ORs) with 95% confidence intervals (CIs) from logistic regression.

    RESULTS: Women reporting genital ulcers in the last 12 months were over twice as likely to be HIV positive after adjustment for sociodemographic factors and number of lifetime sexual partners (OR, 2.5; 95% CI, 1.9-3.4). Equivalent associations were stronger for men (OR, 3.2; 95% CI, 2.2-4.7) but weaker for teenagers (OR, 2.0, 95% CI, 0.5-8.7). Number of lifetime sexual partners was associated ( p <.05) with HIV status for women, men, and teenagers independently of reported genital ulcers. Teenagers reporting casual partners were over four times ( p <.001), and men reporting condom use almost twice ( p <.001), as likely to be HIV positive. Neither history of genital discharge nor other measures of sexual behavior were independently related to HIV status.

    CONCLUSION: Reported STIs and sexual behavior are independently associated with HIV in rural Uganda. Community-based interventions to reduce HIV should target both and should include teenagers.

  • 5. Dalmar, Abdirisak Ahmed
    et al.
    Hussein, Abdullahi Sheik
    Walhad, Said Ahmed
    Ibrahim, Abdirashid Omer
    Abdi, Abshir Ali
    Ali, Mohamed Khalid
    Ereg, Derie Ismail
    Egal, Khadra Ali
    Shirwa, Abdulkadir Mohamed
    Aden, Mohamed Hussain
    Yusuf, Marian Warsame
    Abdi, Yakoub Aden
    Freij, Lennart
    Johansson, Annika
    Mohamud, Khalif Bile
    Abdulkadir, Yusuf
    Emmelin, Maria
    Eriksen, Jaran
    Erlandsson, Kerstin
    Gustafsson, Lars L.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Klingberg-Allvin, Marie
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Källestål, Carina
    Målqvist, Mats
    Osman, Fatumo
    Persson, Lars-Åke
    Sahlén, Klas-Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wall, Stig
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Rebuilding research capacity in fragile states: the case of a Somali-Swedish global health initiative2017Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, nr 1, artikel-id 1348693Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 6.
    Edin, Kerstin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. MRC/ Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Nilsson, Bo
    Umeå universitet, Humanistiska fakulteten, Institutionen för kultur- och medievetenskaper.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. MRC/ Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Norris, Shane A
    Kahn, Kathleen
    Umeå universitet, Humanistiska fakulteten, Institutionen för kultur- och medievetenskaper. MRC/ Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Perspectives on intimate relationships among young people in rural South Africa: the logic of risk2016Ingår i: Culture, Health and Sexuality, ISSN 1369-1058, E-ISSN 1464-5351, Vol. 18, nr 9, s. 1010-1024Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This paper explores how young people in rural South Africa understand gender, dating, sexuality and risk-taking in adolescence. The empirical material drawn upon consists of 20 interviews with young men and women (aged 18-19) and reflects normative gender patterns characterised by compulsory heterosexuality and dating as obligatory, and representing key symbols of normality. However, different meanings of heterosexual relationships are articulated in the interviews, for example in the recurring concept of 'passing time', and these meanings show that a relationship can be something arbitrary: a way to reduce boredom and have casual sex. Such a rationale for engaging in a relationship reflects one of several other normative gender patterns, which relate to the trivialisation of dating and sexual risk-taking, and which entail making compromises and legitimising deviations from the 'ideal' life-script and the hope of a better future. However, risks do not exclusively represent something bad, dangerous or immoral, because they are also used as excuses to avoid sex, HIV acquisition and early pregnancy. In conclusion, various interrelated issues can both undermine and/or reinforce risk awareness and subsequent risk behaviour. Recognition of this tension is essential when framing policies to support young people to reduce sexual risk-taking behaviour.

  • 7.
    Eklund Wimelius, Malin
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Statsvetenskapliga institutionen.
    Eriksson, Malin
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Ghazinour, Mehdi
    Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för polisutbildning vid Umeå universitet.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Strandh, Veronica
    Umeå universitet, Samhällsvetenskapliga fakulteten, Statsvetenskapliga institutionen.
    Sundqvist, Johanna
    Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för polisutbildning vid Umeå universitet.
    Den lokala nivåns betydelse i det förebyggande arbetet mot våldsbejakande islamistisk extremism2017Ingår i: Våldsbejakande extremism: en forskarantologi / [ed] Christofer Edling och Amir Rostamni, Stockholm: Wolters Kluwer, 2017, s. 225--255Kapitel i bok, del av antologi (Refereegranskat)
  • 8.
    Eklund Wimelius, Malin
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Statsvetenskapliga institutionen.
    Eriksson, Malin
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Strandh, Veronica
    Umeå universitet, Samhällsvetenskapliga fakulteten, Statsvetenskapliga institutionen.
    Ghazinour, Mehdi
    Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för polisutbildning vid Umeå universitet.
    What is local resilience against radicalization and how can it be promoted?: a multidisciplinary literature review2018Ingår i: Studies in Conflict and Terrorism, ISSN 1057-610X, E-ISSN 1521-0731Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    In this research note, we present results from a review of research on local resilience in relation to radicalization in public health, social work, crisis management, and community policing using terrorism studies as a point of departure. In order to identify agreements between literatures, we focus on how local resilience is understood, how it is said to be promoted, and how this knowledge could be synthesized. We show that resilience by and large is understood as both a process and a capacity underpinned by cooperation, social networks, and community resources and that an initial mapping of existing strengths and resources is pivotal for local resilience-building.

  • 9. Gerrits, Trudie
    et al.
    Kinsman, John
    University of Amsterdam.
    From training to action: the process of engaging health professionals in operational research on adherence to antiretroviral therapy2006Ingår i: From access to adherence: the challenges of antiretroviral treatment. Studies from Botswana, Tanzania and Uganda. / [ed] A Hardon, S Davey, T Gerrits, C Hodgkin, H Irunde, J Kgatlwane, J Kinsman, A Nakiyemba, R Laing, Geneva: World Health Organization , 2006, s. 35-61Kapitel i bok, del av antologi (Övrigt vetenskapligt)
  • 10.
    Godefay, Hagos
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Abrha, A
    Yang, HS
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Myléus, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mulugeta, A
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Assessing the performance of the Ethiopian family folder system for collecting community-based health informationArtikel i tidskrift (Refereegranskat)
  • 11.
    Godefay, Hagos
    et al.
    Tigray Regional Health Bureau, Mekelle, Ethiopia.
    Abrha, Atakelti
    Tigray Regional Health Bureau, Mekelle, Ethiopia.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Myléus, Anna
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom.
    Undertaking cause-specific mortality measurement in an unregistered population: an example from Tigray Region, Ethiopia2014Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, s. 25264-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The lack of adequate documentation of deaths, and particularly their cause, is often noted in African and Asian settings, but practical solutions for addressing the problem are not always clear. Verbal autopsy methods (interviewing witnesses after a death) have developed rapidly, but there remains a lack of clarity as to how these methods can be effectively applied to large unregistered populations. This paper sets out practical details for undertaking a representative survey of cause-specific mortality in a population of several million, taking Tigray Region in Ethiopia as a prototype.

    SAMPLING: Sampling was designed around an expected level of maternal mortality ratio of 400 per 100,000 live births, which needed measuring within a 95% confidence interval of approximately ±100. Taking a stratified cluster sample within the region at the district level for logistic reasons, and allowing for a design effect of 2, this required a population of around 900,000 people, equating to six typical districts. Since the region is administered in six geographic zones, one district per zone was randomly selected.

    IMPLEMENTATION: The survey was implemented as a two-stage process: first, to trace deaths that occurred in the sampled districts within the preceding year, and second to follow them up with verbal autopsy interviews. The field work for both stages was undertaken by health extension workers, working in their normally assigned areas. Most of the work was associated with tracing the deaths, rather than undertaking the verbal autopsy interviews.

    DISCUSSION: This approach to measuring cause-specific mortality in an unregistered Ethiopian population proved to be feasible and effective. Although it falls short of the ideal situation of continuous civil registration and vital statistics, a survey-based strategy of this kind may prove to be a useful intermediate step on the road towards full civil registration and vital statistics implementation.

  • 12. Godefay, Hagos
    et al.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Graham, Wendy J
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mulugeta, Afework
    Risk Factors for Maternal Mortality in Rural Tigray, Northern Ethiopia: A Case-Control Study2015Ingår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, nr 12, artikel-id e0144975Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Maternal mortality continues to have devastating impacts in many societies, where it constitutes a leading cause of death, and thus remains a core issue in international development. Nevertheless, individual determinants of maternal mortality are often unclear and subject to local variation. This study aims to characterise individual risk factors for maternal mortality in Tigray, Ethiopia. Methods: A community-based case-control study was conducted, with 62 cases and 248 controls from six randomly-selected rural districts. All maternal deaths between May 2012 and September 2013 were recruited as cases and a random sample of mothers who delivered in the same communities within the same time period were taken as controls. Multiple logistic regression was used to identify independent determinants of maternal mortality. Results: Four independent individual risk factors, significantly associated with maternal death, emerged. Women who were not members of the voluntary Women's Development Army were more likely to experience maternal death (OR 2.07, 95% CI 1.04-4.11), as were women whose husbands or partners had below-median scores for involvement during pregnancy (OR 2.19, 95% CI 1.14-4.18). Women with a pre-existing history of other illness were also at increased risk (OR 5.58, 95% CI 2.17-14.30), as were those who had never used contraceptives (OR 2.58, 95% CI 1.37-4.85). Previous pregnancy complications, a below-median number of antenatal care visits and a woman's lack of involvement in health care decision making were significant bivariable risks that were not significant in the multivariable model. Conclusions: The findings suggest that interventions aimed at reducing maternal mortality need to focus on encouraging membership of the Women's Development Army, enhancing husbands' involvement in maternal health services, improving linkages between maternity care and other disease-specific programmes and ensuring that women with previous illnesses or non-users of contraceptive services are identified and followed-up as being at increased risk during pregnancy and childbirth.

  • 13. Godefay, Hagos
    et al.
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mulugeta, Afework
    Understanding maternal mortality from top-down and bottom-up perspectives: case of Tigray Region, Ethiopia2015Ingår i: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 5, nr 1, s. 83-90, artikel-id 010404Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Unacceptably high levels of preventable maternal mortality persist as a problem across sub-Saharan Africa and much of south Asia. Currently, local assessments of the magnitude of maternal mortality are not often made, so the best available information for health planning may come from global estimates and not reflect local circumstances.

    METHODS: A community-based cross-sectional survey was designed to identify all live births together with all deaths among women aged 15-49 years retrospectively over a one-year period in six randomly selected districts of Tigray Region, northern Ethiopia. After birth and death identification, Health Extension Workers trained to use the WHO 2012 verbal autopsy (VA) tool visited households to carry out VAs on all deaths among women aged 15-49 years. All pregnancy-related deaths were identified after processing the VA material using the InterVA-4 model, which corresponds to the WHO 2012 VA. A maternal mortality ratio (MMR) was calculated for each District and expressed with a 95% confidence interval (CI).

    RESULTS: The MMRs across the six sampled Districts ranged from 37 deaths per 100 000 live births (95% CI 1 to 207) to 482 deaths per 100 000 live births (95% CI 309 to 718). The overall MMR for Tigray Region was calculated at 266 deaths per 100 000 live births (95% CI 198 to 350). Direct obstetric causes accounted for 61% of all pregnancy-related deaths. Haemorrhage was the major cause of pregnancy-related death (34%). District-level MMRs were strongly inversely correlated with population density (r(2) = 0.86).

    CONCLUSION: This simple but well-designed survey approach enabled estimation of maternal mortality in Tigray Region on a local, contemporary basis. It also provided insights into possible local variations in MMR and their determinants. Consequently, this approach could be implemented at regional level in other large sub-Saharan African countries, or at national level in smaller ones to monitor and evaluate maternal health service interventions.

  • 14.
    Godefay, Hagos
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Admasu, K
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    A national programme of freely-available ambulance transportation for women in labour halves maternal mortality in Ethiopia: an operational analysis from Tigray Region2015Ingår i: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 20, nr Suppl. 1, s. 72-72Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Introduction: One of the challenges for maternal health services across Africa is physically getting women to health facilities for delivery at the appropriate time. A lack of transportation has often been cited as a major obstacle. The Ethiopian Federal Ministry of Health implemented a national programme of freely available ambulance transportation in every District from 2012, and this operational analysis investigated the effects of the ambulance programme on maternal mortality.

    Methods: Maternal mortality was measured in a survey of six randomly selected districts in Tigray Region over a 1-year period in 2012/13. For the same time period, data from ambulance log books from the same six Districts were captured and ambulance trips associated with deliveries extracted. Data on month, distance to health facility and mobile network coverage at local area level were included.

    Results: The survey identified 51 maternal deaths and 19 179 live births, corresponding to an overall maternal mortality ratio (MMR) of 266 per 100 000 live births. Districts using ambulances for at least 25% of deliveries had an MMR of 116 per 100 000 compared with 407 per 100 000 elsewhere. Distance from home to facility, the availability of a mobile telephone network and utilisation of ambulances were all independently associated with maternal mortality. When all these factors competed in a multivariable model at local area level, only utilisation of ambulances persisted as a significant factor, with a maternal mortality rate ratio of 0.51. One maternal death was estimated to have been averted for every 5000 ambulance-kilometres driven.

    Conclusions: Freely available ambulance transport in Ethiopia was associated with significant reductions in maternal mortality, although this was a strategy requiring substantial investment. Similar results could probably be achieved elsewhere given sufficient investment in vehicles and operational infrastructure.

    Acknowledgements: The Tigray Regional Health Bureau funded this operational assessment, including the maternal mortality survey and capturing the ambulance data. A collaboration grant from the Swedish Research Council facilitated analysis.

    Disclosure: Hagos Godefay is the Head of Tigray Regional Bureau and Kesetebirhan Admasu is the Minister of Health, Federal Democratic Republic of Ethiopia.

  • 15.
    Godefay, Hagos
    et al.
    Tigray Regional Health Bureau, Mekele, Ethiopia..
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Admasu, Kesetebirhan
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Can innovative ambulance transport avert pregnancy-related deaths?: One-year operational assessment in Ethiopia2016Ingår i: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 6, nr 1, artikel-id 010410Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND:

    To maximise the potential benefits of maternity care services, pregnant women need to be able to physically get to health facilities in a timely manner. In most of sub-Saharan Africa, transport represents a major practical barrier. Here we evaluate the extent to which an innovative national ambulance service in Ethiopia, together with mobile phones, may have been successful in averting pregnancy-related deaths.

    METHODS:

    An operational assessment of pregnancy-related deaths in relation to utilisation of the new national ambulance service was undertaken in six randomly selected Districts in northern Ethiopia. All 183 286 households in the six randomly selected Districts were visited to identify live-births and deaths among women of reproductive age that occurred over a one-year period. The uptake of the new ambulance transport service for women's deliveries in the same six randomly selected Districts over the same period was determined retrospectively from ambulance log books. Pregnancy-related deaths as determined by the World Health Organization (WHO 2012) verbal autopsy tool [13] and the InterVA-4 model [14] were analysed against ambulance utilisation by District, month, local area, distance from health facility and mobile network coverage.

    FINDINGS:

    A total of 51 pregnancy-related deaths and 19 179 live-births were documented. Pregnancy-related mortality for Districts with above average ambulance utilisation was 149 per 100 000 live-births (95% confidence interval CI 77-260), compared with 350 per 100 000 (95% CI 249-479) for below average utilisation (P = 0.01). Distance to a health facility, mobile network availability and ambulance utilisation were all significantly associated with pregnancy-related mortality on a bivariable basis. On a multivariable basis, ambulance non-utilisation uniquely persisted as a significant determinant of mortality (mortality rate ratio 1.97, 95% CI 1.05-3.69; P = 0.03).

    CONCLUSIONS:

    The uptake of freely available transport in connection with women's obstetric needs correlated with substantially reduced pregnancy-related mortality in this operational assessment, though the design did not allow cause and effect to be attributed. However, the halving of pregnancy-related mortality associated with ambulance uptake in the sampled Districts suggests that the provision of transport to delivery facilities in Africa may be a key innovation for delivering maternal health care, which requires wider consideration.

  • 16. Haafkens, Joke
    et al.
    Blomstedt, Yulia
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Eriksson, Malin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Becher, Heiko
    Ramroth, Heribert
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Training needs for research in health inequities among health and demographic researchers from eight African and Asian countries2014Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, artikel-id 1254Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: To support equity focussed public health policy in low and middle income countries, more evidence and analysis of the social determinants of health inequalities is needed. This requires specific know how among researchers. The INDEPTH Training and Research Centres of Excellence (INTREC) collaboration will develop and provide training on the social determinants of health approach for health researchers from the International Network for the Demographic Evaluation of Populations and Their Health in Low- and Middle-Income Countries (INDEPTH) in Africa and Asia. To identify learning needs among the potential target group, this qualitative study explored what INDEPTH researchers from Ghana, Tanzania, South Africa, Kenya, Indonesia, India, Vietnam, and Bangladesh feel that they want to learn to be able to conduct research on the causes of health inequalities in their country.

    METHODS: Using an inductive method, online concept-mapping, participants were asked to generate statements in response to the question what background knowledge they would need to conduct research on the causes of health inequalities in their country, to sort those statements into thematic groups, and to rate them in terms of how important it would be for the INTREC program to offer instruction on each of the statements. Statistical techniques were used to structure statements into a thematic cluster map and average importance ratings of statements/clusters were calculated.

    RESULTS: Of the 150 invited researchers, 82 participated in the study; 54 from Africa; 28 from Asia. Participants generated 59 statements and sorted them into 6 broader thematic clusters: "assessing health inequalities"; "research design and methods"; "research and policy"; "demography and health inequalities"; "social determinants of health" and "interventions". African participants assigned the highest importance to further training on methods for assessing health inequalities. Asian participants assigned the highest importance to training on research and policy.

    CONCLUSION: The identified thematic clusters and statements provide a detailed understanding of what INDEPTH researchers want to learn in order to be able to conduct research on the social determinants of health inequalities. This offers a framework for developing capacity building programs in this emerging field of public health research.

  • 17. Hardon, A P
    et al.
    Akurut, D
    Comoro, C
    Ekezie, C
    Irunde, H F
    Gerrits, T
    Kglatwane, J
    Kinsman, John
    University of Amsterdam.
    Kwasa, R
    Maridadi, J
    Moroka, T M
    Moyo, S
    Nakiyemba, A
    Nsimba, S
    Ogenyi, R
    Oyabba, T
    Temu, F
    Laing, R
    Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa2007Ingår i: AIDS Care, ISSN 0954-0121, E-ISSN 1360-0451, Vol. 19, nr 5, s. 658-665Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Adherence levels in Africa have been found to be better than those in the US. However around one out of four ART users fail to achieve optimal adherence, risking drug resistance and negative treatment outcomes. A high demand for 2nd line treatments (currently ten times more expensive than 1st line ART) undermines the sustainability of African ART programs. There is an urgent need to identify context-specific constraints to adherence and implement interventions to address them. We used rapid appraisals (involving mainly qualitative methods) to find out why and when people do not adhere to ART in Uganda, Tanzania and Botswana. Multidisciplinary teams of researchers and local health professionals conducted the studies, involving a total of 54 semi-structured interviews with health workers, 73 semi-structured interviews with ARTusers and other key informants, 34 focus group discussions, and 218 exit interviews with ART users. All the facilities studied in Botswana, Tanzania and Uganda provide ARVs free of charge, but ART users report other related costs (e.g. transport expenditures, registration and user fees at the private health facilities, and lost wages due to long waiting times) as main obstacles to optimal adherence. Side effects and hunger in the initial treatment phase are an added concern. We further found that ART users find it hard to take their drugs when they are among people to whom they have not disclosed their HIV status, such as co-workers and friends. The research teams recommend that (i) health care workers inform patients better about adverse effects; (ii) ART programmes provide transport and food support to patients who are too poor to pay; (iii) recurrent costs to users be reduced by providing three-months, rather than the one-month refills once optimal adherence levels have been achieved; and (iv) pharmacists play an important role in this follow-up care.

  • 18.
    Hardon, Anita
    et al.
    University of Amsterdam.
    Davey, SheilaGerrits, TrudieUniversity of Amsterdam.Hodgkin, CatherineRoyal Tropical Institute, Amsterdam.Irunde, HenryKgatlwane, JoyceKinsman, JohnUniversity of Amsterdam.Nakiyemba, AliceLaing, RichardWorld Health Organization.
    From access to adherence: the challenges of antiretroviral treatment. Studies from Botswana, Tanzania and Uganda2006Samlingsverk (redaktörskap) (Övrigt vetenskapligt)
  • 19. Hardon, Anita
    et al.
    Gomez, Gabriela B
    Vernooij, Eva
    Desclaux, Alice
    Wanyenze, Rhoda K
    Ky-Zerbo, Odette
    Kageha, Emmy
    Namakhoma, Ireen
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Spronk, Clare
    Meij, Edgar
    Neuman, Melissa
    Obermeyer, Carla Makhlouf
    Do support groups members disclose less to their partners? The dynamics of HIV disclosure in four African countries2013Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, s. 589-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Recent efforts to curtail the HIV epidemic in Africa have emphasised preventing sexual transmission to partners through antiretroviral therapy. A component of current strategies is disclosure to partners, thus understanding its motivations will help maximise results. This study examines the rates, dynamics and consequences of partner disclosure in Burkina Faso, Kenya, Malawi and Uganda, with special attention to the role of support groups and stigma in disclosure.

    METHODS: The study employs mixed methods, including a cross-sectional client survey of counselling and testing services, focus groups, and in-depth interviews with HIV-positive individuals in stable partnerships in Burkina Faso, Kenya, Malawi and Uganda, recruited at healthcare facilities offering HIV testing.

    RESULTS: Rates of disclosure to partners varied between countries (32.7% - 92.7%). The lowest rate was reported in Malawi. Reasons for disclosure included preventing the transmission of HIV, the need for care, and upholding the integrity of the relationship. Fear of stigma was an important reason for non-disclosure. Women reported experiencing more negative reactions when disclosing to partners. Disclosure was positively associated with living in urban areas, higher education levels, and being male, while being negatively associated with membership to support groups.

    CONCLUSIONS: Understanding of reasons for disclosure and recognition of the role of support groups in the process can help improve current prevention efforts, that increasingly focus on treatment as prevention as a way to halt new infections. Support groups can help spread secondary prevention messages, by explaining to their members that antiretroviral treatment has benefits for HIV positive individuals and their partners. Home-based testing can further facilitate partner disclosure, as couples can test together and be counselled jointly.

  • 20. Hardon, Anita
    et al.
    Kageha, Emmy
    Kinsman, John
    University of Amsterdam.
    Kyaddondo, David
    Wanyenze, Rhoda
    Obermeyer, Carla Makhlouf
    Dynamics of care, situations of choice: HIV tests in times of ART2011Ingår i: Medical Anthropology, ISSN 0145-9740, E-ISSN 1545-5882, Vol. 30, nr 2, s. 183-201Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    In the 1990s, African AIDS programs followed a voluntary counseling and testing (VCT) approach to HIV testing. In the wake of large scale AIDS treatment programs, policymakers opted for routine provider-initiated testing (PITC) with less emphasis on counseling, which led to concerns about the ethical conduct of HIV testing. Inspired by Annemarie Mol, we ask if PITC can be framed as good care, rather than as medical domination that threatens to violate patients' rights. Based on fieldwork in Ugandan and Kenyan health facilities, we reveal that situations of choice vary: patients in hospital wards, are given time to decide whether they want a test, while in antenatal care testing women find it very hard to opt-out. We argue that the medical context inherent in PITC provides an attractive moral space for people to undergo HIV tests.

  • 21. Hardon, Anita Petra
    et al.
    Akurut Aurugai, Dorothy
    Comoro, Christopher
    Ekezie, Cosmas
    Irunde, Henry
    Gerrits, Trudie
    Hodgkin, Catherine
    Kglatwane, Joyce
    Kinsman, John
    University of Amsterdam.
    Kwasa, Richard
    Maridadi, Janneth
    Nakiyemba, Alice
    Nsimba, Stephen E.D.
    Ogenyi, Robert
    Oyabba, Thomas
    Temu, Florence
    Laing, Richard
    On hunger, transport costs and waiting time: a synthesis of challenges to ARV adherence in three African countries2006Ingår i: From access to adherence: the challenges of antiretrovial treatment. Studies from Botswana, Tanzania and Uganda / [ed] A Hardon, S Davey, T Gerrits, C Hodgkin, H Irunde, J Kgatlwane, J Kinsman, A Nakiyemba, R Laing, Geneva: World Health Organization , 2006, s. 1-20Kapitel i bok, del av antologi (Övrigt vetenskapligt)
  • 22. Henschke, Nicholas
    et al.
    Mirny, Anna
    Haafkens, Joke A.
    Ramroth, Heribert
    Padmawati, Siwi
    Bangha, Martin
    Berkman, Lisa
    Trisnantoro, Laksono
    Blomstedt, Yulia
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Avdelningen för medicin.
    Becher, Heiko
    Sankoh, Osman
    Byass, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Strengthening capacity to research the social determinants of health in low-and middle-income countries: lessons from the INTREC programme2017Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 17, artikel-id 514Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The INDEPTH Training & Research Centres of Excellence (INTREC) collaboration developed a training programme to strengthen social determinants of health (SDH) research in low-and middle-income countries (LMICs). It was piloted among health-and demographic researchers from 9 countries in Africa and Asia. The programme followed a blended learning approach and was split into three consecutive teaching blocks over a 12month period: 1) an online course of 7 video lectures and assignments on the theory of SDH research; 2) a 2-week qualitative and quantitative methods workshop; and 3) a 1-week data analysis workshop. This report aims to summarise the student evaluations of the pilot and to suggest key lessons for future approaches to strengthen SDH research capacity in LMICs. Methods: Semi-structured interviews and questionnaires with 24 students from 9 countries in Africa and Asia were used to evaluate each teaching block. Information was collected about the students' motivation and interest in studying SDH, any challenges they faced during the consecutive teaching blocks, and suggestions they had for future courses on SDH. Results: Of the 24 students who began the programme, 13 (54%) completed all training activities. The students recognised the need for such a course and its potential to improve their skills as health researchers. The main challenges with the online course were time management, prior knowledge and skills required to participate in the course, and the need to get feedback from teaching staff throughout the learning process. All students found the face-to-face workshops to be of high quality and value for their work, because they offered an opportunity to clarify SDH concepts taught during the online course and to gain practical research skills. After the final teaching block, students felt they had improved their data analysis skills and were better able to develop research proposals, scientific manuscripts, and policy briefs. Conclusions: The INTREC programme has trained a promising cadre of health researchers who live and work in LMICs, which is an essential component of efforts to identify and reduce national and local level health inequities. Time management and technological issues were the greatest challenges, which can inform future attempts to strengthen research capacity on SDH.

  • 23. Hofman, Karen
    et al.
    Blomstedt, Yulia
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Addei, Sheila
    Kalage, Rose
    Maredza, Mandy
    Sankoh, Osman
    Bangha, Martin
    Kahn, Kathleen
    Becher, Heiko
    Haafkens, Joke
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Addressing research capacity for health equity and the social determinants of health in three African countries: the INTREC programme2013Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, s. 1-7, artikel-id 19668Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The importance of tackling economic, social and health-related inequities is increasingly accepted as a core concern for the post-Millennium Development Goal framework. However, there is a global dearth of high-quality, policy-relevant and actionable data on inequities within populations, which means that development solutions seldom focus on the people who need them most. INTREC (INDEPTH Training and Research Centres of Excellence) was established with this concern in mind. It aims to provide training for researchers from the INDEPTH network on associations between health inequities, the social determinants of health (SDH), and health outcomes, and on presenting their findings in a usable form to policy makers.

    OBJECTIVE: As part of a baseline situation analysis for INTREC, this paper assesses the current status of SDH training in three of the African INTREC countries - Ghana, Tanzania, and South Africa - as well as the gaps, barriers, and opportunities for training.

    METHODS: SDH-related courses from the three countries were identified through personal knowledge of the researchers, supplemented by snowballing and online searches. Interviews were also conducted with, among others, academics engaged in SDH and public health training in order to provide context and complementary material. Information regarding access to the Internet, as a possible INTREC teaching medium, was gathered in each country through online searches.

    RESULTS: SDH-relevant training is available, but 1) the number of places available for students is limited; 2) the training tends to be public-health-oriented rather than inclusive of the broader, multi-sectoral issues associated with SDH; and 3) insufficient funding places limitations on both students and on the training institutions themselves, thereby affecting participation and quality. We also identified rapidly expanding Internet connectivity in all three countries, which opens up opportunities for e-learning on SDH, though the current quality of the Internet services remains mixed.

    CONCLUSIONS: SDH training is currently in short supply, and there is a clear role for INTREC to contribute to the training of a critical mass of African researchers on the topic. This work will be accomplished most effectively by building on pre-existing networks, institutions, and methods.

  • 24.
    Ivarsson, Anneli
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Johansson, Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Mohamud, Khalif Bile
    Weinehall, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Freij, Lennart
    Wall, Stig
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dalmar, Abdirisak Ahmed
    Ibrahim, Abdirashid Omer
    Hagi, Abdisamad Abikar
    Abdi, Abshir Ali
    Hussein, Abdullahi Sheik
    Shirwa, Abdulkadir Mohamed
    Warsame, Amina
    Ereg, Derie Ismail
    Aden, Mohamed Hussain
    Qasim, Maryan
    Ali, Mohamed Khalid
    Elmi, Abdullahi
    Afrah, Abdullahi Warsame
    Sabtiye, Faduma Omar
    Guled, Fatuma Ege
    Ahmed, Hinda Jama
    Mohamed, Halima
    Tinay, Halima Ali
    Mohamud, Kadigia Ali
    Yusuf, Mariam Warsame
    Omar, Mayeh
    Abdi, Yakoub Aden
    Abdulkadir, Yusuf
    Johansson, Annika
    Kulane, Asli Ali
    Schumann, Barbara
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Essen, Birgitta
    Kalengayi, Faustine Nkulu
    Elgh, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Norström, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lönnberg, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Norder, Helene
    Schröders, Julia
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Erlandsson, Kerstin
    Edin, Kerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sahlen, Klas-Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Lars L.
    Persson, Lars-Ake
    Eriksson, Malin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Emmelin, Maria
    Hasselberg, Marie
    Klingberg, Marie
    Preet, Raman
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hogberg, Ulf
    Sjostrom, Urban
    Omar, Saif
    Healing the health system after civil unrest2015Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, s. 1-4Artikel i tidskrift (Övrigt vetenskapligt)
  • 25. Kamali, A
    et al.
    Quigley, M
    Nakiyingi, J
    Kinsman, John
    Medical Research Council Programme on AIDS, Uganda.
    Kengeya-Kayondo, J
    Gopal, R
    Ojwiya, A
    Hughes, P
    Carpenter, L M
    Whitworth, J
    Syndromic management of sexually-transmitted infections and behaviour change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial.2003Ingår i: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 361, nr 9358, s. 645-52Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Treatment of sexually-transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. We aimed to assess the effect of these interventions on incidence of HIV-1 and other sexually-transmitted infections.

    METHODS: We randomly allocated all adults living in 18 communities in rural Uganda to receive behavioural interventions alone (group A), behavioural and STI interventions (group B), or routine government health services and community development activities (group C). The primary outcome was HIV-1 incidence. Secondary outcomes were incidence of herpes simplex virus type 2 (HSV2) and active syphilis and prevalence of gonorrhoea, chlamydia, reported genital ulcers, reported genital discharge, and markers of behavioural change. Analysis was per protocol.

    FINDINGS: Compared with group C, the incidence rate ratio of HIV-1 was 0.94 (0.60-1.45, p=0.72) in group A and 1.00 (0.63-1.58, p=0.98) in group B, and the prevalence ratio of use of condoms with last casual partner was 1.12 (95% CI 0.99-1.25) in group A and 1.27 (1.02-1.56) in group B. Incidence of HSV2 was lower in group A than in group C (incidence rate ratio 0.65, 0.53-0.80) and incidence of active syphilis for high rapid plasma reagent test titre and prevalence of gonorrhoea were both lower in group B than in group C (active syphilis incidence rate ratio, 0.52, 0.27-0.98; gonorrhoea prevalence ratio, 0.25, 0.10-0.64).

    INTERPRETATION: The interventions we used were insufficient to reduce HIV-1 incidence in rural Uganda, where secular changes are occurring. More effective STI and behavioural interventions need to be developed for HIV control in mature epidemics.

  • 26. Kamali, Anatoli
    et al.
    Kinsman, John
    Medical Research Council Programme on AIDS, Uganda.
    Nalweyiso, Norah
    Mitchell, Kirstin
    Kanyesigye, Edward
    Kengeya-Kayondo, Jane F
    Carpenter, Lucy M
    Nunn, Andrew
    Whitworth, James A G
    A community randomized controlled trial to investigate impact of improved STD management and behavioural interventions on HIV incidence in rural Masaka, Uganda: trial design, methods and baseline findings2002Ingår i: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 7, nr 12, s. 1053-1063Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To describe study design, methods and baseline findings of a behavioural intervention alone and in combination with improved management of sexually transmitted diseases (STDs) aimed at reducing HIV incidence and other STDs.

    DESIGN: A three-arm community randomized controlled trial (RCT) of 18 rural communities (approximately 96 000 adults) in SW Uganda. A standardized behavioural intervention was implemented in 12 communities (arms A and B) through community-based education, meetings and information leaflets. Six of these communities in addition received improved STD management through government and private health units (arm B). Arm C communities received routine government health services. Impact assessment was through three questionnaire and serological surveys of 750-1000 adults in each community at 18-24-month intervals. The primary outcome measure was HIV incidence and secondary measures were syphilis and herpes simplex virus type 2 incidence, prevalence of Neisseria gonorrhoea and Chlamydia trachomatis and sexual behaviour changes.

    RESULTS: Approximately 15 000 adults (72% of eligible population) were enrolled at baseline. HIV baseline prevalence rates were 9-10% in all arms and demographic and behavioural characteristics and STD prevalence were also similar. In intervention communities, there were 391 995 attendance at 81 502 activities (6.1 per target adult), 164 063 leaflets distributed (2.6 per person) and 1 586 270 condoms (16.5 condoms per adult). In the STD communities a total of 12 239 STD cases (65% women) were seen over a 5-year period (7.7 per 100 adults/year).

    CONCLUSION: This is the first community RCT of its type with a behavioural component. There is fair baseline comparability between study arms and process data suggest that interventions were adequately implemented.

  • 27.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    "A time of fear": local, national, and international responses to a large Ebola outbreak in Uganda2012Ingår i: Globalization and Health, ISSN 1744-8603, E-ISSN 1744-8603, Vol. 8, artikel-id 15Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: This paper documents and analyses some of the responses to the largest Ebola outbreak on record, which took place in Uganda between September 2000 and February 2001. Four hundred and twenty five people developed clinical symptoms in three geographically distinct parts of the country (Gulu, Masindi, and Mbarara), of whom 224 (53%) died. Given the focus of previous social scientific Ebola research on experiences in those communities that have been directly affected, the article examines the ways in which fear, altruism, and stigma were felt and enacted in a wider variety of contexts - local, national, and international - over the course of the outbreak. METHODS: Responses to the outbreak were gauged through the articles, editorials, cartoons, and letters that were published in the country's two main English language daily national newspapers: the New Vision and the Monitor (now the Daily Monitor). All the relevant pieces from these two sources over the course of the epidemic were cut out, entered onto a computer, and the originals filed. The three a priori codes - based on the local, national, and international levels - were expanded into six, to include specific issues that emerged inductively during analysis. The data within each code were subsequently worked into coherent, chronological narratives. RESULTS: A total of 639 cuttings were included in the analysis. Strong and varied responses to the outbreak were identified from across the globe. These included, among others: confusion, anger, and serious stigma in affected communities; medical staff working themselves to exhaustion, with some quitting their posts; patients fleeing from hospitals; calls on spiritual forces for protection against infection; a well-coordinated national control strategy; and the imposition of some international travel restrictions. Responses varied both quantitatively and qualitatively according to the level (i.e. local, national, or international) at which they were manifested. CONCLUSIONS: The Ugandan experience of 2000/2001 demonstrates that responses to an Ebola outbreak can be very dramatic, but perhaps disproportionate to the actual danger presented. An important objective for any future outbreak control strategy must be to prevent excessive fear, which, it is expected, would reduce stigma and other negative outcomes. To this end, the value of openness in the provision of public information - and, critically, of being seen to be open - cannot be overstated.

  • 28.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    AIDS policy in Uganda: evidence, ideology, and the making of an African success story2010 (uppl. 1)Bok (Övrigt vetenskapligt)
    Abstract [en]

    This book presents a comprehensive history of Africa's best-known AIDS "success story," from the start of the epidemic in the early 1980s up until 2005. It focuses on the various ways in which evidence and ideology have contributed to AIDS policy in Uganda, and it places the development of the country's innovative prevention and treatment strategies into the context of international, national, and local processes. Through this, John Kinsman shows how the country became an important influence in defining global AIDS control strategies.

  • 29.
    Kinsman, John
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    de Bruijne, Kars
    Jalloh, Alpha M.
    Harris, Muriel
    Abdullah, Hussainatu
    Boye-Thompson, Titus
    Sankoh, Osman
    Jalloh, Abdul K.
    Jalloh-Vos, Heidi
    Development of a set of community-informed Ebola messages for Sierra Leone2017Ingår i: PLoS Neglected Tropical Diseases, ISSN 1935-2727, E-ISSN 1935-2735, Vol. 11, nr 8, artikel-id e0005742Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The West African Ebola epidemic of 2013-2016 was by far the largest outbreak of the disease on record. Sierra Leone suffered nearly half of the 28,646 reported cases. This paper presents a set of culturally contextualized Ebola messages that are based on the findings of qualitative interviews and focus group discussions conducted in 'hotspot' areas of rural Bombali District and urban Freetown in Sierra Leone, between January and March 2015. An iterative approach was taken in the message development process, whereby (i) data from formative research was subjected to thematic analysis to identify areas of community concern about Ebola and the national response; (ii) draft messages to address these concerns were produced; (iii) the messages were field tested; (iv) the messages were refined; and (v) a final set of messages on 14 topics was disseminated to relevant national and international stakeholders. Each message included details of its rationale, audience, dissemination channels, messengers, and associated operational issues that need to be taken into account. While developing the 14 messages, a set of recommendations emerged that could be adopted in future public health emergencies. These included the importance of embedding systematic, iterative qualitative research fully into the message development process; communication of the subsequent messages through a two-way dialogue with communities, using trusted messengers, and not only through a one-way, top-down communication process; provision of good, parallel operational services; and engagement with senior policy makers and managers as well as people in key operational positions to ensure national ownership of the messages, and to maximize the chance of their being utilised. The methodological approach that we used to develop our messages along with our suggested recommendations constitute a set of tools that could be incorporated into international and national public health emergency preparedness and response plans.

  • 30.
    Kinsman, John
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Elgh, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Virologi.
    Angrén, John
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Case studies on preparedness planning for polio in Poland and Cyprus2016Rapport (Övrigt vetenskapligt)
    Abstract [en]

    ​The last cases of poliomyelitis due to wild poliovirus in Poland and Cyprus were registered in 1984 and 1995, respectively. Current efforts against polio are therefore aimed at maintaining the two countries’ polio-free status. The overall objective of this report is to support these two EU Member States in updating their polio preparedness planning. The specific aims of the case study were to: critically review implemented actions and identify gaps in order to propose approaches for strengthening the national polio plans; identify health system elements that are important in polio preparedness planning; and provide examples of collaborative efforts between these sectors in planning measures for outbreak response to polio as a cross-border health threat.

  • 31.
    Kinsman, John
    et al.
    Medical Research Council Programme on AIDS, Uganda.
    Harrison, S
    Kengeya-Kayondo, J
    Kanyesigye, E
    Musoke, S
    Whitworth, J
    Implementation of a comprehensive AIDS education programme for schools in Masaka District, Uganda1999Ingår i: AIDS Care, ISSN 0954-0121, E-ISSN 1360-0451, Vol. 11, nr 5, s. 591-601Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    As part of a large IEC (Information, Education and Communication)/STD intervention trial, a 19-lesson, comprehensive school-based AIDS education programme was implemented and evaluated in 50 primary and 16 secondary schools in 12 parishes of Masaka District, Uganda. A series of three teacher-training and evaluation workshops spread over a year was held in each parish, between which teachers implemented the programme in the classroom. One hundred and forty-eight teachers were trained and about 3,500 students were subsequently exposed to the programme. Both teachers and students responded positively, which suggests that this type of programme has much to offer young people who attend school. However, some problems were encountered: language, programme content, community resistance to teaching about condoms, and several practical issues. Proposed solutions include flexibility with the English language policy, alternative approaches to role play activities, targeting influential individuals with information about the need for young people to learn about safer sex, and a parallel community-based IEC programme to facilitate community acceptance of the need for the programme. In addition, implementation may be incomplete unless comprehensive AIDS education is fully incorporated into the curriculum, and properly examined. These findings are placed in the context of other life skills/AIDS education programmes being introduced both in Uganda and elsewhere in Africa.

  • 32.
    Kinsman, John
    et al.
    Medical Research Council Programme on AIDS, Uganda.
    Kamali, A
    Kanyesigye, E
    Kamulegeya, I
    Basajja, V
    Nakiyingi, J
    Schenk, K
    Whitworth, J
    Quantitative process evaluation of a community-based HIV/AIDS behavioural intervention in rural Uganda2002Ingår i: Health Education Research, ISSN 0268-1153, E-ISSN 1465-3648, Vol. 17, nr 2, s. 253-265Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    This paper describes the implementation of a large community-based HIV/AIDS behavioural intervention in rural Uganda and presents 4 years' worth of quantitative process data. The intervention involved 560 field-based workers (57% male, 76% subsistence farmers, mean age 35 years), supervised by six central staff. Intervention channels included drama and video shows, Community Educators (CEs), as well as leaflet and condom distribution. Activities focused on one or more of 16 key topics. In total, 392 000 attendances (51% female) were recorded--a mean of over 6 for each of the 64 000 target adults--at 81 000 activities, with CEs attracting 71% of the total attendance; 164 000 leaflets and 242 000 condoms were also distributed. The annual cost of the intervention per target individual was approximately US$1.76. Our voluntary workforce experienced an annual attrition rate of 11%, with 'stable' workers more likely to be older, married or opinion leaders in their community than those who dropped out. We calculate that even a significant increase in the proportion of female field workers would have made little difference either to the sex ratio of attendees or to overall attendance. In spite of some initial resistance to the intervention, particularly in relation to condoms, we have demonstrated that people in rural Africa can accept and actively participate in the dissemination of HIV/AIDS prevention messages throughout their own communities.

  • 33.
    Kinsman, John
    et al.
    Medical Research Council Programme on AIDS, Uganda.
    Kamali, A
    Whitworth, J
    Statistical methods and the evaluation of school-based AIDS education in Africa2000Ingår i: International Journal of STD and AIDS (London), ISSN 0956-4624, E-ISSN 1758-1052, Vol. 11, nr 8, s. 553-554Artikel i tidskrift (Refereegranskat)
  • 34.
    Kinsman, John
    et al.
    Medical Research Council Programme on AIDS, Uganda.
    Nakiyingi, J
    Kamali, A
    Carpenter, L
    Quigley, M
    Pool, R
    Whitworth, J
    Evaluation of a comprehensive school-based AIDS education programme in rural Masaka, Uganda2001Ingår i: Health Education Research, ISSN 0268-1153, E-ISSN 1465-3648, Vol. 16, nr 1, s. 85-100Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    A 19 activity extracurricular school-based AIDS education programme lasting 1 year was conducted in rural southwestern Uganda using specially trained teachers, and was evaluated using mutually supportive quantitative and qualitative methods. In total, 1274 students from 20 intervention schools and 803 students from 11 control schools completed questionnaires at baseline, and their classes were followed up. In addition, 93 students from five of the intervention schools participated in 12 focus group discussions. The programme had very little effect--seven of the nine key questionnaire variables showed no significant increase in score after the intervention. Data from the focus group discussions suggest that the programme was incompletely implemented, and that key activities such as condoms and the role-play exercises were covered only very superficially. The main reasons for this were a shortage of classroom time, as well as teachers' fear of controversy and the unfamiliar. We conclude that large-scale comprehensive school-based AIDS education programmes in sub-Saharan Africa may be more completely implemented if they are fully incorporated into national curricula and examined as part of life-skills education. This would require teachers to be trained in participatory teaching methods while still at training college.

  • 35.
    Kinsman, John
    et al.
    Medical Research Council Programme on AIDS, Uganda.
    Nakiyingi, J
    Kamali, A
    Whitworth, J
    Condom awareness and intended use: gender and religious contrasts among school pupils in rural Masaka, Uganda2001Ingår i: AIDS Care, ISSN 0954-0121, E-ISSN 1360-0451, Vol. 13, nr 2, s. 215-220Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    A cross-sectional questionnaire survey examining knowledge, attitudes and intended use of condoms was conducted among 1,821 pupils (mean age = 14.2 years, range = 9--24) from 27 primary and secondary schools in rural south western Uganda. Condom education is not provided in Ugandan schools, but both boys and girls had relatively high overall levels of knowledge, even though boys demonstrated a higher level than girls. This suggests that respondents had successfully obtained reliable information from other sources. Boys and girls had similar and fairly positive attitudes towards condoms, although considerable shyness was expressed, both about discussing condoms with a partner and buying them. Fifty-eight per cent said that they themselves would use a condom if one were available, but girls were far less likely than boys to say so. Roman Catholics (46% of the sample) were less knowledgeable and less positive about condoms than non-Catholics, and the boys in this group, but not the girls, were also much less likely to say they would use one. Possible interventions based on these findings are discussed, and a research agenda for the delivery of assertiveness training to girls is proposed.

  • 36.
    Kinsman, John
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Norris, Shane A
    Kahn, Kathleen
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Twine, Rhian
    Riggle, Kari
    Edin, Kerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Mathebula, Jennifer
    Ngobeni, Sizzy
    Monareng, Nester
    Micklesfield, Lisa K
    A model for promoting physical activity among rural South African adolescent girls2015Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, artikel-id 28790Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: In South Africa, the expanding epidemic of non-communicable diseases is partly fuelled by high levels of physical inactivity and sedentary behaviour. Women especially are at high risk, and interventions promoting physical activity are urgently needed for girls in their adolescence, as this is the time when many girls adopt unhealthy lifestyles.

    OBJECTIVE: This qualitative study aimed to identify and describe facilitating factors and barriers that are associated with physical activity among adolescent girls in rural, north-eastern South Africa and, based on these, to develop a model for promoting leisure-time physical activity within this population.

    DESIGN: The study was conducted in and around three secondary schools. Six focus group discussions were conducted with adolescent girls from the schools, and seven qualitative interviews were held with sports teachers and youth leaders. The data were subjected to thematic analysis.

    RESULTS: Seven thematic areas were identified, each of which was associated with the girls' self-reported levels of physical activity. The thematic areas are 1) poverty, 2) body image ideals, 3) gender, 4) parents and home life, 5) demographic factors, 6) perceived health effects of physical activity, and 7) human and infrastructural resources. More barriers to physical activity were reported than facilitating factors.

    CONCLUSIONS: Analysis of the barriers found in the different themes indicated potential remedial actions that could be taken, and these were synthesised into a model for promoting physical activity among South African adolescent girls in resource-poor environments. The model presents a series of action points, seen both from the 'supply-side' perspective (such as the provision of resources and training for the individuals, schools, and organisations which facilitate the activities) and from the 'demand-side' perspective (such as the development of empowering messages about body image for teenage girls, and encouraging more parental involvement). The development of physical activity interventions that incorporate this supply- and demand-side model would represent an additional tool for ongoing efforts aimed at tackling the expanding non-communicable disease epidemic in South Africa, and in other resource-constrained settings undergoing rapid health transitions.

  • 37.
    Kinsman, John
    et al.
    Medical Research Council Programme on AIDS, Uganda.
    Nyanzi, S
    Pool, R
    Socializing influences and the value of sex: the experience of adolescent school girls in rural Masaka, Uganda2000Ingår i: Culture, Health and Sexuality, ISSN 1369-1058, E-ISSN 1464-5351, Vol. 2, nr 2, s. 151-66Artikel i tidskrift (Refereegranskat)
  • 38.
    Kinsman, John
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Stöven, Svenja
    Umeå universitet, Teknisk-naturvetenskapliga fakulteten, Europeiska CBRNE-centret.
    Elgh, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi.
    Murillo, Pilar
    Umeå universitet, Teknisk-naturvetenskapliga fakulteten, Europeiska CBRNE-centret.
    Sulzner, Michael
    Good practices and challenges in addressing poliomyelitis and measles in the European Union2018Ingår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, nr 4, s. 730-734Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: All European Union (EU) and European Economic Area (EEA) Member States have pledged to ensure political commitment towards sustaining the region's poliomyelitis-free status and eliminating measles. However, there remain significant gaps between policy and practice in many countries. This article reports on an assessment conducted for the European Commission that aimed to support improvements in preparedness and response to poliomyelitis and measles in Europe.

    Methods: A documentary review was complemented by qualitative interviews with professionals working in International and EU agencies, and in at-risk or recently affected EU/EEA Member States (six each for poliomyelitis and measles). Twenty-six interviews were conducted on poliomyelitis and 24 on measles; the data were subjected to thematic analysis. Preliminary findings were then discussed at a Consensus Workshop with 22 of the interviewees and eight other experts.

    Results: Generic or disease-specific plans exist in the participating countries and cross-border communications during outbreaks were generally reported as satisfactory. However, surveillance systems are of uneven quality, and clinical expertise for the two diseases is limited by a lack of experience. Serious breaches of protocol have recently been reported from companies producing poliomyelitis vaccines, and vaccine coverage rates for both diseases were also sub-optimal. A set of suggested good practices to address these and other challenges is presented.

    Conclusions: Poliomyelitis and measles should be brought fully onto the policy agendas of all EU/EEA Member States, and adequate resources provided to address them. Each country must abide by the relevant commitments that they have already made.

  • 39. Kyaddondo, David
    et al.
    Wanyenze, Rhoda K
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hardon, Anita
    Disclosure of HIV status between parents and children in Uganda in the context of greater access to treatment2013Ingår i: SAHARA-J: Journal of Social Aspects of HIV/AIDS, ISSN 1729-0376, E-ISSN 1813-4424, Vol. 10, nr Suppl 1, s. S37-S45Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    While disclosure of HIV sero-status is encouraged in the management of the HIV and AIDS epidemic, it remains a challenge, especially among family members. This article examines the moral dilemmas and pragmatic incentives surrounding disclosure of HIV status in contemporary Uganda. Our findings are based on 12 in-depth interviews, 2 focus-group discussions, 6 key informant interviews with AIDS activists, and open-ended responses derived from 148 HIV-positive persons in a quantitative survey. The study was conducted in 2008-2009 in Kampala, Mpigi, and Soroti districts in Uganda. We found both parents and adult children facing dilemmas in disclosure, whether it was parents revealing their own HIV status to their children or the status of their perinatally infected children, or young people infected through sexual intercourse telling their parents. For both groups, there is fear of blame, stigma, discrimination, and shame and guilt related to unsafe sex, while young people also fear loss of privileges. On the other hand, there are practical imperatives for disclosure in terms of gaining access to care, treatment, and material resources. Faced with these dilemmas, HIV-positive people and their families require professional counselling to help them work through the emotional challenges encountered and identify mechanisms of support and coping.

  • 40. Kyaddondo, David
    et al.
    Wanyenze, Rhoda K
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hardon, Anita
    Home-based HIV counseling and testing: client experiences and perceptions in Eastern Uganda2012Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 12, nr 1, s. 966-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Though prevention and treatment depend on individuals knowing their HIV status, the uptake of testing remains low in Sub-Saharan Africa. One initiative to encourage HIV testing involves delivering services at home. However, doubts have been cast about the ability of Home-Based HIV Counseling and Testing (HBHCT) to adhere to ethical practices including consent, confidentiality, and access to HIV care post-test. This study explored client experiences in relation these ethical issues.

    METHODS: We conducted 395 individual interviews in Kumi district, Uganda, where teams providing HBHCT had visited 6-12 months prior to the interviews. Semi-structured questionnaires elicited information on clients' experiences, from initial community mobilization up to receipt of results and access to HIV services post-test.

    RESULTS: We found that 95% of our respondents had ever tested (average for Uganda was 38%). Among those who were approached by HBHCT providers, 98% were informed of their right to decline HIV testing. Most respondents were counseled individually, but 69% of the married/cohabiting were counseled as couples. The majority of respondents (94%) were satisfied with the information given to them and the interaction with the HBHCT providers. Most respondents considered their own homes as more private than health facilities. Twelve respondents reported that they tested positive, 11 were referred for follow-up care, seven actually went for care, and only 5 knew their CD4 counts. All HIV infected individuals who were married or cohabiting had disclosed their status to their partners.

    CONCLUSION: These findings show a very high uptake of HIV testing and satisfaction with HBHCT, a large proportion of married respondents tested as couples, and high disclosure rates. HBHCT can play a major role in expanding access to testing and overcoming disclosure challenges. However, access to HIV services post-test may require attention.

  • 41. Lucas, Henry
    et al.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Distance- and blended-learning in global health research: potentials and challenges2016Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, artikel-id 33429Artikel i tidskrift (Refereegranskat)
  • 42. Melaku, Yohannes Adama
    et al.
    Berhane, Yemane
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Reda, Hailemariam Lemma
    Sexual and reproductive health communication and awareness of contraceptive methods among secondary school female students, northern Ethiopia: a cross-sectional study2014Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, s. 252-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Adolescent girls continue to fall victim to unintended pregnancy and its consequences, with particular problems arising in low income countries. Awareness about methods of contraception is an important step towards gaining access and using suitable contraceptive methods. However, studies assessing the relationship between sexual and reproductive health communication and awareness of contraceptive methods among secondary school female students are lacking. METHODS: A cross sectional study was conducted among 807 female students in six secondary schools in Mekelle town, Ethiopia. Study participants were selected with a stratified cluster sampling technique. Data collection was carried out using a structured, self-administered questionnaire, and data entry was done using EPI Info Version 3.3.2 software. The data were then cleaned and analyzed using SPSS version 20. Bivariate and multivariate logistic regressions were used to determine factors associated with awareness of female students on methods of contraception. RESULT: Of all the students, 127(15.8%) reported ever having had sex, of whom 109(85.8%) had ever used contraceptives. Twenty (16%) of the sexually active students reported having been pregnant, of whom 18(90%) terminated their pregnancies with induced abortion. Discussion on sexual and reproductive health matters with their parent/s and peer/s in the six months prior to the study was reported by 351(43.5%) and 493(61.1%) of the students respectively. 716(88%) students were aware of different methods of contraception. Discussing sexual and reproductive health issues with parents (AOR =2.56(95% CI: 1.45, 4.50)) and peers (AOR = 2.46(95% CI: 1.50, 4.03)) were found to be independent predictors for contraceptive awareness among students. CONCLUSIONS: Discussion on sexual and reproductive health issues with family and peers has a positive effect on contraceptive awareness of students. Therefore, strategies to improve open parent-child communication, and appropriate peer-to-peer communication in schools on sexual and reproductive health should be established and strengthened.

  • 43.
    Melaku, Yohannes
    et al.
    College of Health Sciences, Mekelle, Ethiopia.
    Weldearegawi, Berhe
    College of Health Sciences, Mekelle, Ethiopia.
    Tesfay, Fisaha
    College of Health Sciences, Mekelle, Ethiopia.
    Abera, Semaw
    College of Health Sciences, Mekelle, Ethiopia.
    Abraham, Loko
    College of Health Sciences, Mekelle, Ethiopia.
    Aregay, Alemseged
    College of Health Sciences, Mekelle, Ethiopia.
    Ashebir, Yemane
    College of Health Sciences, Mekelle, Ethiopia.
    Eshetu, Friehiwot
    CDC-Ethiopia, Addis Ababa, Ethiopia.
    Haile, Ashenafi
    CDC-Ethiopia, Addis Ababa, Ethiopia.
    Lakew, Yihunie
    Ethiopian Public Health Association (EPHA), Addis Ababa, Ethiopia.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Poor linkages in maternal health care services: evidence on antenatal care and institutional delivery from a community-based longitudinal study in Tigray region, Ethiopia2014Ingår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, nr 1, artikel-id 418Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Progress towards attaining the maternal mortality and maternal health targets set by Millennium Development Goal 5 has been slow in most African countries. Assessing antenatal care and institutional delivery service utilization and their determinants is an important step towards improving maternal health care services.

    Methods: Data were drawn from the longitudinal database of Kilite-Awlaelo Health and Demographic Surveillance System. A total of 2361 mothers who were pregnant and who gave birth between September 2009 and August 2013 were included in the analysis. Potential variables to explain antenatal care and institutional delivery service utilization were extracted, and descriptive statistics and logistic regression were used to determine the magnitude of maternal health care service utilization and associated factors, respectively.

    Results: More than three-quarters, 76% [95% CI: 74.8%-78.2%] (n = 1806), of mothers had undergone at least one antenatal care visit during their previous pregnancy. However, only 27% [95% CI: 25.3%-28.9%] (n = 639) of mothers gave birth at a health institution. Older mothers, urban residents, mothers with higher education attainment, and farmer mothers were more likely to use antenatal care. Institutional delivery services were more likely to be used among older mothers, urban residents, women with secondary education, mothers who visited antenatal care, and mothers with lower parity.

    Conclusions: Despite a relatively high proportion of mothers attending antenatal care services at least once, we found low levels of institutional delivery service utilization. Health service providers in Kilite-Awlaelo should be particularly vigilant regarding the additional maternal health needs of rural and less educated women with high parity.

  • 44.
    Melaku, Yohannes
    et al.
    Department of Public Health, Mekelle University, College of Health Sciences, Mekelle, Ethiopia.
    Zeleke, Ejigu
    Department of Epidemiology and Biostatistics, University of Gondar, Institute of Public Health, Gondar, Ethiopia.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Abraha, Akberet
    Department of Public Health, Mekelle University, College of Health Sciences, Mekelle, Ethiopia.
    Fertility desire among HIV-positive women in Tigray region, Ethiopia: implications for the provision of reproductive health and prevention of mother-to-child HIV transmission services2014Ingår i: BMC Women's Health, ISSN 1472-6874, E-ISSN 1472-6874, Vol. 14, nr 1, s. 137-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BackgroundThere is growing recognition of the difficult reproductive decisions faced by HIV-positive women. Studies in both resource-constrained and developed countries have suggested that many HIV-positive women continue to desire children in spite of their understanding of the possible risks that HIV poses. This study investigates the factors associated with fertility desire among HIV-positive women in Tigray region, Ethiopia.MethodsA cross-sectional survey was conducted among 964 HIV-positive women receiving HIV care in 12 health centers of Tigray region. In each health center, the number of study participants was allocated proportionally to the load of HIV-positive women in the chronic care clinics. A descriptive summary of the data and a logistic regression model were used to identify factors associated with fertility desire using odds ratios with a 95% confidence interval and P-value of 0.05.ResultsFour hundred and thirty nine (45.5%) of the participants reported a desire to have children in the future. Eighty six percent of the women had given birth to at least one live baby at the time of study, with the median number of live births being 2 (Inter quartile range¿=¿1,3). Women in the age group of 15¿24 years [AOR¿=¿2.64(95% CI: 1.44, 4.83)] and 25¿34 years [AOR¿=¿2.37(95% CI: 1.60, 2.4 3.50)] had higher fertility desire as compared to women in the age group of 35¿49 years. Having no children [AOR¿=¿25.76(95% CI: 13.66, 48.56)], having one to two children [AOR¿=¿5.14 (95%CI: 3.37, 7.84)] and disclosing HIV status to husband/sexual partner [AOR¿=¿1.74(95% CI: 1.11, 2.72)] were all independently associated with fertility desire.ConclusionsAge, HIV disclosure status to husband/sexual partner, and relatively few live children were all found to influence HIV-positive women¿s fertility desire. Programmers and policy makers should consider the effects of these factors for HIV-positive women as they develop HIV/AIDS interventions.

  • 45. Micklesfield, Lisa K
    et al.
    Pedro, Titilola M
    Kahn, Kathleen
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pettifor, John M
    Tollman, Stephen
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Norris, Shane A
    Physical activity and sedentary behavior among adolescents in rural South Africa: levels, patterns and correlates2014Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, s. 40-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Physical inactivity is increasing among children and adolescents and may be contributing to the increasing prevalence of overweight and obesity. This study examines physical activity and sedentary behavior patterns, and explores associations with individual, maternal, household, and community factors amongst rural South African adolescents.

    Methods: In 2009, 381 subjects, stratified by ages 11-12-years and 14-15-years, were randomly selected from 3511 children and adolescents who had participated in a growth survey two years previously. Weight and height were measured and self-reported Tanner pubertal stage was collected. A questionnaire quantifying frequency and duration of physical activity (PA) domains and sedentary time for the previous 12 months was administered. Moderate-vigorous physical activity (MVPA mins/wk) was calculated for time spent in school and club sport. Socio-demographic and other related data were included from the Agincourt health and socio-demographic system (HDSS). The Agincourt HDSS was established in 1992 and collects prospective data on the community living in the Agincourt sub-district of Mpumalanga Province in rural north-east South Africa.

    Results: Puberty, maternal education and socio-economic status (SES) contributed significantly to the mulitiple linear regression model for sedentary behavior (R-2=0.199; adjusted R-2=0.139; p < 0.000), and sex, SES and maternal education contributed to the tobit regression model for school and club sport MVPA (p < 0.000). MVPA, calculated from school and club sport, was higher in boys than girls (p < 0.001), and informal activity was lower (boys: p < 0.05 and girls: p < 0.01) while sedentary time was higher (girls: p < 0.01) in the older than the younger groups. Ninety-two percent (92%) of the sample reported walking for transport.

    Conclusions: In this study of rural South African adolescent boys and girls, SES at the maternal, household and community level independently predicted time spent in sedentary behaviors, and school and club MVPA. This study provides local data that can be used to develop health promotion strategies specific to this community, and other similar communities in developing countries.

  • 46.
    Nahar, Nazmun
    et al.
    Protecting Human Rights (PHR) Program, Plan International Bangladesh, Dhaka, Bangladesh.
    Blomstedt, Yulia
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wu, Beidi
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kandarina, Istiti
    Universitas Gadjah Mada, Yogyakarta, Indonesia .
    Trisnantoro, Laksono
    Universitas Gadjah Mada, Yogyakarta, Indonesia .
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Increasing the provision of mental health care for vulnerable, disaster-affected people in Bangladesh2014Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, nr 1, s. 708-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Bangladesh has the highest natural disaster mortality rate in the world, with over half a million people lost to disaster events since 1970. Most of these people have died during floods or cyclones, both of which are likely to become more frequent due to global climate change. To date, the government's post-disaster response strategy has focused, increasingly effectively, on the physical needs of survivors, through the provision of shelter, food and medical care. However, the serious and widespread mental health consequences of natural disasters in Bangladesh have not yet received the attention that they deserve. This Debate article proposes a practical model that will facilitate the provision of comprehensive and effective post-disaster mental health services for vulnerable Bangladeshis on a sustainable basis.

    DISCUSSION: A series of socially determined factors render the women and the poor of Bangladesh particularly vulnerable to dying in natural disasters; and, for those who survive, to suffering from some sort of disaster-related mental health illness. For women, this is largely due to the enforced gender separation, or purdah, that they endure; while for the poor, it is the fact that they are, by definition, only able to afford to live in the most climatically dangerous, and under-served parts of the country. Although the disasters themselves are brought by nature, therefore, social determinants increase the vulnerability of particular groups to mental illness as a result of them. While deeply entrenched, these determinants are at least partially amenable to change through policy and action.

    SUMMARY: In response to the 2004 Indian Ocean tsunami, the World Health Organisation developed a framework for providing mental health and psychosocial support after major disasters, which, we argue, could be adapted to Bangladeshi post-cyclone and post-flood contexts. The framework is community-based, it includes both medical and non-clinical components, and it could be adapted so that women and the poor are actively sought out and provided for. After training, these services could be run by Bangladesh's pre-existing 50,000-strong Cyclone Preparedness Programme workforce, alongside the country's extensive network of community-based health workers.

  • 47. Nyanzi, S
    et al.
    Pool, R
    Kinsman, John
    Medical Research Council Programme on AIDS, Uganda.
    The negotiation of sexual relationships among school pupils in south-western Uganda2001Ingår i: AIDS Care, ISSN 0954-0121, E-ISSN 1360-0451, Vol. 13, nr 1, s. 83-98Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The objective of the study was to explore how school-going adolescents in south-western Uganda negotiate sexual relationships. Qualitative data were obtained from 15 boys and 15 girls (14-18 years old), during a series of role plays, focus group discussions and one-to-one interviews. A questionnaire was administered to 80 pupils (12-20 years old) from the same school. Most of the pupils were sexually active. Sexual relationships between boys and girls were mediated by peers. Boys initiated relationships. Exchange played an important role in the negotiation of sexual relationships. Money or gifts were given and received in exchange for sexual favours and to strengthen the relationship. To maximize gains, some adolescents had sexual relationships with adults. Sexual relationships were characterized by ambiguity. Love is intertwined with sexual desire, money and prestige. Girls have to be explicit enough to get a good deal; if they are too explicit they will be stigmatized as 'loose' but if they are not interested in money they may be suspected of wanting to spread HIV. Boys try to persuade girls that they have money, but do not want to emphasize this too much. In sexual negotiations a boy must persuade a girl that although he is modern and sophisticated (i.e. experienced) he does not chase after every girl; the girl does not want to come over as an unsophisticated virgin, but does not want to give the impression that she is loose either. There is a tension between the traditional ideal of female chastity and submissiveness and the modern image of sexual freedom. Multiple partnerships were highly valued as a sign of sophistication. Condoms were not considered important. Interventions aimed at reducing the spread of HIV do not seem to be having an effect on the behaviour of this group of adolescents. On the contrary, risky attitudes and behaviour are part of an adolescent ideal of modernity and sophistication. New approaches are needed to persuade this group of the need for change. Shifting the source of interventions from adults to the adolescents themselves, encouraging girls to try other means of earning money and debunking the idea that having many partners is sophisticated may be productive alternatives.

  • 48. Okware, S
    et al.
    Kinsman, John
    University of Amsterdam.
    Onyango, S
    Opio, A
    Kaggwa, P
    Revisiting the ABC strategy: HIV prevention in Uganda in the era of antiretroviral therapy2005Ingår i: Postgraduate medical journal, ISSN 0032-5473, E-ISSN 1469-0756, Vol. 81, nr 960, s. 625-628Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The ABC strategy is credited for bringing the HIV/AIDS epidemic under control in Uganda. By promoting abstinence, being faithful, and condom use, safe(r) behaviours have been identified that are applicable to people in different circumstances. However, scaling-up of antiretroviral therapy in the country raised concerns that HIV prevention messages targeting the uninfected population are not taking sufficient account of inherent complexities. Furthermore, there is debate in the country over relative importance of abstinence in reduction of HIV incidence as well as over the morality and effectiveness of condoms. The purpose of this paper is to examine each component of ABC in light of current developments. It is argued that there is still a strong justification for condom use to complement abstinence and being faithful. There is an urgent need to update and relaunch Uganda's ABC strategy--its three elements are complementary, synergistic, and inseparable in the national HIV prevention programme.

  • 49. Quigley, Maria A
    et al.
    Kamali, Anatoli
    Kinsman, John
    Medical Research Council Programme on AIDS, Uganda.
    Kamulegeya, Ignatius
    Nakiyingi-Miiro, Jessica
    Kiwuwa, Sylvia
    Kengeya-Kayondo, Jane F
    Carpenter, Lucy M
    Whitworth, James A G
    The impact of attending a behavioural intervention on HIV incidence in Masaka, Uganda2004Ingår i: AIDS (London), ISSN 0269-9370, E-ISSN 1473-5571, Vol. 18, nr 15, s. 2055-2063Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: Changing behaviour is an important method for preventing HIV infection. We examined why a community randomized trial of a behavioural intervention found no significant effect of this on HIV incidence in rural Uganda.

    DESIGN: An individual-level analysis of a community randomized trial.

    METHODS: All sexually active, initially HIV-seronegative individuals with data on sexual behaviour were included (1558 men and 1836 women). Uptake of the intervention was measured using self-reported attendance at meetings, videos, dramas, and interactions with community educators in the past year. Sexual behaviour was assessed using self-reported condom use and the number of sexual partners in the past year.

    RESULTS: Overall, 81% of individuals in the intervention communities and 9% in the comparison communities reported attending at least one of the intervention activities in the past year. Attendance was lower in women, in those aged 55 years or older, and in the widowed. There was a lower HIV incidence in those who reported attending at least one intervention activity compared with those who attended none, and in women this effect was statistically significant (in women, adjusted rate ratio 0.41, 95% CI 0.19-0.89, P = 0.024; in men, adjusted rate ratio 0.66, 95% CI 0.25-1.79, P = 0.42). Reported behaviour change did not differ markedly between those who did and did not report attending any intervention activities.

    CONCLUSION: Although the intervention had no significant benefit in the communities as a whole, it resulted in a reduced risk of HIV acquisition in women who attended it. The methodological implications for future trials are discussed.

  • 50.
    Schumann, Barbara
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindvall, Kristina
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    ClimRef project – Resilient public health in the context of large-scale, drought-related migration in East Africa: Knowledge status and knowledge needs: Ethiopia country report2018Rapport (Övrigt vetenskapligt)
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